Concerned About Unconventional Mental Health Interventions?

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

Wednesday, August 19, 2015

Craig Childress Tries to Drag Attachment Theory Into the Parental Alienation Swamp

It was only a few weeks ago that I first encountered the name of the California psychologist Craig Childress. The context was a discussion with advocates of the concept of parental alienation (PA to its familiars). If you have not yet encountered PA, you have been lucky so far, but that luck is about to run out if you keep reading. There may be such a thing as PA—no doubt there sometimes is—but it is embedded in a morass.
PA is a designation for the events and results that may occur in a divorce if one parent influences a child to reject the other. The rejection is evidenced by the child’s willingness to remain in the care of one parent but fear of and reluctance to be with the other. If the first of these people is seen to be persuading the child to fear and avoid the other parent, the former is sometimes described as the alienating parent, and the latter as the alienated parent (although this last is rather confusing because it is the child who feels alienated from the rejected parent, not the parent himself or herself). My own preference would be to call the people the accepted parent and the rejected parent, respectively.

 Some students of PA, especially, it seems, those connected with fathers’ rights groups, propose that a child cannot develop in a mentally healthy fashion without relationships with both parents, and that therefore the alienation must be resolved for the child’s own sake. As a result of this assumption, they define situations of PA as child abuse, unless there are rational motives for the child’s rejection, for example that the rejected parent has been frightening or abusive in the past. If PA is abusive, the accepted parent is an abuser, and needs to have his or her behavior corrected; the rejected parent is a victim, and needs the relationship with the child restored in order to facilitate the child’s emotional development. When courts are in the picture, of course, the treatment of the accepted and rejected parents can include the threat or reality of custody or visitation changes as means to stop PA, or court-ordered therapies designed to correct the situation and foster good relations between the child and the parent(s) who cooperate in the process.

Advocates of PA have argued that there is a definable parental alienation syndrome (PAS) that should have been included in DSM-5. The DSM-5 group rejected this proposal on the grounds that there is no evidence that PAS exists in some way that makes it separate from other diagnoses in the manual. Similarly, there is at this time no support for the idea that any treatment used for PA is an evidence-based treatment. (This is why I refer to all this stuff as the parental alienation swamp.)

Now, here’s where we get to Craig Childress. Childress, a licensed clinical psychologist in California with a Psy.D. degree, and a faculty member at California Southern University, a distance-learning, on line outfit, has attacked others’ claims to treat PA and has presented his own claim that he knows 1) what causes PA behavior by accepted parents, and 2) how to treat the child’s rejection of one parent. He has published a book with a “boutique” publisher, Oaksong Press, about how this all works, and maintains an elaborate Facebook page and web site to argue for his views.  There he comments on the “abject ignorance” of his opponents, a statement no doubt entertaining to some of the FB audience, but certainly not professional discourse. (Childress’ on line CV appears to show no activity between 1985 and 1998, raising more than one question about his professional history.)

Let’s have a look at Childress’ claims about the sources of PA behavior by the accepted parent and the impact it has on a child. Childress attributes a parent’s persuasion of a child to reject the other parent to re-enactment of the accepted parent’s own traumatic attachment history.  Where such a history exists, he proposes, the affected parent develops a narcissistic/borderline personality, with a tendency to “split” the world into all-good and all-bad components. Childress chooses two aspects of a problematic development of attachment as critical here: the early existence of disorganized attachment, and relationships that involve role reversals, so that, e.g., child cares for mother. These characteristics, according to Childress, make the accepted parent a “pathogenic parent”.  This is an interesting set of ideas, and eminently testable by empirical means. But… Childress has not done this testing, and although on his web site he refers to his claims as “well established in the scientific literature” (notably omitting a list of references), this is certainly not the case if we assume as many do that “scientific literature” involves empirical work beyond the level of anecdote or clinical report. Yes, attachment theory is based on careful observational work and on longitudinal studies, but the fact that there is a scientific foundation for some aspects of attachment does not mean that the foundation can properly be generalized to every statement that shares concepts with attachment theory. (There is a good deal of this kind of thing around just now, I’m afraid.) As for pathogenicity of any parenting pattern, this requires longitudinal study to ascertain.

Let’s look at Childress’ claims about treatment of PA effects on children. He rejects the idea that reunification can be facilitated by work with the child and both parents. Instead, he proposes that help can be given only by “protective separation” of the child from the accepted parent. During this period of separation, the child experiences treatment as described by Childress on his web site, with the goal of coming to enjoy and seek to be with the formerly rejected parent. If the child is successful in meeting this goal for 10 weeks, two one-hour Skype or phone sessions per week with the formerly-accepted parent will be allowed. According to Childress, this method empowers the child: “It is in the child’s power to extend or shorten the Treatment period. If the child continues to remain symptomatic [i.e., express rejection of the parent], then the Treatment period can be continued to six months or longer. However, if the child chooses [sic, N.B.] to become non-symptomatic, then the Treatment period can be ended in as little as 8 weeks or less, based on the child’s behavior. “ Childress argues that a study design can be used to demonstrate the effectiveness of this method, but he does not appear to have done this, nor does he take into account the effect of maturational change.  

Is Childress’ approach less supported by empirical work than other PA approaches? No, it is not, although his pugnacity and undue confidence about his statements tend to obscure that fact. Actually, all of the PA discussions of which I am aware, as well as many judicial decisions concerned with parenting relationships, have the same flaw. They completely neglect  to consider the effects of developmental change on the child’s interactions with the social environment and their effect on him or her. The effects of parenting patterns on children involve transactional processes in which each person affects the other in ways that change over time; the changes occur because of learning by both parties and because of maturational changes, rapid in the child and slow but present in the adult. This means that when treatment is appropriate (an enormous issue), the way it is done, especially if it is to involve separation from the accepted parent, must be congruent with the child’s developmental needs for attachment and for exploration. These are vastly different in toddlers and in kindergarteners, and different from both in teenagers. Perhaps Childress does not mean to suggest that a two-year-old who resists going with his father should be separated from the mother for 8 or 10 weeks or longer--  but if he does not mean this, he would do well to say so.

There are many more issues to be considered here. I am still taken aback, I must say, by Childress’ view that a child may “choose” whether or not to show fear and rejection of a parent; there is a flavor of “breaking the spirit” about the whole thing. But the main considerations, I think, are 1) show us the evidence for these claims,  2) tell how developmental age should be taken into account, and 3) describe the treatment goals in transactional terms. This is a challenge that I hope will eventually be addressed not only by Childress but by other PA proponents.

Sunday, August 16, 2015

APA and Torture: A More General "Nocere" Issue

People who are interested in psychology as a subject of study or as a profession can hardly have missed the recent brouhaha in the American Psychological Association, following public attention to the complicity of psychologists and the organization itself with the use of torture in the interrogation of prisoners at Guantanamo. This complicity of the organization included some shuffling of the ethical code to make it acceptable for psychologists to recommend “enhanced” interrogation techniques and thus to make themselves agreeable to the Department of Defense. (The American Psychiatric Association refused to do this, and they are most pleased with themselves--  which I acknowledge that they have every right to be.)

 At the recent APA (that’s the psychologists) annual convention  in Toronto, “town hall” meetings discussed the ethical issues concerned, and a resolution was passed, with only one dissenting vote. Among other things, the resolution stated that APA members should not be involved in national-security-related interrogations in any way, including supervising or advising on how other people do them. Members of APA were invited by e-mail to give feedback on this resolution, and I did so. Here is what I said:

“In my opinion, the resolution, with its focus on national security issues, completely misses the point. Psychologists should not employ or contribute to methods that are potentially harmful, whether the context is national security, domestic prisons, residential treatment centers, or outpatient treatment. In addition, there should be a clearly-stated ethical obligation for psychologists who become aware of such actions by other psychologists to call attention to them by reporting to APA or to licensing authorities. APA, in turn, needs to be responsive to such reports and to make public statements about substantiated reports even when the offending psychologist is not an APA member.”

Psychologists as a group have never adopted the principle of primum non nocere (first, do no harm). There has been a long-standing assumption that what psychologists do must be beneficial—why would we call it “therapy” if it isn’t good for you? Nocere has not been considered to be one of the options; in fact, when patients found treatments distressing, it was assumed that such distress was needed to motivate change or to overcome resistance, and that in the long term such unpleasant experiences were actually beneficial. This attitude was especially prevalent in the ‘70s, when bullying at Esalen was considered a viable intervention, when two practitioners in Flagstaff, AZ caused the death of an adult patient through physical methods, when Robert Zaslow lost his California psychology license after serious injuries to a patient, and John Rosen in Philadelphia apparently pushed a patient down a flight of stairs. Today, painful “psychotherapy” for adults is less common, but distressing methods for children, especially adoptees, are still advocated by some practitioners. These people may argue that just as chemotherapy for childhood cancer is painful but necessary, the treatments they use are similarly distressing but needed; unfortunately for their argument, they forget that there is good evidence for the efficacy of chemotherapy, but no such evidence for distressing psychological interventions.

In recent years, a small groundswell of disapproval for harmful behavior by psychologists has begun to appear. I can point to my own efforts to fight holding therapy by describing its distressing and physically harmful effects, beginning in 2001. Scott Lilienfeld in 2007 suggested the term “potentially harmful treatments” (PHTs) for interventions that have a history of doing harm or that could reasonably be expected to cause harm. The PHT designation provided a category whose existence indicated that nocere was in fact one of the options for psychologists—not all “therapies” were actually therapeutic. More recently, Michael Linden, a German psychiatrist, has put forward the concept of adverse events of various types that can accompany psychological interventions, just as they may occur with physical or pharmaceutical treatment. In a 2013 paper, Linden argued that feeling distress during psychological treatment should be considered an “emotional burden” and an unwanted side effect that should be avoided if at all possible.

These facts about psychological treatment and its potential for harm, in my opinion, need to be added to APA’s discussion of the harm done by psychologists who supervised torture. Simply to refrain from engagement with the Department of Defense provides only a small part of the solution to the problem. It is time for psychologists--  and not only psychologists, but other mental health workers—to recognize that there is a power for ill as well as good effects in our practices. It is time for us to stop passing by “on the other side”, like the priest and the Levite, when harm is caused to any person by the exercise of psychological skills. When APA recognizes this and builds awareness into the code of professional ethics, we may be able to move forward. As long as we point the finger only at the guilty parties at Guantanamo, we cannot.

Follow the Child's Lead to Create Attachment

A recent e-mail from Jessica Pegis called my attention to a set of “rules for bonding” as put out by the magazine Adoption Today ( An on line article on this topic, “Jump-starting attachment with babies and toddlers”, by Mary Ostyn, contains a range of misunderstandings about attachment and young children’s needs, as well as some good advice – e.g., that nurturing does not “spoil” a child.

My first concern about Ostyn’s remarks is that they suggest that attachment (not bonding) is something an adult can do TO a child, and that it is accomplished by ritually re-enacting with toddlers the behaviors that are normal parts of caring for infants. The term attachment refers primarily to attitudes and behaviors of young children toward adults, although some authors have tried to bring all later relationships under the attachment umbrella. As far as we presently know, attachment of a child to a caregiver occurs when the caregiver is sensitive and responsive to the messages the child sends about needs and wishes—that is, when the caregiver pays close attention to the child’s communications about both affectionate interactions and autonomy. (This kind of attention and response is just one detail of what is sometimes called “following the child’s lead”).

Ostyn seems to assume that the caregiving behaviors that typically precede an infant’s attachment to a parent are identical with the behaviors that will encourage attachment in a toddler or preschooler. My guess is that she takes this position because she shares with advocates of attachment therapy the belief that a child who has experienced separation has in some way been blocked from and stopped further development, and therefore experiences characteristic of early life must be recapitulated in order to “jump-start” typical development. However, the fact is that no living child stops developing in any way. Development may be distorted by events, but it continues to occur. This means that a toddler who has undergone separation cannot be considered to be stuck at the stage of development where she was at the time of separation. It’s more accurate by far to consider that aspects of development have been derailed and need to be guided back onto a desirable track.

Re-enacting baby care with an older child is thus not a plausible approach to helping kids who have experienced rough histories. What’s more, this kind of re-enactment of events ignores the important role played in attachment by the caregiver’s responsiveness to the child’s signals. Just doing what a caregiver thinks ought to be done may well involve being unresponsive to child communications, especially if a child is hard to “read”.

As Mary Dozier has pointed out, improving the parent’s ability to understand subtle child cues is the way to improve the child’s attachment to that parent; caregivers who proceed to follow “rules” without considering the child’s signals are working against attachment, not toward it. Ostyn suggests actually ignoring child cues to insist upon physical contact. She also ignores the fact of the typical extreme ambivalence of the toddler toward being held and being let go – the behavior that Margaret Mahler called a “rapprochement crisis”, where a normally-developing child wants to be held and then put down, wants help and then has a tantrum when receiving it, etc.  Rather than recognizing age-appropriate behavior, Ostyn is confused by her assumptions about  “stuck” development into thinking that this is an expression of genuine reluctance to develop a relationship. Instead, it’s an opportunity for a caregiver to show responsiveness to the confused and confusing signals the child is giving. The child’s desire for autonomy needs to be honored as much as the child’s desire for attachment—and I am at a loss as to how hours of carrying a big child can accomplish this, especially when the child resists. Once again, following the child’s lead as much as is practical is the way to go; carrying out a ritual re-enactment of some idea of infant care is not.

This leads me to the whole feeding issue. According to Ostyn, “bottlefeeding is great for bonding”—but there’s certainly no evidence that it makes any difference to attachment, any more than breastfeeding does. Does she mean that bottlefeeding makes a caregiver feel good? That would make sense if she’s really talking about bonding, which is the increased positive feeling of the adult for the child. Not so much if she means attachment, the feeling and behavior of the child toward the adult, however. A toddler or preschool child is likely to resist being given a bottle and will probably want to hold it herself and even take the nipple off to drink better, but caregivers who are convinced by Ostyn will not follow this lead as they should. (Some will even interpret these actions as a refusal to attach to them and a personal dislike.)

 As a further comment on feeding, Ostyn advises that only the mother should feed the child, and all treats should come from the mother. Here we have a clear commitment to the Freudian concept of attachment as “cupboard love” created by associating a caregiver with food or other gratification. This outmoded view has long ago been replaced by the idea of attachment as a robust development that occurs in response to pleasurable social interactions and adult sensitivity to child communications. Certainly mealtime offers many opportunities for happy social engagement and responsiveness to the child’s cues, but these are not based on satisfaction of hunger or experience of “treats”. I might point out also that the idea of monotropy, the attachment of the child to a single individual, as initially argued by John Bowlby in an analogy to the imprinting of ducklings, is long gone from professional discussions of attachment. Most children experience attachment to several caregivers, including fathers and grandparents, and benefit from learning that there are a variety of ways of having pleasurable social play.

Ostyn should be given credit for a couple of good suggestions. One is about responsiveness to children’s night-time concerns, and in her comments about this she does encourage sensitivity and responsiveness to child communications. Her comments about playing on the floor every day are also excellent. “Floortime” (as it was dubbed by Stanley Greenspan) offers many opportunities for pleasurable, sensitive, and responsive communication and for following the child’s lead in play.  

You can’t “jump-start” attachment by making the child go through ritual re-enactments of infancy. But you can gradually encourage a child’s attachment by becoming sensitive to subtle communications and being willing to follow the leads he gives you. If this seems difficult, sometimes it can be helpful to make videos of your interactions with the child and to look at them later to see whether there are cues that you are missing and leads you are not following. Keep in mind, too, that a toddler is developing attachment relationships that include negotiation and compromise, not just dependence, and that autonomy is an essential goal for development. That toddler or preschooler is not literally “stuck” at a baby’s emotional level—he or she needs experiences that resonate with current needs, not to what some adults imagine as past needs.