Concerned About Unconventional Mental Health Interventions?

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

Thursday, June 19, 2014

What Is Childhood Trauma About, and What Can Be Done to Lessen Its Effects?

A reader kindly commented on yet another Tina Traster claim—that adopted children in general have suffered from the trauma of a “broken maternal bond” or “primal wound”. Traster is apparently under the much mistaken impression that a child’s emotional attachment to the mother occurs before birth, and that therefore all adopted children have experienced a distressing separation from an attachment figure. These ideas are authority-based, not evidence-based; someone told Traster these things, and now she is taking her chance as a temporarily famous person to pass them on to others. She is unconcerned with the fact that easily observable evidence shows us her claims are incorrect.

Is it possible that an adopted child can have experienced trauma? Yes, most certainly! Some adopted children did experience trauma as a result of separation from the birthmother or other familiar caregivers, if that separation occurred between about 8 months and about three years of age, if the separation was abrupt and permanent, and if new caregivers treated the child insensitively and unresponsively. Please note that I say “or other familiar caregivers”, because there are many cases where a child who is to be adopted is separated very young from the birthmother, placed with foster parents for many months, and then abruptly separated from the foster parents. Children with these latter experiences are not traumatized by the separation from the birthmother, but may have experienced the separation from the foster family as traumatic.

Other adopted children may have experienced separations at younger or older ages and not found these traumatic as might have been the case for separation during the most vulnerable period. It’s possible that a baby can go from hospital to adoptive parents without experiencing any traumatic events. However, many cases of adoption occur in the wake of trauma of all kinds. Debilitating illness and death of a parent may leave the child parentless, or one parent may kill the other in front of the child and go to prison as a result. Vicarious traumas like these may occur singly, or may be combined with  direct traumatic experiences like car wrecks, physical attacks and injuries, sexual penetration, or uncontrolled and threatening adult rage. When children are adopted later than the first few weeks of life, the chances are that neglect, abuse, or exposure to others’ trauma have been experienced by the child; if nothing had happened, the child would not have been placed for adoption, unless he or she has handicapping conditions that the first caregivers found they could not manage.

In addition to these problems, it is possible that both adopted and nonadopted children may also react negatively to the later experience of coming to understand past events. Perhaps a child did not really know that his father killed his mother; now he finds out and grows mature enough to try to make sense of this. Perhaps a child adopted from China learns that her birthparents may have abandoned her because they wanted to have a son. Perhaps a nonadopted child comes to understand that his parents “had to get married” and may resent his existence because of this. One father of my acquaintance jocularly described to his teenage son all the efforts to abort that the parents had made without successfully ending the pregnancy. All of these later experiences can compound early traumas if such occurred, or can have powerful distressing effects on their own.  

One of the major effects of  traumatic experiences is the tendency for the individual to become emotionally dysregulated in the presence of “triggers”--  events that are not in themselves harmful but are reminiscent of or associated with the original experience. (“Triggers” are much in the news lately, as instructors are being asked to give warnings about reading or classroom material to students who may have experienced related trauma in the past.) Although children in general become dysregulated more often than adults do, they can usually be helped to calm and regulate themselves by familiar people—but when a child’s dysregulation is set off by the effects of past trauma, even familiar caregivers may not be able to help control a tantrum, rage, “meltdown”, or panic. The effect on the family, on the child’s relationships with siblings and friends, and on the child’s education may be devastating.

What can be done to help these difficult family situations? There are presently no treatments that are strongly supported by research evidence. However, there have been some attempts to create  multimodal treatments for these problems. One of these, Trauma Systems Therapy (TST) was described by Richard M. Smith in the Brown University Child and Adolescent Behavior Letter for June, 2014 (p. 1, pp. 6-7). Smith described TST as “the disciplined use of the whole range of tools targeting all levels of the system”. Careful assessment of problems includes understanding of child symptoms, family stressors like unemployment or caring for many or special needs children, school history, and financial pressure. Eventually, Smith says, “the work centers on analyzing what triggers and follows from the child’s dysregulated behavior, and then on how to prevent the triggers… It’s like looking at a football game in super slo-mo, only maybe the players don’t even know what game they’re playing or how. Families often start out reporting that there are no triggers whatsoever—‘he just blows up, it’s random’, they may say. Only after a lot of work can they be coaxed to see that it’s much more complicated, and also less, because the triggers are knowable, predictable, and often preventable. Getting people to accept their own role in the triggering can be harder still.”

There has been some work on the outcome of TST, but high levels of evidence are not yet in place. But even in the absence of such support, it’s clear that TST is a highly plausible approach. Unlike the assumptions made by Tina Traster, it is congruent with other things we know about children and families. It does not commit the fundamental attribution error by claiming that any problem is caused by a characteristic of the child, but instead works with a range of child and parent characteristics, temporary and permanent stressors, and long-term strengths and weaknesses of family and community. Whether TST will turn out to be the primary evidence-based treatment for traumatized children is unpredictable,  but it is clear that its approach to problems following trauma is free from the neurobabble and the superstition about early development that dominate Traster’s remarks.    



Wednesday, June 18, 2014

Trauma, Attachment, and "Adoption Today"

A glance at the magazine Adoption Today for June 2014 is enough to raise many questions about this publication’s purposes and accuracy. From page 48 to page 73, we have nothing but advertisements for therapists who purport to handle issues of “attachment and trauma”.

And what names are here! It’s like a history of potentially harmful treatments. I see a number who use checklists to diagnose “attachment disorders”. I see at least one who advocates holding therapies for babies. I see one who is under investigation in her home state after a suicide attempt by a 12-year-old whose parents followed her instructions. I see at least one whose advice was associated with the death of a young child. And I see a lot who think attachment occurs telepathically before birth.

In the midst of these listings is nestled a cameo photo of Ronald Federici (no oil painting as shown here) having a chat with Heather Forbes. The text notes that these two are “top experts”, although they have never published in a peer-reviewed journal; however, they say they are top, and I suppose they should know, shouldn’t they?  (Presumably money changed hands to achieve this conspicuous position for the picture.) In any case, the “as told to” text contains an interesting remark, quite relevant to the matters I want to discuss in this post: “Trauma goes much deeper than attachment. We must work with our children from a developmental spectrum and not focus solely on attachment, otherwise we miss a huge window for healing.”

I am not at all sure what working “from a developmental spectrum” might mean. The reference is possibly to the importance of developmentally appropriate practice, so rarely considered in Attachment Therapy or its various cousins. If that is what’s meant here, that would be a step in the right direction, as most of the therapists in the Adoption Today listings have long persisted in the view that they can “regress” a child to any developmental period and then move him back to his original stage, so consideration of his actual developmental status is not necessary.

But what about the rest of the statement? Here’s how I translate it: “Trauma is the flavor of the month! It’s all about trauma-informed stuff nowadays. Attachment issues are old-fashioned and too many people are getting to know that what we’ve been saying about attachment is wrong. Our business plans had better include moving to the trauma thing, or we’re sunk. But attachment is still a good buzzword, so what to do? How about we say ‘attachment and trauma’ for a while, just like we used to say ‘attachment and bonding’? That should work, because the public will start finding ‘trauma” just as familiar as ‘attachment’. Then we can pull in the families that obviously don’t have attachment problems (like the ones where the kid was in the NICU) and we can tell them the problem is trauma--  or even more likely, they’ll come and tell us that there must be trauma.”

Am I saying that trauma is not a problem? No, of course not. A trauma is by definition an event that causes long-term adverse outcomes of physical or psychological development and functioning. An event that looks horrible to bystanders may not act as a trauma and may cause no adverse outcomes. Another event that seems innocent to bystanders may be experienced by the victim in such a way that it acts as a trauma and causes adverse outcomes over the long term. For example, in Susan Clancy’s work on  adults who had been sexually abused as children, some of the experiences did not act as traumas, even though we might have expected them to, but for some people their later thinking about the childhood events was somewhat traumatic in light of their learned expectations and  beliefs. Traumatic events are often re-assessed as the individual’s development progresses, and they may be remembered vaguely, vividly, or anywhere in between, but it does not seem likely that they are “repressed” or show up later as “recovered memories.”

There are both good and bad messages about trauma in circulation today. The accurate messages remind adults that a child’s resistance to certain actions or reluctance to come close to certain people may be caused by earlier trauma and are not evidence of defiance or opposition. When adults understand this, they can learn to manage the child’s experiences more appropriately and will be less tempted to threaten or punish a traumatized child into compliance. The right messages about trauma are helpful in this way.

Inaccurate messages, on the other hand, suggest that if children show unwanted moods or behaviors, they must have experienced trauma, even if no other evidence supports this idea. These messages encourage adults to forget the roles played by the situation and by non-traumatic learning in bringing about problem behavior. Bad trauma messages also tend to “horribilize” the child’s position by stating that his entire body is a repository of unconscious memories of trauma, and that the memories can only be released by non-cognitive methods. These messages also imply that trauma is monolithic--  that every bad experience, at every point in the child’s development, causes equal difficulty. As a result, adults who receive inaccurate messages about trauma are persuaded to ignore some useful approaches to helping the child, and to accept treatments that may be ineffective and even potentially harmful.  

What’s the connection between attachment and trauma? It’s certainly true that there can be one. When children between about 8 months and three years of age are abruptly separated from familiar caregivers for many months, and when they do not receive sympathetic support from a small number of new caregivers, they respond with serious distress and grief. They sleep poorly, are reluctant to eat, and do not play or seem interested in engaging with other people. Their physical health may suffer and language and cognitive development is slowed. Not only do they seem to experience distress over the loss, but they miss out on a variety of experiences like speech interactions that contribute to normal development. If they have the opportunity to form new attachments to good caregivers, the children recover from this experience (although they may assess it as traumatic when they learn about it in later life). If they do not have that opportunity, they will show problems of development--  but it’s hard to say whether this is because of trauma or because the situation involves a cascade of other unusual experiences unsupportive of good development.

Children who are under perhaps 6 months of age, or over three years, at the time of separation from familiar caregivers do not respond with the intense distress we see during the period described above. The older they are, the better their cognitive and language abilities enable them to withstand the potential effects of their experiences. If they are young enough, and if they now are in the care of sensitive and responsive adults, little or no distress will occur, and no trauma is experienced. (This statement, of course, is at odds with the beliefs of a number of the therapists listed by Adoption Today, who are convinced that attachment occurs prenatally and that all adopted children have experienced traumatic separation, no matter when the adoption occurred.)

What take-home messages do we have here? One is that whether a specific event is experienced as traumatic depends on a number of factors, among which a primary one is developmental age. Attachment-related events, especially, can be traumatic during a particular age range, and if supportive caregivers are absent--  but they are less traumatic when a child receives sensitive, responsive adult care, and still less traumatic when the child is younger or older than the most vulnerable age period. A second is that worrisome child moods or behaviors are not in themselves evidence of earlier trauma, and that assuming this connection robs caregivers of tools to use in helping the child. Third, there are a number of much mistaken assumptions about the nature of therapy for either trauma or attachment-related problems.

Good therapy for children with mood or behavior problems works in the same ways whether the difficulties are caused by trauma, attachment history, genetic factors, social learning, or situational variables. Each of these factors needs to be considered as it affects the individual child. Among the social learning and situational variables, the influences of adult caregivers are especially powerful, and that means that understanding and managing adult behavior must be given high priorities.

How do parents find therapists who will do this? They need to look for practitioners whose licensure and training show them to have the needed skills, acquired in respected academic programs. Such people are not to be found by looking in the listings of Adoption Today or Psychology Today, nor do they call themselves Registered Attachment Therapists or overemphasize the importance of trauma, and I doubt that many are members of the American Psychotherapy Association. The website of a state psychological association can be helpful for concerned parents, and licensure verification can be done through state websites. But these methods are not enough, if parents have the wrong expectations about how treatment works, and if they reject the possibility that they are part of a problematic situation. Parents who genuinely want to help children need to understand that they themselves may need to change in order to achieve the outcomes they want.



Tuesday, June 17, 2014

Can Post-Partum and Post-Adoption Worry Amount to Maternal Depression?

Over the last couple of days, the New York Times has been featuring articles on maternal mental illness in the year following childbirth. A striking account of one tragic case is at www.nytimes.com/2014/06/17/health/maternal-mental-illness-can-arrive-months-after-baby.html?hpw&rref=health. In this case, a mother developed terrible fears that she had caused, or permitted by her carelessness, serious brain damage to her perfectly healthy child. She sought extensive diagnostic work for the baby, but the assurances that there was no brain damage, and that brain damage could not have occurred under the circumstances she described did nothing to change her distress or her delusions. When the baby was ten months old, she put him in a carrier and jumped with him from a height that killed her, but the child was cushioned by her body and survived.

It is only in the last ten years that real understanding of perinatal mental illness has begun to develop. (I use the term perinatal because such disorders can show up or be predictable before the baby is born, not only post-partum.) One important step has been the demonstration that screening of all new mothers can help identify those who may need treatment while their babies are young. I am happy to say that my own state, New Jersey, has screening for all new mothers, thanks to the impressive leadership of Mary Jo Codey, wife of former governor Richard Codey and herself a survivor of perinatal mental illness. Such screening is based in part on the understanding that perinatal mental illness is not a single entity, but involves a continuum of trouble that ranges from the sadness and slowing of responses we usually think of as depression, to the hallucinations and delusions that have led to suicide and murder in cases like that of the tragic Andrea Yates. Concerns about perinatal mental illness have been led to some extent by the understanding that for every child’s or mother’s death due to perinatal mental illness, there are probably hundreds in which a child’s language and cognitive development are impacted by her mother’s depression.

It has been enormously important for people to understand that poor care for babies, or even attacks on them, are not necessarily because the mothers are “bad people”, or even because poor environmental circumstances push the mothers past a breaking point. These events may be part of a mental illness that will respond to medication and psychotherapy. Blaming the mothers will not help them or their children.

The Times articles bring up two other important points. One is that it is now clear that maternal mental illness does not necessarily appear right after childbirth. An older view that tried to attribute perinatal mood disorders to hormonal changes tended to insist on an onset fairly soon after the birth. But it is now clear that there is much more to these disorders than a response to changing hormones, as is shown by emergence of the mental disturbance months after a new hormonal balance has been achieved, in some cases.

The second point is that although we think of mood disorders and depression as characterized by sadness and hopelessness, anxiety may be an important feature for some people, and in perinatal mental illness it is likely to be focused on the baby. Although every parent worries about their baby, a constant concern, with an inability to be reassured, and a sense of having harmed or being about to harm the baby, can be an indication of maternal mental illness and should be treated as such. (I am saying nothing here about fathers’ mood disorders because they have received very little study, but presumably they can exist.)

Reading about the Times case, in which the mother could not escape the delusion that she had damaged her child’s brain, made me think of some questions I receive from readers of this blog. Not all, but a few people who comment, seem to be excessively worried about the possibility that their child is autistic, and that they, the parents, may be at fault either because they caused the condition or because they are not getting treatment soon enough.

One post I wrote several years ago (http://childmyths/blogspot.com/2011/07/eye-contact-with-babies-what-when-why.html) has had thousands of reads and is almost always the post that gets most reads in any given day. Many readers have responded with questions about eye contact and autism, often in reference to babies of a few weeks old, who are far too young for anyone to diagnose autism even if they had it (which they probably don’t). Now, it is not surprising that people worry about this. First, there is a great deal of misunderstanding about what baby eye contact actually consists of, and many young parents think their baby will look steadily into their eyes for minutes at a time; young babies don’t do this, so the parents are disappointed and frightened. Second, sensational journalism has spread the idea that there is an “epidemic” of autism, rather than the actual shift in diagnostic criteria, so young parents are sure that this “epidemic” is threatening their babies, especially the boys. Third, young parents have heard about early intervention and the logical position that early treatment can prevent the development of some problems, so they naturally do not want to fail to get early treatment for any disorder. Add these to the natural tendency to worry about early development, and it’s hardly surprising that there’s so much concern.

However, I am asking myself whether severe concerns about autism, concerns that are taken from specialist to specialist without any reassurance ever being successful, can be evidence of maternal mental illness. Obviously a line has to be drawn between the typical worried state of young parents, which will resolve with ordinary support, time, and experience, and a mood disorder that becomes more and more frantic, at best creates developmental problems, and at worst culminates in tragedy. But when there seems to be no reason to be concerned about a baby, but a young mother is constantly deeply distressed, whether about brain injury or autism, would it not be a good idea for someone to ascertain whether this is really about treatable mental illness? The mother’s own primary care physician will probably not be aware of the problem; her OB/Gyn may pick it up at some point; but her pediatrician is most likely to know whether she is repeatedly asking for referrals. (The health insurer may also know this, but probably will not figure it out for many months.)  Her partner, friends, and relatives may also catch on to the fact that there is more at stake than is typical of this stage of life. And clearly the handling of this situation by anyone who is aware of it must be most delicate, because the stigma of mental illness is still such that the affected person may essentially flee in panic anyone who suggests that she needs help.

I want to make one more point about this issue, and that is to remind people that maternal mental illness may emerge not only post-partum, but post-adoption. It is perfectly reasonable for adoptive parents to think about their adopted child’s background. Were alcohol or drugs a factor in relinquishment by the biological parents? What might have been the outcomes of neglect or abuse in earlier life? The answers to these questions might sometimes help adoptive parents to know what they may expect and what they need to do, but there may be no answers. It is perhaps in response to this set of concerns that adoptive parents can become terribly worried about disorders caused by fetal exposure to alcohol, and about Reactive Attachment Disorder. Certainly they are bombarded by descriptions and explanations of these problems even when they do not ask. Unfortunately, some of these descriptions and explanations are quite inaccurate, and they convey the message that such disorders can have signs that are so subtle that only a very few diagnosticians can detect them--  or even that the children can slyly conceal their problems in order to cause trouble.

As is the case for nonadoptive parents, adoptive parents can have their natural worries ratcheted up painfully by misinformation. In addition to that problem, however, when maternal mental illness emerges following adoption, its symptoms may include the inability to believe that a child does not have an attachment disorder or suffer from drug or alcohol effects. Mothers with these mood-disorder-fueled terrors can be easy prey for charlatans, who may be unable or unwilling to consider that a mother seeking them out might be mentally ill. In addition, medical professionals, partners, friends, and relatives may be bogged down in the old belief that perinatal mood disorders are caused by hormonal change, and therefore may dismiss the possibility that an adoptive mother could have a mental disturbance related to the adoption.

Could injuries to adopted children--  including starvation, caging, and so on—be caused in part by unrecognized maternal mental illness? I emphasize the words in part, but I believe this possibility deserves serious consideration by those of us who  are concerned with the welfare of all children.
  


Friday, June 13, 2014

Having a Look at Love and Logic

A reader suggested that having written a post about the plausibility of alternative psychotherapies, I might examine the available facts about the program Love and Logic ®. The website www.loveandlogic.com is informative when looked at carefully, although other sources add much to an understanding of this program.

A quick look at materials describing Love and Logic gives the impression that the program is intended to improve parenting practices and therefore to lead to better developmental and educational outcomes for children. However, this does not seem to be exactly the case, according to the website. This describes Love and Logic as “a philosophy of raising and teaching children which allows adults to be happier, empowered, and more skilled in the interactions with children. Love allows children to grow through their mistakes. Logic allows children to live with the consequences of their choices. Love and Logic is a way of working with children that puts parents and teachers back in control, teaches children to be responsible, and prepares young people to live in the real world, with its many choices and consequences.”

I see in this paragraph two types of outcomes predicted for Love and Logic users. The first is that parents and teachers are happier and have more success in controlling children. The second is that children become responsible (without further definition of how this responsibility is displayed behaviorally) and will eventually be prepared to live in the “real world” (where have they been living up to that point, I wonder, and how does their preparation play out behaviorally now or later?). The statements about Love and about Logic are difficult to relate to specific outcomes. I am not sure how children can be prevented from growing (i.e., learning) from their mistakes, nor whether an absence of love would be considered a cause of such a notional outcome. Neither do I see how Logic lets children live with consequences or whether illogic would prevent them from doing so. Semantically, these two statements would seem to have the same meaning, or lack thereof, if we were to reverse the tasks of Love and of Logic. But let’s drop these side issues and focus on the clearly predicted outcomes: happier parents and teachers who successfully make children do what the adults want. A later paragraph on the website says that Love and Logic “products help parents and teachers enjoy working with children”, and this predicted effect on adults is described more clearly than any statements about the effects on children.

I’m trying to figure out the outcome wanted by users of Love and Logic , because I see that various other websites (e.g., www.colorado.edu/content/fsap-workshops-parenting-love-and-logic(R)-course-starts-july-18 )  refer to this approach as “research based”. (I haven’t found this on www.loveandlogic.com yet.) Research, as the term is usually used, would involve an assessment of whether the predicted outcomes resulted from use of Love and Logic. However, the expression “research based” is a vague one without a common or clear definition, and it may not be intended to communicate the same evaluation of effectiveness as “evidence-based” does.  I note that the California Clearinghouse for Evidence Based Programs (www.cebc4cw.org/program/love-and-logic/detailed) does not give a ranking for scientific evidence to Love and Logic because of the absence of research information. A critique of parent education programs done by Christina Collins (www.joe.org/joe/2012august/a8.php) ranked Love and Logic as an “additional” program, rather than as “top” or “promising”. Love and Logic is described as “innovative” but without an evidentiary foundation in a document developed by Prevent Child Abuse Iowa in 2011; the Iowa document points out that Love and Logic is not listed in SAMHSA’s National Registry of Evidence-Based Practices and Programs (NREPP).

At www.loveandlogic.com/t-research.aspx, a graph representing how parenting stress went down after parents attended a Love and Logic program also shows a reduction in child misbehavior, suggesting that this outcome is also a goal of Love and Logic and may be an operational definition of “responsibility” and “preparation for the real world”.  The same page provides a link to an unpublished article by Charles Fay, a member of the Love and Logic group along with his father Jim Fay and the holding therapy proponent Foster Cline. Fay’s 2012 paper is entitled “Effects of the Becoming a Love and Logic Parent  training program on parents’ perceptions of their children’s behavior and their own parental stress”. As the title suggests, Fay asked for responses from parents who were about to begin the training program and compared those to post-training responses for 2431 of them. There was no comparison group receiving treatment as usual or no treatment, and Fay did not report how many parents failed to complete the program, were lost to follow-up, or showed negative changes following the program. As Fay himself seemed to be aware in the discussion of this study, this evidence is at a very weak level, and there are obvious alternative explanations for the results.

In addition to these research weaknesses, an examination of the evidentiary foundation for Love and Logic requires attention to the fact that Love and Logic® is a highly commercialized, for-profit program, with the ® indicating a registered name. This situation makes it very difficult to have the valuable replication of a study by an independent researcher. That Fay, Fay, and Cline have not been eager to have independent examination of relevant evidence is shown by a copyright infringement suit  (www.plainsite.org/dockets/ic5dk1os/colorado-district-court/love-and-logic-institute-inc-et-al-v-slattengren-et-al).

Is Love and Logic a plausible program? Is it congruent with established information about child development and learning? Its basic ideas about the role of reward in learning have long been supported by clear evidence, although I am not sure why a citation of the work of Edward Thorndike in the 1920s is needed, and I am sure that a citation of John B. Watson is not relevant. There are also elements of William Glasser’s “reality therapy” as used in some schools in the ‘60s and ‘70s, and a plausible approach on the face of it but without much research support. Certainly the advice given to parents and teachers about relaxation and avoidance of anger and punishment is congruent with most established thinking about early relationships, although the suggestion that one simply repeat over and over “I love you too much to argue with you” seems questionable in terms of the transactional view of development.   Love and Logic is said to be easy to learn and to have “immediate results”; these statements appear to be at odds with the experiences of most evidence-based parenting programs that are successful in bringing about changes in parent-child interactions (Parent-Child Interaction Therapy, for instance). It is notable, of course, that specific methods of Love and Logic are available only upon purchase of proprietary books and CDs, so a complete analysis of plausibility is difficult.

It is not usually desirable to pursue an examination of this kind ad hominem, because even the most unpleasant characteristics of individuals (if they existed) would not be relevant to the plausibility or effectiveness of a treatment they advocated. However, as Love and Logic provides little to discuss ad rem, it seems appropriate to look at aspects of the website and of its founders. Once again, a high degree of commercialism is shown by the website. Testimonials and anecdotes abound, and there is no indication that Love and Logic may be inappropriate or even potentially harmful in some cases. “Parenting products” are for sale, and one may join an “Insider’s Club” (the position of the apostrophe suggests that there is only one insider).

Much of the Love and Logic website is devoted to selling training and to attracting trainers, who when they have completed their studies, can take advantage of a “facilitator map” and national referral list. Purchasing a book “gives you the ability to offer an unlimited number of parenting classes… No additional training is required.”   This statement seems to confirm what I was told several years ago by a Love and Logic trainer--  that there was no quality control after a course was taken.

What about the three founders of Love and Logic? Little is available about Jim Fay, except from his short bio on the website. He appears to have been a high school teacher. Charles Fay has a Ph.D. in psychology (possibly with a specialty in school psychology, although it is hard to tell). His dissertation had the title “Factors affecting teachers’ impressions and judgments of students: Individual differences, social-contextual factors, and underlying cognitive processes” (University of South Carolina, 1997). This title does not suggest any formal study of developmental principles or of parenting processes, although Fay may certainly have studied these topics post-doctorate.

A source of concern about Love and Logic comes from the involvement of Foster Cline. Cline’s associations with holding therapy, a physically-intrusive, potentially harmful treatment without an acceptable evidence basis, are undeniable. Cline surrendered his Colorado medical license following a 1995 letter of admonition in connection with the accidental or suicidal death of a child.  His books in the early 1990s stressed his belief that “all bonding is trauma bonding”, suggesting that the relationship between a parent and an infant is parallel to the relationship between a kidnapper and his victim who develops Stockholm syndrome. His long-term mentoring relationship with Connell Watkins, one of the therapists under whose treatment Candace Newmaker died, is well-known, as are his involvements with the defense of parents who killed their children.

Cline’s books have supported the idea that powerful adult authority is essential for the rearing of psychologically-healthy children. Like his colleague and mentor, Robert Zaslow, Cline has stressed the ideas that obedience is evidence of attachment and that adult attachment figures must be seen as powerful by children. Although Cline’s version of holding therapy had strong physical components, there seems to be no reason to think that physical coercion is a part of Love and Logic, which concentrates instead on psychological control. Whether children who “fail” in Love and Logic are then recommended for holding therapy is an unanswered question, but this suggestion was made to me by an individual who had received Love and Logic training.

In the past, Cline was willing to state that holding therapy was not abusive. He was one of several holding therapy-oriented expert witnesses in an investigation of an Arizona man who taught a mother to use unsupervised holding with her daughter (www.azbbhe.us/pdfs/BoardOrder/1994-0002.pdf). Cline’s position has been countered by a multitude of arguments, including the report of a task force of the American Professional Society on Abuse of Children and of Division 37 of the American Psychological Association. Given this history, it is perhaps not surprising that he presses Love and Logic without any evidence that it is an effective treatment, either for parent education or for working with mild childhood behavior problems.

If there are all these problems related to the effectiveness of Love and Logic, why do school systems purchase its training for their teachers? There are some simple answers, I think. One is that K-12 educators are rarely skilled at assessing the evidence for a treatment. Instead, as a group, they tend to be “faddy” and to clutch at attractive proposals, especially if they do not involve much cognitive effort. (Does anyone remember “Paddlin’ Madeline home” T-shirts for teachers?) In addition, Love and Logic is beautifully marketed, with repeated claims of “easy to learn” and “instant results”. The Love and Logic website even suggests ways to create enthusiasm for its trainings--  administrators are not to offer training to all teachers, but to make the opportunity a reward for some.

Conclusion: Love and Logic is a business like any other. Caveat emptor.





Wednesday, June 11, 2014

Plausibility, Persuasion, Propaganda, and Reactive Attachment Disorder

In my forthcoming book, Alternative Psychotherapies, I’ve discussed how an alternative psychotherapy can be identified by examining its support by empirical research and its plausibility--  the extent to which it is in agreement with established information. Mental health professionals should be able to carry out this kind of examination, but it’s often difficult even for them because they may not have access to research publications, or time to carry out a detailed comparison of a treatment’s assumptions to accepted facts about human beings. It can be even more challenging to try to chase down the historical backgrounds of treatments and to understand their plausibility in that way. (I’ve done this with respect to the so-called “attachment cycle” on another blog: http://thestudyofnonsense.blogspot.com/2012/08/parsing-attachment-cycle-fox-terrier-of.html.)

If it’s hard for mental health professionals to do these tasks, there’s no doubt that it’s even harder for the interested reader whose training is in a different area. Nevertheless, I think it’s possible to use critical thinking to understand when someone is trying to use techniques of persuasion that don’t stand up to close examination. By doing this, we can identify alternative views of psychological phenomena—views that are at odds with what evidence supports. If people have research evidence to support their claims, they almost invariably present it. When they can present no evidence, but use other persuasive methods, we can usually tell this by examining what they say.

There have been some excellent expositions of ways in which scientific thought is different from the pseudoscientific approach characteristic of alternative psychotherapies. Elaine Gambrill, in her book Critical thinking in clinical practice: Improving the quality of judgments and decisions, has provided an almost encyclopedic compilation of comments on this issue, and much of my commentary here will be drawn from her material.

We need an example to use, and although I’m tempted to go at the Primal Wound again, I think  alternative ideas about Reactive Attachment Disorder may be a better instance. Here’s a goodie: www.attachmentexperts.com/whatisattachment.html. This is the site of the Evergreen Psychotherapy Center, interestingly named for the town that was the focus of Attachment Therapy and the location of the death in therapy of Candace Newmaker in 2000.

A common persuasive device is the appeal to authority, and the attachmentexperts  site puts this right to work on the About Us page. There, two Evergreen staff members, Michael Orlans and Terry Levy, are said to be Master Therapists of the American Psychotherapy Association. And no doubt they are; some readers will remember how the pussycat Zoe D. Katze received her Diplomate from this group (check her out on Wikipedia if you haven’t heard about this). In addition to this claim of authority, the website notes that the Evergreen Psychotherapy Center is the only agency in Colorado to be registered with ATTACh (Association for Treatment and Training of Attachment in Children), a parent-professional organization that is in no way associated with licensure or accreditation of treatment facilities. This claim appears to enhance the authority of attachmentexperts, but upon examination under a strong light it is exposed as irrelevant.

The appeal to authority here does not survive even the simplest glance into the claimed sources of authority. Any literate adult could easily find this out. Having found it out, a reader should proceed with eyes wide open, because attachmentexperts has already demonstrated an attempt to persuade without presentation of evidence.

Let’s go on to another example of an attempt to persuade readers to accept a viewpoint that is not supported by evidence. Under the heading “What is attachment disorder?”, attachmentexperts  repeats an argument that has been around since the early days of Attachment Therapy. Here’s what they say: “Research has shown that up to 80% of high risk families… create severe attachment disorders in their children. Since there are one million substantiated cases of serious abuse and neglect in the U.S. each year, the statistics indicate that there are 800,000 children with severe attachment disorder coming to the attention of the child welfare system each year.” What have we here except a common persuasion strategy designed to bypass a reader’s logical examination? “Up to 80%” is not the same as “80%”, as we have all discovered when optimistically going to a sale with “up to 80%” price reductions. Attachmentexperts has committed the fallacy of composition, in which it is assumed that what is true about a part of something is also true about the whole. By referring to what “statistics” say, this paragraph again appeals to authority. Finally, by invoking fear of a disturbing situation, the paragraph tries to distract the reader from the obvious question: if these claims are true, and severe disturbances associated with violence and aggression (see “Attachment disorder: Traits and symptoms”) have been occurring at this rate for, say, 20 years, there should be 16 million such persons in the United States, out of a population of 300 million. In 2010, there were 2, 270, 100 people incarcerated in the U.S., less than half of whom had committed violent crimes. Where do attchmentexperts think the other 14 million people are? (Do I dare to walk out my front door?) If they are violent and aggressive, why have they not been caught and imprisoned for their crimes?  

Let’s look at one other way in which attachmentexperts attempt to persuade the unwary reader. If you look at the site, you will notice that the term “Reactive Attachment Disorder” is not used; instead, the reference is to “Attachment Disorder”. This is done in spite of the fact that books on the site’s suggested list in many cases reference Reactive Attachment Disorder. The attachmentexperts site depends on the resemblance between these two terms to work a little reification and word magic. With one hand, the site’s authors have pointed out the importance of established information about attachment and about Reactive Attachment Disorder, while with the other hand they wag their index fingers and say “that’s not what we’re talking about at all”. Providing a term, Attachment Disorder, that resembles the conventional term Reactive Attachment Disorder, enables attachmentexperts and their supporters to reify their concept--  to claim that since the words exist, such a disorder must also be. (This has come up repeatedly on this blog as readers have argued ferociously that the problems their children have must be Reactive Attachment Disorder, even though they overlap in no particular with that disorder as conventionally defined.)

I’m not claiming that everybody wants to spend their vacation dissecting the persuasive techniques used to support alternative psychotherapies. I’m just saying that even if you don’t have research design and statistics at your fingertips, or if you forgot everything Piaget ever wrote, you can still identify enough ill-omened attempts to persuade you and can figure out when there’s an attempt to pull the wool over your eyes. When you see a few of these attempts, you can be wary about any other communications from the same people. Critical thinking is the way to defend ourselves from those who want to persuade us against our own best interests, whether the persuaders are politicians or psychotherapists.  


Tuesday, June 3, 2014

Bessel van der Kolk is an Old-Fashioned Guy

The Sunday New York Times Magazine ran a worshipful story a few weeks ago about Bessel van der Kolk and his beliefs about the treatment of post-traumatic disorders (www.nytimes.com/2014/05/25/magazine/a-revolutionary-approach-to-treating-ptsd.html?r=0). The article stressed van der Kolk’s claims about the role of physical contact, tapping, massage, movement, and dance in lessening the impact of traumatic experiences. I know a lot of infuriated people have already responded to this story, and I’m trailing along in the rear--  but I do have a few things to say.

Van der Kolk’s views were described as “revolutionary” in the article, but in fact they go back at least 150 years. Jean Strouse, in her biography of Alice James (sister of Henry and William), tells of the use of massage for Alice’s depression and mental turmoil in the 1870s. Van der Kolk’s claims are very little different from those made off and on in the intervening years, and are no better substantiated by empirical evidence than the earlier ones.

I’m going to give a brief summary of van der Kolk’s unsung predecessors.

  1. Chiropractic treatment (sorry, I can’t bring myself to noun this adjective as its practitioners do):
From the 1920s until about 1960, there were chiropractic mental hospitals where spinal adjustments were used to treat mental illness. One Dr. Quigley reported that it was ”a deeply rewarding experience to watch an extremely agitated delusional patient  respond to chiropractic adjustments … well enough to go home in a month to six weeks.” The adjustments were considered to remove blockages in the Innate or Life-Force and to allow the vis mediatrix naturae  to circulate and heal the patient’s problems.
  1. Georg Groddeck:
Groddeck (1866-1934) was a considerable influence on Sigmund Freud, and an even stronger influence on Sandor Ferenczi and other “wild psychoanalysts” (Freud’s term for them). Groddeck published Das Buch vom Es (The Book of the It) in 1923. (The Book of the It was re-issued in 1947 with a forward by the novelist Lawrence Durrell.) Groddeck’s view was that both mind and body are “lived by” a life-force he called “It”, which existed before an individual brain and even caused that brain to be created. Groddeck attributed accidents and illness to patients’ beliefs and wishes, and considered early deaths to be forms of suicide. He illustrated this belief system with various anecdotes, including his treatment of a pregnant woman approaching full term with the baby presenting in the breech position; Groddeck explained to her how childbirth was very pleasant, even sexually gratifying, and lo and behold the baby turned head-down. Groddeck presented a paper on massage at a conference and considered physical treatment to be a major factor in managing mental illness. He also discussed recovery from untreatable illness following a “talking cure”.
  1. Wilhelm Reich:
Reich (1897-1957) is best known for his invention of the “orgone box”, a device that was supposed to collect life-energy and use it to treat cancer and other diseases, and for his death in prison after he was convicted of fraud for continuing to sell the boxes. However, his place in the intellectual ancestry of Bessel van der Kolk has more to do with his belief in “character armor”, muscle tension caused by early traumatic events,  that interfered with genuine human emotion and made sufferers unable to have real relationships, sorrows, or pleasures. Character armor was treated by prodding and poking the patient under the arms while forcing eye contact; patients had to be naked or nearly so, to allow the practitioner to detect areas of muscle tension. (If this seems to you unlikely to be convincing to anyone, let me point out that it was described in a textbook I used in college [White, The abnormal personality]). Reich considered the effects of trauma to be stored through muscle tension in specific body parts, and to be removed when the tension relaxed. Incidentally, Reich claimed to have “cured” his infant son of the Moro reflex in about the same amount of time it normally takes for this reflex of newborns to disappear.
  1. Gurdjieff, Steiner, Chestnut Lodge:
I’ll put together several related phenomena that all have connections to van der Kolk’s beliefs. The first was the invention of dance rituals that were supposed to give spiritual benefit by G.I.Gurdjieff (1855-1949), a Russian mystic and guru who had a philosophical institute near Paris. Gurdjieff passed on these dance rituals to Mme. Ouspensky, a former member with her husband of the Theosophical Society, who took them to England. Another former Theosophist, Rudolf Steiner (1861-1925), founder of the Waldorf Schools, was at about the same time developing his practice of Eurhythmy, a dance form that represented speech sounds and that was supposed to be the work of one’s “etheric body”.  In the 1930s and ‘40s, Frieda Fromm-Reichmann (lightly fictionalized as a central character of I never promised you a rose garden), working at the Chestnut Lodge mental health foundation in Maryland, invited two dance therapists to work with patients, in the belief that spontaneous movement conveys meaning that can be interpreted or responded to with other movements for therapeutic purposes.

  1. Alice Miller:
I don’t really want to get into Alice Miller as background to van der Kolk, but does the title The body never lies suggest anything?

So, I think you will see what I mean. There is nothing revolutionary about van der Kolk’s methods--  on the contrary, they are quite old-fashioned. Far from getting credit for being new and innovative and not having had time to develop an evidentiary foundation, they have been around for years and years without developing one. This just might be because they are not effective, much as was the case with the Recovered Memory Therapy he once supported. Instead, they seem to be results of what Freud called the furor sanandi—the frenzy for healing.

{Incidentally, thinking about evidence, I note in the Times article that there has been some objection to the statement that some techniques were not scientifically investigated.  The page has added a statement that the evaluations for those techniques were done by “blinded” evaluators. That’s great, but there are quite a few other criteria that such studies would need to meet—including  randomization to treatment groups, intervention fidelity, and certainly a big issue: what happens to the comparison group?}