Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Saturday, February 28, 2015

No Primal Wound in France: The Exception Tests the Rule

What do you frequently hear when someone has claimed that something is true, but then the evidence shows one or more cases where it is not? What I hear is the claimant (often with a self-satisfied expression) declaring, “that’s the exception that proves the rule”.

Now, it does happen to be true that exceptions “prove rules”, but not in the sense of “prove” that is often intended. Exceptions don’t “prove rules” in the sense of showing that the rules are correct. Exceptions do test rules and show that at least under some circumstances they do not hold true. This is like the way we refer to the proof of whiskey, meaning the proportion of alcohol shown when it is tested. Because exceptions test rules, it’s important to pay attention to them, especially when unusual claims or ones that are difficult to test otherwise are made.   

Proponents of the Primal Wound theory, as it has been stated by Nancy Verrier, claim that baies have become emotionally attached to their mothers before they are born and are traumatized by being separated from their birth mothers and adopted or fostered by other people. This trauma, according to the Primal Wound belief system, stays with an individual indefinitely, causing lasting sadness and discomfort and interfering with all relationships.

Aren’t there already known exceptions to this claimed rule? Yes, occasionally people point out that they do not feel that way in spite of their family history, but on the whole those who are not committed to the Primal Wound view simply go about their normal business without taking time out to comment. In addition, when people speak up either about their sense that the Primal Wound belief is true or about their conviction that it is nonsense, it’s rare that we have any real records of what happened in the adoptee’s life, or about the thoughts of the birth parents or adopted parents (I should just say the mothers, because that’s what the Primal Wound theory focuses on, but let’s keep in mind that there are fathers as well.)

An unusual case in France provides an exception that really does test the rule, however. In this case (www.nytimes.com/2015/02/25/in-france-a-baby-switch-and-a-test-of-a-mothers-love.html?r=0), there are records of what happened and when it happened, as well as information from both birth and adoptive parents. Here’s the story. About 20 years ago, in Cannes, the baby girls of Sophie Serrano and another mother (who wants to remain anonymous), were given to each other’s mothers. Both babies had neonatal jaundice and were receiving light therapy, but because of a shortage of bassinets, they were placed nude in the same bassinet. Both babies had been given identity bracelets, but one had apparently fallen off, and the nurses accidentally gave the babies to the wrong mothers (both 18 years old at the time).
Ms. Serrano noticed that the baby she was given had more hair than she remembered her baby having had, and she questioned the nurse, who told her that phototherapy could do that. The other mother asked why her baby seemed to have less hair, and she was told that phototherapy could do that, too. Both young women accepted this explanation.

As Ms. Serrano’s baby, whom she named Manon, grew older, the mother’s partner became suspicious about his paternity. Manon’s skin color was darker than the parents’, and her hair was frizzier. By the time Manon was 10, Ms. Serrano’s partner had left--  then he demanded a paternity test because he did not want to pay child support for someone else’s child. To the astonishment of all, the results showed that Manon was biologically related to neither her putative mother or father, Ms. Serrano then remembered her questions about the baby’s hair, and she sought an investigation, which eventually revealed that Manon’s  “real” parents were living not far away, with their daughter, who of course was the biological child of Ms. Serrano and her former partner. (Too bad Gilbert and Sullivan aren’t alive to do something with this!)

Now, of course, comes the part that’s relevant to the Primal Wound. The two families met and tried to get to know each other. Manon commented, “When I first met them, I noticed how much I looked like them…But I was sitting in front of complete strangers, and I didn’t know how to position myself ”. The Times article goes on to say, “The families saw each other several times, during which Manon explored her Creole origins [her biological parents came from the island of Reunion]. But the parents and daughters had trouble building any rapport, and they eventually stopped seeing each other. In the end, after some discussion, both families preferred to keep the child they had raised, rather than taking their biological one. Ms.Serrano said, “My biological daughter looked like me, but I suddenly realized that I had given birth to a person I didn’t know, and I was no longer the mother of that child.” Ms. Serrano went on to say, “It is not the blood that makes a family…What makes a family is what we build together, what we tell each other. And I have created a wonderful bond with my nonbiological daughter”. (The young women’s attitudes were not reported in this article, but it seems unlikely that the parents could have reached these decisions without the agreement of their 20-year-old daughters. Manon commented, “The story of my birth has made me stronger”.)

Here we have a most unusual, but definitive, “test” of the Primal Wound rule. We have the responses of people who were simultaneously birth and adoptive parents, and what we see is that the relationship built through adoption was much more powerful than the relationship based on birth and genetic relationship.
Please note that none of this, or any other arguments against the existence of a Primal Wound, means that all adopted children and their parents are happy and satisfied with life. What it does mean is that where there is unhappiness, its causes need to be sought somewhere other than in early separation from the birth mother.

[By the way, the two birth mothers are suing that clinic for plenty of euros. ]   


Thursday, February 19, 2015

Occupational Therapy in New York Schools: Expensive, But Not Evidence-Based

An article in yesterday’s New York Times bore the headline “Occupational Therapy Increases Sharply in New York’s Schools: Methods Improve Focus and Motor Skills” (www.nytimes.com/2015/02/18/nyregion/new-york-city-schools-see-a-sharp-increase-in occupational-therapy-cases.html). [There’s a curious contrast right there, as the article actually concentrates on the use of OT methods, not the number of “cases” that need them.]

The Times article, by Elizabeth Harris, begins by describing the “tools” of occupational therapy being used in a first-grade classroom. These were small plastic armchairs, a tight vest that provides pressure to the child’s chest, and a weighted, velvety blanket. Accompanying photographs showed a child on a trampoline and others playing Jenga, a game involving stacking wooden rods and keeping them balanced. Bumpy cushions that demand efforts to balance were mentioned later, as were other methods of strengthening specific muscles and practicing perceptual skills.

The techniques were described as a possible alternative to medication like Ritalin that may be helpful to children with real attention problems. In addition, the article quoted an educational consultant as saying that parents who were applying to private schools for their children were sometimes putting the children into occupational therapy programs as preparation. She commented, “Here [in New York] you have accelerated or demanding curriculums, so they put them in O.T.to bring them up to speed…. They want to enhance their basic skills. New York is a fast-paced city, and sometimes they don’t want to wait for the child to develop the skills they may need.”

Do children develop improved skills as a result of these or other occupational therapy methods? As evidence of the effectiveness of these methods, another photograph in the Times displayed a nine-year-old’s handwriting samples from February 2014 and May 2014, describing the second one as “after occupational therapy”. The samples looked pretty much the same, except that on the first one the child had written not only between small lines, but in much larger letters in an unlined space; the second sample showed only letters written between lines. The first sample did show a larger number of tall letters that crossed the lines above them than the second one did.

It’s not very surprising that a 9-year-old could develop somewhat improved handwriting over a two month period, whether receiving “treatment” or not, and neither is it surprising that a child might write somewhat differently at different times, even if the times were on the same day. But when people conclude that treatment must have caused any changes that occur, we see the post hoc, ergo propter hoc error so common in educational thinking--  the belief that whatever changes have occurred in a child after some experience, they have occurred because of a treatment or because of instruction, not because of the natural course of maturational change. It’s not surprising that teachers think this way, because after all it’s their job to provide instruction that is intended to bring about large, important cognitive changes, and their focus is on what they do to contribute to the child’s development. Parents too tend to concentrate on what they should or should not do.

But if we’re really to understand how development works, and what interventions are effective, we have to differentiate between the effects of treatment or instruction, and the changes that occurred during a time period because maturation continued along its normal lines whether  a treatment was taking place or not. That means that in order to know whether bumpy cushions, vests, weighted blankets, etc. change a child’s abilities and behavior, we have to investigate this in a systematic way, not just display a couple of handwriting samples. Because human beings are different from each other, we need our study to include a large number of children. Because people can respond differently to treatments they have chosen than to other treatments, we need to have children randomly assigned to treatments, not just given the ones a parent or teacher wants. Because special attention or activities may have a positive effect on a child, we need to be sure that the children in our study who are not receiving occupational therapy do get some comparable set of experiences of attention and play. Only by following these guidelines will we be able to tell whether changes that follow occupational therapy, if any, are actually caused by the treatment.

As it turns out, there have been very few studies that have met these requirements. As a result, the occupational therapy techniques discussed in the Times article have never been demonstrated to be effective. This does not mean that they have been shown to be ineffective. Nor does it mean that they have been shown to be harmful (although indirect harm is certainly done if a child is given ineffective treatment when effective treatment exists). However, the absence of supportive evidence does raise serious questions about the 58 million dollars apparently spent by the city of New York for 42,000 students, often under circumstances where a child might cope well if not required to behave like someone a year or more older.
I should point out that the techniques discussed in the Times article are not the entirety of occupational therapy. Occupational therapists do a wide variety of tasks, ranging from helping prematurely-born infants learn to nipple-feed, to working with stroke patients. The techniques mentioned above, like pressure vests and weighted blankets, are part of a treatment called Sensory Integration Therapy (SIT).

SIT is based on a theory of sensory integration offered in the 1960s by the occupational therapist A. Jean Ayres. Ayres posited that many cognitive and motor problems result from difficulty with organizing the many sources of sensory stimulation each of us experiences. She saw the organizational difficulty as resulting primarily from problems of vestibular and tactile sensitivity, which she considered to be the foundation of perceptual and motor organization. Ayres felt that providing extra or modulated tactile and vestibular experiences could guide the developing perceptual and motor system toward better integration. This was the basis of the use of weighted vests, swings, trampolines, and so on as treatments for children with various handicapping conditions. Awkwardly for SIT, the vestibular and tactile systems are the first to become myelinated and thus to have mature communication in the nervous system, and as a result are not shaped by experience in the same way as vision is. SIT is not a plausible intervention for that reason. In addition, there is little empirical evidence to support such treatments for autism, for cerebral palsy, or for attention problems--  and certainly none to support the use for attachment disorders found on some Internet sites.

One more point: the educational consultant quoted by the Times article spoke of OT methods being used to “bring children up to speed”. She presumably was referring to children well within the normal range, whose parents wanted them to match a curriculum, rather than looking for a curriculum to match the child’s needs. Can a normal child’s development be hastened in this way? There is no good evidence to suggest that it can, and if we look at other aspects of development, there seem to be suggestions that it cannot. For example, giving children extra Vitamin C has no useful effect, as the extra is excreted in the urine. Poor nutrition slows growth in height and can reduce adult stature, but extra good nutrition does not speed growth beyond the rate seen with adequate nutrition. Just as children only need “good enough” parents, they only need “good enough” nutrition or “good enough” instruction to allow them to develop at their own best rate. Children can be harmed by an environment that is not “good enough”, but if they are developing normally, extra food or instruction will not result in “extra” development.    



Sunday, February 15, 2015

Mindfulness in Early Intervention, Sure; Tapping, No

The publication Zero to Three makes a point of connecting science, policy, and practice related to work with young children, and for several decades it has done a good job of this. But occasionally somebody slips, either in writing or in the review process, and something emerges that cannot be called science-based.

That has happened in an article in the January 2015 issue (Shahmoon-Shanok, R., & Stevenson, H.C. [2015]. Calmness fosters compassionate connections: Integrating mindfulness to support diverse parents, their young children, and the providers who serve them. Zero to Three, 36(3), 18-30). The authors spend pages emphasizing the role of mindfulness and calm in allowing us to be aware of the thoughts and needs of other people—and no one can argue with the idea that a person who is not calm is likely to misread others’ communications and behave in ways that are mistaken and noncompassionate. An angry or fearful caregiver can do a very poor job, especially with children whose communications are hard to understand.

But--  by page 25 it becomes clear that one of the authors has a curious take on mindfulness. Not only does she connect awareness with EMDR (Eye Movement Desensitization and Reprocessing), a form of psychotherapy based on an implausible theory and with weak empirical support, but she favors the methods of one Laurel Parnell, author of Tapping in: A step-by-step guide to activating your healing resources through bilateral stimulation. (Boulder, CO: Sounds True [sic]). And yes, this means actual physical tapping.

The Zero to Three article advises using Parnell’s technique, and describes a situation where an early intervention worker was having difficulty helping an undocumented Mexican immigrant mother who complained a great deal (and had much to complain about!). Her EI worker had been in the habit of asking the client to give more and more information about each of her complaints. But, after learning about Parnell’s technique, the EI worker instead asked the woman to describe where she felt tension in her body and guided her to breathe deeply and relax. The worker then asked for a description of a “safe place”—a time when the mother had felt safe and optimistic. Following a description of being in her grandmother’s lap, the EI worker guided the woman to remember sensations and smells she associated with the sense of safety.

And here’s where the “tapping” comes in. “Once the mother elaborated these sensory details, the worker said ‘Let’s tap this in’…, alternating tapping her feet on the floor, or her hands on her thighs. The worker smiled and said, ‘When you tap one side of your body and then the other, you make this happy memory of your yaya even stronger. This is a good place to go when you’re upset. She’s right there to help you calm down and feel better. You can practice this coming week and when I come next time, we’ll practice some more” (Shamoon-Shanok & Stevenson, 2015, p. 21).

Sounds harmless, even pleasant, doesn’t it? So why am I concerned that this practice is being presented as scientifically supported through publication in Zero to Three? The first reason is simply that there is no scientific evidence that these methods are effective. There have been lengthy arguments about EMDR, the claimed source of the “tapping” technique, and these have concluded that to the extent that EMDR is an effective treatment, it is so because it shares various factors common to all effective psychotherapies, such as interaction with a warm and supportive therapist or helper. The specific methods of EMDR--  eye movement and other forms of bilateral stimulation--  are probably irrelevant to the outcome of the treatment. Similarly, while it was comforting for the mother described earlier to think of a pleasant and safe memory, and while this was a positive experience which might help her stay calm and responsive to her children, “tapping it in” had nothing to do with the outcome.

Telling either the mother or the EI worker that bilateral tapping is magically helpful is not only untrue, but encourages them to think about mental processes in inaccurate ways and thus opens them to consideration of treatments that are potentially harmful in either direct or indirect ways. In addition, the stress on tapping distracts people from using evidence-based treatments that they may find more challenging than the simple ritual they are offered. A persuasive analogy to computer programming is employed when the EMDR language of “installation” is used.

Where does the tapping ritual come from? Parnell references the writings of Francine Shapiro, originator of EMDR, and her claim that when the body is bilaterally stimulated this experience hastens the “processing” of negative thoughts and events. Shapiro apparently based this claim on her experience when walking in the woods one day and moving her gaze back and forth while brooding on an unhappy memory. After her walk, she felt better--  which she attributed not to the passage of time or a pleasant walk, but to the fact that she had been moving her eyes back and forth. Because she naturally had been using both eyes in a coordinated fashion, she decided that it was the bilateral movement that did the trick.

Now, it’s nice that Shapiro felt better, but how could she not have been experiencing bilateral movement, during her walk or at almost any other time in her life? Except for people who have lost an eye or have paralyzed eye muscles on one side, all of us are coordinating our right and left gazes at all times, whether by changing the direction of the gaze to one side or the other or by converging or diverging the eyes as we look at nearer or more distant objects. Similarly, the act of walking involves bilateral coordination, as one foot takes up the body weight transferred from the foot that is taking a step. Simultaneously, the shoulders and torso counter-rotate in order to maintain the body’s balance as a foot is lifted; the counter-rotation in turn causes the arms to swing back and forth in opposition to the legs’ movements. We are all doing this all the time, so Shapiro’s  and Parnell’s claims that EMDR uses a specialized technique can hardly be supported.

The idea that bilateral activity is special and magical seems to have derived from the claims of the alternative practitioners Doman and Delcato in the 1960s. These people argued that the movement of crawling involved bilateral action as walking did not (but see above), and that this bilateral action provided sensory feedback that acted to “build” the brain. Those who had brain-related disorders such as autism or cerebral palsy must not have had enough bilateral movement, and they could be cured by being forced to crawl, or subjected to “patterning” in which helpers moved the patient’s head, legs, and arms in ways that imitated reflexive crawling movements of very young infants. It has been well known for many years that these methods are completely ineffective, but the appeal of bilateral stimulation persists and the na├»ve are still easily sold on this idea.

Another book by Parnell, A therapist’s guide to EMDR (W.W.Norton), provides another insight into the “tapping” approach. Parnell’s “tapping in” is clearly related to the various energy therapies such as Thought Field Therapy and Emotional Freedom Technique, where physically tapping at certain points on someone’s body and at certain rates of speed are expected to free the individual from emotional distress. This practice appears to be based on the idea that the human body has  “meridians”--  lines that enable the flow of psychic energy or qi and which if blocked will cause unpleasant psychological experiences. Tapping at a given rate of speed on a given meridian is claimed to release qi to flow appropriately. In spite of various efforts to test these claims, there is no evidence that energy therapies employ tapping to good effect, and of course the theories behind that use of tapping are implausible in terms of the accepted foundations of the scientific study of psychology.

Of course it is tempting to say that if the mother described earlier liked tapping, she should get to have it—until we question whether public funds should be expended on ineffective treatments.. The mother and her EI worker may well feel that if she feels better following her tapping experience, her improvement must have been caused by that experience, and the treatment should be not only allowed but encouraged. However, today’s standards for how we spend scarce public resources are much more stringent than that, and professionals on the whole turn to scientific evidence to help decide whether a method is actually effective. I hope that in the future Zero to Three’s reviewers will also take that approach.  




Thursday, February 12, 2015

"Conversion Therapy" Is Judged Consumer Fraud

Over the last several years, several states, including New Jersey and California, have passed legislation prohibiting mental health professionals from using “conversion therapy” with minors. “Conversion therapy” is an alternative mental health treatment that purports to change same-sex attraction to opposite-sex attraction through various techniques like cuddling, nude exercise, and beating an object representing one’s mother. These methods have not shown to be effective in accomplishing anything but misery for clients, and this is not surprising, as current thought regards homosexuality as an unlearned behavior, a normal aspect of human sexuality, and a characteristic of a significant portion of any population. Considering how little professional organizations like to be regulated from outside, it is significant that national professional groups have supported the prohibition of the treatment and have emphasized their positions about the nature of same-sex attraction, about the inappropriateness of attempts to change it, and about the ineffectiveness of “conversion” methods.

Nevertheless, there are still many states where “conversion therapy” is not prohibited, and even where prohibitions exist, they exist only for licensed mental health professionals working with minors. Members of the clergy are not prohibited from using the treatment for minors, and persons over 18 may choose for the treatment to be done by licensed mental health practitioners if they wish.

Because there are many ongoing concerns about “conversion therapy” and its unlicensed practitioners, some organizations have chosen to approach the problem by means of lawsuits. An important judicial finding--  one that I hope will be a real breakthrough—was reported today at www.philly.news.com/philly/news/new_jersey/20150212_N_J_judge_calls_gay_conversion_theapy_claims_fraud.html. This story, also reported by the Southern Poverty Law Center (www.splcenter.org), described a lawsuit brought by S.P.L.C. on behalf of several victims against the organization Jews Offering New Alternatives for Healing (JONAH), a New Jersey group that advocates and offers “conversion therapy”.
In the course of this ongoing suit, Superior Court Judge Peter Barsio has ruled that JONAH may not state that homosexuality is a mental disorder or disease. He also ruled that reporting “success” statistics when advertising or selling “conversion therapy” is in violation of the New Jersey Consumer Fraud Act. According to the Philadelphia Inquirer report, the Southern Poverty Law Center plans to bring evidence that JONAH defrauded clients by advertising its services in terms of discredited theories.

As far as I know, this is the first case in which a treatment billed as a psychotherapy has been held subject to consumer fraud protections. Often, fraudulent actions go unpunished when a service provider claims that he or she did not know that a service was not effective, or when a victim cannot prove that he or she was harmed. In consumer fraud, it’s possible for misleading information to be given simply by the omission of important points (such as the positions of the American Psychiatric Association and American Psychological Association about homosexuality). With respect to psychotherapy, it would be fraudulent to omit information about possible adverse events associated with a treatment—and professional therapists are supposed to provide informed consent documents communicating such matters to a client before treatment begins.

This does seem like a legal breakthrough--  but can we expect that the “conversion therapy” lawsuit will lead to successful suits in cases where children were treated with Attachment Therapy, or received chelation therapy for autism? I am afraid these events won’t happen tomorrow. The thing is, the legislation prohibiting “conversion therapy” for minors, and the suit brought by the S.P.L.C. against JONAH, were supported by well-organized, politically-savvy, and well-funded adults whose own same-sex orientations made them deeply concerned about the harm done by the treatment. Those adults garnered the support of professional organizations and put their skills and energies into preparing legislation and lawsuit. In a time of increasing commitment to civil rights for people of all orientations, this was relatively easy to accomplish, given the abilities of those who contributed.

But who will do the same tasks to bring legal redress for children and adolescents who have been ill-treated in the name of psychotherapy? If they are minors, they can’t bring suit themselves, but instead are dependent on the parents or guardians who made the decision to seek the harmful treatment—adults who are likely to ignore any resulting problems or to blame the child for them. When minors pass the age of 18, and “age out” of the services they have been receiving, they find themselves struggling to make a life--  often with little educational background—as time hurries by and statutes of limitations quickly begin to apply. When they get older and manage to settle down a bit, they find that it is too late for them to sue. Or, alternatively, they want to forget all about what happened to them and try to make up for the time they lost if they were in residential treatment. These victims have no support group or organized representatives who will act for them or help them act.

Other alternative psychotherapies for children are consumer fraud, just as “conversion therapy”  is. But how will we bring that fact home to those who advocate potentially harmful treatments? Without an answer to that question, it seems that Judge Barsio’s admirable decisions must be received with slightly modified rapture.



Friday, February 6, 2015

An Observable Problem for Adopted Children, and Why We Need Not Look for a "Primal Wound"


Periodically, I receive complaints and vituperation from readers who insist that any emotional discomfort they feel as adoptees is evidence for a “primal wound”--  damage posited by authors like Nancy Verrier to result from the breaking of a prenatal emotional attachment when an infant is separated from the birth mother. I’ve pointed out repeatedly that there is no evidence that attachment of baby to mother occurs prenatally, although obviously many, even most, women develop preoccupation with and love for their baby during the course of the pregnancy. There are plenty of factors other than a “primal wound” that could account for the distress reported by some adoptees when they reach adulthood.

As a general rule of critical thinking, it’s better not to assume that there exist more factors than are needed to account for an event. This is a rule often called the law of parsimony, or “Ockham’s razor”. This rule does not say that there could never be any causal factors other than the ones you know about--  just that it’s wiser not to think that there are unless you have really good evidence to support the idea. That’s why I follow an old tradition of scientific thought in saying that if there’s no evidence for a “primal wound” except that some adoptees feel distressed, and there are other factors that appear to cause that distress, the best decision is to reject the idea of the “primal wound”.

The decision that’s made about the “primal wound” idea is one that has many practical implications. One is that if the PW exists as an insurmountable problem, there is no point considering other issues about adoption, fostering, and the way children are cared for or transitioned between caregivers. Accepting the PW idea means that there should be no adoption except in cases where all of a baby’s relatives are dead or incapable of care. Yet it’s clear that there are many cases where birthmothers and others are very much alive, but have social, emotional, or medical reasons for choosing not to care for a child. There are also many cases where birthmothers or relatives want to care for a child but are not safe people for the child to be with. Although there are strong arguments against allowing adoptions to be “brokered” by people whose agendas push for separation of parents and children (see Kathryn Joyce’s Child Catchers), either adoption or institutional care continues to be needed for numbers of children across the world, and we continue to need to know more about how best to handle this situation.

A recent article in the journal Adoption & Fostering is very relevant to that need (Boswell, S., & Cudmore, L. (2014). “The children were fine”: Acknowledging complex feelings in the move from foster care into adoption. A & F, 38, 5-21). The authors, two British child psychotherapists in the Child and Adolescent Mental Health Service,  focused on what happens as children who have been fostered move into adoptive homes. Boswell and Cudmore point out that “Adoption involves huge long-term gains for children, but leaving the care of their previous home will also involve a major loss”--  the loss of a foster parent, who may be the only caregiver a young child can remember, and who is very likely to be the only stable caregiver he or she has known.

Boswell and Cudmore noted that “In order for children to feel safe enough to settle into their new family and start the process of forming a trusting relationship with their adoptive parents, they will need adults around them who recognize that they are experiencing a major loss [the loss of the foster parent—JM], and who are able to support them emotionally by remaining attuned to what this loss means for them. This involves holding in mind the loss of a meaningful relationship while doing everything they can to nurture a new one.”

Boswell and Cudmore stressed the lack of research or other sources of guidance on how these transitions were best made.  Looking at current practice in Britain, they found that “children are usually moved within seven to 14 days of meeting their new parents  and once moved, generally do not see their foster carer again for at least three months, often longer, and some not at all. Younger children and babies tend to be moved more quickly.” Some agencies stated that a child’s strong attachment to the foster parent was a reason to avoid contact, not to encourage it.

Part of Boswell and Cudworth’s research focused on the attitudes and expectations of foster parents as they prepare to let an infant or toddler whom they experience as “theirs” go to an adoptive family. “Although a great deal of attention was paid to the continuity of routine—food, toys, smells, bedtime arrangements, life story books—it seemed much harder for the adults to remain fully in touch with the children’s emotional state and the fact that they would be losing a very  significant relationship.” Foster parents were told, and told themselves, that they must keep a professional perspective and not allow their own feelings to dominate. This was “to protect adoptive parents from being burdened with the child’s attachment and impending loss… [The adoptive parents] already in a state of high anxiety, … felt they could not have coped with the foster carer bombarding them with her own feelings of loss, or with the level of attachment between herself and the child”.

According to Boswell and Cudworth, deep emotions about the transition from the foster to the adoptive homes were usually seen as belonging to the adults, not to the children, who were generally considered as “fine”. This was taken as a reason not to encourage early contact with the foster parent--  “the prospect of a premature contact with the carer raised fears of an uncontained outpouring of distress, images of a clinging, sobbing child... there seemed to be a shared belief among adopters, foster carers, and social workers that old attachments needed to be broken and forgotten about before new ones could be made, leaving any underlying grief to subside as quickly and as quietly as possible.” 

This report about adoptive transitions in Britain jibes with events in the United States, where adoption caseworkers may also feel that their object is to break whatever connection has been made with the foster parent in order to facilitate a new attachment, and where one occasionally hears of such things as a caseworker picking up a sleeping one-year-old from the foster home and placing her still asleep in bed at the adoptive home, to awaken later completely bewildered.

As Boswell and Cudworth point out, and as Mary Dozier has also shown, both theory and research emphasize that gradual transitions in care are best for young children and for their caregivers. In fact, an old attachment does not have to be “broken” through abrupt separation in order for new attachments to occur; that old idea seems to have hung on from the days when John Bowlby posited monotropy of attachment, with a single attachment figure. We know now that attachments to several adults and perhaps some children are normal parts of young children’s emotional development, and one attachment does not have to be wrenched away in order for others to thrive. Considering the course of human evolutionary development, it’s difficult to see how else things could be.

When transitions to adoption are abrupt, young children have experiences with foster parents who withdraw from the relationship out of their own adult grief and the fear that they will be unprofessional, as well as with adoptive parents who can’t bear to face what the newly-resident child might actually be feeling. Neither set of adults can possibly offer the emotional support the young child needs in the face of overwhelming change, These are just facts of life, not ways of blaming either foster or adoptive parents. In order to help the parents help the child, we need to provide them with serious professional support--  which can be brought to bear only when everyone in the picture has a better understanding of the realities of attachment. That hasn’t happened yet.


It certainly won’t happen if the focus is on the “primal wound/”

Thursday, February 5, 2015

What Is Therapeutic Respite Care? (This Is a Serious Question)

Can anyone define for me what “therapeutic respite care” is, either from a practical or from a legal/licensing viewpoint? I understand respite care, a service provided by foster families or agencies that provide care for a few days for children or adults with special needs, whose families are exhausted with caring for them. I also understand the concept of therapeutic foster care and of special training for resource parents who want to provide a supportive environment for children with physical, cognitive, or emotional disabilities. Organizations or individuals who provide either of these kinds of care are normally licensed by their states, and 
staff  have been subjected to criminal background checks and evaluation of their educational qualifications.

It’s also possible for states to license residential treatment facilities for children and adolescents with chronic emotional, behavioral, or mental health issues. These facilities care for larger numbers of children than would be possible in a foster home, they must have trained professional staff, and they provide educational services as appropriate for each child. They are required to establish treatment plans and goals, rather than simply to “warehouse” children and adolescents whose parents are having difficulty coping.

But therapeutic respite care? Google shows one use of the term to refer to actual brief respite for families with special needs children (www.nvfs.org). Otherwise,  I am not sure there is any such animal under discussion in the conventional world of child and adolescent mental health care. 

When I Google this term, here’s what I see: raisinamazin.com/therapeutic-respite-services, an Oregon outfit that claims to deal with “deep seeded” [sic] problems through the use of chores, journaling (or coloring for younger children), “affirmations and I-statement work”, while keeping the child in the caregiver’s line of sight at all times except when under the surveillance of a video monitor at night. Raisinamazin states that one of the trainers for their staff is Nancy Thomas, of dog-training and holding therapy fame, the lady who has stated that she can tell when parents are good to foster or adopted children because the children still have their heads and arms and legs on. Thomas also advises withholding quantities or varieties of food in response to undesired child behavior--  for example, providing only peanut butter sandwiches and milk rather than regular meals.

Google also shows a 2007 page by the Attachment Therapy/Holding Therapy advocate Deborah Hage, deborahhage.com/articles/respt2rescu.html. In her discussion of therapeutic respite and therapeutic motivational respite ( her term for  a treatment “set up when the child has regressed to such a level that a change of venue is needed in order to motivate him to ‘shift gears’ “), Hage  references practices like those mentioned by the raisinamazin organization and Nancy Thomas, including the use of journaling, chores, and exercise, which “gets oxygen to the brain and enables it to think more clearly”. In addition, the therapeutic respite provider must be eternally vigilant, and “her attention must be so excruciating for the child that he gets the message loud and clear that he never wants to return and be subject to such scrutiny again”. These methods are recommended for use with children whose behaviors Hage attributes to disorders of attachment.

 Google lists a series of providers of therapeutic respite care, including Nancy Thomas, at attachmenttraumanetwork.com/respite.html. This organization attributes unwanted behavior to Reactive Attachment Disorder, and presumably that is the diagnosis considered treatable through therapeutic respite care.

One more: Google shows home4healinghearts.com/about-us/the-support-we-offer/what-is-therapeutic-respite as an entity that offers therapeutic respite care. Such care is intended to make “your child… respectful, responsible, and fun to be around. Your child is expected to work hard to get a strong heart so that he or she can return to the family that loves them. Of course, the duration of the stay will be determined by the adults and specialists involved, but your child will be under the impression [! JM] that they’re earning their way home by exhibiting positive changes in behavior.” Once again, home4healinghearts cites Reactive Attachment Disorder as a major reason for this treatment, but (rather terrifyingly) proposes that children with PTSD and even autism should be subjected to the regimen. This apparently undated site does not describe its founder’s educational background.

I’m not wanting to jump to any conclusions, but it looks to me as if “therapeutic respite care” is a term used almost exclusively by advocates of Attachment Therapy/Holding Therapy and by proponents of the authoritarian practices of Nancy Thomas, Foster Cline, and others. I can see that small groups of this kind could be run under the radar of the law if the caregivers are licensed as foster parents--  or, in fact, if all payment is private, and no complaint is ever brought, whether they are licensed or not. But what about larger facilities, which I know exist? Are these not residential treatment facilities and required to be licensed as such in most states?

Perhaps readers can fill me in on this issue. How often is the term “therapeutic respite care” used in a legitimate way rather than as a description of a small, unmonitored, facility for a very concerning form of treatment? Is there any reader who has experienced such treatment either as a child or as a parent who placed a child?





Friday, January 2, 2015

Conversion Therapy and the Change.org Petition

Several days ago I received a message from Change.org about a petition whose goals I certainly share, but I hesitated to sign it because of some of the language used and its implications, As far as I can tell, these messages only allow you to join or stay out of the petition, rather than to comment or suggest statements. Yesterday I received a comment on this blog from reader Marianne M., and I responded to her, but I’m going to go into this further today. (If you read my response to Marianne’s message, at http://childmyths.blogspot.com/2014/12/mistaken-attachment-beliefs-persuasion.html, please excuse some repetition here.)

The Change.org petition was triggered by the suicide of a girl who had been subjected to Conversion Therapy, the “alternative psychotherapy” claimed to alter sexual orientations, now illegal in several states for mental health professionals to use with minors (but legal everywhere when practiced by members of the clergy). Marianne commented on the text of the petition as follows: “Children in distress should have access to *RESEARCH”-based therapies to help them with their depression and/or other mental health issues. Conversion Therapy is quackery at best. Torture under the name of  ”therapy” at worst. It should be banned, as should all other therapies applied to under-age children, until supported by research. We control substances that treat mental health through the FDA. Why shouldn’t other treatments be effectively regulated?” [1/4/14  PLEASE NOTE that in writing this I originally confused a statement that Marianne M. had made with the actual text of the petition, so read this para as a more general comment on whether it's possible to prohibit all but evidence-based therapies.--JM] 

Let me begin my comments by saying that Conversion Therapy is very much an “alternative psychotherapy”. It has no basis in outcome research; it is implausible in the sense that it is incongruent with well-established principles of emotional development; and it has been associated with harm and distress to clients. Because commercial speech is so well protected in the United States, I doubt that we can ever prove that the treatment is fraudulent when used with adult patients or prohibit it by law for adults, but legal protection for minors is much easier to establish, and this fact has permitted legislation to prevent mental health professionals from using the method to treat minors. I applaud that legislation and hope that more states will pass similar laws. 

But why am I hesitating about the rest of the language about research bases, when I’ve put so much energy into fighting Attachment Therapy and other alternative child psychotherapies? Although I agree strongly with the petition’s aspirations and Marianne M.'s comments, I have two problems with the suggestion that an evidentiary foundation for a psychotherapy shows that it is a desirable practice. One is that I am not at all sure what everyone means by research-based therapies. There are several levels of research evidence that can be adduced to support the effectiveness of a treatment. The use of the terms “research-based” or “evidence-based” has become exceedingly vague outside disciplines like psychology that use these terms technically. Proponents of some treatments call their methods “evidence-based” when the research is at a much lower level than what that term technically means. Others call a program “evidence-based” when only one of many components meets this standard. This is not how it should be, but is how it is.

To establish the highest level of evidence for a child psychotherapy is difficult, time-consuming work, and most treatments now in use fall short of having that level of evidence. Some have never been subjected to systematic investigation. Legislation prohibiting the use of treatments with weak or no evidence bases would potentially make criminals of therapists who used Dance and Movement Therapy or Sensory Integration Therapy with minors. Although in a perfect world this might be a desirable outcome, I don’t see such legislation as being supported by professional groups in the foreseeable future.

So, I am worried about defining what is “research-based” and about the logical outcome of legislation banning child psychotherapies that are not well-supported by research evidence. But I have another worry too, about a concern that I would place at a higher level even than the need for evidence-based treatment. This concern has to do with adverse events associated with a child psychotherapy. It’s well-known that medical treatments, even those that are effective cures for a problem, may have side effects that can range from dandruff to death. It’s less well-understood that psychological treatments can also have side effects. Awareness of this fact advanced with news about child deaths associated with Attachment Therapy/HoldingTherapy. A 2013 paper by Michael Linden, “How to define, find,and classify side effects in psychotherapy: From unwanted events to adverse treatment reactions” (Clinical Psychology and Psychotherapy,4, 286-296)  did an admirable job of spelling out the adverse events that can accompany psychotherapy. Linden proposed an event he referred to as the “emotional burden” of psychotherapy--  distress and unhappiness caused by the treatment, but not necessarily needed as an instrument of change. Linden pointed out that if there are treatments that do not involve making people cry and feel unhappy, those treatments that are emotionally painful should never be chosen.

I believe that , wonderful though the goals are, it's a mistake to focus on the research basis of child psychotherapies before considering the problem of adverse events from suicide to unnecessary emotional pain. In my opinion, regulation of psychotherapies should begin with examination of their actual or potential adverse effects—of which Conversion Therapy has many. Prohibiting the use of treatments associated with adverse effects is a most important first step in controlling the use of therapies whose evidence basis may not be well established. Legislation or regulatory guidelines based on the potential harmfulness of a child psychotherapy would be far easier to put into place than regulation on the basis of outcome research evidence. I would be very happy to sign a petition that took that approach rather than using the language as presently written.  


In closing, though, let me note once again that prohibition of Conversion Therapy by legislation has affected only mental health professionals. To prevent members of the clergy from doing this “treatment” would require a major First Amendment battle and would probably work only if there were more suicides to function as poster children for this issue. For myself, I do not know that I would want to win the victory on those grounds.