A Dangerous Alternative Mental Health Intervention
Read about the dangers of coercive therapy for children with attachment disorders.
Physicians caring for adopted or foster children should be aware of the use of coercive restraint therapy (CRT) practices by parents and mental health practitioners. CRT is defined as a mental health intervention involving physical restraint and is used in adoptive or foster families with the intention of increasing emotional attachment to parents. Coercive restraint therapy parenting (CRTP) is a set of child care practices adjuvant to CRT. CRT and CRTP have been associated with child deaths and poor growth. Examination of the CRT literature shows a conflict with accepted practice, an unusual theoretic basis, and an absence of empirical support. Nevertheless, CRT appears to be increasing in popularity. This article discusses possible reasons for the increase, and offers suggestions for professional responses to the CRT problem.
The term coercive restraint therapy (CRT) describes a category of alternative mental health interventions that are generally directed at adopted or foster children, that are claimed to cause alterations in emotional attachment, and that employ physically intrusive techniques. Other names for such treatments are attachment therapy, corrective attachment therapy, dyadic synchronous bonding, holding therapy, rage reduction therapy, and Z-therapy. CRT may be carried out by practitioners trained in extracurricular workshops, or such practitioners may instruct parents who perform all or part of the treatment.
CRT practices involve the use of restraint as a tool of treatment rather than simply as a safety device. While restraining the child, CRT practitioners may also exert physical pressure in the form of tickling or intense prodding of the torso, grab the child's face, and command the child to kick the legs rhythmically. Some CRT practitioners lie prone with their body weight on the child, a practice they call compression therapy. Most practitioners restrain the child in a supine position, but some place the child in prone when using restraint for calming purposes.[1,2] Although it is less common than it once was, CRT practitioners may employ a rebirthing technique, in which the child is wrapped in fabric and required to emerge in a simulacrum of birth.
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CRT practices are generally accompanied by adjuvant child care practices that may be carried out by a therapeutic foster parent or by the child's adoptive or foster parent. These practices, which we may call coercive restraint therapy parenting (CRTP), stress the adult's absolute authority. For example, a child receiving CRTP is not to be told when or if he/she will see his/her parents again. The child may not have access to food without the parent's involvement and may not use the bathroom without permission. Food may be withheld, or an unpalatable and inadequate diet may be provided. A child who asks for a hug or kiss may not have one, but the child is required to respond to the adult's offers of affection and to participate in developmentally inappropriate rocking and bottle-feeding.
CRT is employed primarily in the treatment of adopted and foster children whose parents believe that they are lacking in affection, emotional engagement, and obedience -- a group of factors that CRT advocates consider to show attachment. CRT practices may also be applied preemptively to asymptomatic adopted children, on the principle that these children are concealing their pathology, which will emerge later in serious forms, such as lying and cruelty. Practitioners of CRT and CRTP use the conventional diagnosis of reactive attachment disorder, although they claim to be able to detect a more serious disturbance, which they term attachment disorder. Attachment disorder is diagnosed by a questionnaire instrument, the Randolph Attachment Disorder Questionnaire (RADQ), which obtains parent answers about issues, such as the frequency with which the child makes eye contact.
There is obvious potential danger in the use of physical restraint and the withholding of food characteristic of CRT and CRTP. The impact of these practices began to be apparent with the death of 10-year-old Candace Newmaker in Evergreen, Colorado, in April 2000. Candace's asphyxiation in the course of a rebirthing procedure at first appeared to be a freak event due to the mishandling of 2 CRT practitioners, but further investigation revealed a number of other child deaths caused by parents following the instructions of CRT advocates. It appears to be the CRT belief system, rather than specific techniques, that causes adults to make dangerous decisions.
In response to Candace's death, some professional organizations, such as the American Psychiatric Association, issued resolutions condemning CRT practices. Two issues of the APSAC Advisor rejected the beliefs and practices of CRT. The journal Attachment and Human Development dedicated an issue to articles on this topic, most of them strongly condemning the use of restraint as a therapeutic measure. Two activist Web sites, Advocates for Children in Therapy and KidsComeFirst.info, were created for public education purposes. Medicaid has declined to pay for CRT. A Congressional resolution condemned the use of rebirthing, although without mentioning other CRT practices.
These points suggest a successful anti-CRT movement. On the contrary, however, CRT advocacy and practice appear to have increased despite all efforts against them. Over 100 commercial Internet sites offer or advocate CRT and CRTP. State government Web sites list CRT publications as appropriate reading for professionals and adoptive parents (for example, NJ ARCH), and describe CRT beliefs in the guise of educational material (for example, "Child and Adolescent Mental Health Problems"). Services of CRT practitioners (for example, Post Institute for Family-Centered Therapy) have been used for military dependents, a group that is particularly vulnerable to concerns about attachment and that may be seen as suitable adoptive parents for children with attachment problems (National Adoption Information Clearinghouse).