Attachment Therapy

Attachment therapy also sometimes called "holding therapy" or rebirthing is an ambiguous term which is sometimes used to describe a form of treatment for behavioral difficulties in children suffering from attachment disorder. However, because the term has no common meaning, or generally accepted meaning, in the professional community, its actual definition is unclear. As such, it has little commonly agreed upon meaning in the professional literature. For example, it is not a term found in the Amereican Medial 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 nearly all treatments for children with disorders of attachment as "attachment therapy" and attempt to discredit those therapies. The American Professional Society on Abuse of children (APSAC) (Chaffin et al.,2006, PMID 16382093) has disapproved of coercive and intrusive methods of treatment as inappropriate for treatment while approving a broad range of effective treatments that do not use coercive methods.

Treatment characteristics
The "attachment therapy," rebirthing, or "holding therapy" group of treatments vary in their specifics, but may have some common features. However, these common traits are subject to much debate and are ill-defined since there is no common definition for this term. For example, it is not a term found in the American Psychiatric Associations's DSM IV-R or in the American Medical Association's book of CPT codes for treatment methods. Enforced coercive physical restraint is a shared characteristic of some versions of this ill-defined approach.

"Attachment therapy" or "holding therapy" or rebirthing is not a mainstream approach to treating children experiencing attachment disorder. The term is not applicable to generally accepted approaches to the treatment of children and adolescents with disorders of attachment (see APSAC report). "The holding approach would be viewed as intrusive and thereforer non-sensitive and counter therapeutic" (O'Connor & Zeanah, (2003), p. 235).

Treatment and prevention programs that use methods congruent with attachment theory and with well established principles of child development (American Academy of Child and Adolescent Psychiatry) include: Alicia Lieberman (Parent-child Psychotherapy) (Lieberman & Pawl in Infant Mental Health, 1993)(Liberman 2003), Stanley Greenspan (Floor Time), Daniel Hughes (Dyadic Developmental Psychotherapy) (Becker-Weidman & Shell, 2005) (Hughes, 2003), Mary Dozier (autonomous states of mind), Robert Marvin (Circle of Security) (Marvin & Whelan 2003), Phyllis Jernberg (Theraplay), Daniel Schechter (intergenerational communication of trauma), and Joy Osofsky (Safe Start Initiative) (in Infant Mental Health, 1993). None of these approahes use coercive methods nor do they fit the defination of "Attachment Therapy" described by Advocates for Children in Therapy cited in the next section.

Definition of Attachment Therapy
There is no generally accepted definition of "Attachment Therapy," and it is not a term that is found in generally recognized texts on treatment modalities, such as Bergin & Garfield's Handbook of Psychotherapy and Behavior Change, nor is there any specific text that describes this "treatment" approach. However, the advocacy group, Advocates for Children in Therapy (ACT) does offer guidance on this subject. While this group is not a professional mental health group in the same manner that the American Psychiatric Association or American Psychological Association or NASW are and none of the leaders are licensed mental professionals or clinicians, they do offer some ideas for a description of what this term can mean.

ACT states, "Attachment Therapy (AT) is a growing, underground movement for the "treatment" of children who pose disciplinary problems to their parents or caregivers." In discussing Attachment Therapy they state, "there is a hands-on treatment involving physical restraint and discomfort." "Attachment Therapy (AT) 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".

ACT further defines attachment terapy as, "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 also uses the terms rebirthing and "holding therapy" as terms similiar to "Attachment Therapy."

Parenting methods association with attachment therapy
"Attachment therapy" treatments, using the defination above, may be accompanied by parenting interventions that are coercive, painful or shaming (ACT website). These approaches have been criticized as inappropriate in accordance with some professional association standards, such as the American Academy of Child and Adolescent Psychiatry and APSAC. For example, obedience-training techniques such as "strong sitting" (frequent periods of required silence and immobility) and withholding or limiting food (Thomas, 2001). However, since this is not a clearly defined treatment, it is generally unclear what methods fall under this approach.

Theoretical background
Advocates of "attachment therapy" claim that the treatment derives from John Bowlby's theory of the development of emotional attachment (Bowlby, 1982). Bowlby's work stresses the infant's experiences of social interactions in the second half of the first year as the foundation of attachment; his theory considers attachment to be shown by an infant's ability to use an adult as a secure base for exploration and learning, as well as by concerns about separation.

Some practitioners of "Attachmant therapy" connect their practice to belief systems such as those of Verny (Verny & Kelly, 1981) and Emerson (1996), who claimed that memories dating from the time of conception (or earlier) shape personality and that these memories are contained in all cells. The ideas that attachment resulted from stimulation of cathartic expression of rage and on the experience of the complete authority of the adult were codified by Cline (1994), Levy (2001), and Zaslow (Zaslow & Menta,1975), whose practices involved physically-intrusive actions intended to bring about those events. However, there is ample evidence that at birth neonates can distinguish the voice (see infant), smell, and taste of their birth mother from that of others. Furthermore, new-borns show clear evidence of an ability to relate socially and interact with others in a responsive and contingent manner. (see works by pediatrician, Marshall Klaus.

Criticisms
Some components of "Attachment Therapy" have been disapproved by a task force of the American Professional Society on Abuse of children. (Chaffin et al.,2006, PMID 16382093) Specifically, the task force addressed coercive methods and practices as inappropriate for treatment. In this regard the task force's recommendations mirror that of generally accepted practices for treatment generally, and specifically for children. Some have criticized the treatment as using coercion and physically painful methods to achieve the desired results.

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 Furthermore, what seems to be focus of this proposed page only addresses a very narrow area, “Controversies have arisen about potentially harmful attachment therapy techniques used by a subset of attachment therapists.” Pg 76 Attachment therapy is better discussed in context, especially if the focus is on “a particular subset of attachment therapy techniques developed by a subset of attachment therapy practitioners” pg 77. The controversy is a narrow one and should be placed in context so that readers understand the full range of issues. “ 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.

On April 19, 1999 Candace Newmaker was killed during rebirthing therapy. The two unlicensed therapists were convicted of murder in 2001. "Rebirthing" is a "treatment" that is prohibited by the APSAC Task Force Report and the ethical standards of various professional organizations, such as the American Psychological Association, National Association of Social Workers, and other groups. It is not a treatment, but a coercive, intrusive act that in the Candace Newmaker case was found to be criminal. However, the practitioners involved intended their actions to be therapeutic, as is sometimes the situation in cases of malpractice.