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 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 (, 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.)
            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.
            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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Saturday, December 1, 2012

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 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 ( 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://; , 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://  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.(  Nevertheless practitioners deny that these methods are abusive. They compare the child’s distress during treatment to that during chemotherapy     ( 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 (, 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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