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Attachment Therapy (also known as attachment therapy, holding therapy, rebirthing therapy, or corrective attachment therapy) is an ambiguous term often used to describe a variety of controversial, non-mainstream treatments for children allegedly suffering from attachment disorder, which is itself an ambiguous term. The term has no common or generally accepted meaning in the professional community and is not found in the American Medical Association's Physician's Current Procedural Manual.

The treatments often involve coercive and intrusive methods, including variants of holding therapy, rebirthing, and rage-reduction which do not adhere to accepted psychological theories of attachment. According to Prior and Glaser (2006), "these therapies are not based on an accepted version of attachment theory and there is no objective evaluation of them." Mainly but not entirely an American phenomenon, many professional bodies and some States in the USA have outlawed rebirthing and a number of American professional organizations prohibit the use of coercive interventions as described in this article.

In a report for the American Professional Society on the Abuse of Children (ASPAC), Chaffin et al state "controversies have arisen about a particular subset of attachment therapy techniques developed by a subset of attachment therapy practitioners, techniques that have been implicated in several child deaths and other harmful effects." They attempt to define this subset of therapies (see below) and state that "popularly, on the Internet, among foster or adoptive parents, and to case workers, they are simply known as 'attachment therapy,' although these controversial therapies certainly do not represent the practices of all professionals using attachment concepts as a basis for their interventions." .

A number of advocacy groups, such as Advocates for Children in Therapy and Quackwatch, have outlined what they believe to be a set of unvalidated treatments that are used within attachment therapy or by attachment therapists. .

Care should be taken to distinguish between the subset of therapies covered by this article and more mainstream therapies, particularly as what is and what is not described as an 'Attachment Therapy' within the meaning of this article is controversial and advocacy groups such as ACT and Quackwatch include a broadly defined range of therapies in their description of Attachment Therapy, some of which are not coercive or intrusive as described in this article.

Definition of Attachment Therapy

There is no generally accepted definition of attachment therapy. It is not a term found in the American Medical Association's Physician's Current Procedural Manual nor in generally recognized texts on treatment modalities, such as Bergin & Garfield's Handbook of Psychotherapy and Behavior Change. There is not any specific text that describes this treatment approach. Chaffin et al (2006) describe 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), having said "The terms attachment disorder, attachment problems, and attachment therapy, although increasingly used, have no clear, specific, or consensus definitions", (p 83) attempt to describe this subset as follows: "The attachment therapy controversy has centered most broadly on the use of what is known as “holding therapy” (Welch, 1988 ) 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 holding therapy," "corrective attachment therapy," "the Evergreen model," "holding time," or "rage-reduction therapy" (Cline, 1991; Lien, 2004 Levy & Orlans, 1998, Welch, 1988 ). Popularly, on the Internet, among foster or adoptive parents, and to case workers, they are simply known as attachment therapy, although these controversial therapies certainly do not represent the practices of all professionals using attachment concepts as a basis for their interventions." p83. Chaffin et al also cite, "encouraging children to regress to infant status" as a feature of these therapies and as a technique to be avoided. p83

Speltz (2002) in a paper published in the APSAC newsletter APSAC Advisor describes "corrective attachment therapy" as follows: "… the holding therapies included in "corrective" attachment therapy do not address safety needs. They differ in that 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." p4.

Prior and Glaser (2006) describe "Attachment therapy" as a variety of treatments offered to desperate carers of troubled, maltreated children which often include variants of holding, eg. holding time (Welch 1988 ), therapeutic holding (Howe and Fearnley 2003), rage reduction therapy (Cline 1991) and rebirthing. They state, "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. Moreover, 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."

The advocacy group Advocates for Children in Therapy define Attachment Therapy (AT) "...as a growing, underground movement for the treatment of children who pose disciplinary problems to their parents or caregivers. AT practitioners allege that the root cause of the children's misbehavior is a failure to 'attach' to their caregivers. The purported correction by AT is — 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." They state "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 group identify rebirthing as a form of Attachment therapy.

History and underlying principles

Speltz (2002) states that the roots of "Attachment Therapy" are traced to Robert Zaslow in the 1970s. 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.

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 behaviour (Cline 1991 )." p263 Chaffin et al describe 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."

Prior and Glaser cite the one published study by Myeroff et al (1999) which "purports to be an evaluation of holding therapy". 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." Prior and Glaser also state, "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." According to Bowlby, "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."

Treatment characteristics

"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; Nichols,Lacher & May, 2004)." Chaffin et al, 2006..

In contrast with accepted theories of attachment, according to O'Connor and Zeanah (2003 p235 ) "The holding approach would be viewed as intrusive and therefore non-sensitive and counter therapeutic". Chaffin et al (2006) describe how the conceptual focus of these treatments is the childs 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 of the controversial therapies emphasize the child's resistance to attachment and the need to break down the child’s resistance. 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, 2001 ). Also requiring children to submit totally to adult control over all their needs and barring children's access to normal social relationships outside the primary parent or caretaker.

The APSAC report states, "The terms attachment disorder, attachment problems, and attachment therapy, although increasingly used, have no clear, specific, or consensus definitions." pg 77 "Controversies have arisen about potentially harmful attachment therapy techniques used by a subset of attachment therapists." pg 76 "The attachment therapy controversy has centered most broadly on the use of what is known as "holding therapy" (Welch, 1988) 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" pg 83.

ACT's site contains descriptions of Attachment Therapy, including a link to the transcript of the rebirthing process that lead to the death by suffocation of Candace Newmaker at the hands of her unlicensed therapists. According to ACT "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."

Evidence-based mainstream therapies

Prior and Glaser (2006) describe evidence based treatments, all of which revolve around enhancing caregiver sensitivity, or change of caregiver if that is not possible. Based on meta-analyses by Bakermans-Krananburg et al (2003) covering 70 published studies for assessing sensitivity, 81 studies on sensitivity and 29 on attachment security and many further randomised intervention studies involving over 7,000 families, among the methods singled out to have shown good results were 'Watch, wait and wonder' (Cohen et al 1999), manipulation of sensitive responsiveness, (van den Boom 1994 and 1995), modified 'Interaction Guidance' (Benoit et al 2001), 'Preschool Parent Psychotherapy', (Toth et al (2002) and 'Circle of Security' (Marvin et al 2002).

The American Academy for Child and Adolescent Psychiatry, under their 'Minimum Standard' guidance, state effective attachment treatment must focus on creating positive in-teractions with caregivers and cite encouraging sensitive responsiveness in the caregiver (Hart and Thomas, 2000)therapy with the child and primary caregiver (Leiberman and Zeannah 1999, Leiberman et al (2000) and McDonough (2000).

Craven & Lee (2006) undertook a literature review of 18 studies and classifed them into : Category 1:Well-supported, efficacious treatment; Category 2:Supported and probably efficacious; Category 3: Supported and acceptable; Category 4: Promising and acceptable; Category 5: Novel and experimental; and Category 6: Concerning Treatment. Only two studies were in the attachment category, Dyadic Developmental Psychotherapy, Becker-Weidman, A. (2004). and Holding Therapy, Myeroff, R., Mertlich, G., & Gross, J. (1999) Both therapies were placed in Category 3. Both Myeroff's study and Becker-Weidman (2006) (a four year follow up of his earlier study) were criticised in the November 2006 follow up to the main Taskforce report by Chaffin et al and stated to be not evidence-based.

Therapies named as attachment therapies

Attachment Disorder

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".

Attachment disorders are classified in DSM-IV-TR and ICD-10. DSM describes Reactive Attachment Disorder of Infancy or Early Childhood, divided into two subtypes, Inhibited Type and Disinhibited Type. The ICD classification describes two types, Reactive Attachment Disorder of Childhood and Disinhibited Attachment Disorder of Childhood. 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.

Chaffin et al and Prior and Glaser describe the proliferation of alternative "lists" and diagnoses, particularly on the Internet, by proponents of Attachment Therapies that do not accord with either DSM or ICD classifications and which are partly based on the unsubstantiated views of Zaslow and Menta (1975) and Cline (1991). Neither do these lists accord with alternative diagnostic criteria as proposed above. According to Chaffin et al, "These types of lists are so nonspecific that high rates of false-positive diagnoses are virtually certain." Prior and Glaser 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.

Prevalence

There are no reliable statistics on how many professionals actually practice Attachment Therapy (also known as attachment therapy, holding therapy, rebirthing therapy, or corrective attachment therapy). However, as defined in this article, Attachment Therapy involves the use of practices prohibited by a large number of professional organizations such as the following: the American Psychological Association , the National Association of Social Workers (Utah Chapter), the American Professional society on the Abuse of Children (APSAC) , Association for the Treatment and Training in the Attachment of Children, the American Academy of Child and Adolescent Psychiatrry ("Practice Parameter for the Assessment of Children and Adolescent with Reactive Attachment Disorder of Infancy and Early Childhood" in the Journal of the American Academy of Child and Adolescent Psychiatry, vol 44, Nov 2005 and at , and the American Psychiatric Association. .

Members of those organizations are prohibited from using methods and techniques proscribed by these organizations' codes of ethics and practice parameters. Violation of the standards could result in expulsion from the organization. Several American states have outlawed rebirthing, making members using such methods guilty of malpractice in those states.

It is difficult to ascertain the prevalence of these therapies but they are sufficiently prevalent to have prompted reactions as outlined by Chaffin et al 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 , 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.)."

Prior and Glaser (2006) state ‘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".p263

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

See also

Notes and references

1. ^ Prior, V., and Glaser, D. (2006) Understanding Attachment and Attachment Disorders : Theory, Evidence and Practice, Child and adolescent mental health series, Jessica Kingsley Publishers, ISBN 1 84310 245 5 Cite error: The named reference "Prior 2006" was defined multiple times with different content (see the help page).
2. ^ Chaffin, M. et al (2006) Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment problems. | Journal= Child Maltreatment 2006;11;76| pages=76-79 | DOI: 10.1177/1077559505283699 | Cite error: The named reference "Chaffin" was defined multiple times with different content (see the help page).
3. ^ Welch, H., Holding Time, New York, Fireside Cite error: The named reference "Welch" was defined multiple times with different content (see the help page).
4. ^ Cline, F., (1991) Hope for High Risk and Rage Filled Children: Attachment Theory and Therapy, Golden CO: Love and Logic Press Cite error: The named reference "Cline"" was defined multiple times with different content (see the help page).
5. Lien, F. (2004). Attachment therapy. In B. E. Saunders, L. Berliner, & R. F. Hanson (Eds.), Child physical and sexual abuse: Guidelines for treatment (Revised Report: April 26, 2004, pp. 57-58). Charleston, SC: National Crime Victims Research and Treatment Center.
6. Levy, T. M., & Orlans, M. (1998), Attachment, trauma and healing: Understanding and treating attachment disorder in children and families. Washington, DC: Child Welfare League of America.
7. ^ Speltz Matthew L., Description, History and Critique of Corrective Attachment Therapy, The APSAC Advisor 2002 14(3), pages 4-8 Cite error: The named reference "Speltz 2002" was defined multiple times with different content (see the help page).
8. Bowlby, J. (1998) A Secure Base: Clinical Application of Attachment Theory. London Routledge. p265.
9. ^ Zaslow, R., & Menta, M. (1975) The psychology of the Z-process: Attachment and activity. San Jose, CA: San Jose University Press. Cite error: The named reference "Zaslow" was defined multiple times with different content (see the help page).
10. ^ Myeroff R., et al, Comparative effectiveness of holding therapy with aggressive children', Child Psychiatry and Human Development 29. 4, 303-313 Cite error: The named reference "Myeroff" was defined multiple times with different content (see the help page).
11. Howe D., & Fearnley, S., (2003) Disorders of attachment in adopted and fostered children: recognitionand treatment. Clinical Child Psychology and Psychiatry 8, 369-387
12. Bowlby, J. (1998) A Secure Base: Clinical Application of Attachment Theory. London Routledge.
13. Haugaard, J. J. (2004a). Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: Introduction. Child Maltreatment, 9, 123-130
14. Nichols, M., Lacher, D.,&May, J. (2002). Parenting with stories: Creating a foundation of attachment for parenting your child. Deephaven, MN: Family Attachment Counseling Center.
15. O'Connor, C., & Zeanah, C., Attachment disorder: assessment strategies and treatment approaches, Attachment and Human Development. 5, 223-244
16. Thomas, N. (2001). Parenting children with attachment disorders. In T.M. Levy (Ed.), Handbook of attachment interventions. San Diego, CA: Academic.
17. Craven, P., & Lee, R., (2006), "Therapeutic Interventions for Foster Children: A Systematic Research Synthesis," Research on Social Work Practice, vol 16, #3, pp. 287-304
18. Dyadic developmental psychotherapy: An effective treatment for children with trauma-attachment disorders
19. Mark Chaffin, Rochelle Hanson and Benjamin E. Saunders | Reply to Letters | Child Maltreat 2006; 11; 381 | DOI: 10.1177/1077559506292636

References

• Becker-Weidman, A., & Shell, D. (2005). Creating Capacity for Attachment. Oklahoma City, OK: Wood 'N' Barnes.
• Becker-Weidman, A.(2006a) Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. 23(2).
• Becker-Weidman, A., (2006b) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,” Child and Adolescent Mental Health Published article online: 21-Nov-2006 doi: 10.1111/j.1475-3588.2006.00428.x.]
• Berliner, L. (2002). Why caregivers turn to "attachment therapy" and what we can do that is better. APSAC Advisor, 14(4), 8-10.
• Bowlby, J. (1982). Attachment. New York: Basic.
• Chaffin, M., Hanson, R., Saunders, B.E., Nichols, T., Barnett, D., Zeanah, C., Berliner, L., Egeland, B., Newman, E.; Lyon, T., LeTourneau, E., & Miller-Perrin, C. (2006). Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. Child Maltreatment 11(1):76-89. PMID 16382093
• Cline, F. (1994). Hope for high risk and rage-filled children. Evergreen, CO: EC Publications.
• Hughes, D., (2003). Psychotherapeutic interventions for the spectrum of attachment disorders and intrafamilial trauma. Attachment and Human Development 5-3, 271-279.
• Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 3, 263–278.
• Krenner, M. (1999). Ein Erklaerungsmodell zur "Festhaltetherapie" nach Jirina Prekop. Retrieved Oct. 25, 2000, from http://wwwalt.uni-wuerzburg.de/gbpaed/mixed/work/mkrenner1.html.
• Levy, T.M., Ed. (2000). Handbook of attachment interventions. San diego: Academic.
• Lieberman, A., (2003). The treatment of attachment disorder in infancy and early childhood. Attachment and Human Development, 5-3, 279-283.
• Marvin, R., & Whelan, W., (2003) Disordered attachment: toward evidence-based clinical practice. Attachment and Human Development 5-3, 284-299.
• O'Connor, C., & Zeanah, C., Attachment disorder: assessment strategies and treatment approaches, Attachment and Human Development, 5, 223-244.
• Schechter, D.S. (2003). "Intergenerational communication of maternal violent trauma: Understanding the interplay of reflective functioning and posttraumatic psychopathology." In Coates, S.W., Rosenthal, J.L., & Schechter, D.S. (Eds.), September 11: Trauma and Human Bonds. New York, NY: The Analytic Press, pp. 115-143.
• Thomas, N. (2001). Parenting children with attachment disorders. In T.M. Levy (Ed.), Handbook of Attachment Interventions. San Diego, CA: Academic.
• Verny, T., & Kelly, J. (1981). The Secret Life of the Unborn Child. New York: Dell.
• Welch, M.G. (1989) Holding time. New York: Fireside.
• Welch, M.G., Northrup, R.S., Welch-Horan, T.B., Ludwig, R.J., Austin, C.L., & Jacobson, J.S. (2006). Outcomes of prolonged parent-child embrace therapy among 102 children with behavioral disorders. Complementary Therapies in Clinical Practice, 12, 3-12.
• Zaslow, R., & Menta, M. (1975) The psychology of the Z-process: Attachment and activity. San Jose, CA: San Jose University Press.
• Zeanah, C., (1993) Infant Mental Health. NY: Guilford.

External links

• AICAN - Australian Intercountry Adoption Network
• Advocates for Children in Therapy- Advocacy group opposed to Attachment Therapy
• "Be Wary of Attachment Therapy" from Quackwatch

• Psychological theories
• Interpersonal relationships
• Human development
• Therapy