Thursday, March 1, 2018
Trust Based Relational Intervention (TM) (TBRI): Another Case of Claims Without Evidence
The alternative psychotherapy for adopted and/or traumatized children, Trust Based Relational Intervention or TBRI, promulgated by the late Karyn Purvis, is receiving much attention from adoptive and other parents’ groups. The major adoption agency Holt International shows much enthusiasm for TBRI methods on its Internet sites. A presentation by Purvis, “Introduction to TBRI”, is available at https://www.youtube.com/watch?v=TvjVpRffgHQ.
Purvis was a warm and charming presenter, and she conveyed genuine affection and concern for children who have come, as she says, from “hard places”. But it’s clear that much of what she says in this youtube piece is without empirical support and to a considerable extent without plausibility.
What is TBRI in practice? Here is a description I gave in a recent article in Child and Adolescent Social Work Journal, including a long quotation from Purvis and her colleagues:
"A treatment called Trust-Based Relational Intervention (TRBI®; Purvis, McKenzie, Razuri, Cross, & Buckwalter, 2014) ) bears some resemblance to AT/HT principles and practices. In a case study of this treatment as it was used with an aggressive and self-harming teenaged girl, Purvis et al. described a three-phase intervention in which Phase I was meant to mimic the early social relationship between child and caregiver which results in secure attachment. “ Rachel was assigned one specific staff member to be with her at all waking hours during the day, with approximately 36 inches or less to separate them. When Rachel’s mother was present, she assumed the 36-inch role, with a staff member remaining in close proximity. Proximity between the child and caregiver is important. The rationale for maintaining this close proximity is twofold. First, proximity is important from an attachment perspective. In line with attachment literature that suggests that the proximity between a caregiver and infant in a secure attachment relationship is important for maternal responsiveness …, bringing Rachel’s caregiver closer allowed the caregiver to be aware of Rachel’s needs and meet them quickly so that Rachel could learn to trust the adult and build connection. Second, proximity is necessary for a temporally loaded response and is important to support learning” (Purvis et al., 2014, p. 362). In addition, “in mirroring the development of the infant-caregiver attachment relationship, Rachel was not given choices that pertained to her daily routine (e.g., what to eat or wear), but rather those choices were made for her. During the program, choices were presented in a compassionate and kind tone, often utilizing a playful voice to neutralize any negative affect on her part. Again, this transference of choices from Rachel to staff was intended to simulate early life experiences where a child is cared for, rather than needing to care for herself. There was the potential for compromises if Rachel’s reaction to a caregiver’s choice was too disagreeable” (Purvis et al., 2014, p. 363). A second phase of treatment involved role-playing."
In her youtube presentation (one of several, incidentally) Purvis specifically stated that TBRI is evidence-based. She referred to the treatment as having “proven efficacy with children of all ages:. She stated that TBRI “can bring any child back on line” and spoke of “many documented cases” where TBRI had been useful.
The term evidence-based treatment (EBT) has a fairly clear definition among professional psychologists and clinical social workers. Before a treatment can be said to be evidence-based, its efficacy must have been supported by two independently-done randomized clinical trials. Under some circumstances, well-implemented nonrandomized trials may also help to establish an evidence basis for a treatment. None of these exist for TBRI, Purvis published several before-and-after studies concluding that TBRI improved aspects of children’s moods and behavior, but those study designs are not acceptable, particularly for research on children whose development may change rapidly and be mistaken for the effect of a treatment. It is incorrect for these reasons to say that TBRI is an EBT. (It is also incorrect to claim, as some alternative psychotherapists do, that EBTs are simply treatments about which articles have been published in peer-reviewed journals.)
Purvis also claimed in the youtube piece that treatment of children who had experienced abuse and neglect should take the form of recapitulation of events in their earlier lives. I was astonished at the use of this particular term, which I have often used in critiques of attachment therapy, primal scream therapy, “breathwork”, and so on, but I have never before seen this assumption stated so plainly. Yes, Purvis believed and said clearly that in order to treat emotional problems, it is necessary to replicate the experiences of care that a child should have had but did not receive. This theme is apparent in the quotation from the Purvis publication I gave earlier. In the youtube piece, Purvis referred to this assumption as a “scientific parable” – that if a capacity is lost, its causes must be recapitulated by going “back to the beginning”. In addition to the proximity and absence of choices used in the treatment of “Rachel”, Purvis proposed needs for hydration every two hours, food every two hours, and motor activity every two hours, a schedule based on care of a newborn infant, and implausibly applied to every age group right up into the teens. This would appear to be sympathetic magic at work, not psychotherapy.
Further implausibility behind TBRI was shown in Purvis’ belief that mental illness is caused solely by experiences from conception onward rather than by genetic and other biological factors as they interact with experiences (although she mentions substance exposure as a possible factor). She agrees with the Association for Pre- and Perinatal Psychology and Health (APPPAH) that maternal psychological stress (e.g., from family difficulties) can cause childhood emotional disturbances. In order to counteract these difficulties, which she saw as based on sensory processing disorders, she recommended following a range of treatment methods as recommended at one time by the occupational therapist A. Jean Ayres. These include a “sensory diet” involving the Wilbarger protocol of light and deep pressure stimulation, the use of weighted blankets, and toys buried in dry rice so that children receive skin stimulation as they try to find the toy.
Purvis referred to herself in her presentation as “a woman of science”. It would be a great deal more accurate to use the term “pseudoscience”. A recent article by David Grimes and Dorothy Bishop (“Distinguishing polemic from commentary in science…”, Child Development, 2018, 89, 141-147) offered a list of questions that are useful ways to examine claims about TBRI as Purvis made them.
1. 1. Is there a plausible mechanism for the effect claimed? No, there is no evident way in which recapitulation of early events could cause a repetition of development from scratch, especially not the claimed reshaping of the brain.
2. 2. Does evidence come from peer-reviewed sources? There are publications in peer-reviewed journals , but they do not meet standards for claims of an acceptable evidence basis.
3. 3. Are all relevant studies considered? The published studies are not at a level that makes them relevant to the claims made.
4. 4. Are results of specific studies misrepresented? Because of the design problems of the existing studies, it is a misrepresentation to conclude that they provide acceptable evidence about the effects of TBRI.
5. 5. Are there claims of impacts on multiple diseases and disorders? This is difficult to answer because of omissions of diagnoses and proportions of specific problems in published material, but certainly there are claims of efficacy for children in such a broad age range that multiple problems must be under consideration, the problems of preschoolers and teenagers being different.
6. 6. Are causal claims based on experiment, correlation, or analogy? The published studies are nonrandomized, before-and-after comparisons. Analogy to animal studies is a major argument brought in favor of TBRI.
7. 7. Is technical, scientific information used to obfuscate rather than clarify? Yes, obfuscatory references to brain and hormonal functions are a major part of the youtube presentation. For example, Purvis followed the popular belief by recommending half a turkey sandwich for a sleepless child (but see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2077351/ for a discussion of this idea.) She stated that it takes “400 repetitions of an act to get one synapse”, or 12 such acts done with joy and laughter to create one synapse. (There are plenty more examples if anyone would like to follow up on this point.)
Claims made about TBRI are not evidence-based or plausible, and organizations like Holt International would do well to examine them carefully before making a commitment. Adoption has been described as the most effective treatment for children who have had bad beginnings to their lives, and experiencing sensitive, responsive care will facilitate good development for any child. Where TBRI has been helpful to families, those general factors are likely to be responsible for any benefits. Whether or not TBRI carries a risk of harm may depend on the age and other characteristics of a child. How ”Rachel” felt about the 36-inch rule, and what effect this practice had on her, is an important question yet unanswered.