Sunday, May 17, 2015
A piece in the Week in Review section of the Sunday Times today described how the writer visited a New York post office, and looking at the rubber stamps available, discovered one marked PRETENTIOUSLY HAZARDOUS. I can’t let this golden trouvaille go to waste. It is the perfect category description for the whole attachment therapy-holding therapy- Nancy Thomas parenting-industrial complex, as well as for more than a few other treatment methods.
Some years ago, the clinical psychologist Scott Lilienfeld introduced the term potentially harmful treatment (PHT), to describe therapies that were already known to have caused harm to patients, or which might logically be expected to do so. This term, of course, did not mean that every use of a treatment would end in harm to a patient, simply that there was a reasonable possibility that this would occur. The PHT concept stressed the fact that despite the etymology of their name, “therapies” might actually do harm—that safety as well as effectiveness could be issues for psychological treatments. The idea of a PHT was not obvious to a Georgia attorney who cross-examined me in a holding therapy case; he argued that no harm had apparently been done, until I gave him the example of running across a busy highway and by some miracle not getting hit by a car-- he had to agree that this was a potentially harmful act that should be prevented, even though the runner came through unscathed this time.
The psychologist Michael Linden added to the PHT concept by pointing out that various types of harm could be associated with misconceived psychotherapies—for example, that the “emotional burden” of feeling distressed during treatment was harmful and should be avoided if at all possible.
So, why am I not content to call AT-HT-NTP potentially harmful treatments? Why not just point out the emotional burdens children experience when subjected to these methods? In fact, why not stick to the term “alternative psychotherapies”, which I have used myself to designate treatments that are without an empirical evidence basis, that are incongruent with established information about human development, and that are potentially harmful?
PRETENTIOUSLY HAZARDOUS treatments display problems in addition to those just stated as they retrofit theory and diagnosis to support treatment methods that are in fact derived from old ways of punishing children (perhaps even from the old German “black pedagogy”). Proponents of these treatments have spun out of straw a prosperous belief system which meets the definition of pretentiousness given by my big old Webster’s: “making claims, explicit or implicit, to some distinction, importance, dignity, or excellence”. The claims include the putting forward of an unfounded “attachment cycle” theory that states that attachment is affected by caregivers’ boundary-setting in the second year of a child’s life (such boundary-setting is important, but is not a factor in attachment). The “attachment cycle” concept is used to justify age-inappropriate actions like insisting on bottle-feeding a ten-year-old or hand-feeding sweets to a child. It is also used to justify intrusive and rigidly-controlling actions toward children that are defined as equivalent to boundary-setting.
The “attachment cycle” concept and related adult actions make the explicit claims to importance mentioned in the Webster’s definition of pretentiousness. But they in turn are based on an implicit claim that is all too easily swallowed by parents and other caregivers—in fact, that may be believed to a considerable extent by many adults. This is the claim of recapitulation, the repetition of earlier events, but it is not the old familiar but faulty idea that the development of the individual repeats events in the development of the species. This concept of recapitulation holds that it is possible to magically cause the recapitulation of past development, and to make it come right where it has gone wrong, simply by ritually re-enacting some past events that might be associated with the desired developmental change. For example, if a child is thought to have problems with attachment because she was not sufficiently cuddled as an infant, cuddling her now, feeding her with a baby bottle, and gazing into her eyes are thought of as ways to recapitulate and correct her early emotional life. If a child’s problems are thought to have come from failures of limit-setting in the second year, rituals of demanding that the child ask for everything he needs or sit motionless for long periods are considered to recapitulate and correct the earlier problems.
There are several problems that make such treatments PRETENTIOUSLY HAZARDOUS. One is that it is very unlikely that attachment does result from feeding experiences per se, and it is particularly unlikely that ingestion of sweet things is related to attachment in infancy. It is similarly unlikely that attachment is the aspect of development affected by boundary-setting. But suppose for the sake of argument we were to assume that those events did cause attachment in infancy? Why would we think that experiences characteristic of infancy would have the same effects on older children as they do on infants? To imagine that would be like thinking that an all-milk diet, healthy and appropriate for young infants, would also be suitable for older children with different nutritional needs and growth patterns. Magical recapitulation rituals cannot return children to the developmental needs and patterns of an earlier stage of life, and it is pretentious to claim that they do. In fact, one might well argue that it is fraudulent to do so.
It’s clear that AT-HT-NTP methods are PRETENTIOUS. Need I also argue that they are HAZARDOUS? Proponents of these methods have stated that they no longer lie down on top of children or do other things that have caused death by asphyxia in the past, and perhaps they do not. Nevertheless, the recent license revocation case of “Kali” Miller in Oregon has shown the suicidal response of a boy to treatments that did not risk suffocation but appear to have carried an unbearable emotional burden. In my opinion, this is hazardous enough to argue against use of any such methods.
These treatments are not prohibited, in spite of all we know about them. But there should be large PRETENTIOUSLY HAZARDOUS stamps on all their websites.
Friday, May 15, 2015
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.
Wednesday, May 6, 2015
While looking for some recent comments about Reactive Attachment Disorder recently, I chanced upon a 2014 doctoral dissertation that gave me considerable pause. This was a dissertation written in fulfillment of requirements for a doctorate in social work at the University of Iowa. The doctoral candidate, Matthew Lorenzo Vasquez, titled his dissertation “The impact of Reactive Attachment Disorder on adoptive family functioning”. This in itself was a bit attention-getting, because I would expect a dissertation done today to look at the effects of RAD and adoptive family functioning on each other, not to assume that the disorder was there to begin with, and it caused changes in family functioning. But I wanted to read the thing to see whether I was right to question the nature of the document.
You can read this dissertation for yourself if you have the stomach for it-- it’s at ir.uiowa.edu/cgi/viewcontent.cgi?article=5299&context=etd. I’ll just give you some high points that will no doubt resonate with aficionados of the attachment therapy/holding therapy belief system.
We get right underway in the abstract and the first page of the introduction. Here we are told that “[c]hildren with RAD are known to engage in self-destructive behavior, talk of killing others or themselves, [and] direct verbal and physical aggression toward peers and adults”. This is of course true, just as it is true that children with other diagnoses, or with no diagnosis, may sometimes do some of these things. What is not true is that children who engage in self-destructive behavior, talk of killing, etc., etc., therefore have RAD. Although Vasquez references the DSM-IV-Tr description of RAD, he appears to have some other, unnamed source of information about diagnosis of RAD-- perhaps the work of Wimmer et al which appears in Vasquez’s reference list and which certainly posits RAD symptoms that are not to be found in any conventional discussion of RAD diagnostic characteristics. Although he mistakenly cites Parker, Forrest, and Reber, a non-existent source, it is plain to those of us who have studied the AT/HT belief system that Vasquez really means Reber (1996), a problematic paper, hard to find on the Internet nowadays, that made a variety of unsupported claims about RAD and used to be quoted frequently by practitioners of alternative psychotherapies.
Vasquez collected information by interviewing members of five volunteer families, and some interesting information it was, I can tell you. For example, in discussing the methods a family used to respond to a child’s “meltdowns”, he comments, “In an effort to find some relief from Adam’s rages, Nancy [adoptive mother] started to bring Adam into the bathtub [with or without water is not stated] and would hold him there in the dark while he continued to scream” [as who wouldn’t scream? J.M.]. Nancy states that she learned this technique when working in a nursing home with people who had transient ischemic attacks…and seizures and hoped it would help Adam. Nancy then explained:
‘That’s when the meltdowns got shorter, and shorter, and shorter. Because he lost all his power. He had no power. Because sometimes he would get me frazzled you know and I was overwhelmed, you know? You don’t want to go there but you would. So he lost all his power when it went to the tub. And they just got, I bet, six to eight months before his meltdowns were 10 to 15 minutes in length.’
Vasquez then speculates that the approach was “so effective” (a speculation in itself of course) because the child could consciously decide whether he preferred to tantrum or to be held in the bathtub; Vasquez is uncertain whether he always had this ability or was given it as a result of the bathtub treatment.
Rather than considering the meaning from the child’s viewpoint of being immobilized in the dark (and possibly in water), Vasquez is concerned with what it all meant for the parents. “Personally, I found the image of a young child being held in a bathtub, in the dark, while he screamed uncontrollably for hours at a time both profound and moving. … It … shows… what lengths some of these parents went to provide these children comfort and solace. Undoubtedly, to sit in a bathtub for multiple hours a day, restraining a screaming child for 6 to 8 months shows an incredible level of devotion and commitment to the care and well-being of these children”. Although many of us would query whether this behavior actually shows an incredible level of ignorance or of sadism, Vasquez does not mention that alternative explanation. Instead, he stays with the AT/HT tenet that adoptive parents are loving and good, as well as able and determined to make the best choices for children.
This is very depressing, but let me mention one other topic Vasquez mentions. It’s the old Darkness Behind the Eyes (see www.attachmentandtraumaspecialists.com/attachment_disorder/symptoms and other AT/HT sources). Vasquez says “hearing numerous reports about how these rages can be seen in the eyes of their child, I began to see this attribute as a significant feature in discussing these rages. “ He inquired of one mother about the idea that her child’s eyes changed color. She said “Mmm-hmm. Her eyes change color. They all do. They go DARK.” Another parent made the following statement: “When he would rage… it would almost look like there’s a fire in the whites of his eyes. He wore the footed pajamas, and at bedtime sometimes I would have to hold him down, and he would kick, and with all the lights off there would be sparks everywhere, I mean he was raging that fast.” Vasquez did not question these reports of physical impossibilities, but did note that the parents did not seem to attribute the events they reported to demonic possession. He did not examine the possibility that alternative practitioners and support groups had told the parents these things would happen.
So, do I blame Vasquez for this piece of work that repeats without question or comment various tenets of the AT/HT belief and treatment systems? Yes, to some extent I do. The man is not a scholar, although he seems to think he is, and he has done a sloppy job at best, mismanaging citations and references. He fails to note the discrepancies between the DSM criteria for RAD and the symptom list he emphasizes. He notes his attempts to manage his own biases by journaling, but does not attempt to discuss alternative interpretations for some of his conclusions. He did not do this work with due diligence, and if I contemplated employing him, I would be most concerned that the same degree of bias and carelessness would contaminate his professional contributions.
On the other hand, though, I cannot say that all the fault lies with Vasquez. As a doctoral student, he had a supervisor and a dissertation committee, all of them apparently with doctoral degrees. Why did they sign off on this level of work? Did they not realize that a dissertation may be cited, quoted, and used as the basis for further claims? As far as I can see, none of the committee specialize in adoption issues or in childhood mental health problems. Why did they agree to support this work if they knew little about it? Given that a doctoral candidate temporarily knows more about what he or she did than anyone else in the world, why did they not at least insist that this student explore alternative explanations of his interview findings? Do they not think that the discipline of social work depends on adequate research, not just on sympathy with suffering people?
It’s my hope that this committee and others supervising social work graduate students will read the forthcoming book by Bruce Thyer and Monica Pignotti, Science and pseudoscience in social work practice (Springer, 2015). Meanwhile, the rest of us have to deal with the release of yet another AT/HT proponent armed with an apparently respectable doctoral degree.