Friday, February 17, 2017
A recent discussion on a child psychology listserv brought up once again some misunderstandings about Reactive Attachment Disorder. One correspondent, who spoke of a child who had been diagnosed with RAD, surprised me by offering the old holding-therapy-related symptom list, including “superficial charm” and “lack of cause-and-effect thinking”. I responded by pointing out that even now, when few practitioners do holding therapy, there are dangers in the associated authoritarian belief system—a system that considers disobedience a symptom of poor attachment and holds that once a command is given, a child must be made to comply with it. (This view was the one that led to the death of Candace Newmaker in a situation which was not in itself dangerous unless pushed much too far.)
During the ensuing discussion, some really valuable comments about obedience were made by Dr. Bradley White, a clinical child psychologist at Virginia Tech, and I asked him whether I could summarize and quote some of what he said for this blog. In his very nice message of agreement, Dr. White commented on how much he has learned about these issues from his own children, but I want to point out that he learned from them because he was paying attention, not because he just happened to be in the same house with them!
Dr. White’s remarks stressed what early-childhood educators call developmentally appropriate practice: the understanding that an action can have different motives and meaning when performed by a child at different times in his or her life. When belief systems or associated treatments assume that all disobedience or noncompliance is pathological, they fail to take developmental changes into account and therefore lack real understanding of what the child’s behavior means from his or her own perspective. These mistakes lead to behavior that fails to provide an adequate model for the child—often at the same time that the adult is expressing concern about the child’s lack of empathy.
Dr. White commented: “If one sees noncompliance as developmentally appropriate and expected, it may simply be accepted and either ignored or redirected. If it is seen as problematic but functional or reflecting a skills or knowledge deficit, it may be helpfully viewed as a learning opportunity requiring extra support including gentle exploration, guidance, and rehearsal of alternatives.” (When adoptive or foster children have had few opportunities for leaning about social behavior and social relations, this viewpoint may be especially helpful. JM) Dr. White pointed out that when child behavior is always interpreted as provocative or manipulative, parents may see punishment as the only suitable response—potentially damaging the child’s attachment relationship with the adults as well as teaching the child coercive methods for solving problems. Parents’ interpretation of child behavior helps determine how, and how effectively, they respond to the behavior.
Commenting that becoming socialized (understanding social rules and taking the perspectives of other people) takes many years and progresses slowly, Dr. White also made this important statement: “I think we adults are … often impaired at seeing the world through the eyes of a child or adolescent, since it calls for empathic sensitivity and perspective taking, which often don’t come automatically but require effortful focus. Yet from a child’s point of view caregivers are often overly demanding and distracted due to their over-involvement in boring, confusing, or simply weird and senseless adult-level responsibilities e.g. getting the kids to school on time, holding down a job, maintaining order and organization), in contrast to the things perfectly reasonable kids care about (e.g., eating sweets, sleeping in, grabbing others’ attention with gross/silly/provocative acts, having fun now, and exploring how the world works by pushing and pulling on it and tossing it all around the house and yard, etc.).” In addition, Dr. White pointed out, it’s hard to cope with adult demands when tired, hungry, excited, and so on—“which arguably summarizes at least half of the day of an average healthy young child.”
Neither Dr. White nor I wants to argue that children don’t need to comply with rules and adult requests. Safety alone demands a certain level of obedience and cooperation, because adults often are able to foresee dangers that children know nothing about. The point here is that there are many reasons why a developing child may sometimes-- perhaps often—fail to comply with adult rules, ranging from the limited abilities of the young child to the budding negotiating powers of the preschooler to the growing autonomy of older children and adolescents.
From a practical point of view, a partial solution to this problem may be to have few rules and make few demands, but to follow through carefully on the ones you have. A corollary of this would be never to institute a rule or make a demand that cannot be enforced, especially if the issue is that a child is not capable of obeying. And, of course, working toward a good, mutually supportive and cooperative relationship between adult and child will do more good than all the exertion of authority in the world.
It is a huge mistake to define obedience or disobedience as indications of mental illness or as related to emotional attachment. Thinking in those terms increases parents’ anxiety and makes them feel that there is a crisis that must be addressed every time a child fails to comply. Such anxiety limits the parents’ ability to use the “effortful focus” Dr. White mentioned. It also makes the parents vulnerable to unconventional and potentially harmful ideas about children’s mental health.
Thursday, February 2, 2017
On the whole, it’s pretty easy to tell whether a method of working with people should be labeled psychotherapy, or should be considered as an educational approach. Psychotherapies usually have as their primary goal some changes in a client’s moods and the behaviors related to those moods, and although there may be associated cognitive changes, the latter are not the major concern of the treatment. Education is ordinarily thought of as involving cognitive change and the mastery of new information and skills; the information and skills may have to do with social or emotional concerns, and a person may feel happier because of mastery, but these latter are relatively minor points.
What do these differences have to do with the price of beans, or anything else? I am bringing them up here because I see that to an increasing extent, practitioners whose goal is mood and behavior change are claiming that what they do is not psychotherapy, but is education. It is certainly true that education can play an important role in psychotherapy, as clients or their families learn useful information about the nature of mental or behavioral disorders and come to understand better what is happening in their lives. (This is what is usually meant by the term “psychoeducation”.) However, psychological treatment has different goals and principles from education.
Why would practitioners of one approach claim to be doing the other? The answer may be a simple one: psychologists’ work is regulated by state professional licensing boards to a much greater extent than educators experience. As a result, a person who is not licensed as a psychologist may be punished for claiming to provide psychological treatment, but almost any person may freely present himself or herself as providing education, “family life coaching”, or “parenting coaching”. To be hired as an educator in a public school, an individual must have appropriate state certification as a teacher, but no such certification is required for “coaches”, teachers in independent schools, or tutors. If a person wants to provide services focused on mood and behavior change, but is not licensed as a psychologist (or other mental health professional), the easiest solution to the lack of licensure is to redefine the treatment as education.
Let’s look at some examples of this problem. I recently posted an account given by a young woman who had experienced a program that claimed to alter her relationship with her mother (http://childmyths.blogspot.com/2016/09/when-threats-substitute-for-therapy.html). She and her sister were taken against their will by youth transportation service workers and transported to another state, where they were confined to a hotel room and forced into interaction with the mother and her boyfriend. They were shown videos of the kind often used in introductory psychology courses, but in addition they were threatened with disturbing options if they did not cooperate—placement in residential treatment centers or wilderness programs where they would be unable to communicate with anyone outside, and where escape would be difficult or even dangerous. A psychologist in charge of this treatment had already had his license to practice psychology suspended, but he argued, so far successfully, that what he was doing was not psychotherapy but was simply education, and that the state psychology licensing board could therefore not discipline him.
A New York Times article (“Weak support for treatment tied to De Vos”, 1/31/2017, A1, A21) yesterday discussed similar issues with respect to the company Neurocore, which has called itself an educational organization in the course of a trademark dispute. Neurocore employs neurofeedback methods, recording brain wave patterns that indicate attention or inattention and manipulating interesting material clients are watching, so that indications of inattention cause a video to freeze. The method is used for both children and adults with autism, anxiety, ADHD, depression, and so on, and there are plans for marketing the approach to elderly people with cognitive problems. Unfortunately, however, evidence that this method effectively treats any of the listed disorders is missing. If Neurocore called itself a purveyor of psychotherapy, regulation would be possible (although professional psychology licensing boards do not usually concern themselves much with the use of ineffective treatments), but as long as the treatment is “education”, it is not. Yet it seems that that the purpose of the Neurocore treatment is to alter mood and behavior, not to effect cognitive changes, so classifying this approach as educational rather than psychotherapeutic does not make sense—except from the financial and regulatory perspectives.
A third example of calling a psychological treatment “education” under questionable circumstances comes from the history of the Miracle Meadows School in West Virginia, which I discussed some time ago in this blog (http://childmyths.blogspot.com/2014/09/more-mistakes-about-RAD-time-to-mow-hay.html). Miracle Meadows, which was closed down some months ago, was a Seventh Day Adventist-sponsored institution that focused on emotional and behavior problems of teenagers, many of them adopted from other countries. In one case, a child was sent to Miracle Meadows from another state when her adoptive parents were under investigation for abusive treatment. In another, children in a Tennessee residential treatment program that has been accused of child abuse were threatened with being sent to Miracle Meadows if they did not cooperate. Miracle Meadows had been investigated several times for abusive treatment of residents, but had successfully argued in court that staff need not comply with guidelines about the use of physical restraint and seclusion with children, because as an educational institution they were not required to follow guidelines that were intended for residential treatment centers dealing with psychological problems. More recently, a series of complaints and investigations of staff actions led to the closing of Miracle Meadows, as the argument that abusive practices could be classed as “education” could no longer be sustained.
The moral of this story? When choosing a treatment for mood, emotional, or behavioral problems, especially one for children, watch out for those programs that call themselves “education” but claim to help non-cognitive problems. They are not well-regulated and may present themselves as educational only to avoid compliance with guidelines for mental health practices. If you like the idea of an “education” approach because you dread the stigma of mental health treatment, do think carefully about your choices—by avoiding the idea of emotional disturbance, you may be placing your child in treatment that is not only ineffective but potentially harmful.