Thursday, December 20, 2012

Jirina Prekopova's Holding Therapy: Scientific Support, or Non-Scientific Foundations?


N.B. This paper is a draft prepared for presentation at a meeting of the International Working Group on Abuses in Child Psychotherapy, London, April 20, 2013.



                                         Jirina Prekopova’s Holding Therapy: 
                             Scientific Support, or Non-scientific Foundations?
                                                        
                                                           Jean Mercer

                         The “holding therapy” method practiced by Jirina Prekopova
                         and others as a mental health intervention for children is described and
examined with respect to its scientific and nonscientific foundations. It is
concluded that the treatment is without scientific basis, but is closely related
 to  other unconventional beliefs and practices that began in the 20th century.
                         “Holding therapy” of the type Prekopova uses is probably not child abuse
by legal definition, but includes actions that are considered abusive by  
definitions used in research

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