N.B. This paper is a draft prepared for presentation
at a meeting of the International Working Group on Abuses in Child Psychotherapy, London, April 20, 2013.
Jirina Prekopova’s Holding Therapy:
Scientific Support, or Non-scientific Foundations?
Scientific Support, or Non-scientific Foundations?
Jean Mercer
The “holding therapy”
method practiced by Jirina Prekopova
and others as a mental
health intervention for children is described and
examined with
respect to its scientific and nonscientific foundations. It is
concluded that
the treatment is without scientific basis, but is closely related
to other
unconventional beliefs and practices that began in the 20th century.
“Holding therapy” of the type
Prekopova uses is probably not child abuse
by legal
definition, but includes actions that are considered abusive by
definitions used
in research
The Czech child psychotherapist, Jirina Prekopova, who
practiced in Germany (where she was called Prekop) for some years, has returned
to the Czech Republic and is promulgating her therapy method there and in other
countries in Europe and Latin America (see www.prekopova.pevne-objeti.cz).
Prekopova’s technique is called “holding therapy” (HT) in English and is also
known as Festhaltetherapie; the term
as used in other languages is sometimes translated to English as “hard hug” or
in other ways. HT as practiced by Prekopova is directed toward autistic
children and toward typically-developing children who are resistant or
uncooperative “little tyrants”. In HT, parents hold young children ventre-a-ventre and restrain their
movements during a period of an hour or more. The children resist, scream, and
cry, and the parents speak to the child of their own negative and positive
emotions about the child. The child is expected to reach a peak of resistance,
then to calm, and to end the session with positive feelings on both sides.
Similar methods can be used with older children, but larger children lie supine
while the parent (usually the mother) lies on top of them and restrains them
with her body weight. This technique closely resembles that advised by the
American psychiatrist Martha Welch (1989) and omits some of the more intrusive “rage-reduction” elements
included by Zaslow and Menta (1975) and by Cline ( 1992).
Prekopova also practices a technique called “rebirthing”,
in which an individual of any age re-enacts the events of birth with the real
or a substitute mother, the “fetus” hiding head down under a red sheet in
imitation of the situation before or
during birth. This practice is not the same as HT, but contains similar belief
elements involving the power of physical contact and the possibility of
recapitulation of early steps in development.
Prekopova claims that autism and other behavioral
problems are caused by separation of mothers and infants at birth and a
consequent failure of bonding, which she defines as an emotional change in both
members of the dyad. She proposes that HT recapitulates the face-to-face
contact that should have taken place soon after birth and thus corrects
problems by producing the bonding that should have resulted from that contact (Prekop,
1983; Gruen & Prekop, 1986).
Prekopova states that her approach has scientific support
and that this is evidenced by the approval and encouragement of the 1973
co-winner of the Nobel Prize for Medicine, Nikolaas Tinbergen. Tinbergen stated
his support plainly in a 1983 book (Tinbergen & Tinbergen, 1983), alluded
to its foundational beliefs in his Nobel prize lecture (www.nobelprize.org/nobel_prizes/medicine/laureates/1973/tinbergen-lecture.pdf),
and described autism as a stress disorder in a Science article (1974).
The present paper is intended to examine the claim of
scientific support for HT, first by considering the work of Tinbergen and of
other ethologists, and second by looking at the small number of outcome studies
that have assessed the effect of HT. In addition, the paper will address
nonscientific foundations for the theory and practice of HT. Both treatments
and posited causes of autism will be considered.
Are There
Scientific Foundations for HT?
There are two ways to claim scientific support for an
idea. The first and most obvious is to report systematic investigations that
provide supportive evidence. The second, easier, but less reliable technique is
to show that the idea is plausible in terms of previous work. Prekopova’s work
generally cites previous publications and argues that her methods are plausible
in the contexts of those publications (e.g., Gruen & Prekop, 1986). Most of
the cited publications are ethological in nature.
Ethological
Foundations of HT
Ethology is an observational approach to comparative
psychology, the study of behavioral similarities and differences between
species. Ethologists have generally used extensive observational study to
determine common species-specific behaviors called fixed action patterns
(Eibl-Eibesfeldt, 1970). Using their understanding of fixed action patterns,
ethologists have considered the roles of innate factors, of motivation, and of
learning in the determination of behavior. They examined the function of
environmental triggers called releasers in the initiation of a fixed action
pattern, and posited the existence of innate releasing mechanisms that
responded to a releaser as a lock does to a key, permitting the fixed action
pattern to be carried out. Although ethologists examined the behavior of
mammals, including humans (e.g., Anderson, 1970), for fixed action patterns,
most of this work focused on birds and fish.
One ethological concept was of particular relevance to
HT. This was the idea of imprinting, a particular type of learning that
occurred very early in life and was difficult to undo once it had happened.
Imprinting did not create a fixed action pattern, but did determine exactly what
releaser would call it out. For example, newly hatched ducklings were prepared
to respond to any moving object as a releaser of their following response, but
once they had followed a type of object, it became the only releaser of
following, even though it was a model train or something else other than a
mother duck. When the ducklings reached adulthood, they would then display
mating behavior (a set of fixed action patterns) only toward an object similar
to the one they had initially followed and were imprinted on.
In his early discussions of human emotional
attachment, John Bowlby ( 1982) was influenced by ethological concepts and
suggested that human infants, like ducklings, are monotropic and form an
attachment to a single person. This idea was omitted from attachment theory
before long (Rutter, 1995), but has
continued as an aspect of HT. Bowlby’s
discussion of attachment described this developmental step as occurring in the
second half of the first year, rather than soon after birth, but HT advocates
have continued to claim that events at the time of birth are essential to
emotional development, in a perfect parallel to imprinting in ducks. Such
events have been argued to be the cause of later autistic behavior (Gruen &
Prekop, 1986). (An interesting sidelight on this discussion comes from the fact
that Tinbergen consulted Bowlby about some concerning autistic-like behaviors
in one of his own children [van der Horst & van der Veer, 2010]).
In
addition to the idea of imprinting and its effect on fixed action patterns, ethologists
were interested in behavioral responses to conflict situations, in which an
individual might want both to approach and to escape from a situation. An
animal or person that was simultaneously frightened and attracted by something
might respond with displacement behavior, in which a fixed action pattern that
normally occurred in a different setting was enacted. For example, birds that
are in conflict about an object or situation may preen their feathers, which
they ordinarily do for cleaning purposes; humans may yawn, which they usually
do in response to sleepiness. Some ethologists
considered the stereotyped behaviors of autistic children (such as
hand-flapping) as possible displacement behavior that might be used to regulate
arousal levels in conflict-fraught situations, like exposure to a novel,
interesting, but anxiety-provoking, situation. Hutt and Hutt (1968) observed
stereotypies in a small number of autistic children, defining stereotyped
behaviors as “repetition in an invariant pattern of certain movements having no
observable goal” (p. 278), and reported that the clinical outcomes were better
for children without stereotyped behavior. In another paper, Hutt and Hutt (1969)
examined gaze aversion as resembling a fixed action pattern of which all humans
are capable, but occurring more frequently in autistic children and thus as a
possible displacement behavior indicating high levels of arousal; these authors
discussed the use of conditioning methods and of pharmaceutical approaches to
lowering autistic children’s arousal, in the hope of moving them to more
typical behavior patterns. Hutt and Hutt, who were frequently cited by
Tinbergen, did not refer to HT as a possible treatment for autism.
Tinbergen
and Tinbergen (1983) provided many examples of fixed action patterns and of
imprinting in birds such as herring gulls, and referenced human fixed action
patterns as discussed by Eibel-Eibesfeldt (1970) and others. They argued that
autism was caused by environmental events, as had been suggested by Kanner (1943),
and that it might be possible for environmental factors to reverse the process
and return an autistic child to more typical development. Tinbergen (1974) had
proposed that an autistic child who avoided social contact might be attracted
by a mask with unusually large eyes, which in ethological terms could function
as a supernormal releaser, and could gradually move toward social contact with
more usual releasers such as eye contact and facial expression. The Tinbergens
in their 1983 book put forward the views of Martha Welch, who attributed autism
and other behavior problems to a failure of emotional connection between mother
and child, and who proposed that intense face-to-face physical contact and
emotional expression were required to correct a problem that had developed
early in life. A lengthy appendix describing Welch’s claims was included in the
Tinbergens’ book in spite of the complete lack of empirical support for the
technique. (The Tinbergen support later helped Welch in the publication of her
own 1989 book, followed by a European book tour and meetings with the
Tinbergens, Prekopova, and others.)
The
ethological position provided a number of concepts that were useful for
thinking about autism and even about HT, but there were some serious problems
with the view that ethology provides scientific evidence for HT. Ethology
itself is concerned with species differences and species-specific behavior; it
does not assume that fixed action patterns or other characteristics of a given
species can necessarily be generalized to a different species, although it
suggests that mechanisms like displacement may be shown in different ways in
different species. Ethological studies have shown that imprinting-like mechanisms
occur in some but not all species. Where genuine imprinting does occur, it is
almost by definition extremely difficult to alter, as is seen in hand-reared
captive birds who even if persuaded to mate may push their conspecific mates
away if they see the human on whom they were accidentally imprinted. In its
discussion of imprinting, ethology also focuses on critical or sensitive
periods, age ranges within which members of a species are ready to learn
rapidly from certain experiences, and before or after which their learning of
that type is limited. The study of human attachment, with its strong
ethological influences, has considered a possible critical period for
attachment in the second half of the first year (and not at the time of birth),
but current thinking stresses ongoing developmental changes in attachment as
well as the ability of a child separated from attachment figures to form new
attachments in a way quite different from imprinting. These facts suggest that
although Tinbergen himself was supportive of HT, ethological facts and
principles did not actually provide a foundation for such support.
An
examination of the scientific work cited by Prekopova in support of HT would be
incomplete without attention to some of the authors she has cited (for example,
in Gruen & Prekop, 1986). These include Von Holst, a biologist of behavior
who demonstrated central coordination of movement patterns in fish and worms;
Mittelstaedt, who described the “reafference principle” that allows a moving
creature to distinguish its own movements from the effects of external forces;
Lorente de No, whose experimental work gave insights into the nature of the
nerve impulse and brain events; and Schneirla, a developmental psychobiologist
who worked on responses to the environment by a variety of animals and insects.
Of these, only Schneirla has been thought of as a contributor to the
understanding of early human development, and his approach/withdrawal theory,
proposing that young organisms approach weak stimuli and avoid intense ones,
was at one time of interest to developmental psychologists (McGuire &
Turkewitz, 1978). The others, who made outstanding contributions to the study
of neurology and behavior, were nevertheless not specifically relevant to
treatment of autism or other behavior problems.
Is There Other
Scientific Evidence for or Against HT?
Whether or not a treatment for autism is scientifically
plausible depends to some extent at what is known about autism at the time the
treatment is proposed. Treatment plans often depend on assumptions about the
cause of a disorder, so beliefs about treatments are also based on beliefs
about causes.
Changing
Beliefs About the Causes of Autism
During the 1930s and ‘40s, views on
the sources of mental illness tended to emphasize environmental factors and
situations the individual had experienced or failed to experience. Kanner’s (1943)
approach to autism as associated with types of parental personality and
behavior is a prime example of this tendency, but it is far from unique; work
like that of Kurt Lewin and his colleagues (Lewin, Lippit, & White, 1939),
for example, tried to connect political authoritarianism with childhood
experiences. Supported by both psychoanalytic theory and operant conditioning
approaches, this environmental emphasis continued into the 1970s, when the
claims of John Money (Money & Ehrhardt, 1972) about environmental effects
on gender identity were much publicized. Tinbergen’s support of HT as performed
by Welch and by Prekopova emerged during the 1970s and was plausible in terms
of the way autism was understood at that time, before genetic factors were well
understood.
An
important reference point for Prekopova has been the work of George Victor
(1983). Victor, an American clinical psychologist, focused on early childhood
experiences as the cause of autism, including both “overtraining” of
unresponsive babies by the mother, and the failure of the mother to carry out
the operant conditioning events that Victor considered essential to development
of language. He saw the development of autism as involving reactions of the
child to unpredictability; self-stimulation, for example, was seen as altering
consciousness and further reducing the responsiveness of the child to social
stimulation. This approach is very different from the modern concerns with
genetic factors that will be described later, but clearly supports Prekopova’s
view that autism is essentially learned and therefore can be unlearned or
replaced by different learning.
In
line with the strong emphasis on environmental factors of the mid-20th
century, some views of autism assumed that the disorder resulted from a failure
of emotional attachment; this appears to be one of Prekopova’s tenets. However,
empirical work has indicated that this is not the case, that autistic children
are as attached to caregivers as typically-developing children Gernsbacher et
al., 2005) , and that therefore treatment
posited to influence attachment would be irrelevant to autism.
The present scientific position on autism accepts that
environmental factors can influence both typical and atypical behavior.
However, there are two essential factors in current thinking that take
precedence over the environmental approach. The first is that there are many
different types of autism rather than one general diagnosis that applies to all
autistic individuals. Beaudet (2012) suggested a division into two basic types.
The first, a milder form, involves a higher intelligence quotient, no unusual
physical features, an unknown rate of genetic problems, a mild transient
increase in head size, a sex ratio of 4-8 males to 1 female, regression as a
common phenomenon, responsiveness to the environment, and a possibility of
treatment or prevention by manipulation of environmental factors. The other
form is more severe, involves physical dysmorphisms, features lower
intelligence quotients, can include either microcephaly or extreme
macrocephaly, has a sex ratio of 2-4 boys to 1 girl, is related to paternal
age, rarely involves regression, involves both new and inherited mutations, and
can probably not benefit from attempts at prevention or treatment. Novarino et al (2012) have shown that an inborn error
of metabolism can be associated with autism, intellectual disability, and other
problems, and that supplementation of the diet might prevent children with this
error from developing autism.
Although no one would claim that these approaches have
completely solved the puzzle of autism, it is clear that the current scientific
position stresses genetic factors as causes of autism. Where environmental
factors are emphasized as preventive or treatment measures, the genetic
approaches considers them in terms of metabolic problems and dietary
requirements.
Thinking of autism as a largely genetic problem does not
imply that educational or other therapeutic methods cannot be helpful. Although
methods like Applied Behavior Analysis (Lovaas, 1987) are no longer claimed to
be as effective as they were once said to be ( see Gernsbacher, 2003), it is clear that many
autistic children can benefit from treatments that are in no way related to the
basic cause of their problems. Current thinking about autism does not focus on
social interactions at the time of birth or even in the first year of life, as
Prekopova does (Prekop, 1983), and therefore does not assume that treatment
needs to mimic some posited needed experience that occurs in early life. Thus,
HT is implausible in terms of what is presently understood about the causes of
autism.
Is
There an Evidence Basis for HT?
In addition to examining a treatment for its plausibility
within related scientific contexts, we can assess the treatment’s scientific
support by means of well-designed outcome studies. These studies examine the
effects of a specific treatment in ways that follow the rules established for
evidence-based treatments ( Sackett et al., 1996 ). Because outcome studies for
treatment of mental illness may be difficult to do in ideal ways, such studies
are often considered in terms of levels of evidence, and may range from
excellent studies using randomized controlled trials, to careful but
nonrandomized controlled designs, down to simple descriptive work that employs
no standard of comparison relative to the treatment outcome.
Many proponents of “complementary and alternative
medicine” (CAM) treatments reject the idea of outcome studies or the importance
of an evidence basis, but rely instead on testimonials and anecdotes, or fall
into the “genetic fallacy” by claiming that since they understand how a problem
came about, they must also understand how to treat it. Prekopova has used
anecdotes to suggest empirical support of HT (Gruen & Prekop, 1986). In
addition, during the 1980s, several German-language studies of HT were
published. Prekopova herself published an account of 57 autistic children who
were said to have become capable of trusting human interactions as a result of
HT, but did not state how it was known that they had not trusted human
interactions before treatment (Prekop, 1983). Rohmann and Hartmann (1985)
reported the use of a form of HT with a randomly chosen 7 out of 14 autistic
children; all were reported to have shown significantly more positive than
negative changes as compared to the no-treatment group, and when later given
the treatment, the original comparison group also improved, according to the
reports of parents. Burchard (1988) had parents fill out pre-treatment and
post-treatment questionnaires for autistic and “omnipotent” children and reported
improvement following HT. Prekop and von Stosch (n.d.) reported telephone and
questionnaire surveys of families who had attended HT workshops between 1993
and 1998 and noted that 48% said the results were good to very good, while 8 %
stated that they were minimal or negative; this study excluded families in
which the mother was said to disregard the father rather than to treat him as
the top of the family hierarchy (in line with the influence on Prekopova of
Bert Hellinger, to be discussed later). In all these studies, the outcome
measurement was parent report, and in no case were the parents blinded as to
the treatment they themselves administered.
More
recently, there have been some outcome studies of forms of HT, although none
involving randomized controlled trials or assessments other than those of
parents. In one study concluding that HT was efficacious (Lester, 1997), a
simple before-and-after assessment of children by their parents was used, with
reports of efficacy biased by unblinded parental evaluations and by the failure
to control for normal rapid developmental change during childhood; the
technique used was a method of HT other than that used by Prekopova.. A second publication (Myeroff, Mertlich, & Gross, 1999) was based on a dissertation whose
conclusion was very modest, but the published work made strong claims about
differences between a treated group and another group that had applied for
treatment but did not appear, for reasons that were unclear but potentially
highly confounding; again, the treatment used was not identical with
Prekopova’s. (This paper was briefly
listed as a RCT by a Cochrane review several years ago.) Wimmer, Vonk, and
Bordnick (2009) carried out a similar study, but combined HT with so many other
treatments that cause and effect were impossible to determine.
A method strongly resembling Prekopova’s HT, originally
called “holding time” but now referred to as “prolonged parent-child embrace”
(PPCE), was tested by means of before-and-after treatment evaluations by
parents using one unvalidated instrument and another better-established
instrument, and by means of comparisons of parent reports to normative data
(Welch et al, 2006 ) . As
parents provide the restraint in this method, there is again no possibility
that they can be blinded to the treatment. Although these authors reported
positive outcomes, they noted that a number of confounding variables, plus
regression to the mean, could have had an effect on the results. They did not
mention the effect of using unblinded parent reports rather than professional
observations.
Finally,
a report by Sudbery, Shardlow, and Huntington ( 2010) described positive
results of HT, but in fact was based on surveyed opinions of caregivers rather
than on objective measures of child mood and behavior. It appeared that this
report used a form of HT in which a therapist restrained the child, rather than
Prekopova’s method, in which a parent provides the restraint.
There appear to be neither randomized controlled trial studies,
nor well-designed nonrandomized controlled studies, supporting the efficacy of
HT. As a result, HT cannot be considered to be an evidence-based treatment, and
should not be encouraged or paid for by organizations that claim they approve
only evidence-based therapies.
Where Does HT Come From?
Some Nonscientific Sources
Despite the approval of the Nobel Prize-winner Nikolaas
Tinbergen for HT, and despite the many analogies that can be drawn between
animal behavior and human behavior, HT does not appear to be based on a
systematic scientific foundation. What, then, are the sources of this treatment
and the associated belief system? Some of them involve conventional
psychological work, accepted at one time, but now obsolete, and others are
associated with unconventional or “alternative” treatments. It may be easiest
to divide these into relatively recent sources, say from 1940 on, and then to
examine the earlier historical background.
Sources
from 1940 to 2000
An obvious source of Prekopova’s approach was the work of
Kanner (1943), who first described the syndrome of infantile autism and noted
its association with a lack of warm, nurturing care from mothers who were
popularly referred to as “refrigerator mothers”. Kanner argued for an
environmental cause for autism, as did Bettelheim (1967 ). At about the same
time, Harlow’s( 1964) experiments with rhesus monkeys deprived of maternal care
suggested an autistic-like outcome of deprivation, in which the monkeys had
poor social interactions with others, failed to mate normally, and showed poor
infant care if they did mate and gave birth--
work that was considered important for human development and was
included by Bowlby (1982) in his formulation of attachment
theory. These views, with their emphasis on an environmental source for autism,
were important background for the belief that HT could cure autism and other
disorders.
During roughly the same period, Wilhelm Reich, a former
student of Freud’s who was later thought of as an advocate of “wild
psychoanalysis” (Freud, 1910/2007), immigrated to the United States and
introduced his physically-intrusive method of psychotherapy. This method
involved a naked or near-naked patient who was prodded and poked painfully in
areas of the body that Reich considered to be the source of inflexibility and
“character armor”—primarily around the neck and upper torso (Sharaf, 1983).
Reich assumed a connection between body and mind such that physical states
reflected mental states, and alterations caused in physical states could also
create mental changes. Reich believed that his treatment was responsible for
the reduction of the Moro reflex in his infant son (this reflex normally
disappears gradually in the first months of life and presumably did so in this
case as well). Reich appears to be the major initial source for beliefs about
the therapeutic effects of distressing physical treatment in the period
1940-1990, and thus is important to the background of HT.
The American hypnotherapist Milton Erickson ( 1962 )
advocated the use of restraint in treatment of oppositional children. He
advised a mother to sit on her child for hours at a time and to restrict his
diet to nonpreferred foods. Erickson described the outcome of this treatment as
greatly increased cooperation from the child, to the extent that he trembled
when the mother spoke to him. Erickson’s attitude in this case seems to be
among the first to show approval of treatments that cause child distress, as HT
clearly does.
By the late 1960s and early ‘70s, the American
psychologist Robert M. Zaslow was using physical restraint as a treatment for
autism and other disorders (Zaslow & Menta,1975). Zaslow’s method, which he
called “Z-therapy” or “rage-reduction therapy”, employed two or more adults to
restrain a supine child, sometimes for hours, while Zaslow prodded the child’s
torso and squeezed the face to force the mouth open. Zaslow’s California
psychology license was revoked after he injured an adult patient, but he
traveled, teaching his method, and eventually taught for several semesters at a
German university. Forced eye contact, a part of Zaslow’s method, was discussed
in a later paper that posited a “Medusa complex” and claimed that the vision of
a blind child had been restored through “Z-therapy” (Zaslow, 1982). Although it
is not clear that Zaslow and Prekopova ever met, and although the specific
techniques of “Z-therapy” and HT are far
from identical, the two treatments share assumptions about causes of autism,
about the effects of physical restraint, and about the importance of child
distress for therapeutic purposes.
In the course of Zaslow’s travels, he met an American
physician, Foster Cline, in a remote area of Colorado. Cline began to perform
“rage-reduction therapy”, to write advice about
the method (including in one book the full text of an Erickson paper [Cline,1992]),
and gradually established this version of HT as a cottage industry in the small
town of Evergreen. (The “rage-reduction”, Zaslow-like approach is sometimes
called the “Evergreen model”.) Cline focused his work on adopted children who
were unsatisfactory in their behavior and attributed their problems to the
broken attachment between the child and the birth parent; treatment was to
destroy their rage and permit them to form a new attachment (see Stryker,
2011). Cline later surrendered his professional license after a disciplinary
hearing by the state medical board.
Visitors to Evergreen included Martha Welch, soon to
become the protégée of Tinbergen. Her 1989 book described a version of HT
(“holding time”) that closely resembled Prekopova’s
method and was subsequently cited by Prekopova.
The
1940-1990 period was one in which intrusive psychotherapies, intimidation, and
coercion of various kinds were often tolerated or even approved by mental
health professionals. This was especially the case during the 1970s and ‘80s,
when drug rehabilitation efforts became a major focus of mental health
practice, and organizations like Synanon demanded change from clients (Janzen,
2001). In addition to the attitude of Erickson, mentioned earlier, this period
in the United States saw the performances of Jacqui Schiff , a Transactional
Analyst whose work was associated with the scalding death of a schizophrenic
patient (Marlan, 2001) and John Rosen, a psychologist who was charged with
having pushed a patient down a flight of stairs ( Dolnick, 1998; Sidney Hammer
et al. v. John N. Rosen, 1960 ).
Physical contact with patients, generally
prohibited in earlier psychoanalytically-influenced treatments, was now
accepted by a number of psychotherapists. Among these was an American
practitioner, Daniel Casriel, who was later referenced by Prekopova. Casriel’s
form of treatment involved a face-to-face embrace with prolonged eye contact,
which he considered essential to recovery from emotional disturbance (1972).
Casriel’s early death was preceded by testimony to the U.S. House of
Representatives, in which he spoke glowingly of a friend’s miracle cancer cure,
suggesting that like Wilhelm Reich before him, he did not require scientific
plausibility as support for acceptance of a treatment.
Looking
for sources of Prekopova’s HT methods, it is necessary to look not only for
predecessors who encouraged face-to-face contact as part of therapy, but also
for those who posited that events of early development could be “replayed”
through processes of regression and recapitulation. Although this
psychoanalytic concept was common among psychologists and psychiatrists during
the 20th century (for example, it was accepted by Donald Winnicott,
a leading British child psychologist), the period of the 1970s was one in which
regression, or a functional return of the patient to an early stage of
development, received particular emphasis. The Hungarian-British psychoanalyst
Michael Balint was a strong proponent of the regression concept, and for the
idea that the “basic fault” in mental illness occurred at a point when the
child’s social skills were limited to two-person interactions (i.e., in the
first months of life) (Stewart, Elder, & Gosling, 1996). (Balint also
considered therapeutic progress to be shown when the patient experienced
paranormal events like clairvoyance.) The British psychologist R.D. Laing, a
founder of the “anti-psychiatry” movement, considered regression to impulsive
emotional expression as a key to recovery from mental illness (Laing &
Esterton, 1964/1970).
From
the 1990s onward, an important source for Prekopva’s thinking was the
“spiritual” alternative psychotherapy of the German practitioner Bert Hellinger.
Their work together is still in print (Prekop & Hellinger, 2010).
Hellinger’s Family Constellations method involves group psychotherapy in which
individuals are assigned to represent family members, including stillborn
infants and others unknown to the primary patient. The emotions experienced by
the representatives are taken as true communications of the feelings and
thoughts of the represented person. Emotional or behavioral problems are
attributed to the influence of a distressed ancestor, and
personally-experienced traumas such as rape are considered to be resolvable
only when the attacker is forgiven, and are worsened if the victim seeks
redress. One of Hellinger’s concepts that has been adopted by Prekopova is the
idea of “orders of love”, in which a hierarchy of familial authority (e.g.,
eldest child superior to younger, husband superior to wife) must be observed in
order for mental health to be achieved. The
connection to HT, in which the parent restrains the child until the child submits,
is evident.
Earlier
Background of HT
The previous section of the paper has shown how a number
of more or less well-known practitioners in the 1960s, ‘70s, and ‘80s advocated
coercive physical contact in therapy, accepted the idea that autism and other
mental disorders were caused by early postnatal experiences, and agreed that
intense emotional interaction could cure mental illness. Their acceptance of
these propositions buttressed Prekopova’s justifications for her HT methods,
which emerged toward the end of this time period. However, it may be useful to
ask on what background sources the idea of Balint, Casriel, Zaslow, and many
others were based.
The historical background of those approaches is complex,
and there is room in this paper for only a brief summary of this story.
However, it is important to realize that Prekopova and others did not create
their systems from a totally new perspective. The characteristic emphasis on
the body, on primitive emotions, and on the earliest events of life was foreshadowed
by the German “crisis of culture” in the early 1900s (Henle, 1978; Toole,
2007), and by the Counter-Enlightenment movement (Berlin,1973) that opposed the
previous strong emphasis on reason in the study of human beings.
In 1923, the so-called “schismatic year” for
psychoanalysis (Poster, 2009), former protégés of Freud began to suggest
methods and beliefs that Freud referred to as “wild psychoanalysis”. Rather
than following the austere and controlled techniques of the classical Freudian analyst,
the “wild psychoanalysts” accepted a wide range of methods and were said to be
motivated by the furor sanandi or
frenzy for curing (Langan, 2007). Among the influences on the “wild
psychoanalysts”-- and still influencing
practitioners like Prekopova today—was the physician Georg Groddeck, author of Das Buch vom Es (The book of the it, 1923/1949),
a popularized volume arguing that one’s thoughts and actions are determined
by a life force, not by the self. This life force, the Es (or id, in Freud’s translated term) acted to create unconscious
communication between patient and therapist and to insure that the effects of
treatment were mutual. Both mental and physical illness served the purposes of
the life force rather than of any conscious intention-- a concept easily linked to Hellinger’s
assumption that an individual representing an
ancestor will experience that ancestor’s feelings and wishes.
An essential member of the “wild psychoanalysts” was
Sandor Ferenczi, a colleague of Groddeck’s as well as a former student of
Freud’s. Ferenczi emphasized the need for patients to experience regression in
the therapy session, and he re-enacted aspects of parental care by kissing
patients (Dupont, 1995). Stressing the relational nature of mental illness and
treatment, Ferenczi worked with Otto Rank, who shifted from Freud’s
father-centered perspective to a stress on birth experiences and separation
from the mother. (Michael Balint, who was mentioned earlier, began as a student
of Ferenczi’s and later his colleague in Budapest.)
Discussion
HT as carried out by Prekopova and others is more easily
associated with “wild psychoanalysis” than with any scientific evidence, and in
this it closely resembles a variety of the other unconventional or alternative
mental health treatments that became fashionable during the period from
1940-2000. In addition, Prekopova’s beliefs and practices have clear
connections with beliefs accepted 50
years ago and now rejected; for example, the methods of Zaslow, almost
universally condemned today, were published and discussed in conventional
journals at one time, and Kanner’s perspective on autism was once the
conventional view.
What factors make Prekopova’s HT, old-fashioned as it is,
acceptable not only to clients but to some members of the Czech-Moravian
Psychological Association-- in spite of
the critical efforts of Feuser (1988), Schuster (n.d.), and Stoermer and
Kischkel (1988) during Prekopova’s period of practice in Germany? There are a
number of assumptions that may lend their support to this form of HT. The long
history of “wild psychoanalytic” methods may be supportive in that clients may have a general familiarity with
beliefs about emotion and the role of the body in mental life. Throughout the
developed world, in addition, there is a common assumption that problems of
mental health date back to childhood experience (“something nasty in the
woodshed”), and that the earlier an event, the greater its psychological
impact. In spite of movements toward fathers’ rights, most popular beliefs
place the physical connection between mother and child as the foundation of
later personality development.
Some Judeo-Christian tenets also provide support for HT
assumptions and practices. For example, the role of the parent as an authority
is essential to HT, and for some Christian groups of Calvinistic tendencies the
parent is not only an authority, but the parent-child relationship is the model
for the God-adult relationship. God demands obedience, and child disobedience
prefigures the disobedience to God that will end in damnation. Parents thus
have an obligation to exert their authority, to “break the child’s will”, and
thus to ensure his salvation.
The rituals of child restraint are reminiscent of shamanistic
practices, especially in their efforts to recapitulate events that were omitted
in the past and which are thought to be affecting the present and future. At
the same time, however, HT practices are influenced by the psychoanalytic
concept of regression and the belief posited by a number of psychoanalytic
psychotherapists (e.g., Frieda Fromm-Reichmann,1948) that regression could be
encouraged by ritual repetitions of childhood events, and that recapitulation
of healthy development could follow.
More generally, however, the acceptance of Prekopova’s HT
by parents, and by some professionals as well, may have its foundations in a
present failure of critical thinking as well as in historical factors.
Examination of some of Prekopova’s claims (e.g., Gruen & Prekop, 1986) shows that the arguments given in support
of HT are much weakened by the presentation of irrelevant information and other
logical errors that are commonly used to persuade an audience. Both Tinbergen
and Prekopova were guilty of using a false analogy when they likened early
human emotional development to concepts drawn largely from bird and fish
behavior. This was a surprising fault in Tinbergen’s case, as ethology stresses
the species-specific nature of behavior and notes that even closely related
species may have considerable differences in behavior; for example, if Harlow
had used a different monkey species, he might well have drawn different
conclusions about the effect of separation from the mother (Seay &
Gottfried, 1975). Having begun with this false analogy, however, Prekopova was
in a position to present as foundational to her view a series of legitimate but
irrelevant biological findings like those of von Holst and of Lorente de No
(see discussion earlier in this paper). Clearing away this thicket of fallacies
reveals that there is no scientific information supportive of HT, and in the
absence of empirical evidence no support exists except anecdotes and
testimonials as reported by Prekopova herself. Unfortunately, naïve readers,
and especially parents who are deeply distressed about their child’s autism or
other disorders, are rarely able to search out the information that would let
them bring critical thinking to bear on claims about HT.
Is
HT Child Abuse?
HT appears to be without scientific support and seems to
be closely related to “alternative” beliefs and practices that go back for a
century or more. HT is also obviously associated with severe distress on the
part of children (as evident in Prekopova’s own videos, in testimony like that
shown at www.invisibleengland2.wordpress,com,
and in deaths and injuries resulting from similar treatments in the U.S.) , and
takes time and other resources from families that might be much better expended
in supporting good early development in both typically- and atypically-developing children. If a
practice is not an effective treatment, and if it causes distress and prevents
better treatments, is it appropriate to class it as child abuse? This question
is especially relevant to our consideration of HT in the context of the last
decade of strict regulation about the use of restraint in U.S. residential
treatment centers and hospitals (Haimowirtz, Urff, & Huckshorn, 2006).
Prosecutions for child abuse are usually limited to
situations in which demonstrable physical injury has occurred, and laws do not
usually attempt to list actions (other than sexual ones) that would be
considered abusive even if they could not be shown to have caused injury.
Discussions of emotional abuse have been
of interest in research on parenting practices, and may have played roles in
child custody decisions, but have not been a part of legal definitions of child
abuse.
In the United States, however, some research on child
abuse has been based on a list of adult actions that are to be considered
abusive no matter what their demonstrable impact on the child. This list of criteria, the NIS-4 Maltreatment
Typology (Sedlak, Mettenburg, Schultz,
& Cook, 2003) contains a number of actions that are directly related to HT
as practiced by Prekopova. Among these
are NIS-4 05.1 (Close Confinement, Tying, Binding), including not only the
physical restraint integral to HT, but the use of fabric covers in rebirthing. O6.1,
08.2, and 06.3 involve verbally assaultive or abusive treatment, which would
include the shouting of the mother in HT as she expresses her anger and
resentment about the child’s behavior. Another relevant category, 17.1,
involves refusal to allow or provide care for diagnosed emotional or behavioral
impairment; parents who confine treatment for autistic children to HT may
believe they are providing appropriate care, but they are not using some of the methods that,
while imperfect, do have evidentiary foundations. Finally, the NIS-4 category
17.5, Other Emotional Neglect: Inappropriately Advanced Expectations, seems to
apply to the belief that the child needs to listen to his mother’s expression
of negative emotions in order for the pair to have an appropriate relationship;
this appears to be at odds with the needs of pre-pubescent children for a
secure and supportive attitude on the part of parents, as opposed to a role
reversal in which the child must be supportive of the mother.
Although Prekopova’s HT method has not been reported to
cause injuries or deaths, as has been the case with some methods in the United
States, its use of some of the actions defined as abusive under the NIS-4
Maltreatment Typology suggests that it is appropriate to consider the method a
type of child abuse. Although tort law may not make it possible to pursue
abusive treatment of this type, it is possible that human rights law, which
stresses positive protections, will be able to do so. However, as Prekopova and
other HT practitioners act as coaches for parents rather than having hands-on
contact with children, it becomes difficult to see exactly how their activities
can be regulated, except possibly in terms of deceptive advertising.
Conclusion
As this paper has shown, Prekopova’s HT practices are not
based on scientific foundations or supported by empirical work. On the
contrary, they are derived from nonscientific (and in some cases supernatural)
beliefs. Prekopova’s practices meet
certain research criteria for classification as child abuse, but do not meet
legal criteria.
References
Anderson,
J. W. (1972). Attachment behavior out of doors. In N. Blurton Jones (Ed.), Ethological studies of child behavior
(pp. 199-216). Cambridge: Cambridge
University Press.
Beaudet, A.L. (2012).
Preventable forms of autism? Science, 338, 342-343.
Berlin,
I. (1973). The Counter-Enlightenment. In P. Wiener (Ed.), Dictionary of the history of ideas, Vol II (pp.100-112). New York:
Scribner.
Bettelheim, B. (1967). The empty fortress. New York: Free
Press.
Bowlby, J. (1982). Attachment. New York: Basic.
Burchard,
F. (1988). Verlaufsstudie zur Festhaltetherapie: Erste Ergenbniss bei 85
Kindern. Praxis der Kinderpsychologie und
Kinderpsychiatrie, 37(3),89-98.
Casriel, D. (1972). A scream away from happiness. New York:
Grosset & Dunlap.
Cline, F. (1992). Hope for high risk and rage filled children.
Evergreen, CO: EC Publications.
Dolnick, E. (1998). Madness on the couch. New York: Simon
& Schuster.
Dupont,
J. (Ed.) (1998). The clinical diaries of
Sandor Ferenczi. Cambridge, MA: Harvard University Press.
Eibl-Eibesfeldt,
I. (1970). Ethology: The biology of
behavior. New York: Hol;t, Rinehart, and Winston.
Erickson, M.H. (1962).
The identification of a secure reality. Family
Process, 1(2), 294-303.
Feuser,
G. (1988). [Aspects of a critique of the method of “forced holding” (holding
therapy) in autistic and otherwisedisabled children and young people.] Special Education, 27(2). Retrieved from
http://bidok.uibk.ac.at/library/feuser/festhalten.html#idp645392.
Freud, S. (1910/2007). Wild analysis. London: Penguin.
Fromm-Reichmann,
F. (1948). Notes on the development of treatment of schizophrenics by
psychoanalytic psychotherapy. Psychiatry,
11, 253-273.
Gernsbacher,
M.A. (2003). Is one form of autism early intervention “scientifically proven”? Journal of Developmental and Learning
Disorders, 7, 19-25..
Gernsbacher,
M.A., Dissanayake, C., Goldsmith, H.H., Mundy, P.C., Rogers, S.J., & Sigman,
M. (2005). Autism and attachment disorder (letter). Science, 307, 1202.
Groddeck, G.
(1923/1949). The book of the it. New
York: Vintage.
Gruen,
A., & Prekop, J. (1986). Das Festhalten und die Problematik der Bindung in
Autismus: Theoretische Betrachtungen. Praxis
Kinderpsychologie und Kinderpsychiatrie, 35, 248-253.
Haimowitz,
S., Urff, J., & Huckshorn, K.A. (2006). Restraint and seclusion: A risk
management guide. Retrieved from www.nasmhpd.org/docs/Policy/R-S%20RISK%20MGMT%2010-10-06.pdf.
Harlow,
H.F. (1964). Early social deprivation and later behavior in the monkey. In A.
Abrams, H.H. Gurner, and J.E.P. Tomal (Eds.), Unfinished tasks in the behavioral sciences (pp. 154-173).
Baltimore, MD: Williams & Wilkins.
Henle,
M. (1978). Gestalt psychology and Gestalt therapy. Journal of the History of the
Behavioral Sciences,14,
23-32.
Hutt,
C., & Hutt, S.J. (1969). Biological studies of autism. Journal of Special Education, 3(1), 3-11.
Hutt
, S.J., & Hutt, C. (1968). Stereotypy, arousal, and autism. Human Development, 11, 277-286.
Janzen,
R. (2001). The rise and fall of Synanon:
A California utopia. Baltimore,MD: Johns Hopkins University Press.
Kanner, L. (1943).
Autistic disturbances of affective contact. Nervous
Child, 2, 217-250.
Laing, R.D., &
Esterton,A. (1964/1970). Sanity, madness,
and the family. London: Penguin.
Langan, R. (2007). Embodiment. American Journal of Psychoanalysis, 67, 249-259.
Lester,
V. S. (1997). Behavior change as reported by caregivers of children receiving
holding therapy. Retrieved from http://adoption.com/author/virginia-s-lester/
Lewin,
K., Lippit, R., & White, R.K. (1939). Patterns of aggressive behavior in
experimentally created social climates. Journalof Social Psychology, 10, 271-301.
Lovaas,
O.I. (1987). Behavioral treatment and normal educational and intellectual
functioning in young autistic children. Journal
of Consulting and Clinical Psychology, 55, 3-9.
Marlan,
T. (2000). A most dangerous method. The
Chicago Reader. Retrieved from
www.chicagoreader.com/chicago/a-most-dangerous-method/Content?oid=903012.
Mc
Guire, I., & Turkewitz,G. (1978). Visually elicited finger movements in
infants. Child Development, 49, 362-370.
Money,
J., & Ehrhardt, A. (1972). Man and
woman, boy and girl. Baltimore, MD: Johns Hopkins University Press.
Myeroff,R.,
Mertlich, G., & Gross. G. (1999). Comparative effectiveness of holding
therapy with aggressive children. Child
Psychiatry and Human Development, 29, 303-313.
Novarino,
G., El-Fishaway, P., Kayserili, H., Meguid, N.A., Scott,E.M., Schroth,J.,…
Gleeson,J.G. (2012). Mutations in BCKD-kinase
lead to a potentially treatable form of autism with epilepsy. Science, 338, 394-397.
Poster, M.F. (2009).
Ferenczi and Groddeck: Sympatico. Roots of a paradigm shift in
psychoanalysis. American
Journal of Psychoanalysis, 69, 195-206.
Prekop,
J. (1983). Ds Festhalten als Therapie bei Kindern mit Autismus-Syndrom.
Anwendung der Therapie durch das “Festhalten” nach Welch/Tinbergen. Teil 1. Fruefoerderung Interdisziplinaer, 2(2),
54-64.
Prekop
, J., & Hellinger, B. (2010). Wenn
ihr wuestet, wie ich euch liebe. Munich: Droemer Knaur.
Prekop,
J., & von Stosch, T. (n.d.). Festhaltetherapie im Urteil von Eltern—eine
Nachuntersuchung zur Wirksamkeit einer psychotherapeutische Verfahrens.
Retrieved from www.prekop-festhalten.de/festhaltetherapie.html.
Rohmann,
U.H., & Hartmann, H.(1985). Modifizierte Festhaltetherapie (MFT). Eine
Basistherapie zur Behandlung autistischer Kinder. Zeitschrift fuer Kinder- und Jugendpsychiatrie, 13(3), 182-198.
Rutter,
M. (1995). Clinical implications of attachment concepts: Retrospect and
prospect. Journal of Child Psychology and
Psychiatry,36, 549-571.
Sackett,
D., Rosenberg, W.M., Gray, J.A., Haynes R.B., & Richardson,W.S. (1996). Evidence based medicine: What it is
and what it isn’t. British Medical
Journal, 312, 71-72.
Schuster,
U. (n.d.) . Festhaltetherapie nach Prekop—Wirksame Hilfe oder
pseudowissenschaftlich verbraemte Kindesmisshandlung? Retrieved from http://www/religio.de/Daten/F/festhaltetherapie.html.
Seay,
B., & Gottfried, N. (1975). A phylogenetic perspective for social behavior
in primates. Journal of General
Psychology, 75, 5-17.
Sedlak,
A., Mettenburg, J., Schultz, D., & Cook, D. (2003). NIS
Definitions Review. Rockville, MD: Westat. Prepared for the United States
Department of Health and Human Services.
Sharaf, M. (1983). Fury on earth: A biography of Wilhelm Reich.
New York: St. Martin’s.
Sidney Hammer et al v.
John N. Rosen (1960, Marc 3). Court of Appeals of New York.
Stewart,
H., Elder, A., & Gosling, R. (1996).
Michael Balint: Object relations pure and
applied. London: Routledge.
Stoermer,
N. & Kischkel, W. (1988). Festhaltetherapie.Praxis Kinderpsychologie und
Kinderpsychiatrie, 37, 326-333.
Stryker, R. (2010). The road to Evergreen. Ithaca: Cornell
University Press.
Sudbery, J., Shardlow, S.M., & Huntington,
A.E. (2010) . To have and to hold: Questions
about
a therapeutic service for children. British
Journal of Social Work, 40, 1534-1552.
Tinbergen, N. (1974).
Ethology and stress diseases. Science,
185, 20-27.
Tinbergen,
N. & Tinbergen, E. (1983). “Autistic” children: New hope for a cure. London:
Allen and Unwin.
Toole, A. (2007).
Wilhelm Dilthey on the objectivity of knowledge in the human sciences.
Trames, 11(61/56),
1, 3-14.
Van
der Horst, F.C.P., & van der Veer, R. (2010). The ontogeny of an idea: John
Bowlby and contemporaries on mother-child separation. History of Psychology, 13(1), 25-45.
Victor,G. (1983/1995). The riddle of autism. Northvale, NJ:
Jason Aronson.
Welch, M. (1989). Holding time. New York: Fireside.
Welch, M.G.,
Northrup, R.S., Welch-Horan, T.B., Ludwig, R.J., Austin, C.L., & Jacobson,
J.S. (2006). Outcomes of Prolonged
Parent-Child Embrace therapy among 102 children with behavioral disorders. Complementary Therapies in Clinical
Practice, 12, 3-12.
Wimmer,
J.S., Vonk, M.E., & Bordnick, P. (2009). A preliminary investigation of the
effectiveness of attachment therapy for adopted children with Reactive
Attachment Disorder. Child and Adolescent
Social Work, 26, 351-360.
Zaslow,
R.M.(1982). Der Medusa-Komplex. Die Psychopathologie der menschlichen
Aggression in Rahmen der Attachment-Theorie, widergespiegelt in Medusa-Mythos,
dem Autismus und der Schizophrenie. Zeitschrift
fuer Klinische Psychologie und Psychotherapie, 30(2), 162-180.
Zaslow,
R.M., & Menta,M. (1975). The
psychology of the Z-process: Attachment and activity. San Jose, CA: San
Jose State University Press.
