Concerned About Unconventional Mental Health Interventions?

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

Saturday, November 22, 2014

Children, Faith-healing, and Religious Exemptions

Do your state laws protect parents who allow their children to die without medical care because of their religious beliefs? Until recently I was not sure how this question should be answered for my own state--  and just as a reminder for readers  outside the U.S., the 50 states have differing laws on many topics, so knowing one state’s position does not tell you what happens in other states.

Ordinarily, a failure to provide medical care for a child when it is desperately needed would be considered a criminal matter of neglect and abuse. Civil suits against the parents might also be a possibility. But some states provide religious exemptions to parents who cite religious beliefs such as commitment to the power of prayer as justification for a failure to seek medical care for a child. As far as these parents are concerned, prayer or similar activities are the treatment they should give, and in fact to do otherwise indicates the weakness of their faith in God and endangers their souls and those of their children.

I’m indebted for information about this to CHILD, Inc. (www.childrenshealthcare.org), and to a map displaying the legal positions of the states at www.vocativ.com/culture/religion/faith-healing-deaths/?page=all . (This map is based on data drawn from childrenshealthcare.org.)
You can probably look at the map graphic yourself, but I am going to describe the similar positions taken by groups of states. By the way, as you will see, this does not play out geographically exactly as one might guess.

Let me point out first that six states allow no religious exemptions to either criminal or civil charges involving abuse and neglect. These forward-thinking states are the following: Hawaii, Oregon, Nebraska, North Carolina, Maryland, and Massachusetts. (Boo, New Jersey! I had expected better of you!)

Twelve states allow no criminal exemptions, but they do allow religious exemptions in the case of civil suits resulting from neglect or abuse of children. Exemptions in civil suits may discourage child protective services from pursuing a case at the civil level, which requires a less stringent proof than criminal cases do. The states that allow these religious exemptions to civil suits are these: New Mexico, Arizona, Montana, Wyoming, North Dakota, Michigan, Illinois, Kentucky, Pennsylvania, Connecticut, Vermont, and Florida. Parents who fail to provide medical care to very sick children for religious reasons are liable for criminal prosecution, which has a high standard of proof, but not for civil actions, with their lower standard.

Fourteen states allow religious exemptions only in criminal cases involving misdemeanors like a non-felony level of child endangerment, not in cases of murder or manslaughter. These states are: California, Nevada, Colorado, South Dakota, Kansas, Missouri, Mississippi, Alabama, Georgia, South Carolina, New York, New Hampshire, and Maine.  In those states, there are no religious exemptions for civil suits related to incidents of neglect or abuse.

Nine states allow religious exemptions to prosecution for felony crimes against children, in which sexual assaults are included, as are child endangerment and neglect. These states are: Washington, Utah, Texas, Oklahoma, Minnesota, Wisconsin, Illinois, Tennessee, West Virginia, New Jersey, and Rhode Island.
Finally, almost unbelievably, there are six states that allow religious exemptions to prosecution for negligent homicide, manslaughter, and even capital murder. These are: Idaho, Iowa, Arkansas, Louisiana, Ohio, and Indiana.

The reasons for the broad religious exemptions in this last group of states presumably have to do with the proportion of their populations who want to choose faith-healing over standard medical care, probably for themselves, but most relevantly for their children. The most obvious community for these people to belong to is Christian Science, but there are a wide variety of other faith-healing-oriented groups like Followers of Christ or Church of the First Born. Charismatic churches in general are committed to the principle that once “born again”, Christians can have access to the gifts of the Holy Spirit, including discernment (diagnosis) and exorcism or deliverance (expulsion of the demons responsible for both physical and mental illness). Like other people, these groups of believers are attracted to areas where there are many of their co-religionists, and as they increase in number move into a position where they can influence state laws. In addition, of course, once laws have created religious exemptions for child abuse and neglect, even more such believers will arrive. This process helps to establish the polarization responsible for the current “culture wars” in the U.S.

One more point: this blog usually focuses on issues that have to do with child development from a psychological viewpoint. Do religious exemptions to abuse and neglect charges play a role in those issues? I think they probably do, although child deaths are much less likely even in alternative psychotherapies than they are in cases of medical need. However, injuries short of fatality may still be considered abusive. Religious views seem implicated in the apparent use of Attachment Therapy at the Seventh Day Adventist school, Miracle Meadows, in West Virginia (see above, by the way). There is considerable overlap between the authoritarian views held by some religious groups and those held by practitioners of Attachment Therapy. If practitioners or parents claim that religious beliefs are the justification of child mistreatment as a psychotherapeutic or educational method , there are a number of states in which this reasoning will help them evade prosecution.

There was little discussion of these issues during the successful efforts to ban “conversion therapy” in California and New Jersey. This may have been because only mental health professionals are prohibited from doing this treatment, and then the ban involves minor clients only. Parents and clergypersons can go ahead and use “conversion therapy” if they want to--- but perhaps one day an affected minor will grow up able to prove that he or she was harmed, and we will see whether courts accept the religious exemption then.  



   

Friday, November 7, 2014

That Reber Paper, Attachment Therapy, and Darkening Counsel

Everybody is busy nowadays, and even mental health professionals who should know better sometimes skimp on careful reading of articles that they later quote or reference. Occasionally they make other hurried mistakes like drawing a bibliography from an article without carefully examining the papers that are included. There are worse things to do, you say? Yes, that is surely true – but unfortunately these careless practices can bring misinformation into the mainstream and encourage beliefs and actions that are indeed worse.

A case in point: an article from the 1990s that conveys dozens of erroneous statements about attachment, attachment disorders, and Attachment Therapy has been cited repeatedly, by authors and editors whose positions give them great influence. The article in question is by Keith Reber (1996), “Children at risk for reactive attachment disorder: Assessment, diagnosis,and treatment.” Progress: Family Systems Research and Therapy, 5, 83-98. (Progress was and perhaps still is a publication of the Phillips Graduate Institute in Encino, CA, one of the freestanding mental health training organizations, unaccredited outside the state,  that appeared in California in the 1970s.) Reber’s paper has been cited many times, and has even formed part of the training of lawyers who will serve as guardians as litem for children; a paper on mental health needs of dependent children references Reber (http://guardianadlitem.org/Practice_Manual_files/PDFs/Ch17_MENTAL_HEALTH_NEEDS_OF_DEPENDENT_CHILDREN.pdf).

Yet, almost everything Keith Reber said in that 1996 paper is wrong, and not just wrong, but wrong in ways that are potentially harmful to children and families. So what did he say? I’m going to quote and comment on a number of points, but I have to say that this paper, once easily found on the Internet, is now not to be found there. I have a copy and will forward it to readers who give me an e-mail address.

To begin at the beginning, Reber believed that the emotional attachment of a child to a parent begins before birth as a “connectedness in utero…Attachment begins before birth on a neurological and emotional level. “ In addition to the effects of neurochemicals and hormones on the child, Reber stated that the mother’s attitudes before birth affect the child’s attachment.( It is difficult to quote only a small part of these remarks without losing the effect of the logical jumps of the original, but Reber in a single sentence linked the claims of Verney that unborn children are conscious and aware with the statement of Fahlberg that attachment influences the sense of self. ) However, these statements by Reber are without empirical support in spite of the numerous unrelated citations he provides, and in fact all the evidence tells us that attachment—as discussed and defined by Bowlby and many others--  does not occur  until some months after birth, and develops as a result of social interactions. To assume that Reber’s statements were correct is to open the door to a host of unjustified fears on the part of adoptive families, and to suggest to them that harmful treatments like Attachment Therapy are necessary for them.

Naming some frequent forms of social interaction between parents and babies, Reber stated that when these are absent, infants “can lose interest in the world, become ‘insecure’ or ‘anxiously attached’, or even die”.  No doubt there is a little truth to this last claim, because social interactions so often occur in the context of daily care routines, and where there are few social interactions, the chances are that daily care activities are missing too. It’s also likely that in the absence of normal social interactions, infants may fail to engage with either people or objects. But how do these serious consequences parallel insecure or anxious attachment? Although these qualities of attachment are not ideal, they are nevertheless well within the normal range and are not related either to a disengaged, autistic style, or to unexplained death. Reber appears to have been determined to attribute all unwanted outcomes to attachment problems.

Now, I need to quote an entire paragraph from Reber’s paper (but I will omit citations to save space): “After birth there are several specific child behaviors and maternal responses that need to take place in order for the child to develop normal attachment… The child behaviors include crying, smiling, clinging, rooting, postural adjustment, and vocalization, and are exhibited by children a few days after birth… They are goal-oriented… and are the child’s way of making contact and encouraging the caregiver to respond to him. When a caregiver meets the expressed needs of a child, the child begins to experience trust. This process is often called the Trust Cycle. There is some disagreement, however, about whether or not these behaviors need to take place immediately after birth…”

Let’s examine the statements in this paragraph. First, Reber seems to have had some uncertainty about whether some necessary child behaviors occur a few days after birth, or whether they need to take place immediately after birth in order for attachment to occur. The basic problem here seems to be that Reber was not sure whether he was talking about bonding, the adult’s intense positive response to the baby (at one time erroneously thought to occur only within a brief sensitive period following birth), or about attachment, the baby’s gradually developing desire to maintain proximity to the familiar caregiver. The child behaviors described are certainly attractive to caregivers, and the caregiver’s responses both demonstrate adult bonding to the child and help to facilitate the gradual development of the child’s attachment to the adult. However, Reber was so concerned with early behavior that he barely mentioned the adult social responses that do indeed support the child’s attachment to a familiar person and which need to continue over many months before attachment is apparent. Instead, he seems to have attributed attachment (or trust--  which he seems to have thought to be the same thing) to gratification of needs, as in the old Freudian “cupboard love” principle. As for the proposed process “often” being called the Trust Cycle, I suggest that readers Google this term and let me know if they can find a single use of either Trust Cycle or Attachment Cycle outside the writings of Attachment Therapy proponents. (In fact, you will see that the great majority of references to this involve the National Trust and cycle paths.)

Reber continued his discussion with the statement that “Attachments run along a continuum between securely attached and unattached, with the normal child falling somewhere in the middle” ( as statement he references to the AT proponents Magid and McKelvey). Now, interestingly enough, there is an ongoing discussion among students  of attachment as to whether attachment behaviors can in fact be ranked on a continuum, and whether we might fruitfully regard secure attachment as “more of something” than insecure attachment of various kinds. However, most writers who discuss attachment assume that there is no continuum, but rather several attachment patterns that are qualitatively different from each other. This was the view taken by Mary Ainsworth in her studies during the 1970s, but she and more recent researchers have not usually considered either an “unattached” pattern or the “disorganized” pattern described by Mary Main and others. The three basic attachment patterns were all considered to be  aspects of typical development. In any case, Reber’s reference to a continuum from secure to unattached  with the normal child in the middle would seem to assign the “normal child” to an anxious or insecure position, which Reber earlier classed as a risk with disengagement and even death.

Are any readers still with me? This is a very trying task, isn’t it? But I’m afraid it’s all too much worth doing because of the role Reber’s paper has played in providing misinformation and obfuscation to people who want a quick read on attachment and Reactive Attachment Disorder. Still, I will just mention two other points about the paper.

Let me take one sentence from a paragraph on the third page of Reber’s paper. He says, “The tie in between abuse and attachment disorder is supported by the work of Cicchetti and Barnett (1991) who classify eighty percent of maltreated infants as having insecure/ambivalent attachment.” But---  one moment, please. How did we get from attachment disorder to insecure/ambivalent attachment? Insecure attachment is not ideal, but is one of the normal patterns of attachment originally described by Mary Ainsworth in her studies of normal populations. It is not an attachment disorder, and certainly not Reactive Attachment Disorder as defined by any version of DSM. Reber has conflated a normal attachment pattern with a psychiatric disorder and has thus provided a source for confused thinking about attachment issues, a source that will continue to function until mental health professionals have learned to dismiss his paper as worse than useless.

Now, a final point about the paper, before I go on to report some facts about its author. In spite of just having provided the then-current DSM description of Reactive Attachment Disorder, Reber gave a table that is supposed to guide diagnosis of RAD on completely different grounds than those referenced in DSM. Anyone who has read the writings of Attachment Therapy advocates will recognize the symptoms that Reber wants to have diagnosed as RAD. These include all the usual: superficially engaging, no eye contact, fights for control over everything, affectionate with strangers but not parents, cruel, hoards food,  fascinated with blood and gore, lacks cause and effect thinking, has abnormal speech patterns, etc.,etc. The actual sources of these items are probably to be found in a psychopathy scale created decades ago by Hare, but Reber attributes them to the files of the Family Attachment Center in Salt Lake City. But this is as far as his attribution goes. He does not deal with the obvious unanswered questions: how many children were seen at this center in total? How were the claimed symptoms assessed? What proportion of children had each symptom? And, rather importantly, what information was used to connect any of the symptoms to any attachment behavior or attachment history? In the absence of answers to these questions, it seems most likely that these claims were created more or less out of the whole cloth--  yet poorly trained mental health professionals and many journalists have happily accepted them, and like Reber have seen them as justification for the use of Holding Therapy..

Does Keith Reber still make the same claims? Who was or is he, anyway? As far as I know, he has never published another paper, but he seems to have kept the same belief system. Trained as a marriage and family therapist, he probably received little instruction on the actual development of attachment, but instead was easily convinced by the AT proponents he quotes in his paper. His continued use of Holding Therapy caused his professional license to be revoked in Oregon  (www.oregon.gov/oblpct/BoardAction/Reber.pdf). In 2003, the Utah Division of Professional Licensing asked a state judge to order Reber to cease practicing at a clinic that had been associated with the death of a child (www.deseretnews.com/article/1001664/Orem-therapist-lost-license-over-controversial-methods.html?pg=all). He would now seem to be a hearing aid salesman in Provo, UT.

Whether because of carelessness or genuine misunderstanding, Reber’s 1996 paper—which might have been expected never to be read--  has had an extraordinary  and highly negative impact on public understanding of Reactive Attachment Disorder. When I see this paper in any list of references, I immediately question whether the author of the citing material has any real knowledge of the subject. Sometimes people have apologized to me about citing Reber and have confessed that they simply copied someone else’s reference list. Others presumably actually believe Reber’s claims.

Parents, journalists, and mental health professionals, I ask you to recognize the Reber paper for what it is and to stop using it as a source. For the sake of children and families, let that publication die a well-deserved death and proceed to the obscurity that should have been its original fate!