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Attachment Therapy is the popular (lay) name collectively applied to a loosely identified category of mental health interventions, including parenting techniques or methods, which purport to treat a child for an attachment disorder, problem, disruption or difficulty, or for the behavioral sequelae to such an attachment disorder, problem, disruption or difficulty.

While there is a subset of attachment-related interventions based on generally accepted theory and using generally supported techniques, the category has primarily come to public notice because of another subset of controversial interventions which have been implicated in several child deaths and other harmful effects. "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." (APSAC, 2006, p77)

To date, nearly all public discussion of Attachment Therapy is about this controversy.

Outline of Controversy

Attachment therapy came to the attention of professional bodies and the wider public following a series of prosecutions for deaths or serious maltreatment of children allegedly at the hands of 'attachment therapists' or parents following their instructions, the most well known case being that of Candace Newmaker. The American Professional Society on the Abuse of Children (APSAC) set up a Taskforce. In their report, known as 'Chaffin' or 'APSAC' (2006), they laid down guidelines for the diagnosis and treatment of attachment disorders. Many professional bodies have regulated against such practices but such regulation varies considerably.

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." (APSAC, 2006, p. 83)

Speltz (2002), in a paper published in the APSAC newsletter, 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." (p. 4)

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.

The advocacy group Advocates for Children in Therapy describes 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." They give a list of therapies they state are attachment therapies and a list of adjuvent therapies used by attachment therapists which they consider to be unvalidated..

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.

Speltz cites Martha Welch and ‘holding time’ (1984 and 1989) 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 (1991) and associates at the Attachment Center at Evergreen, Inc. (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 (not to be confused with DSM-IV’s reactive attachment disorder). This was replicated elsewhere such as "The Center" in the Pacific Northwest.

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)." (p. 263)

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." APSAC, 2006, p. 78

Prior and Glaser (2006) 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." (Bowlby, 1998, p. 265)

Treatment characteristics

The APSAC Task Force (2006) describes 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 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..." (APSAC, 2006 p78)

Speltz 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 (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 evenutally 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)

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

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 ). 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." (APSAC, 2006 p79)

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 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."

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 Nichols, Lacher & May, 2004 )." (APSAC, 2006 p77).

Evidence-based mainstream therapies

Prior and Glaser describe a few 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' (MS) guidance, state effective attachment treatment must focus on creating positive interactions with caregivers (MS) and encouraging sensitive responsiveness in the caregiver (Hart and Thomas, 2000) and therapy with both child and primary caregiver (Leiberman and Zeanah, 1999; Leiberman et al, 2000; and McDonough, 2000).

Lack of Evidence Basis for Controversial Therapies

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.(see, e.g., Becker-Weidman, n.d.-b; Kirkland, n.d.; Thomas, n.d.-a)."

The Taskforce state that proponents 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. They argue that their therapies present no physical risk if undertaken properly and that critics concerns are based on unrepresentative occurances 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. (APSAC 2006 ) Some former attachment therapists such as Daniel Hughes have sought to develop their therapy away from any notions of physical coercion and claim that their therapies are based on Bowlby's principles of attachment theory. Prior and Glaser describing his therapy as good therapy for abused and neglected children, though with little application of attachment theory' p 261. ACT placing Hughes within the attachment therapy paradigm. While Craven & Lee (2006) define it as an evidence-based approach.

Both the APSAC Taskforce, p85, and Prior and Glaser, p264, cite and criticize the one published study on "holding therapy" 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 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.

The APSAC Taskforce also express 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. "Some proponents have claimed that research exists that supports their methods, or that their methods are evidence based, or are even the sole evidence-based approach in existence, yet these proponents provide no citations to credible scientific research sufficient to support these claims (Becker-Weidman, n.d.-b). This Task Force was unable to locate any methodologically adequate clinical trials in the published peer-reviewed scientific literature to support any of these claims for effectiveness, let alone claims that these treatments are the only effective available approaches." (APSAC p85)

The APSAC Taskforce maintained this position in their reply of November 2006 following open letters from both proponents and critics of attachment therapy, and after consideration of a study published in 2006. . (APSAC Reply p382) See open letters and Taskforce Reply to Letters

Diagnosis and 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 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".

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."

Both the APSAC Task Force and Prior and 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 ) and Cline (1991). APSAC, 2006 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." 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".

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 , 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.)." (APSAC, 2006)

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". (p. 263)

ACT state "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 professional organizations have specifically prohibited some practices found within attachment therapies to varying degrees. See:American Psychological Association , The National Association of Social Workers , The National Association of Social Workers (Utah Chapter) , American Professional Society on the Abuse of Children (APSAC, 2006), American Academy of Child and Adolescent Psychiatry (AACAP, 2005, American Psychiatric Association. , Association for the Treatment and Training in the Attachment of Children

See also

References

1. ^ Chaffin M (2006). "Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems". Child Maltreatment. 11 (1): 76–79. doi:10.1177/1077559505283699. ISSN 1552-6119. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help); Unknown parameter |quotes= ignored (help) Cite error: The named reference "APSAC 2006" was defined multiple times with different content (see the help page).
2. ^ Welch, M., Holding Time, New York: Fireside. Cite error: The named reference "Welch" was defined multiple times with different content (see the help page).
3. ^ 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).
4. Lien, F. (2004). Attachment therapy. In Saunders, B. E.; Berliner, L.; & Hanson, R. F. (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.
5. 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.
6. ^ Speltz, M. L. (2002). Description, History and Critique of Corrective Attachment Therapy. The APSAC Advisor, 14(3):4-8
7. ^ Prior, V., and Glaser, D. (2006). Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice, Jessica Kingsley Publishers, Child and adolescent mental health series. | ISBN 1 84310 245 5.
8. ^ 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).
9. Bowlby, J. (1998). A Secure Base: Clinical Application of Attachment Theory. London Routledge.
10. O'Connor, C., & Zeanah, C. (2003). Attachment disorder: assessment strategies and treatment approaches. Attachment and Human Development, 5:223-244
11. Thomas, N. (2001). Parenting children with attachment disorders. In T.M. Levy (Ed.), Handbook of attachment interventions. San Diego, CA: Academic.
12. Haugaard, J. J. (2004a). Recognizing and treating uncommonbehavioral and emotional disorders in children and adolescents who have been severely maltreated: Introduction. Child Maltreatment, 9:123-130
13. 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.
14. Hughes D. (2004) 'An attachment-based treatment of maltreated children and young people,' | Attachment and Human Development 6 | p263-278
15. Craven, P., & Lee, R., (2006) Therapeutic Interventions for Foster Children: A Systematic Research Synthesis, Research on Social Work Practice, 16:3, 287-304.
16. Myeroff R., et al, Comparative effectiveness of holding therapy with aggressive children. Child Psychiatry and Human Development, 29(4):303-313
17. Howe D., & Fearnley, S., (2003). Disorders of attachment in adopted and fostered children: Recognition and treatment. Clinical Child Psychology and Psychiatry, 8:369-387
18. Becker-Weidman, A., (2006) “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” | Child and Adolescent Social Work Journal. Vol. 23 #2, pp. 147-171 April 2006
19. Chaffin M. et al (2006). Reply to letters. Child Maltreatment, Vol 11, No.4, 381-386 (2006) | DOI: 10.1177/1077559506292636 |
20. Practice Parameter for the Assessment of Children and Adolescent with Reactive Attachment Disorder of Infancy and Early Childhood. Journal of the American Academy of Child and Adolescent Psychiatry, Nov; 44:

External links

• ATTACh - Trade group for Attachment Therapists
• Advocates for Children in Therapy - Advocacy group opposed to Attachment Therapy
• "Be Wary of Attachment Therapy" from Quackwatch - medical watchdog website

• Interpersonal relationships
• Human development
• Therapy