tag:blogger.com,1999:blog-90871830495003629902024-03-18T02:48:31.149-07:00The Study of NonsenseThis blog is dedicated to the examination of implausible and potentially harmful claims in the social sciences and mental health fields.
"Nonsense is nonsense, but the study of nonsense is scholarship"--(attributed to Saul Lieberman).Jean Mercerhttp://www.blogger.com/profile/14619393019771381980noreply@blogger.comBlogger6125tag:blogger.com,1999:blog-9087183049500362990.post-62316881941449395442013-06-11T06:30:00.000-07:002013-06-11T06:30:51.728-07:00Religious Beliefs and Alternative Psychotherapies: Mutual Influences of Cult-like Groups?<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><b>Abstract</b></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">There has been little
discussion of associations between unconventional religious beliefs and
alternative psychotherapies (APs), a class of mental health treatments that
lack a systematic evidence basis and that are implausible with respect to
conventional psychological systems. This paper examines the possibility of
defining both religious groups and organizations advocating APs as cultic in
nature. Apparent connections between two specific groups are discussed with
respect to their beliefs about mental health diagnosis and treatment. An AP,
Attachment Therapy, is compared with the “deliverance” practices used by
Pentecostals as a mental health intervention, and a number of parallels are
noted between these examples of an AP and a religious belief system. The
importance of understanding connections between religious beliefs and APs is
underscored by the occurrence of injuries and deaths in association with both
the described approaches. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Keywords:
</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">cult-like
groups, religious beliefs, mental health interventions, alternative
psychotherapies, deliverance, adverse events<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt; line-height: 200%;"> </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <b>Religious Beliefs and Alternative
Psychotherapies<o:p></o:p></b></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">During many
years of discussion of the meaning of the term “cult”, the focus has generally
been on groups that are unquestionably religious in nature, with an orientation
toward some form of the supernatural. In their discussion of religious cults,
Stark and Bainbridge (1979) offered several useful definitions. They defined
religions as “solutions to questions of ultimate meaning which postulate the
existence of a supernatural being, world, or force, and which further postulate
that this force is active, that events and conditions here on earth are
influenced by the supernatural” (p. 119). Stark and Bainbridge described
religions as “system[s] of general compensators based on supernatural
assumptions” (p. 121), while defining compensators as “postulations of reward
according to explanations that are not readily susceptible to unambiguous
evaluation” (p. 120). The same authors differentiated cults from conventional
religions by noting that cults “do not have a prior tie with another
established religious body in the society” (p. 125), but instead involve an
independent belief system.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Although
many cult-like groups obviously posit forms of supernatural force and of
related compensators, such groups may also focus on issues that are not
self-evidently supernatural. Richardson (1993) used the example of a communist
“cell” as a possible form of a cult. Stark and Bainbridge (1979) mentioned that
Scientology and another belief system had begun as forms of psychotherapy.
Bainbridge (1978), Lewin (1988), Ayella (1998), and Gaydics (2007) all discussed
forms of psychotherapy they considered cult-like in nature. Noll (1994) and
Eros (2004) addressed cult-like groups concerned with C.G.Jung and Sandor
Ferenczi, respectively.<b> <o:p></o:p></b></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Does
it make sense to think of non-religious belief systems, and particularly of
psychologies, as potentially cultic? How do they compare to cults that clearly
involve the supernatural? Generally, religions contain the seeds of
psychologies in the form of statements about the nature and right actions of
human beings. Psychologies in turn contain elements that may be supernatural
(e.g., some assumptions about the
personality’s survival of bodily death) and which when not supernatural are
likely to be only indirectly observable, or inferable from behavior or
self-report. To borrow Stark and Bainbridge’s terminology, psychologies propose
systems of general compensators (feeling happier, being more productive) based
on those indirectly observable elements that are “not readily susceptible to
unambiguous evaluation”. This unpacking of psychological thought suggests an
overlap with religion; the existence of conventional psychological belief
systems and of other independent systems suggests that the concept of cults, as
discussed by Stark and Bainbridge, can thus also apply to psychological
systems. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Can a specific belief
system that is publicly presented as a psychotherapy be correctly described as
“cultic”? And, if it can, can it be shown to overlap conceptually and
practically, and cooperate rather than compete, with a religious system that
meets many of the criteria used to define cults? This paper will explore those
questions by examining the cult-like nature of an unconventional psychotherapy
for children, called Holding Therapy or Attachment Therapy (Mercer,
Sarner,& Rosa, 2003), and comparing its principles and practices to those
of the “deliverance” beliefs associated with Pentecostalism. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> What Are
Alternative Psychotherapies?<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Before addressing Holding Therapy/Attachment Therapy as a
specific type of unconventional psychotherapy, it will be helpful to consider
unconventional or alternative psychotherapies in general. Psychological and
medical treatments, however unorthodox, are not usually referred to as cults,
although their supporters’ behavior may closely resemble that of cultic groups,
as will be discussed later in this paper. More generally, unconventional
treatments are categorized as “complementary and alternative” (CAM) medical
practice; although this term has been applied to psychotherapies as well as to
medical techniques, unconventional psychotherapies can more accurately be
referred to as “alternative psychotherapies” (APs) as they are rarely employed
in a complementary manner as adjuvants to conventional treatment. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Over
the last decade, investigations of the connections and overlaps between
religious or spiritual belief and CAM medical practice have become more
frequent. The use of CAM techniques for physical ills has been associated with
race or ethnicity as well as with other client factors (Gillum & Griffith,
2010; Krause, 2011; Sutherland, Poloma, & Pendleton, 2003). In spite of the developing interest of
psychologists in evidence-based practice (Chambless & Hollon, 1998),
following the slightly earlier medical discussion (Sackett et al, 1996) that
underscored CAM as a category of medical treatment, and the description of
categories of unconventional and non-evidence-based “alternative”
psychotherapies analogous to CAM (Mercer & Pignotti, 2007), few
psychologists have considered the possible connections between religious
beliefs and the preference for APs. Instead, psychotherapists have tended to
focus on ways in which clients’ religious or spiritual concerns could be
integrated into conventional therapies (Aten, Mangis, & Campbell, 2010;
Gonsiorek, Pargament, Richards, & McMinn, 2009; Post & Wade, 2009), or
treatment of problems experienced after leaving a high-demand group (Coates,
2010)<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">A
client’s choice of an unconventional AP, rather than conventional
psychotherapy, is a different issue from the possibility of integrating
religious and psychotherapeutic principles and is a more basic one, as it deals
with an initial choice of treatment and practitioner. Such a choice may be
based on a framework composed of the client’s experience of religious beliefs
and practices, which may be confirmed by existing membership in a cult-like
group. Religious dogmas, legends, and personal experiences form shared
“traditions of belief” (Bennett, 1987) that can provide the metaphors people
employ in attempting to describe or reason about invisible mental or emotional
processes (Danziger, 1997; Lakoff & Johnson, 1980), and thus about the
nature and treatment of mental illness. For example, the use of folklore or
similar informal traditions of belief to provide metaphors about mental or
physical illness is a point discussed by Ellis (2000), in a careful analysis of
the “Satanism scare” of the 1980s. Folkloric metaphors can help confirm beliefs
in mental health interventions when those beliefs are presented in a cult-like
social context. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Metaphors
Characteristic of Alternative Psychotherapies</span></i></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> CAM treatments have been addressed in more
detail than APs have, and it is difficult to consider metaphors associated with
APs without discussion of the analogous unorthodox beliefs about physical
illness. CAM treatments for physical disorders are those which are not only
without a systematic evidence basis, but are implausible in terms of the causal
frameworks that are the foundation of evidence-based medicine (EBM). (An
experimental treatment that lacks an established evidence basis is thus not
considered a CAM practice if it is plausible in terms of conventional medical
assumptions about the natural world.) The frameworks of EBM involve a number of
<i>a priori</i> assumptions about the nature
of the universe. Included are the beliefs that all forces at work in health and
illness are at least potentially describable by natural science and are
physical in nature, and that causal factors work from past to present rather
than the other way around.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">CAM
treatments for physical disorders are based on alternative <i>a priori</i> assumptions that allow for non-natural/supernatural
factors’ influence on the body. Homeopathic treatment, for instance, assumes that
substances can be changed in their spiritual nature and made effective by
operations that would conventionally be expected to diminish any effect they
could have. Chiropractic treatment is historically based on the belief in a <i>vis naturae</i> or natural healing principle
that can be blocked by muscular distortions (Whorton, 2002).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">APs,
like their CAM cousins, are implausible in natural science terms as well as
lacking in a systematic evidentiary foundation. Some are based on a belief in
an energy system that is not measurable by natural-scientific methods; for
example, Thought Field Therapy (Callahan, 2001) assumes that tapping or
gesturing on or near body parts can change the flow of an untestable energy and
thus affect mood and behavior. Other APs use different concepts that are
contradicted by natural science. Primal Therapy (Janov, 1970) and the belief in
the Primal Wound suffered by adopted children (Verrier, 1993) have as
foundations the assumption of “cellular consciousness” that allows memory to be
mediated by individual cells (even sperm and ova) rather than by the nervous
system. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The
definition of APs is rendered more difficult by the fact that some
conventionally-accepted treatments, such as psychoanalysis, contain some
implausible concepts (e.g., catharsis) and lack clear evidentiary foundations.
In addition, APs may or may not deserve classification as Potentially Harmful
Treatments (PHTs; Lilienfeld, 2007; Mercer & Pignotti,2007), a designation
earned when clearly adverse events such as injury or death of the client are documented
following the treatment. Generally, however, an AP is a treatment that lacks
evidentiary support from either randomized or well-designed nonrandomized
controlled trials AND that is also based on
implausible foundations.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">APs as Practices of
Cult-like Groups<o:p></o:p></span></i></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Are
APs as a general rule cultic in nature? Answering this question brings us up
against the still-evolving definition of “cult”, with its various suggested
criteria, and the fact that few groups actually meet all requirements for
categorization as cults. Rosedale and Langone (n.d.) gave an extensive list of
characteristics that have been suggested as requirements for the “cult”
classification. These include excessive devotion to a person, idea, or thing;
unethical manipulation for purposes of control, for example through social
isolation; information management; promotion of dependency on the group and
fear of leaving it-- all of these aimed
at the promotion of the group leaders’ agendas.
Richardson (1993) cited his own earlier definition of a cult as a small,
informal group with an indefinite authority structure but sometimes with a
charismatic leader, transitory, mystical and evangelistic, and taking its
inspiration from outside the predominant religious culture. In defining
religious cults, as mentioned earlier, Stark and Bainbridge (1979) focused on
groups with no prior tie to established religious bodies in their societies; a
psychological cult may be considered similarly as independent of conventional
psychological thought.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">APs
almost by definition involve excessive devotion to an idea and are associated
with claims of success that are unsupported by the research evidence demanded
in conventional circles. Where research evidence is presented, it may involve
weak research designs or unacceptable anecdotes or testimonials. Each AP has
one or more foundational ideas that are implausible in terms of conventional
systems, but the implausibilities are not addressed or explained. APs are also associated with charismatic group
leaders such as Janov (1970), the originator of Primal Therapy, or Jacqueline
Schiff (1970), the advocate of a “reparenting” procedure that proved fatal in
one case. Some AP leaders consolidate their power by commercializing their
methods and allowing access to information only for those who have paid and
enrolled (for example, Roger Callahan’s
Thought Field Therapy); this ploy also prevents outsiders from conducting
well-designed research by concealing the methods of the AP. Proponents of APs
may be made dependent and prevented from leaving the group by fear of the
disapproval of valued colleagues, but they may also find themselves unable to
move to more conventional practices because they have concentrated their
training in unorthodox areas and lack a network or recommendations from
respected conventional practitioners. AP clients too may have cult-like
commitments to the group, and they may be fearful of leaving because of dire
warnings about worsening of their conditions without the AP, or even of
deleterious effects of conventional mental health treatments. In addition, AP
clients may have formed social networks with other committed believers (often
by Internet) and may have developed social and practical habits that prevent
social engagement with those outside the group; in addition, they may have
maintained secrecy about the AP practices out of a wish to avoid criticism from
outsiders, and this secrecy may have limited their social contacts to group
members. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Groups
of AP proponents thus function in a cult-like manner by Rosedale and Langone’s
definitions. They also meet Richardson’s
criterion of being inspired by something outside the predominant religious
culture as well as outside the predominant, conventional views of mental health
professionals. The “something” outside both of these conventional frameworks
involves explanations or practices founded on non-naturalistic, mystical views
of human life; for example, one common tenet of APs is that human beings have
memories stored in all their cells and therefore are able to remember events
that occurred when they were ova or sperm. However, APs do not meet
Richardson’s criterion of informal, non-hierarchical organization, as the
promulgator of the treatment serves as teacher and mentor as well as therapist
to other group members.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
Attachment Therapy as an Alternative Psychotherapy</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Attachment
Therapy (also known as Holding Therapy, Rage-reduction Therapy, Z-Therapy,
Prolonged Parent-Child Embrace, and so on) is an alternative psychotherapy
originally directed at correcting emotional disturbances such as schizophrenia
and autism (Zaslow & Menta, 1975) but during the 1990s re-invented as a
treatment for adopted children or others said to suffer from attachment
disorders (Cline, 1992 ). It is presently also used for problems of gender
orientation and for marital relationship problems. It has been described as
“cult-like” in nature (Mercer, Sarner, & Rosa, 2003), but without any
specific analysis of its cultic characteristics. Although the treatment has
been rejected by professional organizations (e.g.Chaffin et al, 2006), its
practice has continued and was recently approved by an article in a
professional journal (Sudbery, Shardlow, & Huntington, 2010).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Following the death of a ten-year-old patient,
Candace Newmaker, in 2000, as well as other documented deaths (Mercer, Sarner,
& Rosa, 2003), Attachment Therapy (AT) is said to have altered in its
practices, although some practitioners appear to have continued to use the
original style. AT is, or was, a physically-intrusive proceeding based on the
implausible assumption that adult physical force and dominance are causes of
young children’s emotional attachment to their parents. AT uses a number of
terms derived from Bowlby’s (1982) conventionally-accepted work on emotional attachment,
but ignores Bowlby’s description of the timing of developing attachment in
favor of the implausible belief that infants form emotional attachments to
their mothers before birth and are traumatized by separation from the birth
mother no matter how early it occurs. AT also attributes child disobedience,
mood, or behavior problems to the absence of attachment, and predicts that adopted children will grow up to be serial
killers even if presently asymptomatic. AT practitioners claim to create
attachment by re-enacting with children the dominance relationship that they
believe is the normal cause of continuing attachment following birth. AT is thus implausible in the context of
conventional understanding of early development; in addition, it lacks an evidentiary
foundation (see Mercer, Sarner, & Rosa, 2003).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Proponents
of AT sometimes state that the children they treat are diagnosed with Reactive
Attachment Disorder (RAD), but in fact the stated symptoms (such as “crazy
lying”) do not meet published criteria for the RAD diagnosis (American
Psychiatric Association, 2000). An alternative diagnosis, Attachment Disorder <i>tout court</i> (AD), is often offered. AD is
diagnosed on the basis of a lengthy list of symptoms, as given in the Randolph
Attachment Disorder Questionnaire (RADQ; Randolph, 2000) or on many related
websites (e.g., <a href="http://www.attachmentdisorder.net/">www.attachmentdisorder.net</a>).
This list includes intense control battles, unwillingness to show affection on
the parent’s terms, lack of eye contact except when lying, lack of conscience,
incessant chatter, and a fascination with blood and gore.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">According
to AT proponents, conventional treatments exacerbate the children’s conditions,
but AT may cure them. The intervention is deliberately intimidating,
frightening, and physically intrusive, as therapists or parents hold the child
down or lie on top of him, poke and prod at his or her body, shout, threaten
abandonment, and demand that the child “confess” by repeating the therapist’s
statements about misdeeds or culpable thoughts like a wish to kill the mother
(Mercer, Sarner, & Rosa, 2003). Dire predictions to the effect that the
child will be “the next Jeffrey Dahmer” may be included. These methods are
repeated for several hours at a time, sometimes day after day, as the child is
put through a two-week “intensive” treatment. After a treatment session, the
child goes to a respite/therapeutic foster family rather than rejoining his
parents; at the respite home, he is given assignments of tedious work, and has
limited diet and other comforts. If the child returns to the parental home, he
or she may be required to ask for permission for anything needed, including use
of the toilet, in an age-inappropriate way.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The
cult-like characteristics of AT include the drawing of its ideology from
outside either the predominant religious culture or predominant beliefs of
mental health professionals (see Richardson, 1993). Although the list of
characters has been changing since the death of Candace Newmaker led AT
proponents to reposition themselves, a small number of prominent members form
the group’s leadership, followed in the hierarchy by a larger number of those
trained within the group. As Rosedale and Langone suggested, the financial
affairs of the AT group are directed primarily to the benefit of these leaders.
A parent-professional group, the
Association for the Treatment and Training of Attachment in Children (ATTACh)
provides courses taught by major figures in the group and leading to
certification as “Registered Attachment Therapist”, a title unrelated to any
professional licensure; however, conventional organizations like the National
Association of Social Workers provide approval for continuing education credits
earned through such courses. Parents of children receiving AT form the lowest
echelon of the group and support each other in the face of conventional critics
by means of Internet sites like <a href="http://www.radzebra.org/">www.RadZebra.org</a>
and <a href="http://www.attachchina.org/">www.AttachChina.org</a>. Discussion at these sites emphasizes the
ignorance of conventional sources and the need to turn to the group for support
of unconventional beliefs and practices. Contributors who disagree with the
group are intensely criticized by other members, and because contributions are
anonymous, these exchanges take on the viciousness so often found on the
Internet. Information management
techniques convince parents that their children will grow up to be serial
killers if not treated by AT methods, and that conventional psychotherapies are
not only useless but will exacerbate problems. These threats produce fear of
leaving the group and add to the cultic nature of the organization. Payment for
AT services is out-of-pocket rather than by health insurance, potentially
creating cognitive dissonance for those who might consider recanting after
making this expensive choice.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Who
are the members of the AT group, and what advantages do they derive from their
membership? AT’s primary focus on childhood mental illness means that the
people most affected by the belief system are children and not in a position to
make their own decisions about their involvement. Although personal
communications suggest that some children buy into the beliefs presented to
them and grow up assuming that AT is a conventionally-accepted therapy, and
although most of the children cooperate with the treatment for various reasons,
the children do not seek the treatment and therefore are not the cult members
in the usual sense. The decision to belong to the group rests with adults, who
are the actual members. Leadership of the group belongs primarily to AT
practitioners, who show their authority through child diagnosis and treatment
decisions as well as through published material, videos, Internet sites, and
training workshops (which in some cases are given continuing professional
education credits by approved providers certified by the American Psychological
Association and the National Association of Social Workers; the approved provider
system does not require the national organization to approve of individual
presentations). <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">In
a recent publication of ethnographic observations of AT around 2000, Stryker
(2010) discussed the involvement of adoption caseworkers and agencies as well
as parents in facilitating involvement with AT. Stryker pointed out that both
parents and caseworkers were rewarded by the sense of participating in family
formation. They emphasized the perceived criticism of adoptive parents by
conventional psychotherapists and repeated to each other the belief that
conventional methods exacerbate the childhood mental health problems they had
identified, thus confirming their membership in the group and differentiating
the group’s practices from those in the larger society. Both caseworkers and
practitioners provided a comforting re-frame in the not infrequent case of
disrupted adoptions, by describing the placement of a child in a residential
treatment facility (usually to stay there until “aging out” at 18) as “loving
at a distance”. The adoptive parents were encouraged to consider themselves and
the separated child as a family although there might be no contact between
them. These beliefs contradicted conventional thinking about family ties, and
once again contrasted the supportive attitudes of the AT group with the
criticism to be expected from the larger society. In similar contrast of
conventional and group positions, AT chat groups on the Internet often
mention disapproval of AT methods by
friends and family members and describe the intense need for support by other
AT proponents; a repeated theme in these chats is that no one can understand or
help with their problems unless that person has an adopted child, thus
effectively limiting sources of help or information to group members. (Adoptive
parents who report no particular problems are said to be “in denial” or lying.)
<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">At
a practical level, AT practices provide parents with freedom from child care
responsibilities for days or weeks at a time, or even permanently, outcomes
that would not be encouraged in most cases by conventional child mental health
interventions. In one case in Georgia (in which I testified as an expert
witness), AT-oriented caseworkers managed disruption of an adoption and
adoptive placement of a child with another family, without a conventional
family evaluation, and apparently simply through influence on a judge; when the
child ran away from the new home where she was receiving AT treatment, she was
placed in an AT-oriented facility in another state. Experience of these unconventionally
parent-friendly practices helps to hold members in the group. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
<b>A Religious Framework:
Deliverance Beliefs</b> <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The
purpose of this paper, as stated earlier, is to examine the connections between
an AP and a religious group, each of which meet some of the criteria for
classification as cultic. The possible religious parallel to AT is the commitment
to “deliverance” beliefs and practices, as evinced by Pentecostals and other
charismatic Christians. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">As
is well-known, traditions of exorcism of evil spirits date back to ancient
times. Roman Catholic rituals for exorcism were formulated in the 17<sup>th</sup>
century, as were those of the Church of England (Malia, 2001). However, Pentecostal
deliverance practices are not obvious developments of the Renaissance
tradition. The older rituals did not consider the capacity for deliverance (the
expulsion of demons) as a gift of the Holy Spirit, and as one among several
gifts said to have been received by the Apostles at the event celebrated as
Pentecost or Whitsunday, and described in the New Testament Book of Acts.
Neither were the spiritual gifts, which included “speaking in tongues”, part of
the periodic religious revivals experienced in North America in the 18<sup>th</sup>
and 19<sup>th</sup> centuries. The Pentecostal practice of glossolalia
apparently emerged in about 1830 in a British millennial Presbyterian group
known as the Catholic Apostolic Church (Ellis, 2000). The practice of “pleading
the Blood” and preoccupation with Jesus’ blood as a way of exerting power over
both physical and spiritual worlds began in the early 1900s, and was formalized
as a method of casting out spirits in a book by the Pentecostal author H.A.
Maxwell White in 1959. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">These
developments paralleled the growth of the Pentecostal belief that the
“indwelling” of demons in human beings is responsible for mental illness as
well as for physical problems (see Mercer, in press). More recently, manuals of
deliverance (Banks, 1985/2008; Hammond & Hammond, 1973/2010, 1996/2010; Wagner,
2000 ) have described causes of mental illness and outlined methods of
expelling the related demons; these authors agree that expulsion of demons/evil
spirits involves coughing or vomiting out physical substances. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Is
Pentecostalism a cult, or a loose organization of cult-like groups? To
understand Pentecostalism, it is first
necessary to recognize it as a religion, one of several “solutions to ultimate
meaning which postulate the existence of a supernatural being , world, or
force, and which further postulate that this force is active, that events and
conditions here on earth are influenced by the supernatural” (Stark &
Bainbridge, 1979, p. 119). In describing
religious cults, Stark and Bainbridge identified these groups as having no
prior tie with established religious bodies in their societies, and in that way
differing from schismatic sects. The beliefs of religious cults may have been
imported from an alien group, or they may be innovations with a background in
the same society.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Pentecostal
churches are associated with each other, but there is no over-riding
hierarchical organization or statement of dogmas to be accepted by all
Pentecostals. Constant schismatic splitting means that any specific church may
have somewhat different beliefs and practices from others. Nevertheless, there
is sufficient agreement among the groups for them to share publications that
discuss deliverance and associate it with healing of mental and physical
disorders. These publications and other
Pentecostal materials suggest that the group is cultic in nature.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Pentecostals
believe that each Christian experiences a direct connection to God and is a
potential recipient of the gifts of the Holy Spirit discussed earlier.
Religious training or ordination have little importance in the development of
group leaders, so that any individual who is “charismatic” (in the common
meaning of the term) can exercise authority. Members of the congregation are
devoted to these leaders (as Rosedale and Langone suggest), and the informal
and schismatic nature of the group means that any leader who does not inspire
devotion can quickly be left behind. Pentecostals are also devoted to the idea
that their lives are simultaneously involved with the natural and the
supernatural worlds, in a real day-by-day connection as well as a concern with
the afterlife. This belief, unshared with the great majority of
non-Pentecostals in the developed world, sets the group apart and provides a
strong motivation to remain engaged with similar believers; non-Pentecostals
are thought to behave dangerously and attract evil spirits by their casual
involvement with the occult (e.g., Halloween) and by their ignorance about
association with owl figures or the telling of ghost stories (an innovative
position, as suggested by Stark and Bainbridge). A positive reason for staying
with the group stems from the Pentecostal adoption of “prosperity theology” and
the assumption that right belief and behavior wins the gifts of this world as
well as those of the Holy Spirit (Roberts & Montgomery, 1966). However,
although Pentecostals may fear leaving the group, and desire the “compensators”
they associate with membership, they may feel under less pressure than many
cult members, as they believe that they are individually capable of receiving
the gifts of the Holy Spirit (although paradoxically they consider successful
deliverance to depend on confession of sins). In addition, Pentecostals as a
group assume that every person will sometimes “backslide” and that noncompliant
behavior should not necessarily cause expulsion from the group. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <b>Deliverance Beliefs and Choices of Mental
Health Intervention</b><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The
brief history of deliverance beliefs and practices in the last section shows a cult-like
organization with a rich source of metaphors that can be applied to
consideration of mental illness. These metaphors have the potential to shape
preferences or acceptance of APs that are not in themselves directly
deliverance-related. The stress deliverance believers place on the supernatural
may provide metaphors encouraging acceptance of non-material factors in
explanations of mental illness. These non-material factors may involve posited spiritual components such as demonic presences
or the Holy Ghost, undetectable by
physical measurement, that are said to underlie physical and mental
functioning. They may also involve pre-existing and immortal personality
components that enable the individual to remember events during embryonic life,
or even prior to conception. AP treatments almost invariably posit factors of
these types, and conventional treatments do not, so it can be hypothesized that
a preference for AP mental health interventions can result from metaphors
derived from deliverance beliefs. Such metaphors could result simply from
exposure to these beliefs, and would not necessarily require a serious
commitment or conversion.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Testing
the hypothesis that AP preferences are encouraged by exposure to deliverance
beliefs is not within the realm of practical politics. As an alternative, and
with the goal of accumulating evidence relevant to this issue, this paper will
now discuss resonances between deliverance beliefs and one AP mental health
intervention, AT, described earlier. It is notable that Nancy Thomas, a
long-time proponent of AT, is mentioned with admiration by at least one
deliverance-related website, as are a number of books advocating AT
(“Ministering to deeply troubled children”, n.d.). I am well aware of the
dangers of cherry-picking information and of the inappropriateness of
displaying only those points that support my hypothesis, but for obvious
reasons I will not attempt to list all those hundreds of ways in which AT does <i>not</i> resonate with deliverance beliefs,
and will presume that readers understand why I am taking this preliminary approach.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">What
are the resonances between AT and deliverance beliefs and practices? The most obvious parallel is an element of
the supernatural, shown by the AT claim
that unborn infants communicate with and know their mothers through means that
are unstated but that cannot include natural sensory modes or the level of
cognition usually attributed to the human fetus (Verny, 1983). The unborn child is considered to have
abilities that are superior to those of a neonate, an implausible idea given
that earlier development is invariably characterized by less mature capacities
than is later development. The implication is that the unborn child retains the
abilities of its spiritual origins, which are more advanced than allowed by the
material nature following birth.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">In
addition to the supernatural theme, resonances between deliverance and AT can
be seen in both diagnostic approaches and treatment methods. Some of the
parallels, like that between being “born again” and the “rebirthing” techniques
sometimes associated with AT, are obvious, but most are less apparent unless
examined in detail. The information used for this examination in the next
section will be drawn from Hammond & Hammond (1973/2010; 1996/2010) or
Banks (1985/2008) if it is not otherwise attributed.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Diagnostic
Approaches</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Several diagnostic themes are shared by deliverance and
AT proponents, although the two use different language to describe them.
Generally speaking, these shared items are not found in conventional diagnostic
approaches to Reactive Attachment Disorder, the diagnosis often mentioned for
children who receive AT treatment, or any other mental illness.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <i>Discernment.</i><b> </b>Deliverance believers consider that it
is possible to receive a divine word of knowledge through a vision, dream,
thought, or mental image, and that this knowledge helps to discern which demons
are causing a problem and why they are present. AT proponents do not state
this, but they present themselves as finding it fairly simple to decide whether
a child has an attachment disorder. They may make this diagnosis over the
telephone after asking the parent to respond to a checklist (this occurred for
Candace Newmaker, a child who died during AT treatment; see Mercer, Sarner,
& Rosa, 2003). Elizabeth Randolph, the developer of the Randolph Attachment
Disorder Questionnaire (RADQ), an assessment often used in AT proceedings,
apparently used her own diagnoses of children as the criterion for validation
of the RADQ (Randolph, 2000). It is not clear whether this is simply a matter
of careless or naïve test development, or whether Randolph believed that she
could accurately discern the child’s condition. Randolph also stated that she
could diagnose attachment disorders by noting the child’s inability to crawl
backward on command (Randolph, 2001), an implausible criterion that would
conventionally be considered to have nothing to do with an emotional disorder. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <i>Control battles.</i><b> </b>AT checklists are much concerned with
the child’s desire or attempts to control and manipulate others. Disobedience,
lack of gratitude, and failure to show affection on the parent’s terms are all
seen as symptoms of attachment disorders. Deliverance practitioners similarly
see an intense desire for control as a sign of demonic possession. In addition,
parents are advised to quell disobedience at all costs (Pearl & Pearl,1994).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Fascination with blood and gore.</span></i><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Although an obsessive interest in blood might
well indicate emotional disturbance of some kind, the DSM-IV-TR criteria for
RAD (American Psychiatric Association, 2000) include absolutely nothing related
to blood in any way. As was noted earlier, however, criteria in checklists
about AD, as promulgated by AT advocates, always include the idea that the
child is “fascinated by blood and gore”. There may be a resonance here with the
deliverance theology emphasis on “pleading the Blood” and “the power of the
Blood”. H.A. Maxwell White’s 1959 book on this topic stressed the great
spiritual significance of blood, its use in sacrifice, and the Biblical idea
that “the blood is the life”. Because AT proponents are concerned with children
seeking to control adults, they may read an interest in blood as a desire for
control in a spiritual as well as the obvious material sense.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Lying.</span></i><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Excessive fantasy or efforts at deception may
also be symptomatic of emotional disturbance , but again play no part in the
criteria for RAD. However, Attachment Disorder checklists, used by AT practitioners,
emphasize habitual lying, especially what they call “crazy lying”-- lying that will obviously not be believed.
Demons are thought of as liars, and are of course under the management of
Satan, the “father of lies”. In addition to their lying propensities, demons
are considered to be highly legalistic and to be permitted to lie about or
refuse to answer a question that is not asked in exactly the right way. Demons
are thought to lie in order to escape from deliverance proceedings without
giving up their “indwelling” of the victim’s body. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Eye contact.</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
Although eye contact is unmentioned in descriptions of the criteria for RAD,
and although mutual gaze is a behavior much influenced by cultural demands,
failure to make eye contact except when lying is mentioned by AD checklists,
and eye contact upon demand is part of AT practice. Deliverance proponents in some cases regard
the appearance of the eyes and of the gaze as revealing demon possession, as if
the eye is not only literally “the window of the soul”, but a window into
whatever spirit entity is inside a body. Hammond and Hammond (1973/2010) considered
that a glazed or fixed appearance of the eyes could reveal whether a demon or
the person himself was responsible for speech or movement. (It is also possible
that the AT concern about this symptom was adopted from information about
communicative behavior problems in autism.)<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Chatter.</span></i><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">AT proponents
suggest that attachment disorders are characterized by the child’s constant
chatter and “silly” questions, for example about when they will see their
parents again (Thomas, 2000), and advise caregivers to refuse to answer or to
answer with another question. Deliverance practitioners caution against
yielding to the temptation to exchange banter or persiflage with demonic
entities who are being addressed during a deliverance event; demons are thought
to use words to confuse issues as well as to lie. “Speaking in tongues”, a gift
of the Holy Spirit, involves chatter and incomprehensible speech or singing,
but in its own context is seen as sacred rather than diagnostic of demonic
possession.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">History of adoption.</span></i><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The conventional
criteria for<b> </b>RAD are unusual in their inclusion of
etiology as a factor to be considered along with behavior symptoms. A history
of early neglect or abuse, or inconsistent care, is necessary but not
sufficient for a diagnosis of RAD. Adoption
in itself would not be considered relevant to RAD, unless it occurred when the
child was older, or was accompanied by experiences of neglect or abuse. AT
proponents, however, emphasize the posited role of adoption in interfering with
attachment and creating AD (see Keck & Kupecky, 2009; the publisher of this
book is described as the publishing ministry of an international Christian
organization). Infants adopted in the first days of life and cared for well and
consistently are nevertheless thought to be susceptible to AD. This view
parallels the serious concern of deliverance believers with respect to the
attraction of demons by events preceding adoption, including the death of a
parent, conception outside wedlock or through violence and lust, or under circumstances
such that one or both parents consider the possibility of abortion. Adopted
children are considered to be vulnerable to demonic possession through both the
biological and the adoptive family lines, so generational curses based on
ancestral behavior are exceptionally likely to be at work in adopted persons
(Hammond & Hammond, 1973/2010; 1996/2010).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Incontinence. </span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Accounts
of cases by AT practitioners often note that children urinated or defecated
inappropriately (Thomas, 2000). Incontinence is attributed to demonic
influences by deliverance authors.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Treatment</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> AT and deliverance practices share a number of
procedures; expected behaviors of persons in treatment also have some
similarities. These shared items are not found in conventional scenarios of
treatment for mental health problems.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <i>Restraint.</i><b> </b>Although physical restraint of persons
in treatment is sometimes used for safety and security reasons, restraint is
not conventionally considered to be of psychotherapeutic value. On the
contrary, recommended goals are for reduction in the use of restraint and
seclusion even outside the therapeutic situation . In AT thinking, however,
restraint itself is thought to be of therapeutic benefit , whether as applied
provocatively to an initially calm client (Cline, 1992; Zaslow & Menta,
1975), or to one who is already agitated (Federici, 2001; Ziegler, 2001). Deliverance practices involve parallel
uses of restraint, whether applied when the deliverance candidate begins to
thrash and fight, or initially, when a child might be held on the lap of a
deliverer or a parent. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <i>Eye contact.</i><b> </b>Although conventional therapists use
gaze signals as part of their communication with a client, they do not regard
eye contact as a magical or transformative event. AT practitioners, however,
consider the maintenance of eye contact to be a powerful tool. While
restraining a child across the adult’s lap, or while lying on top of the child,
the practitioner insists on a prolonged mutual gaze and scolds or threatens the
child if he or she does not comply. The child is especially to look into the
therapist’s eyes while making confessions or repeating therapist-supplied
statements about feelings. Similarly, deliverers consider eye contact a useful
tool for communication of commands to demons, although they appear to recognize
that mutual gaze cannot be forced.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Confession.</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
Many conventional psychotherapies involve disclosure of actions, thoughts, and
feelings that a client may have wished to keep secret in the past. In AT
procedures, children are often told what feelings they must have (e.g., hatred
for the biological mother, rage against the adoptive mother) and what actions
they must have wished to carry out. They are instructed to shout related
statements (“I want to kill my Mom!”) repeatedly, and are informed that if they
do not change they will actually do these things and will go to prison (Mercer,
Sarner, & Rosa, 2003). In deliverance proceedings, confession of thoughts
or behavior that could attract demons is a prerequisite to the casting out of
those demons. “Occult” activities, like celebration of Halloween or use of a
Ouija board, must be described as well as more obviously prohibited activities
involving sex or drugs. In a parallel with AT, what is confessed might never have
been acted on, as in the case of a considered abortion (Hammond & Hammond, 1973/2010).
Deliverance proceedings include the verbatim repetition of prayers by the
deliverance candidate and the deliverance team. One point of interest is that
in the course of deliverance, confessions that are spoken may not be clearly
identified as information from the deliverance candidate; the demon might be
speaking and lying.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <i>Vomiting.</i><b> </b>Vomiting, urination, and defecation
are not expected events during most conventional psychotherapy, and if they
occur are considered symptoms of physical illness or of a child’s immaturity.
In AT practice, however, these physical actions are regarded as completely
under the control of the child and as used to resist the therapist’s pressures
for change. A much-quoted paper by Reber ( 1996) described children in AT as
vomiting, begging to use the toilet, and crying that they were going to die,
and positioned these behaviors as normal parts of the therapeutic proceeding
(this paper, incidentally, was cited by Furnari [2005]) . The AT-associated
death of Candace Newmaker in 2000 involved the child’s vomiting while
restrained inside a rolled sheet; several adults present ignored this and its
potential for serious harm, apparently considering it a normal part of
treatment. Deliverance proceedings, in a striking parallel, are not only
tolerant of vomiting, but consider vomiting and coughing phlegm as indices of
the expulsion of demons and therefore as desirable (Bialecki, 2011; Cuneo,
2001). Preparation for the deliverance includes provision of containers and
towels. Again, incontinence may be interpreted as a sign of demonic possession.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <i>Fasting.</i><b> </b>Conventional psychotherapies assume
that good physical health is advantageous for successful mental health
interventions. AT practices, on the contrary, hold that respite or therapeutic
foster care practices encourage emotional change when they limit the amount and
variety of children’s diets (Thomas, 2000), or force food or water as a way to
obtain compliance (Mercer, Sarner, & Rosa, 2003). Deliverance believers use
fasting as a method of purification that is helpful to the deliverer’s
abilities, but they may also advise the deliverance candidate to prepare
himself through fasting and prayer. I have found no evidence that fasting is
imposed on children, however. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <i>Number and length
of treatment sessions.</i><b> </b>Conventional
psychotherapies often use the standard “fifty-minute hour” and employ sessions
that occur weekly, or not much more often. AT sessions last for several hours,
and although they sometimes occur weekly, are much more frequent in the case of
the two-week “intensive”. Deliverance events also last several hours, and
although they are not at daily intervals, they are generally repeated on a
number of occasions, especially because it is thought that the same demons may
return, or other demons may be attracted to the “empty” person.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Practitioners.</span></i><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Licensure for
conventional psychotherapists attempts to ensure an appropriate level of
training. Some AT practitioners have found some ways to avoid such
requirements. They may practice in a state like Colorado, where therapists may
be registered but unlicensed, or may work under the cover of a sympathetic
licensed practitioner. These options permit a AT therapist to limit training on
some topics to weekend seminars (as was the case for Julie Ponder, one of the
persons responsible in the death of Candace Newmaker), or to claim the
credential of “registered attachment therapist” as provided by the Association
for Treatment and Training of Attachment in Children (ATTACh). Some AT
practitioners have doctoral degrees from intermittently-accredited
organizations like the Union Institute. Some have sought licensure as massage
therapists in order to avoid restrictions on physical contact with patients.
Deliverance practitioners have similar training issues. Pentecostal groups are
highly congregational in organization, so the hiring of pastors is based
entirely on the wishes of an individual church, and there is no denominational
set of standards for educational background. Deliverers learn informally from
each other, unless they themselves wish to study conventional materials; there
is no encouragement or requirement for any formal training in any
mental-health-related area. Indeed, their training may depend on items like the
<i>Demon possession handbook for human
service workers</i> (1995).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <i>Further concerns. </i>A
still unexplored issue in the continuing development of both deliverance
beliefs and acceptance of APs is the influence of African Pentecostalism. This
set of beliefs, which to some extent combines African traditional religions
with Pentecostal tenets (Asamoah-Gyadu, 2004), began with missionaries to
Africa from the United States, but may be affecting U.S. Pentecostals in return
as African evangelists return to preach and carry out deliverance in the United
States. An event of recent concern was
the planned (but postponed) visit of the Nigerian evangelist Helen Ukpabio, who
has been associated with many accusations of children as witches, followed by
torture and death of the children (Ngong, 2010; “Marathon deliverance”, 2012).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
Conclusion<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">“Deliverance”
believers and AT proponents both form groups that meet some criteria associated
with cults. Although cult-like groups may be expected to compete rather than
cooperate with each other, these two groups, which have different apparent
goals, share practices and beliefs to such an extent that they seem to be
mutually influential. However, the much longer history of Pentecostalism, as
well as its far broader concerns, suggests that Pentecostal beliefs and
metaphors are more likely to have influenced AT than the other way around. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The<b> </b>parallels between deliverance
practices and AT are clear, but there may well be an equal number of
non-parallel characteristics. As I noted earlier, I can hardly conclude that
the existence of many parallels between a religious framework and an AP
necessarily means that religious beliefs increase the acceptability of the
treatment to believers. However, it is noteworthy that there appear to be many
more overlapping factors between deliverance practices and AT than there would
be between, say, deliverance practices and conventional psychotherapies like Parent-Child
Interaction Therapy (Eyberg & Bussing, 2010) or DIR/Floortime (Greenspan
& Wieder, 2006). Neither of the latter
two treatments (one with and one without a clear evidence basis, but
both highly plausible) employs restraint or the forcing of eye contact or
confession; both emphasize following the child’s lead as an essential part of
establishing a good relationship, rather than seeing a controlling parent as
one who is fostering a child’s attachment.
<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Understanding the possible role of religious beliefs in
encouraging clients to choose AP treatment is especially important because of
the potential for harm in some unconventional methods. That potential goes
beyond the expenditure of scarce resources on ineffective treatment, or even
the possible avoidance of evidence-based treatment because of advice from AP
practitioners. Both deliverance practices and AT have been associated with
injuries and deaths (“Autistic boy’s death at church…”, 2003; “Police: ‘Cult’
starved toddler…”, 2008; Mercer, Sarner, & Rosa, 2003). They deserve to be categorized as Potentially
Harmful Treatments (Lilienfeld, 2007; Mercer & Pignotti, 2007) and to have
their beliefs and practices publicly vetted for the benefit of those who may be
attracted to these cult-like organizations. Some vetting is currently
proceeding in a British case discussed at <a href="http://invisibleengland2.wordpress.com/">http://invisibleengland2.wordpress.com</a>,
as well as in a case in the U.S. in which a man in his 30s is seeking redress
for being confined and treated with AT for eight years of his childhood.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Practical
Effects of Differing Social Environments </span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Although this paper has called attention to resonances
between a cult-like psychotherapy and a cult-like religious system, these two phenomena
cannot be argued to be identical. Psychotherapeutic cults and religious cults
(assuming that both exist) operate under very different social pressures and
are thus forced to behave differently in related ways. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Religious
leaders need not be licensed or conform with specific guidelines or messages
unless they belong to established groups that ordain clergy who are to teach
agreed-upon dogma. Religious leaders may volunteer their services or may be
paid a salary by a congregation, but generally do not perform fee-for-service
work in the usual sense. There is no
pressure for leaders of religious cults to state their conformity with the
beliefs of established groups; on the contrary, their positions may be
strengthened by clear antagonism to conventional beliefs and practices. There
is thus little beyond the opinions of group members to encourage the group to
resemble established religious systems.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Psychotherapists,
on the other hand, cannot ordinarily practice, advertise, or identify
themselves as such without some degree of approval of the larger society. That
approval is generally based on the approval of established professional groups
that work to the benefit of conventional belief systems and practices. Although
there are some states in which unlicensed psychotherapists have practiced,
alone or under the direction of another practitioner, licensure is a common
requirement and is based on meeting conventional standards of education and
training. Unless the unlicensed practitioner can find a licensed individual to
handle billing and other arrangements, he or she will be unable to receive
third-party payment. Without the salary that a religious leader often receives,
the unlicensed AP practitioner may be unable to make a living unless he or she
can convince potential fee-paying clients of the efficacy of the treatment. To
accomplish this involves a high level of information management. In the present
era of emphasis on evidence-based treatment, AP practitioners make claims about
the way their treatment “works” and count on the inability of the client to
understand the systematic evidence required to make such claims (Mercer, Pennington,
Pignotti, & Rosa, 2009). <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">AP
practitioners also provide rationales for their practices that allude to
respected psychological authors whose theories are foundational to conventional
approaches; for instance, AT proponents frequently reference John Bowlby, the
originator of attachment theory, even though the AT concept of attachment is
quite different from that proposed by Bowlby (see <a href="http://www.attach.org/">www.attach.org</a> for examples). AP practitioners
recognize current assumptions in conventional psychotherapy and attempt to
position their treatments either in contradiction or in compliance with them.
In AT circles, for example, authors in the 1990s argued against the
conventional child psychotherapy dictum of “following the child’s lead” and
declared that such practices would exacerbate childhood mental illness.
Following the death of Candace Newmaker and the repositioning of AT thinking,
AT authors have responded to guidelines requiring informed consent of clients
to treatment by claiming that children are always asked if they agree to being
held, a claim that ignores the conventional view that children are in fact not
capable of informed consent, and that bypasses the more important requirement
that parents and guardians must be fully informed of risks and benefits before
giving their consent to treatment. Some AP proponents have addressed their
practical need to appear in conformity with conventional practices by insisting
that professional journals were unfairly excluding submitted papers; in 2001,
the editor of the <i>Journal of Clinical
Psychology</i> permitted non-reviewed publication of papers about the AP Thought
Field Therapy (Callahan, 2001) in order to show openness on this point.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">These
practical issues may conceal the resemblances of the religious and the
psychotherapeutic groups to each other, and their sharing of cult-like
characteristics. Nevertheless, as this paper has shown, the two belief systems examined
here have much in common. The same may be true of other cult-like religious and
psychotherapeutic groups, but in order to determine this it is probably
necessary to compare the details of specific groups with each other rather than
attempting a broad comparison of all
groups of each type. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 2.0in; text-indent: .5in;">
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<br /></div>
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<br />
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">. <o:p></o:p></span></div>
Jean Mercerhttp://www.blogger.com/profile/14619393019771381980noreply@blogger.com14tag:blogger.com,1999:blog-9087183049500362990.post-24179587058213305112012-12-20T16:56:00.002-08:002013-03-26T13:22:06.737-07:00Jirina Prekopova's Holding Therapy: Scientific Support, or Non-Scientific Foundations?<br />
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">N.B. This paper is a draft prepared for presentation
at a meeting of the International Working Group on Abuses in Child<b> </b>Psychotherapy, London, April 20, 2013.<o:p></o:p></span></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> Jirina Prekopova’s Holding Therapy: </span></b><br />
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> Scientific Support, or Non-scientific Foundations?<o:p></o:p></span></b></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> </span></b><br />
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> Jean Mercer<o:p></o:p></span></b></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> The “holding therapy”
method practiced by Jirina Prekopova<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> and others as a mental
health intervention for children is described and<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: 0.5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">examined with
respect to its scientific and nonscientific foundations. It is <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: 0.5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">concluded that
the treatment is without scientific basis, but is closely related <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: 0.5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> to other
unconventional beliefs and practices that began in the 20<sup>th</sup> century.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> “Holding therapy” of the type
Prekopova uses is probably not child abuse<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 77.25pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">by legal
definition, but includes actions that are considered abusive by <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 77.25pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">definitions used
in research<b><o:p></o:p></b></span></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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 <a href="http://www.prekopova.pevne-objeti.cz/">www.prekopova.pevne-objeti.cz</a>).
Prekopova’s technique is called “holding therapy” (HT) in English and is also
known as <i>Festhaltetherapie</i>; 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 <i>ventre-a-ventre</i> 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). <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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 (<a href="http://www.nobelprize.org/nobel_prizes/medicine/laureates/1973/tinbergen-lecture.pdf">www.nobelprize.org/nobel_prizes/medicine/laureates/1973/tinbergen-lecture.pdf</a>),
and described autism as a stress disorder in a <i>Science</i> article (1974). <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Are There
Scientific Foundations for HT?<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Ethological
Foundations of HT<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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]). <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">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.) <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Is There Other
Scientific Evidence for or Against HT?<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Changing
Beliefs About the Causes of Autism<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">In
line with the strong emphasis on environmental factors of the mid-20<sup>th</sup>
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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Is
There an Evidence Basis for HT?<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">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)<sup> </sup>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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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 )<sup> </sup>. 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Where Does HT Come From?
Some Nonscientific Sources<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Sources
from 1940 to 2000<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">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 ). <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">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 20<sup>th</sup> 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). <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Earlier
Background of HT<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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 <i>furor sanandi</i> 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 <i>Das Buch vom Es </i>(<i>The book of the it, </i>1923/1949)<i>,
</i>a popularized volume arguing that one’s thoughts and actions are determined
by a life force, not by the self. This life force, the <i>Es</i> (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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.)<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Discussion<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Is
HT Child Abuse?<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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 <a href="http://www.invisibleengland2.wordpress%2Ccom/">www.invisibleengland2.wordpress,com</a>,
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).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Conclusion<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> 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. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
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Jean Mercerhttp://www.blogger.com/profile/14619393019771381980noreply@blogger.com1tag:blogger.com,1999:blog-9087183049500362990.post-8474509412627912632012-12-01T10:12:00.000-08:002013-07-08T15:47:51.739-07:00Coercive Restraint (Holding) Therapy as an Abusive Treatment<br />
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<br /></div>
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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. </div>
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<br /></div>
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<br /></div>
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<br /></div>
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<br /></div>
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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.</div>
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<b>
Characteristics of CRT<o:p></o:p></b></div>
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Shared
characteristics of practices classed as CRT (cf. Cline, 1992; Levy, 2000) include the following.</div>
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1) CRT interventions are most often done with
children, and particularly with adopted children.</div>
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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 . </div>
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3) CRT interventions stress the power and
authority of the adult and reject the psychotherapeutic principle of following
the child’s lead.</div>
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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”.</div>
<div class="MsoNormal" style="line-height: 200%;">
5) CRT interventions assume the necessity of
emotional catharsis through reexperiencing past trauma. </div>
<div class="MsoNormal" style="line-height: 200%;">
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.</div>
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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.</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
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<br /></div>
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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.</div>
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<br /></div>
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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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i>Care Techniques</i><o:p></o:p></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
“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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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 <a href="http://wwwdartcenter.org/dartaward/2002/winner_08.html">http://www.dartcenter.org/dartaward/2002/winner_08.html</a>)
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
“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).</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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. </div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i>Diagmostic Issues and Treatment
Incidence</i></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
CRT practitioners
generally use a diagnosis of Reactive Attachment Disorder (RAD) for insurance
purposes. This diagnosis, while described in the <i>Diagnostic and statistical manual</i> 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 (<st1:city w:st="on">Randolph</st1:city>,
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. </div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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 (<st1:city w:st="on">Randolph</st1:city>,
2001).</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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 (<a href="http://www.nancythomasparenting.com/attachmenttherapy.htm">http://www.nancythomasparenting.com/attachmenttherapy.htm</a>).
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. </div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<b>Clinical Concerns About CRT<o:p></o:p></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i>Evidentiary Basis of CRT and CRTP<o:p></o:p></i></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.”</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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:// <a href="http://www.adoption.org/">www.adoption.org</a>; http://<a href="http://www.attachmentexperts.com/treatment_outcome.html">www.attachmentexperts.com/treatment_outcome.html</a>)
, 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. </div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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 (<st1:city w:st="on">Randolph</st1:city>, 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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: 4.5pt;">
<b><i>Theory
and Philosophy of CRT</i></b><i><o:p></o:p></i></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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. </div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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://<a href="http://www.soulsong.com/">www.soulsong.com</a>). Some concepts from the popular “primal
scream” technique (Janov, 1970) and some
developments in Transactional Analysis (<st1:place w:st="on">Berne</st1:place>,
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. </div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
3) In the second
year of life, attachment is encouraged when the caregiver sets distinct limits
on the child’s behavior.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
9) Only people who
have lived with attachment-disordered children can understand what forms of
treatment they require.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
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.
</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<b> CRT and CRTP as Maltreatment</b></div>
<div class="MsoNormal" style="line-height: 200%;">
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. </div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<u>04.5 Other Physical Abuse.</u>.
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.(<a href="http://www.upledger.com/therapies/default.htm">http://www.upledger.com/therapies/default.htm</a>). Nevertheless practitioners deny that these
methods are abusive. They compare the child’s distress during treatment to that
during chemotherapy (<a href="http://www.deborahhage.com/holding.htm">http://www.deborahhage.com/holding.htm</a>)
and claim that parents and therapists must regard this distress as essential
for the child’s recovery. </div>
<div class="MsoNormal" style="line-height: 200%;">
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). </div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 4.5pt; mso-list: l0 level2 lfo1; tab-stops: list 0in; text-indent: -4.5pt;">
<!--[if !supportLists]-->05.1.<span style="font-size: 7pt; line-height: normal;">
</span><!--[endif]--><u>Close Confinement:Tying,Binding. </u> (… 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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<u>06.1, 06.2, 06.3. Verbal or
Emotional Assault.</u> (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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 0in; mso-list: l1 level2 lfo2; tab-stops: list 0in; text-indent: 0in;">
<!--[if !supportLists]-->06.3.<span style="font-size: 7pt; line-height: normal;">
</span><!--[endif]--><u>Verbal Assaults and Emotional Abuse.. </u> (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. </div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
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<!--[if !supportLists]-->06.3.1.<span style="font-size: 7pt; line-height: normal;"> </span><!--[endif]--><u>Verbal
threats of other maltreatment. </u> (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.</div>
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<u>07.3 Other/unknown abuse. </u>.
(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 (<a href="http://www.childrenintherapy.org/victims/matthey.html">http://www.childrenintherapy.org/victims/matthey.html</a>),
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).</div>
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<u>10.3. Unstable Custody Arrangements. </u>.
(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 ).</div>
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<u>12.1. Other physical neglect:
Inadequate Nutrition. </u> ( 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 <st1:city w:st="on">Jackson</st1:city> adoptees of <st1:state w:st="on">New Jersey</st1:state> (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).</div>
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<u>13.9. Knowingly Permitted Chronic
Truancy.</u> . (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.</div>
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<u>15.1. Inadequate Nurturance/Affection.</u>.
(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.” </div>
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<u>17.1. Refused to Allow or Provide Needed
Care for Diagnosed Emotional or behavioral impairment.</u> (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.</div>
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<u>17.3. Other Emotional Neglect:
Overprotectiveness.</u> (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. </div>
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<u>17.4. Emotional Neglect: Inadequate
Structure.</u> (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. </div>
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<u>17.5. Other
Emotional Neglect:Inappropriately Advanced Expectations.</u> (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. </div>
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<b><i>Clinical
Outcomes of CRT and Similar Experiences <o:p></o:p></i></b></div>
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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.</div>
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<b><i>Experiences of psychological
control. </i></b>Psychological control
has been defined as:</div>
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“…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).</div>
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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.</div>
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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.</div>
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<b><i>Psychological and emotional
effects of torture. </i></b>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.</div>
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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. </div>
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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).</div>
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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. </div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<b>References</b> </div>
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Jean Mercerhttp://www.blogger.com/profile/14619393019771381980noreply@blogger.com1tag:blogger.com,1999:blog-9087183049500362990.post-73943371628978076942012-08-15T11:20:00.001-07:002012-08-15T11:22:33.281-07:00Parsing the "Attachment Cycle": The Fox Terrier of Attachment Therapy<br />
<div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> Parsing the “Attachment Cycle”: The Fox
Terrier of Attachment Therapy<o:p></o:p></span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> </span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> Jean Mercer<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> Practitioners of Attachment Therapy often
reference the development of attachment according to a pattern they call the “attachment
cycle”. This paper examines the possible sources of this concept, notes that the
“attachment cycle” is not congruent with current conventional views of
attachment but seems to be derived from a mixture of unconventional and older
conventional theories, and suggests that commonly observable aspects of early
development contradict the “attachment cycle”. The potential dangers of belief
in the posited “attachment cycle” are discussed. <o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">According
to Steven Jay Gould, when Darwin was describing the “dawn horse” <i>Eohippus</i> he described it as the size of
a fox terrier. Of course, in his day, most people likely to read his work rode
to hounds and knew what a fox terrier (as opposed to a fox hound) was. They
knew what size Darwin meant. But, as time went on and fewer and fewer people
had the resources or the beliefs that would encourage fox hunting, fox terriers
became less common, and relatively few people knew how big they were and how
big Darwin meant that <i>Eohippus</i> was.
Authors discussing <i>Eohippus</i>
nevertheless copied Darwin and each other, and continued to compare the ancient
animal to a fox terrier, communicating little to their readers. The same thing
can and does happen as authors writing about
mental health issues copy each other--
and it happens most easily when it’s a diagram that’s copied. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">When
an author provides a simple, decorative diagram that illustrates a claimed
connection between events, it’s hard for readers not to assume that the
existence of the diagram confirms the existence of the events and of
connections between them. Maslow’s all-too-famous hierarchy of needs
exemplifies this phenomenon—thousands of people can recognize and even
reproduce the pyramid diagram, even though they may have no clear idea of the
claims being made or the presence or absence of empirical support for them.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">In
discussions of vernacular, unconventional psychological principles-- for example, the belief system behind
“Attachment Therapy” (Holding Therapy, Rage-reduction Therapy, Z-therapy, and
other names as well)—proponents often employ a diagram showing events in an
“attachment cycle”. This diagram can be seen in the works of Foster Cline and
of Vera Fahlberg, and currently at <a href="http://www.emkpress.com/pdffiles-BWattach.pdf">www.emkpress.com/pdffiles-BWattach.pdf</a>,
at <a href="http://e-magazine.adoption.com/articles/379/what-is-attachment-disorder.php">http://e-magazine.adoption.com/articles/379/what-is-attachment-disorder.php</a>,
at <a href="http://www.scottsdalemomsblog.com/2012/01/26/the-attachment-cycle/">www.scottsdalemomsblog.com/2012/01/26/the-attachment-cycle/</a>,
and so on for pages of Google. Diagrams of the “attachment cycle” show repeated
incidents in which a baby feels a need, a caregiver responds appropriately, the
baby is gratified-- and after many
repetitions the baby becomes attached to the caregiver. A disturbed “attachment
cycle” is represented like this:<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
Baby has a need <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> (possibly
including smiles and social reinforcement) <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> \<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> /
\ /<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Trust does not develop,
rage develops instead
Baby cries<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> \ /<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> \
/<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
Caregiver does not respond<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">For some authors, the
“attachment cycle” ends here. Meet the baby’s needs and the baby becomes
attached (defined here as developing trust)--
fail to meet them, and he or she does not become attached (defined here
as responding with rage). For Cline and some others, however, this diagram shows
only a “first year attachment cycle”. Attachment is not complete, they
say, until the child learns to accept
and indeed love the limitations and boundaries created by a powerful caregiver
in the course of a “second year attachment cycle”. We can consider the
first-year cycle by itself and then return to examine the notional second-year
cycle. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">It’s
clear that these repeated sequences, posited by Cline and Fahlberg as part of a
first-year attachment cycle, do occur. Babies cry when they need something, and
they are either helped or not helped by their caregivers. Toddlers also certainly test boundaries, and are either
corrected or not corrected by their caregivers. Because babies cry when they
actually do need something, a baby who is frequently ignored or treated
inappropriately may not survive. In addition, to look forward to the second
year, a toddler whose boundary-testing is not responded to appropriately may be
injured or killed as a result of risk-taking--
these possibilities are plain. What’s not so clear is whether either of
these scenarios has anything to do with attachment in any direct manner-- yet Cline, Fahlberg, and various followers have
insisted that the demonstrably repeated sequences are the causes of
attachment. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Like
the Maslow diagram, this depiction of a “cycle” seems intended to operate as
its own proof. Many readers who see it
seem to be convinced that that where there’s a diagram, there’s reality. Cline
and his colleagues have made no effort to adduce data to support their claims,
but they have attributed some parts of the “cycle” idea to other authors. Fahlberg (1991), for
instance, references Rene’ Spitz’s book <i>The first year of life </i>(1965), but she also shows diagrams of a related
“arousal-relaxation cycle” whose source is unmentioned.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> The “First-Year
Attachment Cycle”<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Is Spitz’s Work the
Source of the “Attachment Cycle”?<o:p></o:p></span></i></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">What
are the actual sources of the “attachment cycle” idea? Fahlberg’s reference to
Spitz suggests that his work is a good place to begin the search. Like many
other authors, Spitz was interested in the long-term effects of the infant’s
repeated experiences with adequate or inadequate caregiving. As he pointed out
with respect to feeding, “the two parts of the experience, the hunger screaming
and the gratification which follows it, become linked in the child’s memory. …
This development should be understood in the terms of Ferenczi’s… propositions
on the stage of infantile omnipotence. Hunger screaming, followed by gratification,
forms the basis for the feeling of omnipotence, which according to Ferenczi is
an early stage of the sense of reality… In this achievement of enlisting the
mother’s help for his needs through screaming, the human being experiences for
the first time the <i>post hoc ergo propter
hoc</i> in connection with his own action” (Spitz, 1965, p.153). But Spitz
associated these sequences of experience with memory, with perception, and with
the understanding of causality. The word “attachment” did not appear in the index
of the book at all. Spitz’s work does not seem to be the source of the
“attachment cycle”.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">How Does Erikson’s
Concept of Trust Relate to the “Attachment Cycle”? <o:p></o:p></span></i></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">What
about other repeated events or cycles as proposed by influential authors? Fahlberg,
Cline, and other authors occasionally refer to Erik Erikson’s concept of basic
trust (Erikson, 1950/1963). A sense of trust is thought to develop in the
course of repeated experiences of good care, but trust is not exactly the same
as attachment. Erikson pointed out the need for an appropriate balance of trust
and mistrust, but conventional attachment theory emphasizes the advantages of
secure attachment over other attachment statuses, both with respect to later
social relationships and with respect to support for childhood exploration and
learning. Erikson speaks of a life cycle, of course, but he does not refer to a
cycle of repeated experiences when he says this-- instead, the life cycle consists of a number
of qualitatively different stages of social and emotional life, occurring in a
predictable order. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">A Behavioristic
Approach</span></i></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Neither
Cline nor Fahlberg gives specific mention of the possibility that operant
conditioning could play a role in attachment. To think along these lines
involves examining the possible process of reinforcement for attentiveness to
the caregiver-- and, in addition, for
the caregiver’s attentiveness to the baby. J.L. Gewirtz (1969) proposed a
theory of mutual effects of parent and child on each other, with social
reinforcement for the child from that care and affectionate attention of the
adult, and for the adult from the pleasure shown by the infant. In a series of
systematic observations of mothers and babies (a strategy all too rare among
theorists addressing this topic), Gewirtz was able to show mutual reinforcement
and gradual change of mother’s and child’s behavior toward each other. In fact,
the “first-year attachment cycle” is quite parallel to Gewirtz’s suggestion, as
both involve spontaneous behavior related to infant needs, adult responses, and
ensuing learning. However, like all operant conditioning approaches, Gewirtz’s
theory would allow for attachment
behavior to be maintained after it is once established, even though the adult
response became less and less frequent; the “attachment cycle” theory suggests
instead that failure to respond produces rage and interferes with the
development of emotional attachment.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Can the “Attachment
Cycle” Be Recognized Under Some Other Name?</span></i></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Fahlberg
herself provides an additional diagram
that may provide a clue to the sources of the “attachment cycle”. This shows
the “arousal-relaxation cycle” mentioned earlier. It involves arousal of energy
and attention by a physical need, a reaction to that need (like crying),
followed by either appropriate care and subsequent relaxation when the need is
gratified or by continued distress and a failure to learn that caregivers will
help. This cycle resembles, in name and otherwise, Wilhelm Reich’s “four-beat”
motivational cycle. Reich ( 1980; originally published 1945) posited that in
all motivation there is some form of mechanical tension, followed by an
increased electrical charge, an electrical discharge, and mechanical
relaxation. This cycle, Reich thought, had a biological foundation and could be
seen in events ranging from orgasm to mitosis.
Reich, who died in prison after conviction for selling fraudulent
medical devices, believed that transfer
of an unknown energy called “orgone” was at work in all these phenomena. I
would suggest that Reich’s motivational cycle was the source of the “ first-year
attachment cycle” presented by Fahlberg and by Cline, as well as by many
imitators (e.g., Golding, 2008 ). <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Neither
Fahlberg nor Cline attributed the arousal-relaxation cycle or the “attachment
cycle” they derived from it to Reich. This is not surprising, because authors
dependent on unconventional beliefs often fail to cite their sources. It’s
notable, though, that Robert Zaslow, Cline’s mentor (and perhaps Fahlberg’s
also?) frequently referred to Reich’s theories as sources (Zaslow & Menta,
1975) and proposed a “soul cycle” that is comparable. Because the “attachment
cycle” is not to be found in any other discussions of early emotional
development, it may well be that this “fox terrier” has been brought back again
and again without sourcing, to the point that few readers know what it is or
where it came from.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> The
“Second-Year Attachment Cycle”<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Fahlberg
had little or nothing to say about a “second-year attachment cycle”, but Cline<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> ( 1992) emphasized the importance of this
period, during which, he claimed, caregiver limit-setting was essential to the
further development of attachment. He backed up this statement by a reference
to Bowlby’s remark that caregivers who become attachment figures are usually
stronger and more authoritative than the children, an idea that Cline tweaked
into the claim that the adult’s strength and power are actually the causes of
aspects of attachment. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">It’s
readily observable that parents all over the world do set limits on their young
children’s actions, usually starting at about the end of the first year, when
expert crawling and the beginning of independent walking make “mischief” more
possible. Toddlers are pressed to become toilet-trained, to use spoken words
rather than screaming or grabbing for what they want, and to stay away from
dangerous or breakable things. There may be poor outcomes of behavioral
development both for children who receive little limit-setting and for those
subjected to many rules and much punishment for infractions. Careful guidance
during the toddler period helps establish self-regulation and self-control.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Does
limit-setting during this period have anything to do with attachment?
Evaluations of attachment like the Strange Situation (Ainsworth, Blehar,
Waters, & Wall, 1978) focus on the beginning of the toddler period at about
12 months of age, before much limit-setting is usually in place. This suggests
that attachment in Bowlby’s sense is already established before the second year
is well underway. Bowlby himself referred to this period of development as one
in which parent-child relationships began to modulate from the intensity of
earlier stranger and separation anxiety to include negotiation and compromise
between the parties-- a situation that
seems to contradict Cline’s claim.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Cline,
Fahlberg, and others have also appealed to the basic trust/ basic mistrust
concept proposed by Erikson as the important developmental issue of the first
year of life. But what does Erikson suggest about the second year? He proposed
that the second year or so of life involves a new focus on a sense of autonomy,
or confidence in one’s own decision-making about how to do things, as opposed
to a sense of shame and doubt that emphasizes other people’s opinions and
worth. Recognizing that toddlers need to be socialized and learn to follow
family rules, Erikson nevertheless suggested that the task of socialization can
be done through consistent gentle guidance, helping the individual to have
confidence in his ability to “do things right”, or as an alternative can
overwhelm the toddler’s abilities and leave a readiness to feel himself in the
wrong. Cline’s stress on the power and authority of the caregiver would seem to
work against a sense of autonomy, which Erikson argued children needed to
develop even though adults are, realistically, stronger and more knowledgeable
than toddlers are.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Like
other object-relations theorists, Spitz considered frustration to be a factor
in the infant’s progress toward understanding reality. Limit-setting, even of
the mildest form, is frustrating to young children-- so does this mean that Spitz’s views support
the Cline “second-year attachment cycle” belief? No, because (again like other
object-relations theorists), Spitz believed that frustration played an
important role in development during the first year, when it would not often be
associated with limit-setting.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">There
seems to be no support from theorists of personality development for the idea
that limit-setting in the toddler period
contributes to the growth of attachment <i>per
se</i>, although it is clear that
experiences of limit-setting influence other aspects of personality and
behavior. Bowlby (1944) considered that some juvenile delinquents were
influenced by poor attachment histories, but did not connect obedience specifically
with attachment. Why, then, did Cline attempt a <i>rapprochement</i> between limit-setting and attachment? He has not
explained this, but we can speculate that the goal is to complete Cline’s
posited association between attachment and obedience. Cline and various
colleagues have claimed repeatedly that problems of attachment are indicated by
the child’s disobedience and undesirable behavior, and that treatment by means
of Attachment Therapy will make the
child “respectful, responsible, and fun to be around” and ensure that he or she
does things “Mom and Dad’s way”. Cline’s commercial parent-education program,
“Love & Logic”, is primarily concerned with obedience and compliance with
adult wishes. The concern with obedience, combined with the assumption that all
behavioral problems ultimately result from attachment issues, appears to have
brought compliance under the attachment umbrella and thus created the
“second-year attachment cycle” belief.<b> <o:p></o:p></b></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> How Can We Know What
Causes Attachment?<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Attachment
behavior is readily observed, but attachment itself (as an internal state and
motivating factor) must be inferred. As a result, no one can see attachment
happening—although Gewirtz (1969) reported what appears to be a relevant set of
processes. Until attachment has happened and attachment behavior is present, we
can only guess at the internal process. This means that the problem of
associating later attachment with one or more causal factors is a serious one. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Various
causes of attachment have been suggested, some more and some less likely.
Authors like Nancy Verrier ( 1993) propose that babies are already emotionally
attached to their mothers at birth, but infants’ behavior does not support this
view. Sigmund Freud attributed attachment to the experience of being fed by a
particular person. John Bowlby emphasized the effect of pleasurable social and
emotional interaction with a caregiver, and proposed that infants in the second
year of life are biologically primed to learn a connection with a familiar
adult. As has been noted already, Cline
and other Attachment Therapists hold that repeated experiences of satisfied
needs create attachment to the adult who provided the satisfaction.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Almost
all attachment phenomena share a particular problem that stands in the way of
accurate analysis. This is the fact that most often, the person (or people) who
plays with and shows affection to a baby is the same person (or people) who
feeds, cleans, rocks, and comforts that child.
The confounding of these factors means that in the ordinary course of
events we are not going to be able to separate the effects of feeding, of
repeated satisfying cycles, or of social interaction. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Nevertheless,
some observations do allow us to think about causes of attachment. For example,
in many families, one parent is much more involved than the other in infant
care. We would expect that parent to be the only important attachment figure,
if the “first-year attachment cycle” applies; yet we see babies display great
interest in a parent who does little physical care but who when present is
playful and socially engaging. Sadly, we also see that children form
attachments to caregivers who are neglectful and even abusive, and grieve when
separated from the adults, suggesting that satisfying care is not very
important to attachment, or that if it is important, very little of it is
required to do the job. Finally, reports on the traditional <i>kibbutz</i> child-rearing methods (see
Bettelheim,1969) suggest that infants cared for with little interaction with
adults, but physically healthy, become engaged with and attached to nearby
“crib-mates” and are distressed if those babies are separated from them for
some reason; other infants cannot have participated in feeding or care, but may
have been either socially interactive or simply familiar in the sense that they
were almost always there. These observations imply that repeated experiences of
the “attachment cycle” are not actually causes of attachment.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Several
other developmental phenomena appear to argue against the “attachment cycle” as
an explanation of emotional attachment. The first of these is the prefiguring of attachment behavior by a
period of infant “wariness”, in which the 6- or 7-month-old, who used to be
highly sociable, begins to regard new people with a serious air and warms up
slowly to those who behave pleasantly and engagingly. At about the same time,
many babies begin to show fear of sounds and events that are familiar but
perhaps startling, like the sound of the garbage truck or a vacuum cleaner
being turned on. This change occurs before and predicts the obviously
attachment-related behaviors of stranger and separation anxiety, but it is
difficult to see how a gradual development by way of a repeated “attachment
cycle” could be connected with the development of fearfulness and its mirror
image, a strong preference for the familiar.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">A
second relevant event is the often dramatic sudden emergence of attachment
behaviors at about 8 to 12 months of age. This developmental milestone would
seem to indicate a reorganization of behavior and emotion of the kind posited
by dynamic systems theory. In Bowlby’s attachment theory, the abrupt change
(sometimes evident over a day or two) involves a combination of maturation and
of experience rather than repeated experience alone. Simple repetition and
reinforcement might be expected to show a conventional learning curve, but not
the sudden increase in a behavior’s frequency shown in observations of infant
and toddler behavior.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">An
additional phenomenon that appears incongruent with the “attachment cycle”
theory is that of transitional objects. The toddler’s attachment to objects
such as “blankies” and teddy bears has been described by Winnicott (1953) and
is familiar to anyone who has cared for very young human beings. The display of
attachment to the transitional object is parallel to attachment to caregivers,
and is notably not a substitute for attachment to a familiar person. The
toddler who is devoted to a transitional object wants the specific object as
well as the familiar caregiver and may not be able to be calmed by the
caregiver alone. Yet the transitional object cannot have participated in an
“attachment cycle”, can provide little in the way of need satisfaction other than
a sense of familiarity, and certainly does not have as many ways of satisfying
needs as a human caregiver can provide. In addition, transitional objects do
not appear to function until after attachment to caregivers begins to be
displayed, and although the object may have been offered to the baby prior to
attachment, it has usually been one of many, all providing equal experience,
but only one eventually being selected as the needed blanket or bear. The
transitional object becomes important only after it has become familiar and the
baby has reached the necessary maturational stage, and the same may well be
true of the human attachment figure.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Finally,
the toddler characteristic of neophobia may be relevant to behaviors we
consider attachment-related. Neophobia, the young child’s aversion to
unfamiliar foods, objects, and situations, can be considered as the mirror
image of the child’s intense preferences for familiar people and places as well
as for a specific transitional object. The child’s fear of strangers and of
separation can also be classed as forms of neophobia. The “attachment cycle”
theory would seem to imply that rejection of a person depends on experience of
that person’s failure to satisfy signaled needs, just as it suggests that
attachment/preference results from experiences of satisfaction mediated by an
adult. Yet unfamiliar foods, places, and people have by definition had no
opportunity either to satisfy or to fail to satisfy infant needs. Examining
attachment behavior in the context of other age-related behavior in this way
leads to the conclusion that an “attachment cycle” would have to be congruent
with several aspects of infant and toddler development in order to be a
reasonable explanation of attachment--
but it is not.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Is It a Problem to Assume There is an “Attachment
Cycle”?<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Does
it matter whether people think there is a “first-year attachment cycle”, with
or without an added second-year cycle? In some ways, no, it does not
matter-- and the belief may even have a
positive outcome. If parents are concerned about attachment as an important
aspect of development, and if they believe that they can foster attachment by
sensitive, responsive treatment of their infant, those beliefs are likely to
produce excellent child care and good development. It’s a much better situation
than if, say, someone advised parents to whip an infant who refused food (see
Pearl & Pearl, 1994). <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">In
other ways, though, the belief in the “attachment cycle” can be quite harmful.
One of the associated problems is the assumption fostered by Attachment
Therapists that child disobedience indicates a failure of attachment, rather
than a variety of other causes, many of which involve poor parenting. A second,
and even more potentially harmful, belief is that both first and second-year
“attachment cycles” can be recapitulated as treatment for older children. Acting
out of this assumption involves efforts to display adult power and authority as
well as arbitrary presentation of sweets, hugs, and eye contact as means of
creating attachment (Thomas, 2000). The
second belief is based on the assumption that it is possible, by re-enacting
some common early childhood experiences, to cause individuals to “regress” and
resume the characteristics of their early lives, then to cause them to develop
back to their present chronological age’s characteristics and to undergo
experiences that will correct whatever problems had initially occurred. These
principles and practices are without
empirical support and are potentially harmful, with a record of
demonstrated child deaths and injuries (Mercer, Sarner, & Rosa,2003).<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
Conclusions<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The
“attachment cycle” theory proposed by Fahlberg, Cline, and other authors is derived
from a salmagundi of other theories, in most cases uncited by authors who have
discussed the concept. The theory, as repeatedly diagrammed by advocates of
Attachment Therapy, is incongruent with Bowlby’s attachment theory and only
partially congruent with some other suggestions about attachment. In addition,
it fails to predict some easily observable phenomena of late infancy and the
toddler period whose association with attachment is evident. Like Darwin’s fox
terrier, the “attachment cycle” material appears to have been repeated
unquestioningly by authors and Internet sites who have accepted it because they
have seen it before-- a sort of
“attachment cycle cycle”. This repetition, and the harmful implications of the
idea for parents and practitioners, are the only reasons for a serious analysis
of the “attachment cycle” like the one given here. Were it not for the
potential harm connected with the belief system, there would be no point in
examining it, as it is not and never has been a part of any conventional
approach to the understanding of attachment. <b><o:p></o:p></b></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">
<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> References<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Ainsworth, M.D.S.,
Blehar, M., Waters, E., & Wall, S. (1978). <i>Patterns of attachment. </i>Hillsdale, NJ: Erlbaum.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Bettelheim, B. (1969). <i>The children of the dream.</i>New York:
Macmillan.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Bowlby, J. (1944).
Fourty-four juvenile thieves: Their characters and home life. <i>International Journal of Psychoanalysis, 25,</i>
19-52, 107-127.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Bowlby, J. (1982). <i>Attachment. </i>New York: Basic.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Cline, F. (1992). <i>Hope for high risk and rage filled children.
</i> Evergreen, CO: EC Publications.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Erikson, E.H. (1950/1963).
<i>Childhood and society. </i>New York: W.W.
Norton.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Fahlberg, V. (1991). <i>A child’s journey through placement. </i>Indianapolis:
Perspectives Press.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Gewirtz, J.L. (1969).
Potency of a social reinforce as a function of satiation and recovery. <i>Developmental Psychology, 1, </i>2-13.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Golding, K. (2008). <i>Nurturing attachments. </i>London: Jessica
Kingsely.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Mercer, J., Sarner, L.,
& Rosa, L. (2003). <i>Attachment Therapy
on trial. </i>Westport, CT: Praeger.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Pearl, M., & Pearl,
D.(1994). <i>To train up a child. </i>Pleasantville,
TN: No Greater Joy Ministries.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Reich, W. (1945). <i>Character analysis. </i>New York: Farrar,
Strauss, Giroux.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Spitz, R. (1965). <i>The first year of life. </i>New York:
International Universities Press.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Thomas, N. (2000).
Parenting children with attachment disorders. In T.Levy (Ed.), <i>Handbook of attachment interventions</i> (pp.
67-111). San Diego: Academic.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Verrier, N. (1993). <i>The primal wound. </i>Lafayette, CA: Author.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Winnicott, D. (1953).
Transitional objects and transitional phenomena. In D. Winnicott (Ed.), <i>Collected papers: Through pediatrics to
psychoanalysis. </i>Middlesex, UK: Penguin.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Zaslow , R.W., &
Menta, M. (1975). <i>The psychology of the
Z-process.</i> San Jose, CA: San Jose State University Press.<o:p></o:p></span></div>
Jean Mercerhttp://www.blogger.com/profile/14619393019771381980noreply@blogger.com5tag:blogger.com,1999:blog-9087183049500362990.post-58972660071412171622012-08-10T07:57:00.000-07:002012-08-10T07:57:21.497-07:00A Case Study in Regulation of a Potentially Harmful Treatment: The Utah Experience<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Because documented
child deaths and injuries have resulted from the use of a physically-intrusive
mental health intervention called Attachment Therapy or Holding Therapy, the
treatment has been categorized as a Potentially Harmful Treatment (PHT; Lilienfeld,
2007; Mercer & Pignotti, 2007) and has been described in detail elsewhere
(Mercer, Sarner, & Rosa, 2003). Unfortunately, before it became clear that
the intervention was not only ineffective but dangerous, enthusiasm for its use
had spread. In a number of states, state agencies and private practitioners during
the past decade cooperated in the use of Attachment Therapy (AT) and training in its
principles. For example, Alabama used
state funds to train social workers in AT principles, and Georgia established
guidelines such as the requirement that foster parents request approval before
sitting on children in their care. That this was and remains an international
problem was shown in a British publication by Sudbery, Shardlow, &
Huntington (2010), reporting approval by staff and parents of AT interventions
in a leading residential treatment center.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
How can the use of
AT be regulated? Is it possible to use administrative or executive decisions to
lessen the use of this PHT? This paper examines the efforts of one U.S. state
to regulate AT, and the limit success that these efforts achieved. Utah is chosen because the history of AT there
is well known, and its details provide us with examples of the difficulties of
regulation, including the problem of support from within state agencies and
institutions.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i>The beginning of AT in Utah.</i></b><u>
</u>In approximately 1990, the State of Utah’s Division of Child and Family
Services sponsored training for therapists by AT advocates from Colorado. Since
that time, state organizations appear to have sponsored, recommended, and paid
for various forms of AR for children in state custody or being adopted
from state custody. After a child death
in 2002 (to be discussed in a later section), state contracts with AT
practitioners were terminated; however, it appears that post-adoptive subsidies
continued to be used to pay for AT.</div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i>The death of Krystal Tibbets. </i></b>In
1995, three-year-old Krystal Tibbets was killed by her adoptive father, Don
Tibbets when he performed AT on her at home. Tibbets claims that he was
following the advice of AT practitioners who referred to themselves as
attachment/holding therapists. Krystal’s state-mandated treatment plan required
what were termed “holding” sessions to be performed both at home and at the
therapist’s office. Tibbets claims to have protested but to have been told that
if he did not comply with the treatment plan, Krystal would be removed from his
care. Tibbets expressed concern to Krystal’s pediatrician, saying that he
worried for her safety. Tibbets, a registered nurse, stated that he was
concerned that in some sessions of AT Krystal had lost consciousness. According
to Tibbets, the therapists treating Krystal said that she was conscious but
“dissociating” (Tibbets, personal communication,, 2002).</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Krystal’s untimely
death occurred when Tibbets lay across her in a AT technique called
“compression therapy.” When Tibbets realized that Krystal was not breathing, he
attempted to resuscitate her but failed. He was later convicted of child abuse
homicide and sentenced to five years in prison. Denied parole, he served the
entire sentence (Fattah, 2002).</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
In a videotaped
interview, Tibbets showed a copy of the treatment plan which mandated the
“holding” sessions and described how he had complained about the treatment. He
kept a copy of a letter written by one of the therapists to a judge, requesting
that Mrs. Tibbets be excused from jury duty because she was needed at home to
assist in Krystal’s treatment. The letter stated that Mrs. Tibbets was being
trained to be a “pseudo therapist” and that jury duty would disrupt the
training. Tibbets said that the attachment/holding therapists assigned by the
state threatened that if he did not follow through with AT sessions at home,
the adoption would be disrupted (Tibbets, personal communication, 2002). </div>
<div class="MsoNormal" style="line-height: 200%; tab-stops: 0in;">
<b><i>The death of Cassandra Killpack. </i></b>In
2002, four-year-old Cassandra Killpack died when her parents, who claimed they
were following the advice of the same AT therapists implicated in Krystal
Tibbets’ death, allegedly forced her to
drink an excessive amount of water. According to newspaper reports, police suspected that the child’s injuries
were sustained during a holding therapy session (Fattah, 2002). Cassandra died
at the home of her adoptive parents, Richard and Jennette,, after the first
week of a two week “intensive” treatment regimen. In the six days prior to her
death, Cassandra had been subjected to 15 or more hours of coercive procedures,
including restraint and forced exercise.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Cassandra was
first evaluated at the clinic by a former therapist whose license had been revoked
in Oregon following his use of AT practices (Collins, 2003; Fattah, 2003). <st1:state w:st="on">Oregon</st1:state> officials had
described his behavior as “egregious and reprehensible” (Warner, 2003). He was
denied a license in Utah and claimed to have been doing “pastoral counseling”
after becoming an ordained minister through the Internet site http://<a href="http://www.ulc.org/">www.ulc.org</a>. This practitioner informed the
Killpacks that Cassandra had severe Reactive Attachment Disorder and prescribed
a two week “intensive”. </div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
The Killpacks
described the first five days of the “intensive” treatment as follows: Sessions
were held daily, Monday through Friday, and were also scheduled for the
following week. Each session lasted approximately three hours. Normally at
least four adults were present, the two parents and two therapists or “support
staff.” </div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Treatment in the
“intensive” sessions alternated between AT restraint methods and forced
physical activity. Cassandra was restrained on the floor by the adults. The
Killpacks said the therapists yelled at the child and told her to fight back,
in an effort to purge her allegedly repressed feelings. When AT was not being
done, Cassandra was forced to perform repetitive physical activity such as
kicking the wall, jumping jacks, running in place , and so forth. Cassandra’s
older sister witnessed some of the sessions and described them to
investigators, saying that the younger child
was repeatedly yelled at during both the restraint and the physical activity
(Fattah, 2002).</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
The Killpacks said
they were instructed to continue this manner of treatment toward Cassandra at
home in order to facilitate a “breakthrough”. They said they were told by one
therapist that if Cassandra did something wrong, like “stealing” food, they
were to use a “paradoxical intervention”, forcing her to repeat the infraction
over and over. They claim that one therapist said that Cassandra should be
forced to drink water as a consequence for misbehavior (Fattah, 2002). </div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
The Killpacks
apparently felt compelled to continue the harsh treatment during the two week
“intensive” because they had been told that if they gave in to Cassandra’s
“manipulation” she would not have the desired “breakthrough.” They claim they
were told that if the two week “intensive” did not work, Cassandra would grow
up to be a prostitute, drug addict, or school shooter and possibly murder her
parents or family members. Furthermore, according to the Killpacks, they were
told that if they followed through with the recommended course of treatment
they were assured a “one hundred percent success rate.”</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
The Killpacks
claimed they were taught to force Cassandra to be completely dependent upon her
adopted mother, Jennette, in order to bond with her. Cassandra was required to
obtain permission from her mother for virtually everything, including food,
drink, and use of the bathroom.</div>
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However, Cassandra
took some of her sister’s drink without permission from her mother. As a
“consequence” (punishment), Jennette forced Cassandra to sit on a bar stool and
drink a large amount of water. When Cassandra became weak and semi-responsive,
her parents interpreted this as manipulation and defiance. Believing Cassandra
to be on the verge of the supposed “breakthrough” predicted by the therapists,
the parents persisted in their treatment. Restraining Cassandra, tilting her
head back, and forcing more water down her throat, using sufficient force that
the autopsy showed cutting and bruising of her lips. </div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Cassandra vomited
a foamy substance and collapsed on the floor. The Killpacks told her to get a
towel to clean up her mess. When she did not get up, they again interpreted her
behavior as defiance and persisted in their demands. When the Killpacks finally
realized that Cassandra was unconscious, they attempted to revive her and called
911. In the recorded 911 call, Richard Killpack explained to the dispatcher
that Cassandra had a lot of “emotional problems”. He said, “she’s very, very
sneaky … we gave her a lot of water.” He told the emergency room physician
thatthey “forced the girl to drink lots of water as therapy.” </div>
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Cassandra died
hours later at the hospital. The cause of death was determined to be
hyponatremia, also known as water intoxication. The Killpacks were tried in
2006 and Mrs. Killpack was convicted.</div>
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<b><i>A non-fatal case.</i></b> Only
weeks after Cassandra Killpack’s death, criminal charges were filed by the Utah
County Attorney against Reed and Teresa Hansen, who had allegedly abused their
adopted Russian children. The Hansens are scheduled for trial in January, 2006,
on charges of felony child abuse, for allegedly locking the starved children in
the bathroom and forcing them to sleep on the tile floor with little or no
bedding. Teresa Hansen had one previous charge of child abuse when one of her
adopted children was found covered in bruises. Investigators found literature
in the house advocating various forms of coercive treatment, as well as
business cards from the clinic where Cassandra Killpack had her “intensive”
(Fattah, 2002).</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
The three adopted
children were removed from the home, and newspaper reports indicate that the
Hansens’ parental rights were either terminated or relinquished (Fattah, 2003).
According to officials, the starved children gained weight and began to thrive
within days of being placed in foster care (Fattah, 2002). </div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><i>Licensing, lawsuits, and
legislation. </i></b>Charges were filed against two of the therapists involved
in these incidents by the Utah state Attorney General, working through the
Division of Occupational and professional Licensing (DOPL). One of these
therapists was killed in an automobile accident in December , 2004. The other
therapist was placed on probation and continued
to treat children in a residential treatment center. Charges against other
persons named by the Attorney General
have never been pursued ( “Notice of agency action…”, 2002). </div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Two
individuals filed separate lawsuits
against the therapists involved in the cases
discussed earlier. One suit alleged that one of the therapists performed
AT on her child without her knowledge or consent. The suit also claimed that
the therapist told the mother to force her children to drink water as a form of
punishment (Thomson, 2004). The second suit made similar allegations. A mother
claimed that AT was performed on her daughter without her consent and that the
daughter suffered emotional trauma from the incident (Fattah, 2003). Both cases
were apparently settled out of court.</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
In 2002 and again
in 2003, Utah State Representative Mike Thompson sponsored a bill to ban AT
practices. The legislation was supported by virtually every mental health
organization and child advocacy group in the state and received broad national
support. The Utah chapter of the National Association of Social Workers
approved of the bill in a position statement.</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
The Utah House of
Representatives passed the measure with a vote of 68-2 (Thalman, 2003). There
was increased momentum for the bill following a call by the United States
Congress encouraging states to pass such legislation. However, several powerful
<st1:state w:st="on">Utah</st1:state> state
senators prevented the bill from coming to a vote in the upper house of the
state legislature. State Senator Parley Hellewell took credit for stopping what
he called a “bad bill”. Hellewell stated that AT techniques practiced by his
longtime neighbor and friend, one of the therapists who had treated Cassandra
Killpack, were beneficial and should not be banned. Senator Hellewell received
support from “pro family” activists who argued that the government should not
dictate the treatment that parents can choose for their children.</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Utah State
Representative Mike Thompson, who sponsored the anti-AT legislation, lost his
bid for reelection. No other legislator expressed willingness to sponsor such a
bill. AT is thus not banned in Utah either by legislation or by state licensing
rule. Although there have been decreases in third party funding of AT by the
state and private insurance companies, AT practices in Utah were apparently
ongoing for some years. Nevertheless, the efforts at legislation had positive outcomes in the drafting of
anti-AT position statements by all major Utah mental health organizations,
including Utah Psychological Association, National Association of Social
Workers Utah Chapter, Utah Association for Marriage and Family Therapy, Utah
Mental Health Counselors Association, and Utah Counseling Association. </div>
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<br /></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<b>Conclusion</b> </div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Legislation.
litigation, and professional policy statements and publications have been only partially successful in
regulating the use of AT, as is shown by the relevant history in the state of Utah. This is perhaps
unsurprising, as professional organizations are disinclined to accept
supervision from outsiders and are likely to claim that they are able and
willing to do their own housecleaning. Support for specific legislation may
thus be minimal even though professional organizations agree that a named
practice is undesirable. In addition, drafts of legislation have problems in
specifying the practices they aim to limit. Changing the name of a treatment or
modifying some part of its procedure can place a practice outside the stated
concern of legislation. Increased
efforts to educate both professionals and the public may be the essential step
toward regulation of harmful practices whose proponents can easily go
“underground” or conceal their activities, but such efforts are undermined when
local authorities continue to provide training or support for problematic
interventions. </div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<b> References</b> </div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Collins, C.( 2003,
Aug. 15). State revokes therapist’s license. <st1:place w:st="on"><st1:placename w:st="on">Baker</st1:placename> <st1:placetype w:st="on">City</st1:placetype></st1:place>
<i>Herald.</i></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Retrieved Aug. 24,
2005 from <a href="http://www.kidscomefirst.info/ReberBakerCityHerald.pdf">http://www.KidsComeFirst.info/ReberBakerCityHerald.pdf</a>.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Fattah, G. ( 2002,
Sept. 17. Parents charged in Springville girl’s death. <st1:city w:st="on">Salt
Lake City</st1:city> <i>Deseret
News</i>. Retrieved August 24,
2005 from <a href="http://deseretnews.com.dn/print/1,1442,405031286,00.html">http://deseretnews.com.dn/print/1,1442,405031286,00.html</a>.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Fattah, G. ( 2003,
May 1). Parents’ trial may be long, complex. Salt Lake City <i>Deseret News</i><u>. </u>Retrieved August
24, 2005 from <a href="http://deseretnews.com/dn/view/0,1249,505036190,00.html">http://deseretnews.com/dn/view/0,1249,505036190,00.html</a>.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Lilienfeld, S.O.
(2007). Psychological treatments that cause harm. <i>Perspectives on Psychological Science, 2,</i> 53-70.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Mercer, J.
(2002). Attachment Therapy: A treatment
without empirical support. <i>Scientific
Review of Mental Health Practice, 1</i>(2), 9-16.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Mercer, J. (2003).
Violent therapies: The rationale behind a potentially harmful child
psychotherapy. <i>Scientific Review of Mental
Health Practice, 2</i>(1), 27-37.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Mercer, J., Sarner, L., & Rosa, L. (2003). <i>Attachment Therapy on trial</i><u>.</u> Westport,CT:
Praeger.<u> <o:p></o:p></u></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Mercer, J., &
Pignotti, M. (2007). Shortcuts cause errors in Systematic Research Syntheses:
Rethinking evaluation of mental health interventions. <i>Scientific Review of Mental Health Practice, 5,</i> 59-77.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
“Notice of agency
action, Case No. DOPL-2002-223.” Retrieved from <a href="http://www.kidscomefirst.info/DOPL-Charges-VanBloem-Gwilliam.pdf">www.kidscomefirst.info/DOPL-Charges-VanBloem-Gwilliam.pdf</a>.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Sudbery, J.,
Shardlow, S.M., & Huntington, A.E. (2010). To have and to hold… questions about
a therapeutic service for children.<i>British
Journal of Social Work,40, </i>1534-1552.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Thalman, J.(2003,
Jan.31). House rejects holding therapy. Salt Lake City <i>Deseret News</i><u> </u> Retrieved August 24, 2005 from <a href="http://www.kidscomefirst.info/">http://www.KidsComeFirst.info</a>.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Thomson, L. (2004,
June 22). Center is sued over therapies. Salt Lake City <i>Deseret News</i> Retrieved August 24, 2005 from <a href="http://deseretnews.com.dn/view/0,1249,595072140,00.html">http://deseretnews.com.dn/view/0,1249,595072140,00.html</a>.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Warner, L. (2003,
Oct. 9). Killpacks face trial in death of daughter. Salt Lake City <i>Deseret News.</i>Retrieved August 24, 2005
from <a href="http://deseretnews.com/dn/view/0,1249,51937467,00.html">http://deseretnews.com/dn/view/0,1249,51937467,00.html</a>.</div>
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<br /></div>
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<br /></div>
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<br /></div>Jean Mercerhttp://www.blogger.com/profile/14619393019771381980noreply@blogger.com0tag:blogger.com,1999:blog-9087183049500362990.post-65216696458217138412012-08-08T11:44:00.003-07:002012-08-10T08:38:43.547-07:00Why Study Nonsense?<br />
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<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Nonsense, as the term is used here, refers to
statements about human behavior and mental health that are implausible because
of their faulty logic and because of their lack of congruence with
well-established information on similar topics. Why should we study this at
all? Why not just ignore or try to get rid of it?<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">In a way, the study of nonsense resembles the work
of teachers at all levels of education. Experienced teachers tend to prefer
essay or short answer exams over multiple choice, even though it’s more work to
grade essays. Why? Because as you examine the details of an essay answer, it’s
possible tell why a student makes a mistake--
to detect the misunderstanding or erroneous assumption that leads to a wrong
answer. In some cases, even the rationale for a “right” answer can reveal
misunderstandings that would go uncorrected if the answer alone were examined.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Similarly, studying examples of nonsense from the
social sciences and mental health practice can reveal the basic misunderstandings and
mistaken <i>a priori</i> assumptions behind
nonsensical conclusions. When these inner workings of nonsense are shown, it
becomes possible to argue along more productive lines than the “yes, it is”, “no,
it isn’t” so characteristic of discussions between proponents of conventional
and unorthodox belief systems. The task is thus worth doing, but it is a
challenging and time-consuming job. A student of nonsense has much to read and
watch, to identify and to cross-check. Authors of nonsense rarely do us the
favor of identifying the sources of their ideas, defining their terms, or announcing
when they have changed their minds or stating their reasons for doing so.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Producing nonsense and believing in nonsense are
actions of interest in themselves, as examples of human cognitive abilities
affected by a complicated network of misdirecting factors. But nonsense is also of interest because of
the potential it offers for harmful outcomes motivated by nonsensical beliefs.
Those harmful outcomes may be waste of time and resources, or they may be
physical or emotional injury to individuals. They may even involve dangers to
populations or nations when political decisions are based on nonsensical
claims. Understanding nonsense and working effectively to oppose it can reduce
the harm it does when uncontradicted.<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">[The study of nonsense is not the same thing as <i>agnotology</i>, a term developed and defined
by Robert Proctor as the study of “culturally
constructed ignorance, purposefully created by special interest groups working
hard to create confusion and suppress the truth”. Special interest groups
certainly produce and benefit from nonsense. However, agnotology seems to focus
on the intentions and motives of propagandists rather on the step-by-step
parsing of their arguments and claims that I am calling the study of nonsense. There’s
no question that agnotology is a juicier term than “the study of nonsense”, and
is anyone wants to call the latter “somniology” from the Latin word for daydreams,
fantasy, and so on, I won’t complain, but I think I’ll stick to the plain
English myself.].<o:p></o:p></span><br />
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><br /></span>
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">N.B. I will be happy to post suitable material from contributors. Let me know by way of a comment.</span><br />
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">J.M.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> <i><o:p></o:p></i></span></div>Jean Mercerhttp://www.blogger.com/profile/14619393019771381980noreply@blogger.com1