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.

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