Abstract
Holding therapy (HT), an alternative intervention for treatment of childhood mental illness, uses physical restraint as a treatment mode, not just as a safety measure. Although one systematic research synthesis (Craven & Lee, 2006) categorized HT as an effective and supported social work intervention, analysis by other authors (Lilienfeld, 2007; Mercer & Pignotti, 2007; Pignotti & Mercer, 2007) contradicted this view and assessed HT as a potentially harmful treatment as well as one unsupported by evidence of effectiveness. A recent review of research in German as well as English has confirmed the latter conclusion (Mercer, 2013). Documentaries and training videos demonstrating HT have shown children screaming, crying, and physically resisting experiences that appear to be painful and frightening. A personal communication from a young woman who experienced HT as a child noted the dread she experienced as she heard other children scream; as an adult, she was treated for an anxiety disorder that was thought to be related to her HT experience. Robert Zaslow, the originator of HT practices, warned that bruising was to be expected (Zaslow & Menta, 1975), and surrendered his professional license following a serious injury to an adult patient.
HT exists in two distinct forms. One, sometimes referred to as Attachment therapy (AT) or by other terms, involves uncomfortable physical restraint by several therapists or by parents, and employs adjuvant methods such as limiting of diet and toilet use. This method, HT/AT, has been associated with a number of child deaths (Mercer, Sarner, & Rosa, 2003). It was once used for treatment of autism (Zaslow & Menta, 1975), but more recently is generally used as a treatment for reactive attachment disorder. The second HT form is carried out by parents with the coaching of therapists, and employs face-to-face restraint of children by parents, either with a small child on the parent’s lap or with the parent lying prone on a supine older child. This method may be called HT/WP, as it is based on the techniques of Martha Welch (Welch, 1989; Welch et al., 2006) and Jirina Prekopova (Prekop, 1983 [Prekopova is the feminine form of the name, as used in Czech]). HT/WP is intended for treatment of autism, oppositional behavior, and reactive attachment disorder. It does not appear to have been associated with adjuvant methods or with child deaths.
HT in both forms appears to have originated in the United States but has spread internationally as a treatment for autism and for attachment disorders. In response to the spread of HT, concerned individuals from the United States, the United Kingdom, the Czech Republic, and Russia have formed the International Working Group on Abuses in Child Psychotherapy with the goal of public and professional education about HT and prevention of its use. The group met in London on April 20, 2013. The present article summarizes background information and the presentations made at the conference, which without exception argued against the use of HT.
Background
International attention was attracted to the problem of HT in 2000 when a 10-year-old American girl died in the course of treatment. Other deaths, caused by parents following the advice of therapists, have been less well publicized (Mercer, Sarner, & Rosa, 2003). In the United States, a Congressional resolution rejected the use of one component of HT (rebirthing); the American Psychological Association, the American Psychiatric Association, the National Association of Social Workers, and other groups joined in this opinion or rejected HT as a whole. In the United Kingdom, the British Association for Adoption and Fostering passed a similar resolution in 2004. The American Professional Society on Abuse of Children (APSAC) mounted a task force to investigate the use of HT and published a report (Chaffin et al., 2006) rejecting the use of the treatment or related methods.
In spite of these rejections, practitioners in several countries have continued to use or support HT in its various forms. The U.S. organization Association for Treatment and Training of Attachment in Children (ATTACh), at one time the leading advocacy group for intrusive HT, has now redefined holding of children as a nurturing approach. In 2010, a publication of the Evan B. Donaldson Adoption Institute, a leading U.S. adoption organization, cited an article and a book favoring HT without noting their positions (Evan B. Donaldson Adoption Institute, 2010, citing Delaney & Kunstal, 1993, and Howe & Fearnley, 2003), while also referring to controversy over HT methods. The same publication spoke approvingly of a made-for-television movie, “Child of Rage,” which purports to tell the tale of a child cured of violent mental illness through HT (Evan B. Donaldson Adoption Institute, 2010, p. 57). In the United Kingdom, professional publications (Howe & Fearnley, 2003; Sudbery, Shardlow, & Huntington, 2010) have argued in favor of HT, and a survivor of the treatment has come forward to describe his experiences (Chaika, 2012). In the Czech Republic, a form of HT has been promoted by the psychologist Jirina Prekopova, who practiced the method in Germany for 20 years, and who has the support of Jaroslav Sturma of the Czech-Moravian Association of Psychologists (www.prekop-festhalten.de/festhaltetherapeut.html); Prekopova has established outreach centers in Greece, in Italy, and elsewhere. A Russian adoption group recently invited a well-known U.S. HT proponent, Nancy Thomas to visit, and HT books have been translated into Russian (http://attach2me.ru).
Presentations at the London Conference
At the meeting of the International Working Group in London, presentations were made by a British social worker and a British barrister, a Czech psychologist and a Czech activist, an American psychologist, and a Russian biochemist with an interest in cult-like activities. It will be noted in the summaries of these presentations that two presenters chose to be identified by assumed names out of concern for professional and personal repercussions that might follow their speaking out.
HT/AT in Britain
A Reported Case
“Anya Chaika,” a British social worker and author of Invisible England (2012), discussed a British case in which a boy had been subjected to HT/AT while under the care of a major provider of residential children’s homes. As a teenager, the boy was moved from the residential treatment center to foster care provided by the person who had been his therapist in the center, and was persuaded by her to change his surname to hers. “Chaika” was contacted by the now-adult former patient after becoming aware that the organization was using HT/AT and after starting a blog to try to collect information about the practice. The former patient has been able to bring a lawsuit against the children’s homes organization and this suit is in progress.
HT Under Common Law
Lucinda Davis, a British barrister, commented on legal issues concerning child abuse of any kind, and ways in which child abuse laws could be used against the practice of HT. Discussing the differences between tort law and human rights law, she noted that British or Czech cases needed to be approached initially as involving torts, with appeal to the European Court of Human Rights possible only after all other appeals were exhausted. As is the case in all the common law countries, the practice of HT can be attacked legally in Britain only when actual harm to the child can be demonstrated or assumed. Physical restraint methods are not in themselves prohibited by law (see Hoyano & Keenan, 2010, for further discussion of these points).
HT in the Czech Republic
The Influence of Jirina Prekopova
“Mrs. Alena,” a Czech autism activist, described the history of HT as performed by Jirina Prekopova and her students. Prekopova, who had practiced HT/WP in Germany (where she worked with the alternative psychotherapist Bert Hellinger; Prekop & Hellinger,1998), returned to the Czech Republic in the 1990s and in 2001 developed an HT working group as part of the Czech-Moravian Psychological Society. A movement against HT began following the broadcast of a documentary film praising the method (www.dokweb.net/en/documentary-network/east-european-docs/-jirina-prekop-im-here-for-love-5453/), but Prekopova has continued to receive the support of the Catholic Church, government officials, the Ministry of Education, the “Our Child” Foundation, and the president of the Czech-Moravian Psychological Society. Prekopova has created outreach programs in Slovakia, Austria, Greece, Mexico, Venezuela, Spain, and Italy.
The Czech Social Climate and HT/WP
Katerina Thorova, a Czech psychologist, discussed psychological mechanisms that might lead parents to the choice of alternative psychotherapies like HT. Thorova emphasized the role of a social climate that is friendly to occult and pseudoscientific beliefs. She described a wide range of problems for which Prekopova recommends HT, including autism, attachment disorders, attention deficit hyperactivity disorder, oppositional and defiant disorder, and conduct disorder. Prekopova’s version of HT has cult-like features, attracts the public by manipulative techniques involving logical fallacies, “global truths,” and false analogies. HT propaganda appeals to emotion and proposes a universal solution of “love” for most problems. Because people are subject to cognitive and confirmation biases, cognitive dissonance, and the desire to comply with authority, they find it difficult to resist the appeal of HT.
Evidentiary Foundation of Prekopova’s Approach
Jean Mercer, an American psychologist, discussed claims that HT/WP method was based on scientific evidence. These claims were originally based on the support for the treatment given by the Nobel laureate Nikolaas Tinbergen, whose ethological studies suggested that specific experiences could direct personality development (Tinbergen & Tinbergen, 1986). In the 1980s, Prekopova and German colleagues published several articles concluding that HT was demonstrated to be an effective treatment (Prekop, 1983; Prekop & von Stosch, undated; Rohmann & Hartmann, 1985), but all of the studies were inadequate in that they had small Ns, the outcome measures were vaguely defined, and the outcome measures depended on parent judgments. Scientific support for Prekopova’s HT method, like that for other HT techniques, is extremely weak, and indeed Prekopova has dropped claims about scientific evidence and today presents religious and spiritual arguments in favor of her practices (www.prekopva-pevneobjeti.cz).
HT Methods Introduced Into Russia
On behalf of Yulia Massino, a Russian biochemist who attended by Skype, Jean Mercer presented a discussion of the intrusion of U.S. HT/AT advocates into Russia at the invitation of some cult-like groups. The major concern of this presentation was the use of “parenting” techniques adjuvant to HT, as recommended by the HT advocate Nancy Thomas, who recommends the establishment of adult authority by parental control of a child’s food, drink, toilet use, and exposure to cold, heat, or darkness (Thomas, 2000). These methods have been associated with malnutrition and in some cases with child death. Books by Thomas and other HT proponents have been translated into Russian. Nancy Thomas visited and lectured in Russia in 2012 at the invitation of an American Pentecostal minister (http://attach2me.ru).
Conclusion
The International Working Group concluded that HT methods are neither safe nor effective as treatments of childhood mental illness and that their spread internationally is an alarming phenomenon that should be recognized and countered by professional and parent groups. What can and cannot be done about this problem?
Legal challenges to HT have so far been ineffective in common law countries, where freedom of speech issues are privileged. Professional groups have opposed specific legislation about HT methods, claiming that they can regulate members of their own disciplines. In addition, it is difficult to write legislation that describes HT methods in such a way that a change of language or a minor change in methods cannot evade a prohibition. Where government appears to support HT, as in the Czech Republic, legal challenges would seem to be of little use.
Professional and public education on the existence and nature of HT methods may be the most effective way to reduce the use of these treatments. However, in the United States, efforts by professional groups occurred after a well-publicized child death and diminished within a few years. With respect to the almost-nonexistent public education about the HT problem, it should be noted that HT proponents in several countries have for years bombarded the public with propaganda in the form of television “documentaries” and films (e.g., “Child of Rage,” www.imdb.com/title/tt0103955/) and that journalists have contributed to these persuasive efforts by assuming that statements by HT advocates are accurate (e.g., www.pennlive.com/midstate/index.ssf/2010/10/parents_of_adopted_boy_who_die.html).
What is really needed is for professional groups to mount a proactive campaign of education about HT, rather than waiting for harm to another “poster child.” This will require the kind of political will that usually exists only when a few members of a group are convinced of the need to solve a problem. Such a campaign needs to direct accurate information to mental health professionals and to take into consideration the emotional arguments to the public that, as Dr. Thorova noted, have been effective in persuading parents to accept HT.
The International Working Group has taken a small step in the direction of professional and public education and is now asking mental health professionals and professional organizations to join in this work. Individuals interested in joining in this work can contact the author at
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.