Friday, May 15, 2015
That Reber Paper, Its History and Consequences
Periodically other people and I refer to an article purporting to discuss Reactive Attachment Disorder, published by Keith A. Reber in 1996 in a journal called Progress. This paper was cited as a foundation of the attachment therapy belief system by Chaffin et al in the 2006 APSAC task force report on attachment therapy and attachment disorders, a report that rejected the use of holding therapy and related methods. Reber’s paper used to be readily available on line, but is no longer easily to be found, and although I have it I can’t post it without exposing myself to complaints about copyright violation. However, I can write about the paper and about its author and his sources.
Let’s start by considering who Keith Reber is and what his professional history has been. He was at one time a marriage and family therapist and was associated in some way with the Phillips Graduate Institute in California (this institute was the publisher of Progress). From 1999 to 2001, Reber was a licensed MFT in Oregon, and in 2001 he was served with a notice of proposed revocation by the Board of Licensed Professional Counselors and Therapists for that state. In 2003, his license was revoked. The explanation for this decision can be seen at www.oregon.gov/oblpct/BoardAction/Reber.pdf.
According to the Board’s statement, Reber had agreed not to use holding therapy (HT) with children referred to him by a state agency, but did indeed use HT with three children who were temporarily placed with foster or potential adoptive parents. To place this action in historical context, I should point out what is not mentioned in the license revocation material: Candace Newmaker had died at the hands of HT practitioners in 2000, and this fact was widely known and of considerable concern, but Reber continued to use this dangerous and unsubstantiated approach despite state agency warnings and his own agreement not to use HT. Reber’s methods, according to the Board statement, were not the “nurturing, cradling hold” often mentioned in more recent times, but included wrapping the child tightly in a sheet, lying on top of the child, and thrusting his fist up into the child’s rib cage. These techniques were used with a child who had been sexually abused as well as with others.
To quote the Board report directly: “Licensee treated SM and VM (from approximately 1999 through 2000) and used holding therapy including wrapping them in a sheet and blanket, laying (sic) with his body on top of the children, pushing his elbow into their abdomen and/or stomach area so hard at times causing vomiting, and occasionally required the children to try to gain freedom from the blanket wrapping themselves, despite the fact that they were wrapped tightly”. [Candace Newmaker died from suffocation while trying to escape from such a wrap.—JM] In addition, Reber refused to release the children or stop the treatment when asked, but instead berated them.
The Board was also concerned that during its disciplinary proceedings, Reber, who had been given notice of a proposed license revocation, had applied for a MFT license in Utah and represented the license matter in Oregon as having been resolved, when it was not. (A curious bit of HT history intrudes here: Reber’s file was reviewed by David Ziegler, who stated that HT was not acceptable-- at almost the same time that he himself was publishing a paper that cited a number of European practitioners who were and still are strong supporters of HT! But-- am I just revealing that I have one of those small minds for which consistency is a bugaboo?)
So what happened next? The next part of Reber’s story is told at www.deseretnews.com/article/1001664/Orem-therapist-lost-license-over-controversial-methods.html?pg=all. Leaving the unappreciative state of Oregon, he went to Idaho and got a job as a counselor at a clinic associated with a child’s death through forced water drinking. Without his MFT license, Reber had claimed pastoral licensing through the Universal Life Church. Presently, it appears that Reber is licensed in Utah as a hearing aid specialist.
There we have a history of weak or nonexistent professional ethical standards—a background for the Reber 1996 paper itself. I will select some intriguing bits from that document.
Reber starts early in the paper to show that his assumptions are not those of conventional attachment theory, in spite of his attempts to use conventional terms and concepts. He cites Verney and Kelly, two APPPAH stalwarts, to the effect that “attachment begins with connectedness in utero”, starting before birth “on a neurological and emotional level”. He states that without critical interactions with the mother, the baby may “lose interest in the world, become ‘insecure’ or ‘anxiously attached’, or even die.” Even omitting the mistaken claim of prenatal attachment, we see here a peculiar list of problems. Insecure or anxious attachment, while not ideal, is well within the normal range and probably was the condition in early childhood of a large number of the people reading this. Losing interest in the world is a far more serious problem, but even maltreated children with disorganized attachment patterns do not show this. As for death—yes, emotionally-neglected children may die, but the causes of these deaths are much more complex than Reber implies. On the second page, we see the interesting statement that attachments “fall on a continuum between secure and insecure, with the normal child falling somewhere in the middle”. This seems to suggest that insecure attachment is really all right, even though it was ranked earlier along with apathy and with death.
But let’s abandon this entertaining journey through Reber’s ideas about attachment and move on to the specific misunderstandings this paper introduced into discussions of Reactive Attachment Disorder. After saying correctly that RAD is difficult to diagnose, Reber provides on his fourth page a table giving symptoms of RAD as collected from the files of the Family Attachment Center in Salt Lake City, Utah. Here we see the first claims in a supposedly peer-reviewed publication of the RAD characteristics that now turn up in newspaper articles. These include superficial engagement and charm, refusal to make eye contact, incessant chatter, fighting for control, indiscriminately affection with strangers but not cuddly with parents, destructiveness, cruelty to children and animals, stealing, lying, hoarding and gorging on food, preoccupation with fire, blood, or gore [I’ve always wondered what the difference may be between blood and gore—JM], lack of cause and effect thinking, lack of conscience, and abnormal speech patterns.
No doubt many children seen at the Family Attachment Center did have one or more of these characteristics. But where is the evidence that they had Reactive Attachment Disorder, alone or in addition to some other diagnosis? Answer comes there none, it would appear. Reber’s paper provides no reason to think that any of the concerning symptoms were in fact indications of RAD. In fact, other authors associated with this belief system, like Elizabeth Randolph, have specifically said that these symptoms do not indicate RAD, but instead a posited “Attachment Disorder” which is different. Not only does this symptom list have no part in descriptions of RAD in DSM-IV, DSM-IV-Tr, or DSM-5—even other proponents of HT did not accept Reber’s association of the list with RAD. But this has not stopped the constant repetition of claims about RAD symptoms, right up to the present day. As an example, I can point to the 2014 doctoral dissertation by Vasquez which I discussed earlier this month, a document that includes items from Reber’s list, and which gives a muddled in-text citation of Reber’s paper.
Where did Reber get his ideas? His table of information from an unpublished sources is one we can’t check on, but a look at his reference section tells a good deal. Here we see some errors suggesting that Reber is not on top of his material: the name of the psychoanalytic theorist Erik Erikson is spelled Erickson, suggesting that Reber has him confused with Milton Erickson, who advised sitting on recalcitrant children and feeding them cold oatmeal; even that ur-holding-therapist Robert Zaslow has his name misspelled. Other sources are Foster Cline, Rick Delaney (who needs discussion in himself, as he has “gone straight” but never really explained why), Jirina Prekopova, and Martha Welch-- all proponents of the most rigorous physical restraint techniques like those that got Reber’s license revoked. Finally, Reber quotes Robert Karen, the 1990s popularizer of attachment theory, and attributes to Karen the statement that in New York City there are one million children with Reactive Attachment Disorder-- this out of a population of 6 million!
Ordinarily, it might not seem very important to go over the mistaken statements of an obscure writer from 20 years ago, especially as his publication does not seem to be available on line any longer. However, the fact that Reber’s claims have been spread as factual through Internet and print journalism, and have been immortalized as checklists for diagnosis of attachment disorders, makes it necessary to trace those claims to their highly unreliable source. Even though, by a sort of psychological Gresham’s law, bad information remains likely to drive out good, it may be that a better understanding of background may help fight the misunderstandings that have spread and continue to spread.