Attachment therapy

Attachment therapy is the popular (lay) name collectively applied to a loosely identified category of interventions, including parenting techniques or methods, for the treatment of a child with an attachment disorder or Reactive attachment disorder, problem, disruption or difficulty, or for the behavioral sequelae to such an attachment disorder, problem, disruption or difficulty. There is no commonly agreed upon definition for this broadly and loosely defined term.

While there are attachment-related interventions based on generally accepted theory and using generally supported techniques, such as Dyadic Developmental Psychotherapy, Parent-Child Interaction Therapy (PCIT), Circle of Security, and other programs, attachment therapy has primarily come to public notice because of the small subset of controversial interventions, popularly called 'attachment therapy, 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." (Chaffin et al, 2006, p77 )

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".

Outline of Controversy
Attachment theory is an evolutionary theory which in relation to infants,  primarily consists of proximity seeking to an attachment figure in the face of threat, for the purpose of survival. Although an attachment is a "tie" it is not synonymous with love and affection (Bowlby 1969, p181). A serious disturbance of attachment which can have significant behavioral consequences, indicates the absence of either or both elements. This can occur either in institutions, or with repeated changes of caregiver, or from extremely neglectful primary caregivers who show persistant disregard for the child's basic attachment needs. There are are also a variety of attachment 'styles', some of which are more problematic than others.

Speltz (2002), in a paper published in the American Professional Society on the Abuse of Children (APSAC) newsletter, described "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, )

In 2003 an issue of Attachment & Human Development, was devoted to the subject with articles by well known experts in the field, such as Dr. Zeanah, Dr. O'Connor, and Dr. Huges, to name a few. The American Professional Society on the Abuse of Children (APSAC) set up a Task Force to report on the subject of attachment therapy, reactive attachment disorder, and attachment problems. The Task Force's Report, also known as Chaffin et al, was published in 2006 and outlined guidelines and suggestions for the diagnosis and treatment of attachment disorders. (Chaffin et al, 2006, p83 ) They describe the controversy as follows:


 * "The attachment therapy controversy has centered most broadly on the use of what has been known as "holding therapy" (Welch, 1989 ) 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)   ). 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." (Chaffin et al, 2006, p83 )

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.

The fringe advocacy group Advocates for Children in Therapy, led by Dr. Jean Mercer, Larry Sarner and his wife, Linda Rosa, 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 adjuvant 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 traceable 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. Zaslow, had to surrender his California psychology license following an injury to a patient.

As he noted in "The psychology of the Z-process", 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, with upper-body stiffness, and with emotional constriction, and was 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. Reich was subsequently imprisoned for breaching an injunction preventing fraudulent practices involving treatment by means of an "orgone box".

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 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 (not to be confused with DSM-IV's reactive attachment disorder). This was replicated elsewhere such as at "The Center" in the Pacific Northwest. A number of clinics later arose in Evergreen, Colarado, set up by those involved in or trained at the Attachment Center at Evergreen (originally the Youth Behavior Program, now renamed the Institute for Attachment and Development). 

Metaphors based on Zaslows original application of ego defences from  psychoanalytic theory were adopted, such as "breaking through" a child's defences, or the child's development being "frozen" and treatment being required to "unfreeze" development. In addition it was believed that holding induced regression enabling a child to make up for physical affection missed earlier in life. 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 )" and that "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 )p263 Cline's text "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 in a format that makes it unclear whether it is Cline's case. The Erickson case report, published in 1961,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.

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 on misapplied metaphors deriving from Zaslow and psychoanalysis, not attachment theory.

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 ).

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." (Chaffin et al, 2006, p78 )

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."

ACT's site contains quite old descriptions of attachment therapy, and a variety of outdated material, including a link to the transcript of the rebirthing process that lead to the death by suffocation of Candace Newmaker during a "two week intensive" at the hands of her unlicensed therapists (unlicensed in the relevant state). 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."

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. " (Chaffin et al, 2006, p79 )

Generally accepted and evidence-based 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 ).

Evidence-based and main-stream treatment approaches
There are a variety of effective prevention programs and treatment approaches for attachment disorder based on Attachment theory. All approaches concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver. Approaches with a sound evidential and theoretical base include the following:
 * 1) 'Circle of Security' (Marvin et al, 2002)
 * 2) Dyadic Developmental Psychotherapy  ,
 * 3) 'Watch, wait and wonder' (Cohen et al, 1999),
 * 4) manipulation of sensitive responsiveness, (van den Boom 1994 and 1995),
 * 5) modified 'Interaction Guidance' (Benoit et al, 2001),
 * 6) 'Preschool Parent Psychotherapy' (Toth et al, 2002)
 * 7) Parent-Child psychotherapy (Leiberman et al 2000).
 * 8) Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders.

Dyadic Developmental Psychotherapy was developed by Dr. Daniel Hughes. Hughes describes the treatment as based on Bowlby's principles of attachment theory. Two studies on Dyadic Developmental Psychotherapy have been published by Dr Becker-Weidman, the second being a four year follow up of the first, which provide empirical evidence of the treatment's effectiveness. (Becker-Weidman 2006).

Craven & Lee (2006) undertook a literature review of 18 studies and classified them under the Saunders, Berliner, & Hanson (2004) system. They considered Dyadic Developmental Psychotherapy. They placed Dyadic Developmental Psychotherapy in Category 3 as "supported and acceptable". Had they had access to the two published empirical studies it is likely that they would have rated the treatment as Category 2, Supported and probably efficacious.

Prior and Glaser (2006) describe what they classify as evidence-based interventions, all of which revolve around either enhancing caregiver sensitivity, (p 233), or change of caregiver if that is not possible, (p252). 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) and 'Preschool Parent Psychotherapy' (Toth et al, 2002). They also include 'Circle of Security' (Marvin et al, 2002) as promising although it is still undergoing the process of validation. For the efficacy of change of caregiver they cite Dozier et al (2001), Steele et al (2003a) and Hodges et al (2003b).

Dyadic developmental psychotherapy is an evidence-based treatment (classed as an acceptable and supported social work intervention under the criteria suggested by Saunders, Berliner, & Hanson (2004)  approach for the treatment of attachment disorder, Complex Post Traumatic Stress Disorder, and reactive attachment disorder.

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).

Controversial approaches
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 ) 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. The Task Force Report was published before the two peer-reviewed empirical studies by Dr. Becker-Weidman had been published.

There is one published study on holding therapy, Myeroff et al (1999)

Both the APSAC Task Force and Prior and Glaser cite and criticize the one published study on "holding therapy" by Myeroff et al (1999) (Chaffin et al, 2006, p85 )(Prior & Glaser 2006, p264 ) 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 )

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.

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 Internet is considered essential to the popularization of holding therapy as attachment therapy.

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 )

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 ) and Cline (1992 ). (Chaffin et al, 2006 ; Prior & Glaser, 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."(Chaffin et al, 2006, p83 ) 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.

A commonly used diagnosis checklist in attachment therapy is the Randolph Attachment Disorder Questionnaire or "RADQ", emanating from the Institute for Attachment in Evergreen. 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. 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 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." It also purports to diagnose attachment disorder for which there is no classification. 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.

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 ).

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 ) BAAF, the British Association for Adoption and Fostering, has issued an extensive position statement on the subject which covers not only physical coercion but also the underlying theoretical principles. 

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. See: American Psychological Association (Division on Child Maltreatment), National Association of Social Workers  (and its Utah Chapter), American Professional Society on the Abuse of Children , American Academy of Child and Adolescent Psychiatry , and American Psychiatric Association. 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.