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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. However, because the term has no common meaning, or generally accepted meaning, in the professional community, its actual definition is unclear. The term is not a term found in the American Medical Association's Physician's Current Procedural Manual. A number of advocacy groups, such as Advocates for Children in Therapy and Quackwatch have undertaken to label a large number of treatments for children with disorders of attachment as "Attachment Therapy" and attempt to discredit those therapies.]. The treatments often involve coercive and intrusive methods including variants of holding therapy or rebirthing or rage-reduction. 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’. Many professional bodies and some American States have outlawed rebirthing.

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.” . p77 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." p85

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 centred 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." p265.

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 1970’s.

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 mechanism’s making them more receptive to others. Speltz point’s 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 Zaslows 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." p 78

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

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 does not describe "Attachment Therapy", it uses the term "attachment therapy" (no caps or quotation marks). They state, “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."

Attachment Disorder

Prior and Glaser (2006) describe "two discourses" on attachment disorder. One 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.

DSM and ICD are limited and some researchers in the field of attachment such as Zeannah have proposed alternative diagnostic criteria to describe broader disorders of attachment but the exact parameters are not yet established.

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" or "rebirthing as it is also known. 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: American Psychological Association], National Association of Social Workers], American Professional society on the Abuse of Children (APSAC) ], Association for the Treatment and Training in the Attachment of Children, 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 those organizations codes of ethics and practice parameters. Violations of those standards would result in expulsion of the organization. Therefore there are very few practitioners of "AT" as defined in this article. Furthermore, several states have outlawed "rebirthing," and anyone using such methods would be guilty of malpractice, which is a small problem in all professions.

See also

Notes and references

1. ^ Prior V., and Glaser D., Understanding Attachment and Attachment Disorders : Theory, Evidence and Practice, Jessica Kingsley Publishers, child and adolescent mental health series, 2006, ISBN 1 84310 245 5
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 |
3. ^ Welch, H., Holding Time, New York, Fireside
4. ^ Cline, F., (1991) Hope for High Risk and Rage Filled Children: Attachment Theory and Therapy, Golden CO: Love and Logic Press
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
8. Bowlby, J. (1998) A Secure Base: Clinical Application of Attachment Theory. London Routledge.
9. ^ Zaslow, R., & Menta, M. (1975) The psychology of the Z-process: Attachment and activity. San Jose, CA: San Jose University Press.
10. Myeroff R., et al, Comparative effectiveness of holding therapy with aggressive children', Child Psychiatry and Human Development 29. 4, 303-313
11. Howe D., & FearnleyS., (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.

References

Becker-Weidman, A., & Shell, D., (2005) Creating Capacity for Attachment. Oklahoma City, OK: Wood 'N' Barnes.

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 BE, Nichols T, Barnett D, Zeanah C, Berliner L, Egeland B, Newman E, Lyon T, LeTourneau E, Miller-Perrin C. Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. Child Maltreat. 2006 Feb;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 S.W. Coates, J.L. Rosenthal, & D.S. Schechter (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