Coercive Restraint (Holding) Therapy as an Abusive Treatment

This paper describes the practices and belief system of an unconventional child mental health intervention and considers the possibility that the treatment should be considered abusive . An examination of the characteristics of Coercive Restraint Therapy (Holding or Attachment Therapy) indicates that its practices can be defined as abusive or neglectful under the criteria used in the fourth national incidence study of child abuse and neglect (NIS-4). In addition to the direct harm to children documented for CRT, there is strong evidence that similar practices are harmful both physically and psychologically.

            The term Coercive Restraint Therapy (CRT) describes a category of interventions that involve physical and mental coercion practiced by adults on children in their care. A number of child deaths have been associated with these practices. CRT practitioners may identify their procedures as Attachment Therapy, Corrective Attachment Therapy, Holding Therapy, Rage-reduction Therapy, Dyadic Synchronous Bonding, and other names such as “hug therapy” and “cradling”. The terms themselves are less informative than the practices and belief systems they tend to share. For example, it is common for CRT practitioners to refer to their interventions as Attachment Therapy, but this usage should be regarded as deceptive; it is unlikely that emotional attachment is affected by this or other CRT treatments.

                                            Characteristics of CRT

            Shared characteristics of practices classed as CRT (cf. Cline, 1992; Levy, 2000)         include the following.

 1) CRT interventions are most often done with children, and particularly with adopted children.

 2) CRT interventions involve physical restraint of some type, varying from situations where the practitioner lies with his or her weight on the prone or supine child, to situations where the child is wrapped in fabric, to situations where the child reclines in the practitioner’s arms or lap and cannot easily move away. Although CRT practitioners currently downplay the issue of physical restraint, one practitioner asks the following question of applicants for training: “Are you physically capable of participating in highly emotional work equivalent to intense physical exercise?” (Post Institute, 2005), suggesting considerable physical contact between therapist and child .

 3) CRT interventions stress the power and authority of the adult and reject the psychotherapeutic principle of following the child’s lead.

 4) CRT interventions are based on a belief in the possibility of developmental regression and recapitulation of a developmental sequence through some form of “reparenting”.

 5) CRT interventions assume the necessity of emotional catharsis through reexperiencing past trauma.

6) CRT interventions aim at the creation of an internal state defined by this group as emotional attachment, which is said to be associated with the child’s display of affection, gratitude, and obedience to the parent.

            It is notable that this description of CRT jibes with that given by Stryker (2010), an author who observed CRT events in the late 1990s and whose report shows no disapproval of CRT practices.

CRT is not defined by the particular type of physical restraint employed, nor by the individual (whether parent or therapist) who carries it out. Therapists who use physical restraint for the safety of emotionally-disturbed children would not be considered to be practicing CRT unless they considered restraint to have a therapeutic effect in and of itself.  The defining characteristic of CRT variants is the belief that the adult’s show of authority, through physical restraint of the child and other means, initiates a chain of events that culminate in the resolution of emotional disturbances. Specific physical and interactional practices emerge from this overarching principle.

Beyond this defining principle, therefore, CRT practices may show considerable variation in details. One important difference among practices has to do with the identity of the adult who carries out the restraint. In more “traditional” CRT practice, dating back to the 1970s and earlier, the therapist carries out the restraint, usually with the assistance of one or several other adults. In another variant, which seems to be progressively more popular, the restraint is carried out by a parent. CRT is far from manualized, and individual therapists may make a variety of choices in the practices they use with a given child.

Because CRT practitioners have done little to publish case studies or other detailed descriptions of their work, much of the available information comes from videotapes. Practitioners have produced videotapes for training purposes, and these show  activities that are considered appropriate  although they do not necessarily depict an entire treatment session or events during different sessions experienced by an individual child. The most detailed information about CRT practice comes from the 11 hours of videotape made by the two therapists whose treatment caused the death of Candace Newmaker in 2000 (Mercer, Sarner, & Rosa, 2003). In these videotape records, the therapist Connell Watkins can be seen holding 10-year-old Candace Newmaker in her lap, with Candace’s legs extended. One of Candace’s arms is sometimes behind the adult and may be sat or leaned on; in other situations, another adult sits nearby and holds the child’s arm. While she restrains Candace in this way, Watkins is seen to grab the child’s face, to cover Candace’s mouth with her hand, and to shout into the child’s face in an intimidating and insulting way, demanding that Candace repeatedly shout sentences back to Watkins. Periodically, the videotapes show Watkins ordering Candace to kick her extended legs in a scissors-kick, then to stop on command. Candace’s death occurred as a result of asphyxiation in a “rebirthing” procedure which involved a fabric wrap and the pressure of  four  adults against Candace’s body for a period of 70 minutes.

Care Techniques

Unlike most child psychotherapists, CRT practitioners advise the use of a set of associated care techniques, either in the child’s own home or during periods with therapeutic foster parents. These techniques, which we may call Coercive Restraint Therapy Parenting (CRTP), have the potential to do serious harm. Most children whose deaths have been associated with CRT have actually been killed by adoptive parents following CRTP guidelines.

There is an extensive CRTP literature, most of it put out by the self-styled parent educator Nancy Thomas (2000), who has worked closely with CRT practitioners, including the two therapists responsible for Candace Newmaker’s death. In this section, we will summarize some of the most common CRTP practices. As will be evident, CRTP focuses on establishing the complete authority and control of the adult.  Some CRTP practices are also used by therapists in intervals between other forms of treatment.

“Strong sitting” is a major CRTP tool. The child is required to sit tailor-fashion on the floor without moving or speaking, three times a day, technically for a period of minutes equal to his or her age in years, In fact, the length of time may extend into hours, as timing begins only when the child is perfectly still and quiet.

Food is an important part of the CRTP armamentarium. Children in treatment may not have food or drink without asking an adult’s permission. The food available may be limited in other ways, as well. There may be only a single type of food, such as peanut butter and jelly sandwiches or oatmeal, given for many weeks. One child, Viktor Matthey, whose death had features related to CRTP practices (for a complete account of this case, see  http://www.dartcenter.org/dartaward/2002/winner_08.html) was fed uncooked beans and grains and was not allowed water unless he finished the food before a buzzer sounded.  Children may be required to carry out physical labor or other difficult tasks such as holding weights over their heads to prove their obedience and gratitude, and to go without eating if they fail (Hafetz, 2000). It appears that some children may have undergone this treatment for years and have had their growth permanently  affected by it (Kaufman & Jones, 2003), although criminal investigations do not necessarily follow up this issue.

Ignoring the child’s expressed desires is a fundamental theme of CRTP (Thomas,2000). Children who are afraid of the dark may not be allowed nightlights and may be locked in their rooms or have alarms placed on bedroom doors. Children’s questions are not answered, even about the possibility of seeing their parents; threats of abandonment are a more likely response to such questions. Children doing “strong sitting” may be told they have to wait rather than being allowed to go to the bathroom. Children are to be hugged or kissed only on the adult’s impulse, not at the child’s request or at a predictable time.

Humiliating, tedious, and unnecessarily difficult work assignments are part of CRTP. For example, children may be required to clean up dog feces with their bare  hands, or to move stones from one side of the yard to another for no particular purpose.

“Paradoxical interventions” are advocated as a part of CRT practice. Although some CRT practitioners use standard therapeutic paradoxical techniques (Haley, 1990), such as demanding that a child intentionally perform an action he seems otherwise to do compulsively, the idea of paradoxical interventions appears to have become distorted in CRTP. Rather than using paradoxical interventions in the original sense, advocates of CRTP seem interested in “making the punishment fit the crime.” Parents may use punishments such as forcing a child to eat a great deal of some food he has taken without permission; one child death occurred when adoptive parents forced a child to drink two liters of liquid after she took part of her sister’s drink without permission (Fattah, 2002).

In addition to these harsh techniques, CRTP also includes practices that are intended to provide a positive experience for the child and to contribute to emotional attachment. For example, it is suggested that parents feed sugar freely, as this is believed to influence attachment. Parents are also to rock and bottle-feed children while gazing into their eyes. However, these potentially gratifying  (but also potentially aversive) experiences are to be available to the child only at the parent’s decision, not in a predictable manner or at the child’s request.     

Diagmostic Issues and Treatment Incidence

The individuals who seek CRT and CRTP interventions are most frequently adoptive or foster parents who are choosing treatment for children in their custody. The children in question are usually of school age, with smaller numbers of preschoolers and young teenagers receiving CRT. (Treatment of infants by CRT practitioners seems to be rare, although related infant treatments do exist.)  Children brought into CRT may or may not display symptoms of emotional disturbance. CRT practitioners claim that all adopted children will eventually show serious emotional disturbances, culminating in violent behavior at the level of serial killing, and that they should be treated preemptively although currently asymptomatic.

CRT practitioners generally use a diagnosis of Reactive Attachment Disorder (RAD) for insurance purposes. This diagnosis, while described in the Diagnostic and statistical manual of the American Psychiatric Association (APA, 2000 ), has been criticized as vague and difficult to use (Hanson & Spratt, 2000 ). However, practitioners of CRT claim to identify RAD by means of a paper-and-pencil instrument, the Randolph Attachment Disorder Questionnaire (Randolph, 2000) which is filled out by the child’s mother. Only the child’s mother or primary caregiver is thought to be aware of the child’s true personality and to be able to report salient information; the child is able to manipulate and fool the  father and familiar teachers or neighbors who might be expected to have had a chance to observe behavior. 

In addition to the RAD diagnosis, CRT proponents claim that they can use the RADQ and other techniques to diagnose a more severe emotional disturbance termed Attachment Disorder (AD). AD is said to remain unrecognized by conventional psychotherapists but to be a serious condition that will worsen rapidly if untreated and end in violently aggressive behavior, directed first toward animals and younger children and finally toward the parents. The developer of the RADQ, Elizabeth Randolph, has claimed that she can diagnose AD by examining motor skills. For example, she states that children who cannot crawl backward on command should be diagnosed as AD (Randolph, 2001).

The actual number of children treated by CRT practitioners is impossible to ascertain at this point. The difficulty of efforts to estimate the frequency of CRT treatment is compounded by the fact that CRT interventions may occur in the home, at a clinic, in a practitioner’s house or office, or in a therapeutic foster home specializing in CRTP. Although insurance records can give an estimation of all treatments for RAD, such documents do not usually tell exactly what form of non-pharmaceutical treatment was used in each case.  The actual prevalence of RAD is considered by conventional clinicians to be quite low, less than 1% of the population (Richters & Volkmar, 1994),  but CRT practitioners have claimed the existence of hundreds of thousands of cases of attachment disorders in the United States (http://www.nancythomasparenting.com/attachmenttherapy.htm). One CRT organization, the Attachment Center at Evergreen (Colorado) had a sufficient number of cases to provide a treatment group of 12 children who stayed in contact during a period of about a year; multiplying this by 100 (the rough number of Internet sites offering CRT) gives us a guess at a minimum number of children treated in one year in the United States.  However, the existence of a large number of highly commercialized CRT Internet sites suggests that enough of these treatments must be occurring to provide an adequate business income. It is only recently that some CRT proponents have turned to treatment of adults, so it is probably reasonable to assume that most CRT sites  now existing are dedicated to treatment of children.

                       Clinical Concerns About CRT

As was noted earlier, a number of child deaths have been associated with the use of CRT and CRTP. Most children exposed to CRT do not die, of course, but neither do they apparently benefit from the intervention, an unsurprising outcome given the absence of a valid theoretical basis and the strong resemblance of CRT to known forms of child maltreatment.

Evidentiary Basis of CRT and CRTP

CRTP has never been subjected to systematic outcome testing, or even described in detail. All statements made by CRTP practitioners appear to fall into the category of “proof by assertion.”

CRT proponents are aware of the current demand for evidence supporting the effectiveness of mental health interventions. They claim that such evidence exists for CRT. Although several studies have examined the outcome of CRT ( Myeroff, Mertlich, & Gross, 1999; http:// www.adoption.org; http://www.attachmentexperts.com/treatment_outcome.html) , it is difficult to determine whether every study involved exactly the same treatment techniques. All studies available are at the second level of evidence, involving types of quasi-experimental designs. Neither case studies nor randomized controlled trial (RCT) studies have been reported. The existing reports have been discussed in detail elsewhere (Mercer, 2002; Mercer, 2003; Mercer, Sarner, & Rosa, 2003 ), and analysis of the research has concluded that the designs employed make it impossible to draw the conclusion that CRT is an effective intervention.  

In addition to the design problem, always an awkward issue in outcome research, studies of CRT outcomes have been weakened by their use of the RADQ, the diagnostic questionnaire mentioned earlier.  The RADQ does not exist in alternate forms, it is apparently administered both before and after treatment by the same person, and the administrator may also be the CRT therapist.  The RADQ items do not control for response bias and uniformly refer to undesirable attitudes or behaviors. Most critically, the RADQ has not been validated against an objective, independent measure of attachment-related disturbances, but has been correlated with Rorschach scores and with the test administrator’s subjective diagnosis. Elaborate statistical analyses of RADQ scores (Randolph, 2000), as well as related psychometric work (Sheperis, Doggett, Hoda, Blanchard, et al., 2002), have been done, but these do not compensate for the basic conceptual problems of the RADQ.

Although when studying other interventions we might look forward to the possibility of further, better-designed research, it seems most unlikely that any Institutional Review Board would agree to a RCT study of CRT techniques. The treatment’s track record of deaths and other adverse events is too worrisome for this to be likely.

Theory and Philosophy of CRT

If outcome studies supported the effectiveness of CRT interventions, there might be less reason to examine the treatment’s theoretical foundations. If a therapy is without an evidentiary basis, however, it is reasonable to ask whether it is at least derived from a well-substantiated theoretical viewpoint.

CRT advocates claim that their system is based on the attachment theory developed by Bowlby and his colleague Mary Salter Ainsworth (Bowlby, 1982 ), and if this were the case CRT would share a well-respected foundation with other approaches. However, examination of the CRT philosophy shows little congruence with Bowlby’s theory. A small proportion of vocabulary is similar, although terms appear to be differently defined in the two approaches. Rather than being derived from Bowlby’s work, the sources of CRT beliefs appear to lie in the work of a number of writers well outside the mainstream of psychological thought.

The actual background of CRT beliefs has been discussed in detail elsewhere (Mercer, 2003; Mercer, Sarner, & Rosa, 2003 ). Briefly, there are connections with the “body therapies” (e.g., hhtp://www.soulsong.com).  Some concepts from the popular “primal scream” technique (Janov, 1970) and  some developments in Transactional Analysis (Berne, 1961) seem to be sources of CRT.  Although few CRT authors mention his influence, the psychoanalytically-trained psychiatrist Wilhelm Reich (Sharaf, 1983)    appears to have been the first to systematize some of the views that have become part of CRT thought. Reich considered that the experience of maternal rejection,prenatally or in the early years, caused changes in physical and emotional functioning he referred to as “character armor.” When character armor developed, the individual’s use of the eyes and upper body became functionally limited, as did the capacity for a full range of emotional experience. Reich treated this problem in adults as well as in children by physically prodding the torso until the patient cried and raged; Reich considered this intervention to releases the strictures limiting functioning and to restore the patient’s potential for a full life.  Reich’s theories appear to have been the source of the belief in an “attachment cycle”, much emphasized by CRT proponents (Cline, 1992) but without foundation in evidence.  

The CRT philosophy is best understood if one realizes that the background is an alternate universe of human development. CRT theory is not congruent with evidence-based views of personality development. The following list of CRT principles was drawn from a variety of print and Internet sources (e.g., Levy, 2000)  , and it is doubtful that every CRT proponent would accede to every point.

1) A belief in the importance of prenatal experience, going back as far as the time of conception, is an essential aspect of CRT. Unborn children are believed to develop an emotional attachment to their birth mothers; some of this connection derives from their shared genetic material. Some CRT proponents assume that the embryo or fetus can be aware of the mother’s thoughts and emotions, particularly those related to acceptance or rejection of the pregnancy, and that such awareness influences prenatal attachment.

2) The first months of life are also considered to be a period of developing attachment. This development results from an “attachment cycle”  in which the child is physically distressed (by hunger, for instance) and an adult caregiver relieves the distress. Social interactions such as prolonged eye contact and feeding also contribute to attachment.

3) In the second year of life, attachment is encouraged when the caregiver sets distinct limits on the child’s behavior.

4) Attachment is manifested by the child’s cheerful obedience to the caregiver and his or her *the child’s) display of affection, nurturing behavior, and gratitude toward the caregiver. Failure of attachment is indicated when the child is overly friendly to people outside the family, aloof or insufficiently affectionate to the caregiver, disobedient, negative, angry, destructive, untruthful, and manipulative, and when there is reluctance to make prolonged eye contact or physical contact.

5) Children who have experienced separation from the birth mother at any age, whose birth mother was unhappy during the pregnancy or considered abortion, who have been abused or neglected, or who have experienced painful medical procedures in early life, may all fail to attach and eventually show the symptoms described earlier, although they may not display any symptoms until later in their lives.

6) Children who fail to attach also show delayed cognitive development and are unable to understand cause-and-effect relationships; as a result, it is useless to employ systems of predictable rewards and punishments to alter their behavior.

7) When attachment has failed, it is possible to create a recapitulation of development in which the child experiences the “attachment cycle” of distress and gratification (described earlier), and has this experience with adults who demonstrate their complete power, authority, and knowledge. In the course of recapitulation of attachment, the adults also need to maintain prolonged eye contact and feed the child sweet foods, as these are considered to be mechanisms of attachment during normal development.

8) Failure to follow CRT principles will result in progressively worse emotional disturbance, and exacerbation of undesirable behavior to the point where the individual becomes a serial killer. Conventional therapies, as well as lack of treatment, are predicted to have this effect.

9) Only people who have lived with attachment-disordered children can understand what forms of treatment they require.

10) CRT and CRTP are more important than school attendance, although teachers can be asked to apply CRTP principles and to form an alliance with the parents by refusing to believe anything the children tell them.

The  beliefs just described are at variance with empirical evidence and with established theories of  personality development and psychotherapy. However, the principles are clearly and logically related to the CRT and CRTP principles described in an earlier section of this paper. It should be noted, however, that some of the principles and practices of CRT and CRTP are not related to formal theory, but are related to disciplinary techniques common in generations past and may be part of the childhood memories of readers who grew up in the Southern and Western United States. 

                                   CRT and CRTP as Maltreatment

Practitioners of CRT and CRTP undoubtedly believe that they are acting for the best and number of cases in which the form of treatment fits a category found in the NIS-4 Maltreatment Typology, a list of criteria used in the fourth national incidence study of child abuse and neglect (Sedlak, Mettenburg, Schultz, & Cook, 2003 ). Here is a list of NIS-4 maltreatment categories and CRT or CRTP practices that are related to each.  

04.5 Other Physical Abuse.. CRT creates physical distress by means other than simple restraint. Practitioners grab the child’s head and face, cover the mouth, and use an elbow or fingers to press into the child’s ribs and underarm area. One practitioner , now deceased, specialized in “visceral manipulation”, a procedure in which fingers were pressed deep into the abdominal area, producing  stimulation of the internal organs.(http://www.upledger.com/therapies/default.htm).  Nevertheless practitioners deny that these methods are abusive. They compare the child’s distress during treatment to that during chemotherapy     (http://www.deborahhage.com/holding.htm) and claim that parents and therapists must regard this distress as essential for the child’s recovery.

 CRTP practices that fall into this category include the use of “paradoxical interventions” as described by CRT practitioners. These are often in response to the child taking food or drink which he or she is forbidden to have without permission. A child who has taken cookies, for example, may be forced to consume an entire box of cookies doused with Tabasco sauce (personal communication of CRT survivor). One child, Cassandra Killpack, died of hyponatremia after her parents forced her to ingest two liters of water as a “paradoxical intervention” subsequent to her taking some of her sister’s drink ( Fattah, 2002).                                                                                                                     

05.1.        Close Confinement:Tying,Binding.  (… restriction of movement as a means of punishment or control). Techniques that fit this category include the use of fabric wraps in the rarely-used rebirthing technique.  Much more frequently, the child is subjected to manual restraint during “holding” sessions, to “compression therapy” which involves an adult lying with full weight on the supine child, and to freely-used “take-down” techniques in response to an adult’s perception of inadequate cooperation.

06.1, 06.2, 06.3. Verbal or Emotional Assault.  (Verbally assaultive or abusive treatment which reflects a systematic pattern.)  Techniques that fit this category include shouting into the child’s face and the use of pejorative terms such as “twerp”, as well as repeated, escalating demands that the child confess to undesirable thoughts such as the wish to kill his mother. Licking the child’s face while lying on him or her should probably also be placed in this category.

06.3.        Verbal Assaults and Emotional Abuse..  (Subcode includes: belittling, denigrating, scapegoating; ridicules or calls child derogatory names…. Uses fear/intimidation as a method of discipline; blames child for problems or events beyond his/her control; repeated punishment inflicted for little or no cause; unjustifiable nonphysical forms of punishment; and, other nonphysical forms of overtly hostile or rejecting treatment as well as excessive nonphysical discipline.) Actions that fit this category are at the heart of CRT and CRTP.  Videotapes, including those intended for the training of CRT practitioners, show therapists employing heavy sarcasm, refusing to provide information about the whereabouts of the child’s parents, and telling the child that if does not cooperate he will one day kill someone. Verbal attacks on the birth mother are a part of this pattern in the case of adopted children. Therapists demand that the child shout answers to questions such as “who’s the boss of you?” In CRTP, parents and therapeutic foster parents are to employ deliberately bizarre and unpredictable behavior as a means of “driving the child sane” ( St. Clair, 1999 ). For children in  therapeutic foster homes, this means an exacerbation of the unfamiliarity and unpredictability of the environment to which they have generally been taken without any explanation. CRTP practices that fall into 06.3 also include the use of required “strong sitting”, in which the child’s involuntary failure to cooperate may lead to extended demands for immobility, far beyond the stated plan.

06.3.1.  Verbal threats of other maltreatment.  (i.e., not sexual abuse). (Subcode includes… verbal threats of… forms of maltreatment, such as abandonment… and threats of emotional abuse). Threats of abandonment are apparently frequent in CRT, especially in its “intensive” form, in which children stay for several weeks in a therapeutic foster home and rarely see their parents. Children may be told that their parents are going to give up and leave them at the treatment facility, or that they will be sent to a residential treatment center for the rest of their childhood and adolescent years. The frequent statement that the child himself will kill someone should probably be included as a verbal threat, in consideration of the loss the child would then experience and the probable legal consequences of such an event.

07.3 Other/unknown abuse. . (Subcode includes: terrorizing a child; intentionally destroying items important to the child to cause emotional pain; … allowing infliction of psychological abuse; intentional withholding of food, shelter, sleep, or other necessities as a form of punishment; overworking or economic exploitation….subjecting another child in the household to an identifiable pattern of abuse or neglect.)   CRT and CRTP practices in this category include withholding of food or limiting food to less palatable items like peanut butter and jelly or oatmeal for weeks at a time. Viktor Matthey (http://www.childrenintherapy.org/victims/matthey.html), who died in circumstances strongly suggestive of CRTP involvement, was fed uncooked grains. Food may be allowed only after the child has performed a difficult task such as holding weights over the head . If a child responds to food unenthusiastically, the food is to be taken away and may be fed to the family pet ( Thomas,2000 ). Locks may be placed on the refrigerator. Also relevant to this category is the practice of denying nightlights to anxious children and locking or placing alarms on bedroom doors.  The denial of permission to use the bathroom, and indeed the requirement that the child always ask for this “privilege”, fits into this category, as well, as does the practice or requiring children to do unnecessarily difficult tasks such as cutting the lawn with shears rather than a mower. In the Killpack case, mentioned earlier, another child in the household was not only the observer of abusive treatment but was called in to help tie Cassandra and force her to drink (Fattah, 2003).

                                                                                                                                                                                  

 10.3. Unstable Custody Arrangements. . (Subcode includes: unstable living arrangements where child is repeatedly shunted back and forth from one household to another… as well as situations where the parent/substitute chronically or repeatedly leaves the child with other caretakers for days/weeks at a time.)  CRT and CRTP principles emphasize the idea that uncertainty and anxiety about living arrangements are beneficial for the creation of attachment. Children in “intensive treatment” are placed without explanation in the homes of therapeutic foster parents and are denied knowledge of planned reunions with familiar people. Parents of children in CRT are encouraged to use “respite” care in order to have a rest from the children; respite caregivers are told not to make eye contact with the children or to feed them anything sweet (Thomas, 2000).    Some children remain in therapeutic foster homes for weeks, months, or years, without formal custody arrangements being made. Investigation of “mega-family” situations, which may be related to CRTP, have shown transfer of children from state to state without attention to legal requirements (Smith-King, 2004 ).

12.1. Other physical neglect: Inadequate Nutrition.  ( Conspicuous inattention to the child’s needs for nutritious foods.) The practice of withholding of food falls into this category. It appears possible that the Jackson adoptees of New Jersey (Kaufman & Jones, 2003 ), whose growth was permanently stunted as a result of food withholding, were subjected to this practice as a part of CRTP. A related practice is the extensive feeding of sweets in the belief that these cause attachment; parents are advised to feed all the sugar they can, and particularly to give caramels because they contain lactose (Thomas, undated).

13.9. Knowingly Permitted Chronic Truancy. . (Includes all cases where the parent knowingly permitted the child’s chronic absence (tardiness or truancy). CRT and CRTP  practitioners advise parents to treat schooling as a privilege and not a right, to form alliances with teachers such that a child is taken home and assigned chores if mildly disobedient in school, and to home-school whether or not the parent is competent.

 15.1. Inadequate Nurturance/Affection.. (Marked inattention to child’s needs for affection, emotional support, attention, or competence or control… apparent lack of concern for child’s emotional well-being or development. ) A number of CRT and CRTP practices and beliefs fit this category. Children are not to be given affection when they request it, but are to be required to accept it at unpredictable times and at the parent’s whim. Children in treatment are considered to be constant liars and manipulators, whose complaints about abuse must always be ignored by adults. To allow children any control over their lives, even knowledge of events that will affect them strongly, is considered therapeutically counter-productive.  One CRTP author has recommended that when children in treatment go out with the family, they must be made to wear dark glasses so their pained expressions do not bring supportive responses from strangers ( Thomas, 2000 ). In the course of CRT, practitioners are expected to remain indifferent and unresponsive to children’s expressed fears of dying, not being able to breathe, or vomiting (Reber, 1996). During Candace Newmaker’s fatal treatment session, one adult told her, “Go ahead and die.”

 17.1. Refused to Allow or Provide Needed Care for Diagnosed Emotional or behavioral impairment.  (Category includes refusing to allow needed and available treatment for a child’s emotional or  behavioral impairment or problem in accord with competent professional recommendation.)  Treatment of children with CRT or CRTP may fall into this category when practitioners claim that conventional treatment exacerbates Reactive Attachment Disorder. In addition, CRT and CRTP practitioners have claimed that their interventions were effective for genetically-determined problems such as Tourette syndrome, thus discouraging parents from seeking suitable treatment. Although early CRT practitioners claimed effective treatment of problems as diverse as autism and asthma, such claims are infrequent today.

17.3. Other Emotional Neglect: Overprotectiveness.  (Category includes… isolating a child from ordinary social contact under circumstances which indicate emotional or social deprivation… interfering in a child’s age appropriate development and social development [e.g., consistently thwarts the child’s developing sense of maturity and responsibility …. infantilizing the child].) This may seem like a category irrelevant to the generally harsh and restrictive CRT approach. However, CRT and CRTP do isolate children from normal contacts, especially during “intensive” treatment or during periods in therapeutic foster homes or in respite care. Paradoxically, while often demanding many chores from the child, CRTP withholds normal responsibilities for decision-making. At an age where children normally determine their own bathroom needs and may be encouraged to prepare food and drink for themselves, children in CRTP are expected to ask permission for eating, drinking, and elimination. One observer (personal communication, 2004) noted that a child who helped a hurt toddler was disciplined because he had “taken control” rather than summoning an adult. Reparenting activities, such as rocking and bottle-feeding school-age children, appear to be aimed at infantilization. Children receive compliance training or “German shepherd training”, in which they practice repeatedly responses to some of the basic commands a dog might be expected to obey, and are drilled in stereotyped responses at an age where a variety of interactions with adults would be considered age appropriate.

17.4. Emotional Neglect: Inadequate Structure.  (Failure to pay adequate attention to child’s needs for sensible rule structures.) Again, this category might be seen as inapplicable because of the intense demands for obedience in CRT and CRTP.  However, we argue that the category is applicable, especially in terms of the operative word “sensible.”  Consistent failures to explain circumstances, coupled with the belief that the child is unable to learn from predictable rewards and  punishments and the assumption that the parent’s whim must govern affectionate interchanges, all militate against the existence of a sensible and appropriate rule structure. The problem is not so much failure to pay attention to the child’s need, but a deliberate effort to work against the need. 

17.5. Other Emotional Neglect:Inappropriately Advanced Expectations.  (Chronically applying clearly inappropriate age expectations to a child; expectations and demands that are beyond the child’s developmental level; places the child in a role-reversal [where child is expected to care for the parent/caretaker]; sets up the child to fail or feel inadequate.). Practices that fit this category include “strong sitting”, in which the child is expected to remain still and silent for  a lengthy period and the “clock” is re-started if the child moves or speaks. CRTP practitioners also require meaningless chores, such as moving stones from one side of the yard to the other, to be carried out with great care, and respond to any error by ordering the task to be repeated or reversed.  One CRTP goal is for children to behave in a role-reversed nurturing way toward the mother, rubbing her feet or bringing her food and drink.    

Clinical Outcomes of CRT and Similar Experiences

On the basis of this discussion of CRT and CRTP, it is not surprising that there is no evidence that the intervention is an  effective one. On the contrary, we might predict an ill effect from such treatment, not a good or even a neutral outcome. However, little information is available about children who have survived CRT. In  recent starvation cases, child protective services and state authorities have concentrated on the harm done to the children rather than the belief system behind it. There are young adults who are CRT survivors, but on the whole they are highly ambivalent about telling their stories publicly. Our best possibility for estimating the effects of CRT and CRTP may be to examine the known outcomes of experiences similar to CRT.

Experiences of psychological control.  Psychological control has been defined as:

“…patterns of family interaction that intrude upon or impede the child’s individuation process, or the relative degree of psychological distance a child experiences from his or her parents and family” (Barber, Olsen, & Shagle, 1994, p. 1121).

Work on psychological control (Barber & Harmon, 2002; Stone, Buehler, & Barber, 2002) has described intrusive and controlling parenting techniques and commented on their probable outcomes.  Psychologically controlling parenting tends to be covert and indirect and to intrude into the child’s thoughts and feelings as well as behavior. Parental strategies may include inducing guilt, instilling anxiety, and making parental attention and affection contingent upon the child complying with parents’ desires. Literature reviews by Barber and his colleagues report that parents who are high in psychological control infantilize children, encourage emotional and psychological dependency, and restrict children to the psychological world of the parent. Controlling parents also play a dominant role in the family, emphasize compliance, and attempt to keep the child in a subordinate role.

  These parental attitudes and behaviors, clearly resembling those found in CRT and CRTP, have been shown to interfere with the child’s self-expression and to frustrate his or her ability to  make decisions . Psychological control has been shown to be positively related to externalizing problems in children and adolescents, including aggression, delinquency, antisocial behaviors, and defiance. Compliance and academic achievement were negatively correlated with psychological control (Barber & Harmon, 2002; Stone, Buehler, & Barber, 2002). The overlap between psychologically controlling behaviors and CRT/CRTP suggests that the outcome of the latter interventions may be diametrically opposed  to the goals sought by parents choosing these treatments.

Psychological and emotional effects of torture. CRT and CRTP contain elements that parallel the deliberate infliction of physical and emotional pain known as torture. Although some readers may consider this an exaggerated comparison, we would argue that it is quite appropriate to compare CRT to torture. Clinical professionals who watch videos of CRT often avert their eyes or ask for the video to be turned off. One informant, who has worked in a facility where CRT was performed, testifies to the screams and sobs of children in treatment. Information about the aftereffects of torture is indeed relevant to the outcome of the CRT/CRTP experience, especially in light of the fact that CRT may go on for several hours at a time and may be repeated daily over a period of weeks.  Extrapolation from the effects of torture to the effects of CRT needs to be followed up with empirical evidence, but it is a useful step in understanding possible outcomes.

Kira (2002) conducted a limited review of the literature on torture and summarized what she termed “cumulative trauma disorders.”  The torture victims in question were generally adults, and it is not clear whether children would be more or less affected than older persons by cumulative trauma.

Survivors who endured cumulative tortures were at risk for psychotic symptoms such as auditory or visual hallucinations.  They were also at risk for developing negative emotional symptoms, with any combination of the following: apathy, affective flattening, avolition, social withdrawal, depression, and impaired emotional processing. Cognitive deficits such as impaired concentration, memory, and executive function were prevalent among torture survivors. Survivors were also likely to develop various mood disorders, including depression with suicidal tendencies, anxiety disorders, and simple Post Traumatic Stress  Disorder (PTSD). In addition, torture survivors were at risk for developing somatic and dissociative disorders. Survicors who had pre-trauma mental health conditions were at risk for exacerbation of symptoms (Kira, 2002).

To the extent that CRT and CRTP practices parallel torture as cumulative trauma, we may speculate on the possibility of similar outcomes for persons who have experienced CRT and torture. The effect of differences in developmental age (CRT affecting children, and torture more often affecting adults) is difficult to evaluate without more information. 

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