Attachment therapy

Attachment therapy is the name applied to a category of alternative child mental health interventions by practitioners and proponents of such treatments. Its proponents aim to treat what they describe as attachment disorders. The term generally includes some accompanying parenting techniques which proponents consider as important as the therapy itself.

Attachment therapy is a treatment used primarily with fostered or adopted children who are said to have certain behavioral difficulties, including disobedience and lack of gratitude or affection for their caregivers. The children's problems are ascribed to an inability to 'attach' to their new parents because of past maltreatment and 'suppressed rage'. Probably the most common form of attachment therapy is holding therapy, in which a child is firmly held (or lain upon) by therapists and/or parents, who then seek to produce in the child a range of responses such as rage and despair for the purpose of 'catharsis'. The aim is to promote attachment with the new carers. Control over the children is usually considered essential and the therapy is often accompanied by attachment therapy parenting techniques which emphasise obedience. These accompanying parenting techniques are based on the belief that a properly attached child should comply with parental demands 'fast, snappy and right the first time' and should be 'fun to be around'.

This form of therapy is not considered to be part of mainstream psychology either as to understanding of attachment theory, (with which it is considered incompatible^[1][2]), diagnosis or treatment, or as to the accompanying attachment parenting techniques. It differs significantly from mainstream attachment based therapies and should not be confused with talking psychotherapies such as attachment-based psychotherapy and relational psychoanalysis or the form of attachment parenting advocated by the pediatrician Sears.

Following publicity for adverse events, including the death of a child in 2000 during an attachment therapy 'intensive', some advocates of attachment therapy began to alter views and practices in ways that would be less potentially dangerous to children. This change may have been hastened by the publication of a Taskforce Report on the subject in 2006, commissioned by the American Professional Society on the Abuse of Children (APSAC) which was largely critical of attachment therapy's theoretical base, practices and claims to an evidence base. (Chaffin et al, 2006)^[3] Attachment therapy therefore divides into two periods, the first from about 1975 to 2001 and the second beginning in 2001 to date.

Presently, there seem to be two groups involved in interventions that resemble those described above. One group has attempted to come more into line with mainstream practices and has produced guidelines prohibiting some of the older treatments, including the more physically coercive practices. The other group, which stresses the importance of parenting techniques, continues to use methods that focus on obedience and affectionate behavior toward caregivers. These historical shifts have made it difficult to say precisely what 'attachment therapy' may or may not mean in current discourse, but there is little doubt what it meant before 2001.

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Brief description

Main article: attachment theory

Main article: attachment disorder

Attachment therapy, which aims to treat disorders of attachment, was developed in the 1960's and 1970's, mainly in the USA by Foster Cline and associates at the Attachment Center in Evergreen. Its proponents maintain it is based on the principles of attachment theory. Its critics disagree. The controversy "has centered most broadly on the use of what has been known as 'holding therapy'" (Welch, 1989^[4]) and coercive, restraining, or aversive procedures such as deep tissue massage, aversive tickling, punishments related to food and water intake, enforced eye contact, requiring children to submit totally to adult control over all their needs, barring children's access to normal social relationships outside the primary parent or caretaker, encouraging children to regress to infant status, reparenting, attachment parenting, or techniques designed to provoke cathartic emotional discharge. Variants of these treatments have carried various labels that appear to change frequently. They may be known as 'rebirthing therapy,' 'compression therapy,' 'corrective attachment therapy,' 'the Evergreen model,' 'holding time,' or 'rage-reduction therapy' (Levy & Orlans (1998), Lien (2004), Welch (1989), Cline (1992)^[5][6][4][7])"(Chaffin et al, 2006, p83)^[3]

It is not considered to be part of 'mainstream' psychology on issues of attachment, either as to its understanding of attachment, definition of attachment disorders, diagnosis or treatment, nor 'attachment parenting' techniques. Apart from two non-randomized studies, much criticised, it is unvalidated. It is primarily aimed at fostered or adopted children whose difficulties and behavioral problems are ascribed to past maltreatment and suppressed rage resulting in an inability to 'attach' to their new caregivers. The ultimate aim of the therapy is to create an attachment with the new caregivers and by doing so reduce behavioral disturbances. There have been criticisms of attachment therapy over time but it really came to the attention of professional bodies and the wider public following a series of prosecutions for deaths (estimated at 6) or serious maltreatment of children from the 1990's onwards, allegedly at the hands of "attachment therapists" or parents following their instructions. Two of the most well known cases are those of Candace Newmaker in 2001 and the Gravelles in 2003-5.

While there are attachment-related interventions based on generally accepted theory and using generally supported techniques, attachment therapy has primarily come to public notice because of this subset of controversial interventions, popularly called attachment therapy. The American Professional Society on the Abuse of Children (APSAC) set up a Task Force to report on the whole subject attachment therapy, and the diagnosis and treatment of reactive attachment disorder and attachment disorder. The Task Force's Report, also known as "Chaffin et al", was published in 2006 and laid down guidelines for the diagnosis and treatment of attachment disorders.^[3] It states "Although focused primarily on specific attachment therapy techniques, the controversy also extends to the theories, diagnoses, diagnostic practices, beliefs, and social group norms supporting these techniques, and to the patient recruitment and advertising practices used by their proponents." (Chaffin et al, 2006, p77)^[3] The Taskforce specifically criticised proponents for describing attachment therapies as 'evidence based' when the Taskforce concluded that no such evidence base existed, and for the use of non-specific 'symptoms' lists for diagnosis published on the internet.

To date, nearly all public discussion of attachment therapy is about this controversy under a number of names, including "rebirthing," "compression therapy," "holding therapy," "the Evergreen model," "holding time," and "rage-reduction".^[3]

Treatment characteristics of attachment therapy

Speltz (2002) describes a typical treatment taken from The Center's material (apparently a replication of the programme at the Attachment Center, Evergreen) as follows:

"Like Welsh (sic)(1984, 1989), The Center induces rage by physically restraining the child and forcing eye contact with the therapist (the child must lie across the laps of two therapists, looking up at one of them). In a workshop handout prepared by two therapists at The Center, the following sequence of events is described: (1) therapist "forces control" by holding (which produces child "rage"); (2) rage leads to child "capitulation" to the therapist, as indicated by the child breaking down emotionally ("sobbing"); (3) the therapist takes advantage of the child's capitulation by showing nurturance and warmth; (4) this new trust allows the child to accept "control" by the therapist and eventually the parent. According to The Center's treatment protocol, if the child "shuts down" (i.e., refuses to comply), he or she may be threatened with detainment for the day at the clinic or forced placement in a temporary foster home; this is explained to the child as a consequence of not choosing to be a "family boy or girl." If the child is actually placed in foster care, the child is then required to "earn the way back to therapy" and a chance to resume living with the adoptive family." (Speltz 2002 p5^[8])

The APSAC Task Force (2006) describes how the conceptual focus of these treatments is the child's individual internal pathology and past caregivers rather than current parent-child relationships or current environment, to the extent that if the child is well behaved outside the home this is seen as manipulative. It was noted that this perspective has its attractions because it relieves the caregivers of responsibility to change aspects of their own behavior and aspirations:

"Proponents believe that traditional therapies fail to help children with attachment problems because the prerequisite of establishing a trusting relationship with the child is impossible to accomplish with these children. In contrast to traditional theories, the controversial treatments hold that children with attachment problems actively avoid forming genuine relationships, and consequently relationship-based interventions are unlikely to be effective (Institute for Attachment and Child Development, n.d.). Proponents of the controversial therapies emphasize the child's resistance to attachment and the need to break down the child's resistance.(Institute for Attachment and Child Development, n.d.)....In rebirthing and similar approaches, protests of distress from the child are considered to be resistance that must be overcome by more coercion. Rebirthing has been repudiated by many practitioners, including those who recommend other controversial techniques (Federici, n.d.). Similar but less physically coercive approaches may involve holding the child and psychologically encouraging the child to vent anger toward her or his biological parents. Coercive techniques, such as scheduled or enforced holding, also may serve the intended purpose of demonstrating dominance over the child, and provoking catharsis or ventilation of rage. Establishing total adult control, demonstrating to the child that he or she has no control, and demonstrating that all of the child's needs are met through the adult, is a central tenet of many controversial attachment therapies. Similarly, many controversial treatments hold that children described as attachment disordered must be pushed to revisit and relive early trauma. Children may be encouraged to regress to an earlier age where trauma was experienced (Becker-Weidman, n.d.-b) or be reparented through holding sessions…" (Chaffin et al, 2006, p78^[3])

According to O'Connor and Zeanah (2003, p. 235^[1]), the "holding" approach would be viewed as intrusive and therefore non-sensitive and counter therapeutic, in contrast with accepted theories of attachment.

According to Advocates for Children in Therapy, an advocacy group that campaigns against attachment therapy, "Attachment Therapy almost always involves extremely confrontational, often hostile confrontation of a child by a therapist or parent (sometimes both). Restraint of the child by more powerful adult(s) is considered an essential part of the confrontation." The purported correction is described as — literally — "... to force the children into loving (attaching to) their parents;… there is a hands-on treatment involving physical restraint and discomfort. Attachment Therapy is the imposition of boundary violations — most often coercive restraint — and verbal abuse on a child, usually for hours at a time;… Typically, the child is put in a lap hold with the arms pinned down, or alternatively an adult lies on top of a child lying prone on the floor." [12] They give a list of therapies they state are attachment therapies and a list of additional therapies used by attachment therapists which they consider to be unvalidated.[13]

Other features of attachment therapy are the 'two week intensive' course of therapy, and the use of 'therapeutic foster parents' with whom the child stays whilst undergoing therapy.

Parenting techniques

Often parents are required to follow programmes of treatment at home, for example, obedience-training techniques such as "strong sitting" (frequent periods of required silence and immobility) and withholding or limiting food (Thomas, 2000^[9]). Earlier authors sometimes referred to this as 'German Shepherd training'.^[7] According to the APSAC Task Force "...because children with attachment problems are conjectured to resist attachment or even fight against it, and to control others to avoid attaching, the child's character flaws must be broken before attachment can occur. As part of attachment parenting, parents may be counseled to keep their child at home, bar social contact with others besides the parent, favor home schooling, assign children hard labor or meaningless repetitive chores throughout the day, require children to sit motionless for prolonged periods of time, and insist that all food and water intake and bathroom privileges be totally controlled by the parent (for an example of some of these types of recommendations, see Federici, 2003). Children described as being attachment disordered are expected to comply with parental commands 'fast and snappy and right the first time,' and to always be 'fun to be around' for their parents (see, e.g., Hage, n.d.-a). Deviation from this standard, such as putting off chores, incompletely executing chores, or arguing, is interpreted as a sign of attachment disorder that must be forcibly eradicated. From this perspective, parenting a child with an attachment disorder is a battle, and winning the battle by defeating the child is paramount." (Chaffin et al, 2006, p79^[3])

Proper appreciation of total adult control is also considered vital and to this end information, such as how long a child will be with 'therapeutic foster parents' or what will happen to it next is deliberately witheld.^[10] It has been stated that attachment disordered children act worse when given information about what is going to occur because they will use the information to manipulate their environment and everyone in it. (Thomas, 2000 p72^[9]).

In addition to this restrictive parental behavior, however, parents seeking to create attachment in foster or adoptive children are also advised to provide daily sessions in which older children are treated as if they were babies.^[9] The child is to be held in the caregiver's lap, rocked, hugged and kissed, and fed with a bottle and with sweet foods such as caramels. These episodes are carried out at the caregiver's wish and not upon the child's request. Attachment therapists believe that these reenactments of some aspects of infant care have the power to rebuild damaged aspects of early development such as emotional attachment.

Traditional attachment theory based methods

In contrast "Traditional attachment theory holds that caregiver qualities such as environmental stability, parental sensitivity, and responsiveness to children's physical and emotional needs, consistency, and a safe and predictable environment support the development of healthy attachment. From this perspective, improving these positive caretaker and environmental qualities is the key to improving attachment. From the traditional attachment theory viewpoint, therapy for children who are maltreated and described as having attachment problems emphasizes providing a stable environment and taking a calm, sensitive, nonintrusive, nonthreatening, patient, predictable, and nurturing approach toward children, (Haugaard, 2004a^[11] Nichols, Lacher & May, 2004^[12])." (Chaffin et al, 2006, p76^[3])

History and underlying theory

Main article: Attachment theory

Main article: Attachment in children

Like a number of other alternative mental health treatments for children, Attachment therapy is based on some assumptions that differ strongly from the theoretical foundations of other therapies.

Attachment theory

Attachment theory, on which attachment therapists claim to based their intervention, is an evolutionary and ethological theory according to which the infant or child, in situations of alarm or distress seeks to be close to a particular person, (called the 'caregiver'), usually but not necessarily the mother. It is not the same as love and/or affection although they often go together and a healthy attachment is considered to be an important foundation of all subsequent relationships. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time. Parental responses lead to the development of patterns of attachment which in turn lead lead to 'internal working models' which will guide the individuals feelings thoughts and expectations in later relationships.^[13]

Underlying theoretical principles of attachment therapy

The APSAC Task Force describes the underlying principles of attachment therapy as follows:

"In contrast to traditional attachment theory, the theory of attachment described by controversial attachment therapies is that young children who experience adversity (including maltreatment, loss, separations, adoption, frequent changes in child care, colic or even frequent ear infections) become enraged at a very deep and primitive level. As a result, these children are conjectured to lack an ability to attach or to be genuinely affectionate to others. Suppressed or unconscious rage is theorized to prevent the child from forming bonds with caregivers and leads to behavior problems when the rage erupts into unchecked aggression. The children are described as failing to develop a conscience and as not trusting others. They are said to seek control rather than closeness, resist the authority of caregivers, and engage in endless power struggles. From this perspective, children described as having attachment problems are seen as highly manipulative in their social relations and actively trying to avoid true attachments while simultaneously striving to control adults and others around them through manipulation and superficial sociability. Children described as having attachment problems are alleged by proponents of the controversial therapies to be at risk for becoming psychopaths who will go on to engage in very serious delinquent, criminal, and antisocial behaviors if left untreated." (Chaffin et al, 2006, p78^[3]).

The tone in which the attributes and descriptions of these children are described has been characterised as "demonising".^[14]

Advocates of this treatment also believe that emotional attachment of a child to a caregiver begins during the prenatal period, during which the unborn child is aware of the mother's thoughts and emotions. If the mother is distressed by the pregnancy, and especially if she considers abortion, the child responds with distress and anger that continue through postnatal life. If the child is separated from the mother after birth, no matter how early this occurs, the child again feels distress and rage that will block attachment to a foster or adoptive caregiver. If the child has had a peaceful gestation, but after birth suffers pain or ungratified needs during the first year, attachment will again be blocked. If the child reaches the toddler period safely, but is not treated with strict authority during the second year, according to the so-called 'attachment cycle", attachment problems will result. Failure of attachment results in a lengthy list of mood and behavior problems, but these may not be revealed until the child is much older. According to the attachment therapist Elizabeth Randolph, attachment problems can be diagnosed even in an asymptomatic child through observation of the child's inability to crawl backward on command.^{[10] [15]}

Historical roots

Speltz (2002)^[8] states that the roots of attachment therapy are traceable to Robert Zaslow in the 1970s.^[16] Zaslow attempted to force attachment in those suffering from autism by creating pain and rage whilst enforcing eye contact. He believed that holding someone against their will would lead to a breakdown in their defence mechanisms, making them more receptive to others. Speltz points out that these ideas have been dispelled by research into autism and that, conversely, techniques based on behavioural principles have proved effective.(Speltz 2002 p )^[8] Zaslow, had to surrender his California psychology license following an injury to a patient.

Zaslow's belief system owed much to Wilhelm Reich, the psychoanalyst who claimed to have discovered a substance related to human sexuality and health called orgone. Reich posited that lack of appropriate care and maternal attitudes, from the prenatal period, would create a muscular-psychic condition he called 'character armor". This was indicated by problems with eye contact, upper-body stiffness and emotional constriction, to be cured by physical contact including painful prodding of the body, carried out in a manner very similar to that later recommended by Zaslow. Zaslow and his 'Z-process' influenced Foster Cline and associates at his clinic in Evergreen, originally the Youth Behavior Program, subsequently renamed the Attachment Centre. ^[10]

Speltz (2002) describes "corrective attachment therapy" as "....a therapist or parent initiates the holding process for the purpose of provoking strong, negative emotions in the child (e.g., fear, anger), and the child's release is typically contingent upon his or her compliance with the therapist's clinical agenda" (goals).(p 4,^[8])

Speltz cites Martha Welch and Holding Time (published in 1984 and 1989^[4]) as the next significant development. Mothers were instructed to hold their defiant child, provoking anger and rage, until such time as the child ceased to resist at which point a bonding process was believed to begin. Foster Cline and associates at the Attachment Center at Evergreen, Colorado began to promote the use of the same or similar holding techniques with adopted, maltreated children who were said to have an "attachment disorder". This was replicated elsewhere such as at "The Center" in the Pacific Northwest.^[8] A number of clinics later arose in Evergreen, Colorado, set up by those involved in or trained at the Attachment Center at Evergreen (now renamed the Institute for Attachment and Development). [14] These include one set up by Connell Watkins, formerly an associate of Foster Cline at the Attachment Centre, one of the therapists convicted in the Candace Newmaker case.

Metaphors based on Zaslows original misapplication of ego defences from psychoanalytic theory were adopted by attachment therapists. These included the notions of "breaking through" a child's defences, or the child's development being "frozen" and treatment being required to "unfreeze" development. According to Prior and Glaser (2006) "there is no empirical evidence to support Zaslow's theory. The concept of suppressed rage has, nevertheless, continued to be a central focus explaining the children's behavior (Cline, 1992^[7])".

In addition it was believed that holding induced age regression enabling a child to make up for physical affection missed earlier in life.^[17] According to Prior & Glaser "Bowlby (1988) explicitly rejected the notion of regression, which is key to the holding therapy approach: "present knowledge of infant and child development requires that a theory of developmental pathways should replace theories that invoke specific phases of development in which it is held a person may become fixated and/or to which he may regress." (Bowlby, 1998, p. 265^[18])p263^[19] Some, but by no means all, attachment therapists have used rebirthing techniques to aid regression.

Cline's privately-published work Hope for high risk and rage filled children also cites the hypnotherapist Milton Erickson as a source, and reprints parts of a famous case of Erickson's published in 1961.^[7][20] The Erickson case report, described the case of a divorced mother with a noncompliant son. Erickson advised the mother to sit on the child for hours at a time and to feed him only on cold oatmeal while she and a daughter ate appetizing food. The child did increase in compliance, and Erickson noted, with apparent approval, that he trembled when his mother looked at him. Cline commented, with respect to this and other cases, that in his opinion all bonds were trauma bonds. According to Cline it illustrates the 3 essential components of 1) taking control, 2) the childs expression of rage; and, 3) relaxation and the development of bonding.

According to O'Connor and Nilsen (2005), although other aspects of treatment are applied, the holding component has attracted most attention because proponents believe it is an essential ingredient. They also considered the lack of available and suitable interventions from mainstream professionals as essential to the popularization of holding therapy as attachment therapy.^[17]

Critics say holding therapies have been promoted as "attachment" therapies, even though they are more antithetical to than consistent with attachment theory. They use language from attachment theory but descriptions of the practices contain ideas and techniques based on misapplied metaphors deriving from Zaslow and psychoanalysis, not attachment theory.^[17] There are many ways in which holding therapy/attachment therapy contradicts Bowlby's attachment theory, not least attachment theory's fundamental and evidence-based statement that security is promoted by sensitivity.^[19] According to Mary Dozier (2003) ”holding therapy does not emanate in any logical way from attachment theory or from attachment research” (Dozier, 2003, p. 253)

In 2003 an issue of Attachment & Human Development, was devoted to the subject of attachment therapy with articles by well known experts in the field.^[21]

In 2006 the American Professional Society on the Abuse of Children (APSAC) Task Force reported on the subject of attachment therapy, reactive attachment disorder, and attachment problems and laid down guidelines for the future diagnosis and treatment of attachment disorders. (Chaffin et al, 2006, p83^[3])

Range of attachment therapies

The APSAC Task Force stated that proponents of attachment therapy correctly point out that most critics have never actually observed any of the treatments they criticize or visited any of the centers where the controversial therapies are practiced. Proponents argue that their therapies present no physical risk if undertaken properly and that critics concerns are based on unrepresentative occurrences and misapplications of techniques, or misunderstanding by parents. Holding is described as gentle or nurturing and it is maintained that intense, cathartic approaches are necessary to help children with attachment disorders. Their evidence for this is primarily clinical experience and testimonial. (Chaffin et al, 2006, p78^[3])

There are controversies within the attachment therapy community about coercive practices. There has been a move away from coercive and confrontational models towards attunement and emotional regulation amongst some leaders in the field, notably Hughes, Kelly and Popper. A number of therapies are quite different to those that have led to the abuse and deaths of children in much publicised court cases. However, the Taskforce point out that all the therapies, including those using frankly coercive practices, present themselves as humane, respectful and nurturing therefore caution is advised. Some practitioners condemn the most dangerous techniques but continue to practice other coercive techniques. Others have taken a public stand against coercion. The Taskforce was of the view that all could benefit from more transparency and specificity as to how the therapy is behaviourally delivered.^[22]

In 2001, 2003 and 2006, ATTACh, an organisation at one time closely associated with attachment therapy, issued a series of statements in which they progressively changed their stance on coercive practices. In 2001 after the death of Candace Newmaker they stated “The child will never be restrained or have pressure put on them in such a manner that would interfere with their [sic] basic life functions such as breathing, circulation, temperature, etc.” (ATTACh, 2001).^[23]) Their 2006 guideline "unequivocally state(s) our opposition to the use of coercive practices in therapy and parenting." They acknowledge ATTACh's historical links with catharsis, provocation of rage, and intense confrontation, among other overtly coercive techniques (and indeed continue to offer for sale books by controversial proponents) but state that the organization has evolved significantly away from earlier positions. They state that their recent evolution is due to a number of factors including tragic events resulting from such techniques, an influx of members practicing other techniques such as attunement and a "fundamental shift... away from viewing these children as driven by a conscious need for control toward an understanding that their often controlling and aggressive behaviors are automatic, learned defensive responses to profoundly overwhelming experiences of fear and terror."^[24][25]

Diagnosis and Attachment Disorder

Main articles: Attachment disorder, Reactive attachment disorder

Disorders of attachment are classified in DSM-IV-TR and ICD-10 as follows: Reactive attachment disorder of Infancy or Early Childhood, divided into two subtypes, Inhibited Type and Disinhibited Type in DSM-IV-TR, and Reactive attachment disorder of Childhood and Disinhibited Attachment Disorder of Childhood in ICD-10. Both classifications are under constant discussion and both warn against automatic diagnosis based on abuse or neglect. Many "symptoms" are present in a variety of other more common and more easily treatable disorders. There is as yet no other accepted definition of attachment disorders although the term is also used to cover a variety of problematic attachment difficulties and styles and further categories have been proposed.^[26]

There are a number of attachment 'styles' namely 'secure', 'anxious-ambivalent', 'anxious-avoidant', (all 'organized') and 'disorganized', some of which are more problematical than others and may be predictive of future social or emotional problems, but none constitute a 'disorder' in themselves. The only officially classified attachment disorder, known as Reactive attachment disorder, requires one or both of the attachment behaviors of seeking to be close to a particular person (attachment figure), and avoiding strangers, to be missing.

In attachment therapy, the diagnoses of attachment disorder and reactive attachment disorder are used in a fashion not recognised in mainstream practice. Prior and Glaser (2006) describe "two discourses" on attachment disorder. One is science based, found in academic journals and books with careful reference to theory, international classifications and evidence. They list Bowlby, Ainsworth, Tizard, Hodges, Chisholm, O'Connor and Zeanah and colleagues as respected attachment theorists and researchers in the field. The other discourse is found in clinical practice, non-academic literature and on the Internet where claims are made which have no basis in attachment theory and for which there is no empirical evidence. In particular unfounded claims are made as to efficacy of "treatments".^[19] The Internet is considered essential to the popularization of holding therapy as attachment therapy.^[17]

The APSAC Task Force describes the polarization between the proponents of attachment therapy and mainstream therapies stating, "This polarization is compounded by the fact that attachment therapy has largely developed outside the mainstream scientific and professional community and flourishes within its own networks of attachment therapists, treatment centers, caseworkers, and parent support groups. Indeed, proponents and critics of the controversial attachment therapies appear to move in different worlds." (Chaffin et al, 2006, p85^[3])

Diagnosis lists and questionnaires

Both the APSAC Task Force and Prior & Glaser describe the proliferation of alternative "lists" and diagnoses, particularly on the Internet, by proponents of attachment therapies that are not in accord with either DSM or ICD classifications and which are partly based on the unsubstantiated views of Zaslow and Menta (1975^[16]) and Cline (1992^[7]).^[3][19]) Neither do these lists accord with alternative diagnostic criteria discussed as mentioned above. According to the Task Force, "These types of lists are so nonspecific that high rates of false-positive diagnoses are virtually certain. Posting these types of lists on Web sites that also serve as marketing tools may lead many parents or others to conclude inaccurately that their children have attachment disorders."(Chaffin et al, 2006, p83^[3]) Prior and Glaser describe the lists as "wildly inclusive" and state that many of the behaviors in the lists are likely to be the consequences of neglect and abuse rather than located within the attachment paradigm. Descriptions of children are frequently highly pejorative and "demonising". Lists found on the internet often include lying, avoiding eye contact except when lying, persistent nonsense questions or incessant chatter and so on. They give an example from the Evergreen Consultants in Human Behavior (2006) which offers a 45 symptom checklist including bossiness, stealing, enuresis and language disorders.^[19]

A commonly used diagnosis checklist in attachment therapy is the Randolph Attachment Disorder Questionnaire or "RADQ", emanating from the Institute for Attachment in Evergreen.^[27] It is presented not as an assessment of RAD but rather attachment disorder. The checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like Conduct Disorder and Oppositional Defiant Disorder or are not related to attachment difficulties.^[28] It is largely based on the earlier Attachment Disorder Symptom Checklist which in itself shows considerable overlap with even earlier checklists for indicators of sexual abuse. A peculiarity of the Attachment Disorder Symptom Checklist is its inclusion of statements about the parent's feelings toward the child as well as statements about the child's behavior. For example, parental feelings are evaluated through responses to such statements as "Parent feels used" and "is wary of the child's motives if affection is expressed," and "Parents feel more angry and frustrated with this child than with other children." The child's behavior is referred to in such statements as "Child has a grandiose sense of self-importance" and "Child 'forgets' parental instructions or directives." Validity of content of the RADQ was claimed by reference to the Attachment Disorder Symptom Checklist. It also purports to diagnose attachment disorder for which there is no classification.^[29] It has been stated that a major problem of the RADQ is that it has not been validated against any established objective measure of emotional disturbance. Validation was against a Rorschach test administered and scored by the creator of the RADQ, who also administered and scored the RADQ, in addition to two of six selected subscales from the Personality Inventory for Children (Lachar, 1979) and two of eight subscales of the Child Behavior Checklist (Achenbach, 1991) and correlation with 1 of 12 subscales of the Millon Adolescent Personality Inventory (Millon, 1982).^[30]

Patient recruitment

In addition to concerns about the use of non-specific diagnostic checklists on the Web being used as a marketing tool, the Taskforce also noted the extreme claims made by proponents as to both the prevalence and effect of attachment disorders. Some suggest most or a high proportion of adopted children are likely to suffer attachment disorder. Statistics on the prevalence of maltreatment are (wrongly) used to estimate the prevalence of RAD. Less desirable or problematical attachment styles such as insecure or disorganized attachment are conflated with attachment disorder. Children are labeled as “RAD’s,” “RAD-kids” or “RADishes.”(Chaffin et al, 2006, p79^[3]) They are seen as manipulative, dishonest, without conscience and dangerous. Some attachment therapy sites predict that attachment disordered children will grow up to become violent predators or psychopaths unless they receive the treatment proposed. A sense of urgency is created which also serves to justify the application of aggressive and unconventional techniques. One site was noted to contain the argument that Saddam Hussein, Adolph Hitler, and Jeffrey Dahmer, were examples of children who were attachment disordered who “did not get help in time”.(Chaffin et al, 2006, p80^[3]) Foster Cline in his seminal work on attachment therapy Hope for high risk and rage filled children uses the example of Ted Bundy.(Cline 1992 p^[7])

In answering the question posed as to how a treatment widely regarded by attachment clinicians and researchers as destructive and unethical came to be linked with attachment theory and to be seen as a viable and useful treatment, O'Connor and Nilson cite not only the use of the Internet but also ill-equipped mainstream professionals and the absence of suitable alternative interventions. They set out recommendations for both the better dissemination of understanding of attachment theory and knowledge of the more recent evidence based treatment options available.^[31]

Prevalence

It is difficult to ascertain the prevalence of these therapies but they are sufficiently prevalent to have prompted reactions as outlined by the APSAC Task Force as follows:

"The practice of some forms of these treatments has resulted in professional licensure sanctions against some leading proponents of the controversial attachment therapies. There have been cases of successful criminal prosecution and incarceration of therapists or parents using controversial attachment therapy techniques and state legislation to ban particular therapies. Position statements against using coercion or restraint as a treatment were issued by mainstream professional societies (American Psychiatric Association, 2002) and by a professional organization focusing on attachment and attachment therapy (Association for Treatment and Training in the Attachment of Children ATTACh, 2001). Despite these and other strong cautions from professional organizations, the controversial treatments and their associated concepts and foundational principles appear to be continuing among networks of attachment therapists, attachment therapy centers, caseworkers, and adoptive or foster parents (Hage, n.d.-a; Keck, n.d.)." (Chaffin et al, 2006, p78^[3]).

Prior and Glaser (2006) state that the practice of holding therapy is not confined to the USA and give an example of a center in the UK practising "therapeutic holding" of the "across the lap" variety. (p 263^[19]). The British Association for Adoption and Fostering, BAAF, has issued an extensive position statement on the subject which covers not only physical coercion but also the underlying theoretical principles. [15]

The advocacy group ACT states, "Attachment Therapy is a growing, underground movement for the 'treatment' of children who pose disciplinary problems to their parents or caregivers."

Two American States have outlawed "rebirthing" and some American mainstream professional societies have specifically prohibited some practices found within attachment therapies to varying degrees.[16] See: American Psychological Association (Division on Child Maltreatment) [17], National Association of Social Workers [18] (and its Utah Chapter[19]), American Professional Society on the Abuse of Children,^[3] American Academy of Child and Adolescent Psychiatry,^[32] and American Psychiatric Association [20]. ATTACh, an organization for professionals and families associated with attachment therapy, the Association for the Treatment and Training in the Attachment of Children, has also issued statements against coercive practices.^[33][34]

Notable cases

• Candace Newmaker a 10 year old adopted girl killed by asphyxiation during an attachment therapy 'intensive' involving a 'rebirthing' script in 2000. The two attachment therapists, Connell Watkins (formerly of the Attachment Centre, Evergreen) and Julie Ponder were each sentenced to 16 years imprisonment for their part in the therapy during which Candace was wrapped in blankets and required to struggle to be reborn, against the weight of several adults. Her adoptive mother and the 'therapeutic foster parents' with whom she had been placed received lesser penalties.

• Gravelles. Michael and Sharon Gravelle adopted 11 special needs children many of whom slept in cages, underwent attachment therapy parenting techniques at home and holding therapy from their attachment therapist. Parents and therapist were prosecuted and convicted.^[35]

• Vasquez. In this California case, three of four adopted children were kept in cages, fed limited diets, and permitted only primitive sanitary facilities. The mother received a prison sentence of less than a year and her parental rights were terminated in 2007. There was no therapist in this case, but the mother reported following suggestions of a book given her by her caseworker.

• Cassandra Killpack. A 4-year-old adopted child died from complications of hyponatremia secondary to water intoxication, which apparently occurred when she was restrained in a chair and forced to drink excessive amounts of water by her parents as part of an “attachment-based” treatment ^[36][37][38]

• Krystal Tibbets. A three year old adopted child killed by her father using holding therapy techniques taught to him by an attachment therapy centre. He lay on top of her and pushed his fist into her abdomen to release visceral rage and enforce bonding. After his release from a 5 year prison sentence the father campaigned to have attachment therapy banned. ^[39] [21]^[40]

Evidence basis and controversial therapies

Evidence based medicine is a term used to mean that proposed medical and psychological treatments should be based upon rigorous testing and independent peer review of findings by the medical community and reviewers using meta-analysis of medical literature, risk-benefit analysis, randomized controlled trials, or other methods. There have been a number of reports on the evidence base for attachment therapy and holding therapies in general.

According to the APSAC Task Force, "Proponents of controversial attachment therapies commonly assert that their therapies, and their therapies alone, are effective for children with attachment disorders and that more traditional treatments are either ineffective or harmful." (Chaffin et al, 2006, p78^[3]) The APSAC Task Force expressed concern over claims by therapies to be "evidence based", or indeed the only evidence-based therapy, when the Task Force found no credible evidence base for any such therapy so advertised.^[41] Nor did it accept more recent claims to evidence base in its November 2006 Reply.^[3][22]

Two approaches on which published studies have been undertaken are holding therapy, Myeroff et al (1999)^[42] and Dyadic Developmental Psychotherapy, Becker-Weidman (2006).^[43] Each of these nonrandomized studies concluded that the treatment method studied was effective.

Both the APSAC Task Force and Prior and Glaser cite and criticize the one published study on "holding therapy" by Myeroff et al (1999) which "purports to be an evaluation of holding therapy".(Chaffin et al, 2006, p85^[3])(Prior & Glaser 2006, p264^[19])^[42] This study covers the "across the lap" approach, described as "not restraint" by Howe and Fearnley (2003) but "being held whilst unable to gain release."^[44] Prior and Glaser state that although the Myeroff study claims it is based on attachment theory, the theoretical basis for the treatment is in fact Zaslow. (p 265^[19])

Dyadic Developmental Psychotherapy was developed by Daniel Hughes, described by the Taskforce as a "leading attachment therapist", with the express intention of developing a therapy away from notions of physical coercion, obedience and control. Hughes states that it is based on Bowlby's principles of attachment theory.[22]^[45] Hughes website also gives a list of attachment therapy techniques specifically forsworn by him. Two studies on Dyadic Developmental Psychotherapy have been published by Dr Becker-Weidman, the second being a 4 year follow up of the first. (Becker-Weidman 2006)^[43] Opinion is divided as to whether Dyadic Developmental Psychotherapy is in fact an attachment therapy with Prior and Glaser stating Hughes' therapy 'reads' as good therapy for abused and neglected children, though with 'little application of attachment theory' (p 261), but the advocacy group ACT and the Taskforce placing Hughes within the attachment therapy paradigm.^[19][23]

In 2004, Saunders, Berliner and Hanson developed a system of categories for social work interventions which has proved somewhat controversial.^[46][47] In their first analysis, holding therapy was placed in Category 6 as a "Concerning Treatment".

Craven & Lee (2006) undertook a literature review of 18 studies and classified them under the Saunders, Berliner, & Hanson (2004) system^[48] They considered both Dyadic Developmental Psychotherapy and holding therapy.^[49][42] They placed both in Category 3 as "supported and acceptable". This categorisation by Craven & Lee has been criticised as unduly favourable (Pignotti & Mercer 2007), a point to which Craven and Lee responded by arguments in support of holding therapy.^[50][51] Both Myeroff et al (1999) and Becker-Weidman's first study (published after the main Report) were examined in the Taskforce's November 2006 Reply to Letters and were criticised as to their methodology. Becker-Weidman (2006) was described as "an important first step toward learning the facts about DDP outcomes" but considered to fall far short of the criteria necessary to constitute an evidence base.^[22]

Some studies are still being undertaken on coercive therapies. A nonrandomized, before-and-after 2006 pilot study by Welch (the progenitor of 'holding time') et al on Welch's 'prolonged parent-child embrace therapy' was conducted on children with a range of diagnoses for behavioral disorders and claimed to show significant improvement.^[52]

Mainstream therapies

Main article: Child therapy

All mainstream interventions with an existing or developing evidential foundation focus on enhancing caregiver sensitivity, creating positive interactions with caregivers, or change of caregiver if that is not possible with existing caregivers. Some interventions focus specifically on increasing caregiver sensitivity in foster parents.^[32][19]

See also

References