Wednesday, August 15, 2012

Parsing the "Attachment Cycle": The Fox Terrier of Attachment Therapy

        Parsing the “Attachment Cycle”: The Fox Terrier of Attachment Therapy
                                   Jean Mercer

 Practitioners of Attachment Therapy often reference the development of attachment according to a pattern they call the “attachment cycle”. This paper examines the possible sources of this concept, notes that the “attachment cycle” is not congruent with current conventional views of attachment but seems to be derived from a mixture of unconventional and older conventional theories, and suggests that commonly observable aspects of early development contradict the “attachment cycle”. The potential dangers of belief in the posited “attachment cycle” are discussed.   

According to Steven Jay Gould, when Darwin was describing the “dawn horse” Eohippus he described it as the size of a fox terrier. Of course, in his day, most people likely to read his work rode to hounds and knew what a fox terrier (as opposed to a fox hound) was. They knew what size Darwin meant. But, as time went on and fewer and fewer people had the resources or the beliefs that would encourage fox hunting, fox terriers became less common, and relatively few people knew how big they were and how big Darwin meant that Eohippus was. Authors discussing Eohippus nevertheless copied Darwin and each other, and continued to compare the ancient animal to a fox terrier, communicating little to their readers. The same thing can and does happen as authors writing about  mental health issues copy each other--  and it happens most easily when it’s a diagram that’s copied.

When an author provides a simple, decorative diagram that illustrates a claimed connection between events, it’s hard for readers not to assume that the existence of the diagram confirms the existence of the events and of connections between them. Maslow’s all-too-famous hierarchy of needs exemplifies this phenomenon—thousands of people can recognize and even reproduce the pyramid diagram, even though they may have no clear idea of the claims being made or the presence or absence of empirical support for them.
In discussions of vernacular, unconventional psychological principles--  for example, the belief system behind “Attachment Therapy” (Holding Therapy, Rage-reduction Therapy, Z-therapy, and other names as well)—proponents often employ a diagram showing events in an “attachment cycle”. This diagram can be seen in the works of Foster Cline and of Vera Fahlberg, and currently at, at, at, and so on for pages of Google. Diagrams of the “attachment cycle” show repeated incidents in which a baby feels a need, a caregiver responds appropriately, the baby is gratified--  and after many repetitions the baby becomes attached to the caregiver. A disturbed “attachment cycle” is represented like this:

                                                  Baby has a need
                              (possibly including smiles and social reinforcement)
                               /                                                                \                             /
Trust does not develop, rage develops instead                     Baby cries
                              \                                                             /
                                 \                                                        /
                                         Caregiver does not respond
For some authors, the “attachment cycle” ends here. Meet the baby’s needs and the baby becomes attached (defined here as developing trust)--  fail to meet them, and he or she does not become attached (defined here as responding with rage). For Cline and some others, however, this diagram shows only a “first year attachment cycle”. Attachment is not complete, they say,  until the child learns to accept and indeed love the limitations and boundaries created by a powerful caregiver in the course of a “second year attachment cycle”. We can consider the first-year cycle by itself and then return to examine the notional second-year cycle.
It’s clear that these repeated sequences, posited by Cline and Fahlberg as part of a first-year attachment cycle, do occur. Babies cry when they need something, and they are either helped or not helped by their caregivers. Toddlers  also certainly test boundaries, and are either corrected or not corrected by their caregivers. Because babies cry when they actually do need something, a baby who is frequently ignored or treated inappropriately may not survive. In addition, to look forward to the second year, a toddler whose boundary-testing is not responded to appropriately may be injured or killed as a result of risk-taking--  these possibilities are plain. What’s not so clear is whether either of these scenarios has anything to do with attachment in any direct manner--  yet Cline, Fahlberg, and various followers have insisted that the demonstrably repeated sequences are the causes of attachment. 
Like the Maslow diagram, this depiction of a “cycle” seems intended to operate as its own proof. Many  readers who see it seem to be convinced that that where there’s a diagram, there’s reality. Cline and his colleagues have made no effort to adduce data to support their claims, but they have attributed some parts of  the “cycle” idea to other authors. Fahlberg (1991),    for instance,  references Rene’ Spitz’s book The first year of life (1965),  but she also shows diagrams of a related “arousal-relaxation cycle” whose source is unmentioned.
                             The “First-Year Attachment Cycle”
Is Spitz’s Work the Source of the “Attachment Cycle”?
What are the actual sources of the “attachment cycle” idea? Fahlberg’s reference to Spitz suggests that his work is a good place to begin the search. Like many other authors, Spitz was interested in the long-term effects of the infant’s repeated experiences with adequate or inadequate caregiving. As he pointed out with respect to feeding, “the two parts of the experience, the hunger screaming and the gratification which follows it, become linked in the child’s memory. … This development should be understood in the terms of Ferenczi’s… propositions on the stage of infantile omnipotence. Hunger screaming, followed by gratification, forms the basis for the feeling of omnipotence, which according to Ferenczi is an early stage of the sense of reality… In this achievement of enlisting the mother’s help for his needs through screaming, the human being experiences for the first time the post hoc ergo propter hoc in connection with his own action” (Spitz, 1965, p.153). But Spitz associated these sequences of experience with memory, with perception, and with the understanding of causality. The word “attachment” did not appear in the index of the book at all. Spitz’s work does not seem to be the source of the “attachment cycle”.
How Does Erikson’s Concept of Trust Relate to the “Attachment Cycle”?
What about other repeated events or cycles as proposed by influential authors? Fahlberg, Cline, and other authors occasionally refer to Erik Erikson’s concept of basic trust (Erikson, 1950/1963). A sense of trust is thought to develop in the course of repeated experiences of good care, but trust is not exactly the same as attachment. Erikson pointed out the need for an appropriate balance of trust and mistrust, but conventional attachment theory emphasizes the advantages of secure attachment over other attachment statuses, both with respect to later social relationships and with respect to support for childhood exploration and learning. Erikson speaks of a life cycle, of course, but he does not refer to a cycle of repeated experiences when he says this--  instead, the life cycle consists of a number of qualitatively different stages of social and emotional life, occurring in a predictable order.
A Behavioristic Approach
Neither Cline nor Fahlberg gives specific mention of the possibility that operant conditioning could play a role in attachment. To think along these lines involves examining the possible process of reinforcement for attentiveness to the caregiver--  and, in addition, for the caregiver’s attentiveness to the baby. J.L. Gewirtz (1969) proposed a theory of mutual effects of parent and child on each other, with social reinforcement for the child from that care and affectionate attention of the adult, and for the adult from the pleasure shown by the infant. In a series of systematic observations of mothers and babies (a strategy all too rare among theorists addressing this topic), Gewirtz was able to show mutual reinforcement and gradual change of mother’s and child’s behavior toward each other. In fact, the “first-year attachment cycle” is quite parallel to Gewirtz’s suggestion, as both involve spontaneous behavior related to infant needs, adult responses, and ensuing learning. However, like all operant conditioning approaches, Gewirtz’s theory  would allow for attachment behavior to be maintained after it is once established, even though the adult response became less and less frequent; the “attachment cycle” theory suggests instead that failure to respond produces rage and interferes with the development of emotional attachment.
Can the “Attachment Cycle” Be Recognized Under Some Other Name?
Fahlberg herself provides an additional  diagram that may provide a clue to the sources of the “attachment cycle”. This shows the “arousal-relaxation cycle” mentioned earlier. It involves arousal of energy and attention by a physical need, a reaction to that need (like crying), followed by either appropriate care and subsequent relaxation when the need is gratified or by continued distress and a failure to learn that caregivers will help. This cycle resembles, in name and otherwise, Wilhelm Reich’s “four-beat” motivational cycle. Reich ( 1980; originally published 1945) posited that in all motivation there is some form of mechanical tension, followed by an increased electrical charge, an electrical discharge, and mechanical relaxation. This cycle, Reich thought, had a biological foundation and could be seen in events ranging from orgasm to mitosis.  Reich, who died in prison after conviction for selling fraudulent medical devices,  believed that transfer of an unknown energy called “orgone” was at work in all these phenomena. I would suggest that Reich’s motivational cycle was the source of the “ first-year attachment cycle” presented by Fahlberg and by Cline, as well as by many imitators (e.g., Golding, 2008 ).
Neither Fahlberg nor Cline attributed the arousal-relaxation cycle or the “attachment cycle” they derived from it to Reich. This is not surprising, because authors dependent on unconventional beliefs often fail to cite their sources. It’s notable, though, that Robert Zaslow, Cline’s mentor (and perhaps Fahlberg’s also?) frequently referred to Reich’s theories as sources (Zaslow & Menta, 1975) and proposed a “soul cycle” that is comparable. Because the “attachment cycle” is not to be found in any other discussions of early emotional development, it may well be that this “fox terrier” has been brought back again and again without sourcing, to the point that few readers know what it is or where it came from.
                                        The “Second-Year Attachment Cycle”
Fahlberg had little or nothing to say about a “second-year attachment cycle”, but Cline
 ( 1992) emphasized the importance of this period, during which, he claimed, caregiver limit-setting was essential to the further development of attachment. He backed up this statement by a reference to Bowlby’s remark that caregivers who become attachment figures are usually stronger and more authoritative than the children, an idea that Cline tweaked into the claim that the adult’s strength and power are actually the causes of aspects of attachment.

It’s readily observable that parents all over the world do set limits on their young children’s actions, usually starting at about the end of the first year, when expert crawling and the beginning of independent walking make “mischief” more possible. Toddlers are pressed to become toilet-trained, to use spoken words rather than screaming or grabbing for what they want, and to stay away from dangerous or breakable things. There may be poor outcomes of behavioral development both for children who receive little limit-setting and for those subjected to many rules and much punishment for infractions. Careful guidance during the toddler period helps establish self-regulation and self-control.
Does limit-setting during this period have anything to do with attachment? Evaluations of attachment like the Strange Situation (Ainsworth, Blehar, Waters, & Wall, 1978) focus on the beginning of the toddler period at about 12 months of age, before much limit-setting is usually in place. This suggests that attachment in Bowlby’s sense is already established before the second year is well underway. Bowlby himself referred to this period of development as one in which parent-child relationships began to modulate from the intensity of earlier stranger and separation anxiety to include negotiation and compromise between the parties--  a situation that seems to contradict Cline’s claim.
Cline, Fahlberg, and others have also appealed to the basic trust/ basic mistrust concept proposed by Erikson as the important developmental issue of the first year of life. But what does Erikson suggest about the second year? He proposed that the second year or so of life involves a new focus on a sense of autonomy, or confidence in one’s own decision-making about how to do things, as opposed to a sense of shame and doubt that emphasizes other people’s opinions and worth. Recognizing that toddlers need to be socialized and learn to follow family rules, Erikson nevertheless suggested that the task of socialization can be done through consistent gentle guidance, helping the individual to have confidence in his ability to “do things right”, or as an alternative can overwhelm the toddler’s abilities and leave a readiness to feel himself in the wrong. Cline’s stress on the power and authority of the caregiver would seem to work against a sense of autonomy, which Erikson argued children needed to develop even though adults are, realistically, stronger and more knowledgeable than toddlers are.
Like other object-relations theorists, Spitz considered frustration to be a factor in the infant’s progress toward understanding reality. Limit-setting, even of the mildest form, is frustrating to young children--  so does this mean that Spitz’s views support the Cline “second-year attachment cycle” belief? No, because (again like other object-relations theorists), Spitz believed that frustration played an important role in development during the first year, when it would not often be associated with limit-setting.
There seems to be no support from theorists of personality development for the idea that limit-setting  in the toddler period contributes to the growth of attachment per se,  although it is clear that experiences of limit-setting influence other aspects of personality and behavior. Bowlby (1944) considered that some juvenile delinquents were influenced by poor attachment histories, but did not connect obedience specifically with attachment. Why, then, did Cline attempt a rapprochement between limit-setting and attachment? He has not explained this, but we can speculate that the goal is to complete Cline’s posited association between attachment and obedience. Cline and various colleagues have claimed repeatedly that problems of attachment are indicated by the child’s disobedience and undesirable behavior, and that treatment by means of  Attachment Therapy will make the child “respectful, responsible, and fun to be around” and ensure that he or she does things “Mom and Dad’s way”. Cline’s commercial parent-education program, “Love & Logic”, is primarily concerned with obedience and compliance with adult wishes. The concern with obedience, combined with the assumption that all behavioral problems ultimately result from attachment issues, appears to have brought compliance under the attachment umbrella and thus created the “second-year attachment cycle” belief.
                           How Can We Know What Causes Attachment?
Attachment behavior is readily observed, but attachment itself (as an internal state and motivating factor) must be inferred. As a result, no one can see attachment happening—although Gewirtz (1969) reported what appears to be a relevant set of processes. Until attachment has happened and attachment behavior is present, we can only guess at the internal process. This means that the problem of associating later attachment with one or more causal factors is a serious one.
Various causes of attachment have been suggested, some more and some less likely. Authors like Nancy Verrier ( 1993) propose that babies are already emotionally attached to their mothers at birth, but infants’ behavior does not support this view. Sigmund Freud attributed attachment to the experience of being fed by a particular person. John Bowlby emphasized the effect of pleasurable social and emotional interaction with a caregiver, and proposed that infants in the second year of life are biologically primed to learn a connection with a familiar adult.  As has been noted already, Cline and other Attachment Therapists hold that repeated experiences of satisfied needs create attachment to the adult who provided the satisfaction.

Almost all attachment phenomena share a particular problem that stands in the way of accurate analysis. This is the fact that most often, the person (or people) who plays with and shows affection to a baby is the same person (or people) who feeds, cleans, rocks, and comforts that child.  The confounding of these factors means that in the ordinary course of events we are not going to be able to separate the effects of feeding, of repeated satisfying cycles, or of social interaction.
Nevertheless, some observations do allow us to think about causes of attachment. For example, in many families, one parent is much more involved than the other in infant care. We would expect that parent to be the only important attachment figure, if the “first-year attachment cycle” applies; yet we see babies display great interest in a parent who does little physical care but who when present is playful and socially engaging. Sadly, we also see that children form attachments to caregivers who are neglectful and even abusive, and grieve when separated from the adults, suggesting that satisfying care is not very important to attachment, or that if it is important, very little of it is required to do the job. Finally, reports on the traditional kibbutz child-rearing methods (see Bettelheim,1969) suggest that infants cared for with little interaction with adults, but physically healthy, become engaged with and attached to nearby “crib-mates” and are distressed if those babies are separated from them for some reason; other infants cannot have participated in feeding or care, but may have been either socially interactive or simply familiar in the sense that they were almost always there. These observations imply that repeated experiences of the “attachment cycle” are not actually causes of attachment.

Several other developmental phenomena appear to argue against the “attachment cycle” as an explanation of emotional attachment. The first of these is the  prefiguring of attachment behavior by a period of infant “wariness”, in which the 6- or 7-month-old, who used to be highly sociable, begins to regard new people with a serious air and warms up slowly to those who behave pleasantly and engagingly. At about the same time, many babies begin to show fear of sounds and events that are familiar but perhaps startling, like the sound of the garbage truck or a vacuum cleaner being turned on. This change occurs before and predicts the obviously attachment-related behaviors of stranger and separation anxiety, but it is difficult to see how a gradual development by way of a repeated “attachment cycle” could be connected with the development of fearfulness and its mirror image, a strong preference for the familiar.
A second relevant event is the often dramatic sudden emergence of attachment behaviors at about 8 to 12 months of age. This developmental milestone would seem to indicate a reorganization of behavior and emotion of the kind posited by dynamic systems theory. In Bowlby’s attachment theory, the abrupt change (sometimes evident over a day or two) involves a combination of maturation and of experience rather than repeated experience alone. Simple repetition and reinforcement might be expected to show a conventional learning curve, but not the sudden increase in a behavior’s frequency shown in observations of infant and toddler behavior.
An additional phenomenon that appears incongruent with the “attachment cycle” theory is that of transitional objects. The toddler’s attachment to objects such as “blankies” and teddy bears has been described by Winnicott (1953) and is familiar to anyone who has cared for very young human beings. The display of attachment to the transitional object is parallel to attachment to caregivers, and is notably not a substitute for attachment to a familiar person. The toddler who is devoted to a transitional object wants the specific object as well as the familiar caregiver and may not be able to be calmed by the caregiver alone. Yet the transitional object cannot have participated in an “attachment cycle”, can provide little in the way of need satisfaction other than a sense of familiarity, and certainly does not have as many ways of satisfying needs as a human caregiver can provide. In addition, transitional objects do not appear to function until after attachment to caregivers begins to be displayed, and although the object may have been offered to the baby prior to attachment, it has usually been one of many, all providing equal experience, but only one eventually being selected as the needed blanket or bear. The transitional object becomes important only after it has become familiar and the baby has reached the necessary maturational stage, and the same may well be true of the human attachment figure.
Finally, the toddler characteristic of neophobia may be relevant to behaviors we consider attachment-related. Neophobia, the young child’s aversion to unfamiliar foods, objects, and situations, can be considered as the mirror image of the child’s intense preferences for familiar people and places as well as for a specific transitional object. The child’s fear of strangers and of separation can also be classed as forms of neophobia. The “attachment cycle” theory would seem to imply that rejection of a person depends on experience of that person’s failure to satisfy signaled needs, just as it suggests that attachment/preference results from experiences of satisfaction mediated by an adult. Yet unfamiliar foods, places, and people have by definition had no opportunity either to satisfy or to fail to satisfy infant needs. Examining attachment behavior in the context of other age-related behavior in this way leads to the conclusion that an “attachment cycle” would have to be congruent with several aspects of infant and toddler development in order to be a reasonable explanation of attachment--  but it is not.
                        Is It a Problem to Assume There is an “Attachment Cycle”?
Does it matter whether people think there is a “first-year attachment cycle”, with or without an added second-year cycle? In some ways, no, it does not matter--  and the belief may even have a positive outcome. If parents are concerned about attachment as an important aspect of development, and if they believe that they can foster attachment by sensitive, responsive treatment of their infant, those beliefs are likely to produce excellent child care and good development. It’s a much better situation than if, say, someone advised parents to whip an infant who refused food (see Pearl & Pearl, 1994).
In other ways, though, the belief in the “attachment cycle” can be quite harmful. One of the associated problems is the assumption fostered by Attachment Therapists that child disobedience indicates a failure of attachment, rather than a variety of other causes, many of which involve poor parenting. A second, and even more potentially harmful, belief is that both first and second-year “attachment cycles” can be recapitulated as treatment for older children. Acting out of this assumption involves efforts to display adult power and authority as well as arbitrary presentation of sweets, hugs, and eye contact as means of creating attachment (Thomas, 2000).  The second belief is based on the assumption that it is possible, by re-enacting some common early childhood experiences, to cause individuals to “regress” and resume the characteristics of their early lives, then to cause them to develop back to their present chronological age’s characteristics and to undergo experiences that will correct whatever problems had initially occurred. These principles and practices are without  empirical support and are potentially harmful, with a record of demonstrated child deaths and injuries (Mercer, Sarner, & Rosa,2003).
The “attachment cycle” theory proposed by Fahlberg, Cline, and other authors is derived from a salmagundi of other theories, in most cases uncited by authors who have discussed the concept. The theory, as repeatedly diagrammed by advocates of Attachment Therapy, is incongruent with Bowlby’s attachment theory and only partially congruent with some other suggestions about attachment. In addition, it fails to predict some easily observable phenomena of late infancy and the toddler period whose association with attachment is evident. Like Darwin’s fox terrier, the “attachment cycle” material appears to have been repeated unquestioningly by authors and Internet sites who have accepted it because they have seen it before--   a sort of “attachment cycle cycle”. This repetition, and the harmful implications of the idea for parents and practitioners, are the only reasons for a serious analysis of the “attachment cycle” like the one given here. Were it not for the potential harm connected with the belief system, there would be no point in examining it, as it is not and never has been a part of any conventional approach to the understanding of attachment.

Ainsworth, M.D.S., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Erlbaum.
Bettelheim, B. (1969). The children of the dream.New York: Macmillan.
Bowlby, J. (1944). Fourty-four juvenile thieves: Their characters and home life. International Journal of Psychoanalysis, 25, 19-52, 107-127.
Bowlby, J. (1982). Attachment. New York: Basic.
Cline, F. (1992). Hope for high risk and rage filled children.  Evergreen, CO: EC Publications.
Erikson, E.H. (1950/1963). Childhood and society. New York: W.W. Norton.
Fahlberg, V. (1991). A child’s journey through placement. Indianapolis: Perspectives Press.
Gewirtz, J.L. (1969). Potency of a social reinforce as a function of satiation and recovery. Developmental Psychology, 1, 2-13.
Golding, K. (2008). Nurturing attachments. London: Jessica Kingsely.
Mercer, J., Sarner, L., & Rosa, L. (2003). Attachment Therapy on trial. Westport, CT: Praeger.
Pearl, M., & Pearl, D.(1994). To train up a child. Pleasantville, TN: No Greater Joy Ministries.
Reich, W. (1945). Character analysis. New York: Farrar, Strauss, Giroux.
Spitz, R. (1965). The first year of life. New York: International Universities Press.
Thomas, N. (2000). Parenting children with attachment disorders. In T.Levy (Ed.), Handbook of attachment interventions (pp. 67-111). San Diego: Academic.
Verrier, N. (1993). The primal wound. Lafayette, CA: Author.
Winnicott, D. (1953). Transitional objects and transitional phenomena. In D. Winnicott (Ed.), Collected papers: Through pediatrics to psychoanalysis. Middlesex, UK: Penguin.
Zaslow , R.W., & Menta, M. (1975). The psychology of the Z-process. San Jose, CA: San Jose State University Press.

Friday, August 10, 2012

A Case Study in Regulation of a Potentially Harmful Treatment: The Utah Experience

Because documented child deaths and injuries have resulted from the use of a physically-intrusive mental health intervention called Attachment Therapy or Holding Therapy, the treatment has been categorized as a Potentially Harmful Treatment (PHT; Lilienfeld, 2007; Mercer & Pignotti, 2007) and has been described in detail elsewhere (Mercer, Sarner, & Rosa, 2003). Unfortunately, before it became clear that the intervention was not only ineffective but dangerous, enthusiasm for its use had spread. In a number of states, state agencies and private practitioners during the past decade cooperated in the use of  Attachment Therapy (AT) and training in its principles. For example, Alabama  used state funds to train social workers in AT principles, and Georgia established guidelines such as the requirement that foster parents request approval before sitting on children in their care. That this was and remains an international problem was shown in a British publication by Sudbery, Shardlow, & Huntington (2010), reporting approval by staff and parents of AT interventions in a leading residential treatment center.

How can the use of AT be regulated? Is it possible to use administrative or executive decisions to lessen the use of this PHT? This paper examines the efforts of one U.S. state to regulate AT, and the limit success that these efforts achieved.  Utah is chosen because the history of AT there is well known, and its details provide us with examples of the difficulties of regulation, including the problem of support from within state agencies and institutions.

The beginning of AT in Utah. In approximately 1990, the State of Utah’s Division of Child and Family Services sponsored training for therapists by AT advocates from Colorado. Since that time, state organizations appear to have sponsored, recommended, and paid for various forms of AR for children in state custody or being adopted from  state custody. After a child death in 2002 (to be discussed in a later section), state contracts with AT practitioners were terminated; however, it appears that post-adoptive subsidies continued to be used to pay for AT.
The death of Krystal Tibbets. In 1995, three-year-old Krystal Tibbets was killed by her adoptive father, Don Tibbets when he performed AT on her at home. Tibbets claims that he was following the advice of AT practitioners who referred to themselves as attachment/holding therapists. Krystal’s state-mandated treatment plan required what were termed “holding” sessions to be performed both at home and at the therapist’s office. Tibbets claims to have protested but to have been told that if he did not comply with the treatment plan, Krystal would be removed from his care. Tibbets expressed concern to Krystal’s pediatrician, saying that he worried for her safety. Tibbets, a registered nurse, stated that he was concerned that in some sessions of AT Krystal had lost consciousness. According to Tibbets, the therapists treating Krystal said that she was conscious but “dissociating” (Tibbets, personal communication,, 2002).
Krystal’s untimely death occurred when Tibbets lay across her in a AT technique called “compression therapy.” When Tibbets realized that Krystal was not breathing, he attempted to resuscitate her but failed. He was later convicted of child abuse homicide and sentenced to five years in prison. Denied parole, he served the entire sentence (Fattah, 2002).

In a videotaped interview, Tibbets showed a copy of the treatment plan which mandated the “holding” sessions and described how he had complained about the treatment. He kept a copy of a letter written by one of the therapists to a judge, requesting that Mrs. Tibbets be excused from jury duty because she was needed at home to assist in Krystal’s treatment. The letter stated that Mrs. Tibbets was being trained to be a “pseudo therapist” and that jury duty would disrupt the training. Tibbets said that the attachment/holding therapists assigned by the state threatened that if he did not follow through with AT sessions at home, the adoption would be disrupted (Tibbets, personal communication, 2002).
The death of Cassandra Killpack. In 2002, four-year-old Cassandra Killpack died when her parents, who claimed they were following the advice of the same AT therapists implicated in Krystal Tibbets’ death,  allegedly forced her to drink an excessive amount of water. According to newspaper reports,  police suspected that the child’s injuries were sustained during a holding therapy session (Fattah, 2002). Cassandra died at the home of her adoptive parents, Richard and Jennette,, after the first week of a two week “intensive” treatment regimen. In the six days prior to her death, Cassandra had been subjected to 15 or more hours of coercive procedures, including restraint and forced exercise.
Cassandra was first evaluated at the clinic by a former therapist whose license had been revoked in Oregon following his use of AT practices (Collins, 2003; Fattah, 2003). Oregon officials had described his behavior as “egregious and reprehensible” (Warner, 2003). He was denied a license in Utah and claimed to have been doing “pastoral counseling” after becoming an ordained minister through the Internet site This practitioner informed the Killpacks that Cassandra had severe Reactive Attachment Disorder and prescribed a two week “intensive”.
The Killpacks described the first five days of the “intensive” treatment as follows: Sessions were held daily, Monday through Friday, and were also scheduled for the following week. Each session lasted approximately three hours. Normally at least four adults were present, the two parents and two therapists or “support staff.”
Treatment in the “intensive” sessions alternated between AT restraint methods and forced physical activity. Cassandra was restrained on the floor by the adults. The Killpacks said the therapists yelled at the child and told her to fight back, in an effort to purge her allegedly repressed feelings. When AT was not being done, Cassandra was forced to perform repetitive physical activity such as kicking the wall, jumping jacks, running in place , and so forth. Cassandra’s older sister witnessed some of the sessions and described them to investigators, saying that the younger child  was repeatedly yelled at during both the restraint and the physical activity (Fattah, 2002).
The Killpacks said they were instructed to continue this manner of treatment toward Cassandra at home in order to facilitate a “breakthrough”. They said they were told by one therapist that if Cassandra did something wrong, like “stealing” food, they were to use a “paradoxical intervention”, forcing her to repeat the infraction over and over. They claim that one therapist said that Cassandra should be forced to drink water as a consequence for misbehavior (Fattah, 2002).

The Killpacks apparently felt compelled to continue the harsh treatment during the two week “intensive” because they had been told that if they gave in to Cassandra’s “manipulation” she would not have the desired “breakthrough.” They claim they were told that if the two week “intensive” did not work, Cassandra would grow up to be a prostitute, drug addict, or school shooter and possibly murder her parents or family members. Furthermore, according to the Killpacks, they were told that if they followed through with the recommended course of treatment they were assured a “one hundred percent success rate.”
The Killpacks claimed they were taught to force Cassandra to be completely dependent upon her adopted mother, Jennette, in order to bond with her. Cassandra was required to obtain permission from her mother for virtually everything, including food, drink, and use of the bathroom.
However, Cassandra took some of her sister’s drink without permission from her mother. As a “consequence” (punishment), Jennette forced Cassandra to sit on a bar stool and drink a large amount of water. When Cassandra became weak and semi-responsive, her parents interpreted this as manipulation and defiance. Believing Cassandra to be on the verge of the supposed “breakthrough” predicted by the therapists, the parents persisted in their treatment. Restraining Cassandra, tilting her head back, and forcing more water down her throat, using sufficient force that the autopsy showed cutting and bruising of her lips.

Cassandra vomited a foamy substance and collapsed on the floor. The Killpacks told her to get a towel to clean up her mess. When she did not get up, they again interpreted her behavior as defiance and persisted in their demands. When the Killpacks finally realized that Cassandra was unconscious, they attempted to revive her and called 911. In the recorded 911 call, Richard Killpack explained to the dispatcher that Cassandra had a lot of “emotional problems”. He said, “she’s very, very sneaky … we gave her a lot of water.” He told the emergency room physician thatthey “forced the girl to drink lots of water as therapy.”
Cassandra died hours later at the hospital. The cause of death was determined to be hyponatremia, also known as water intoxication. The Killpacks were tried in 2006 and Mrs. Killpack was convicted.
A non-fatal case. Only weeks after Cassandra Killpack’s death, criminal charges were filed by the Utah County Attorney against Reed and Teresa Hansen, who had allegedly abused their adopted Russian children. The Hansens are scheduled for trial in January, 2006, on charges of felony child abuse, for allegedly locking the starved children in the bathroom and forcing them to sleep on the tile floor with little or no bedding. Teresa Hansen had one previous charge of child abuse when one of her adopted children was found covered in bruises. Investigators found literature in the house advocating various forms of coercive treatment, as well as business cards from the clinic where Cassandra Killpack had her “intensive” (Fattah, 2002).

The three adopted children were removed from the home, and newspaper reports indicate that the Hansens’ parental rights were either terminated or relinquished (Fattah, 2003). According to officials, the starved children gained weight and began to thrive within days of being placed in foster care (Fattah, 2002).       

Licensing, lawsuits, and legislation. Charges were filed against two of the therapists involved in these incidents by the Utah state Attorney General, working through the Division of Occupational and professional Licensing (DOPL). One of these therapists was killed in an automobile accident in December , 2004. The other therapist was  placed on probation and continued to treat children in a residential treatment center. Charges against other persons named  by the Attorney General have never been pursued ( “Notice of agency action…”, 2002).

Two individuals  filed separate lawsuits against the therapists involved in the cases  discussed earlier. One suit alleged that one of the therapists performed AT on her child without her knowledge or consent. The suit also claimed that the therapist told the mother to force her children to drink water as a form of punishment (Thomson, 2004). The second suit made similar allegations. A mother claimed that AT was performed on her daughter without her consent and that the daughter suffered emotional trauma from the incident (Fattah, 2003). Both cases were apparently settled out of court.

In 2002 and again in 2003, Utah State Representative Mike Thompson sponsored a bill to ban AT practices. The legislation was supported by virtually every mental health organization and child advocacy group in the state and received broad national support. The Utah chapter of the National Association of Social Workers approved of the bill in a position statement.

The Utah House of Representatives passed the measure with a vote of 68-2 (Thalman, 2003). There was increased momentum for the bill following a call by the United States Congress encouraging states to pass such legislation. However, several powerful Utah state senators prevented the bill from coming to a vote in the upper house of the state legislature. State Senator Parley Hellewell took credit for stopping what he called a “bad bill”. Hellewell stated that AT techniques practiced by his longtime neighbor and friend, one of the therapists who had treated Cassandra Killpack, were beneficial and should not be banned. Senator Hellewell received support from “pro family” activists who argued that the government should not dictate the treatment that parents can choose for their children.

Utah State Representative Mike Thompson, who sponsored the anti-AT legislation, lost his bid for reelection. No other legislator expressed willingness to sponsor such a bill. AT is thus not banned in Utah either by legislation or by state licensing rule. Although there have been decreases in third party funding of AT by the state and private insurance companies, AT practices in Utah were apparently ongoing for some years. Nevertheless, the efforts at legislation  had positive outcomes in the drafting of anti-AT position statements by all major Utah mental health organizations, including Utah Psychological Association, National Association of Social Workers Utah Chapter, Utah Association for Marriage and Family Therapy, Utah Mental Health Counselors Association, and Utah Counseling Association.


Legislation. litigation, and professional policy statements and publications  have been only partially successful in regulating the use of AT, as is shown by the relevant history  in the state of Utah. This is perhaps unsurprising, as professional organizations are disinclined to accept supervision from outsiders and are likely to claim that they are able and willing to do their own housecleaning. Support for specific legislation may thus be minimal even though professional organizations agree that a named practice is undesirable. In addition, drafts of legislation have problems in specifying the practices they aim to limit. Changing the name of a treatment or modifying some part of its procedure can place a practice outside the stated concern of legislation.  Increased efforts to educate both professionals and the public may be the essential step toward regulation of harmful practices whose proponents can easily go “underground” or conceal their activities, but such efforts are undermined when local authorities continue to provide training or support for problematic interventions. 

Collins, C.( 2003, Aug. 15). State revokes therapist’s license. Baker City Herald.
Fattah, G. ( 2002, Sept. 17. Parents charged in Springville girl’s death.  Salt Lake City Deseret News. Retrieved August 24, 2005 from,1442,405031286,00.html.
Fattah, G. ( 2003, May 1). Parents’ trial may be long, complex. Salt Lake City Deseret News. Retrieved August 24, 2005 from,1249,505036190,00.html.
Lilienfeld, S.O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.
Mercer, J. (2002).  Attachment Therapy: A treatment without empirical support. Scientific Review of Mental Health Practice, 1(2), 9-16.
Mercer, J. (2003). Violent therapies: The rationale behind a potentially harmful child psychotherapy. Scientific Review of Mental Health Practice, 2(1), 27-37.
Mercer, J.,  Sarner, L., & Rosa, L. (2003). Attachment Therapy on trial. Westport,CT: Praeger.

Mercer, J., & Pignotti, M. (2007). Shortcuts cause errors in Systematic Research Syntheses: Rethinking evaluation of mental health interventions. Scientific Review of Mental Health Practice, 5, 59-77.
“Notice of agency action, Case No. DOPL-2002-223.” Retrieved from
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.
Thalman, J.(2003, Jan.31). House rejects holding therapy. Salt Lake City Deseret News  Retrieved August 24, 2005 from
Thomson, L. (2004, June 22). Center is sued over therapies. Salt Lake City Deseret News Retrieved August 24, 2005 from,1249,595072140,00.html.
Warner, L. (2003, Oct. 9). Killpacks face trial in death of daughter. Salt Lake City Deseret News.Retrieved August 24, 2005 from,1249,51937467,00.html.

Wednesday, August 8, 2012

Why Study Nonsense?

Nonsense, as the term is used here, refers to statements about human behavior and mental health that are implausible because of their faulty logic and because of their lack of congruence with well-established information on similar topics. Why should we study this at all? Why not just ignore or try to get rid of it?

In a way, the study of nonsense resembles the work of teachers at all levels of education. Experienced teachers tend to prefer essay or short answer exams over multiple choice, even though it’s more work to grade essays. Why? Because as you examine the details of an essay answer, it’s possible tell why a student makes a mistake--  to detect the misunderstanding or erroneous assumption that leads to a wrong answer. In some cases, even the rationale for a “right” answer can reveal misunderstandings that would go uncorrected if the answer alone were examined.

Similarly, studying examples of nonsense from the social sciences and mental health practice can  reveal the basic misunderstandings and mistaken a priori assumptions behind nonsensical conclusions. When these inner workings of nonsense are shown, it becomes possible to argue along more productive lines than the “yes, it is”, “no, it isn’t” so characteristic of discussions between proponents of conventional and unorthodox belief systems. The task is thus worth doing, but it is a challenging and time-consuming job. A student of nonsense has much to read and watch, to identify and to cross-check. Authors of nonsense rarely do us the favor of identifying the sources of their ideas, defining their terms, or announcing when they have changed their minds or stating their reasons for doing so.

Producing nonsense and believing in nonsense are actions of interest in themselves, as examples of human cognitive abilities affected by a complicated network of misdirecting factors.  But nonsense is also of interest because of the potential it offers for harmful outcomes motivated by nonsensical beliefs. Those harmful outcomes may be waste of time and resources, or they may be physical or emotional injury to individuals. They may even involve dangers to populations or nations when political decisions are based on nonsensical claims. Understanding nonsense and working effectively to oppose it can reduce the harm it does when uncontradicted.

[The study of nonsense is not the same thing as agnotology, a term developed and defined by Robert Proctor as  the study of “culturally constructed ignorance, purposefully created by special interest groups working hard to create confusion and suppress the truth”. Special interest groups certainly produce and benefit from nonsense. However, agnotology seems to focus on the intentions and motives of propagandists rather on the step-by-step parsing of their arguments and claims that I am calling the study of nonsense. There’s no question that agnotology is a juicier term than “the study of nonsense”, and is anyone wants to call the latter “somniology” from the Latin word for daydreams, fantasy, and so on, I won’t complain, but I think I’ll stick to the plain English myself.].

N.B. I will be happy to post suitable material from contributors. Let me know by way of a comment.