A Personal History … “Attachment Therapy”

This submission is a brief history of my involvement within the attachment and bonding treatment “community.”  What I will represent is a reflection my experience as a treatment provider, and make an attempt to demonstrate how fear and prejudice have affected the development of science as it relates to mental health treatment of a complex disorder.  This piece is the first in a series dedicated to presenting a model for repairing the damage that is caused by parental abandonment at birth or early in a child’s life.

This Blog and ensuing submissions are intended to refute many of the claims about attachment therapy as presented at www.childrenintherapy.org/essays/, as well provide a model for effective interventions based on accepted theoretical principles.  

In April 2000 a little girl named Candace Newmaker (see: https://en.wikipedia.org/wiki/Candace_Newmaker) died as a result of a treatment provided by an attachment therapist, an assistant, the child’s adopted mother, and therapeutic foster parents.  Candace’s death led the way to an uprising against the use of “intrusive” therapies to promote attachment and bonding with children who are adopted.  Since that time the use of “Intensive Therapy” (sometimes referred to as Attachment Therapy) has been abandoned by attachment therapists, and any type of “intrusive” therapy is forbidden by licensing agencies and third party payers for work with adopted children.

The truth, however, with regard to Attachment Therapy is this:  Candace’s death had nothing to do with Intensive Therapy.  Candace Newmaker died because of neglect; the procedure which she had undergone was only loosely related to intensive therapy.  Ms. Watkins was a skilled and experienced interventionist who made a serious mistake; she failed to take seriously the pleas of a child who was deemed “attachment disordered.”  Sadly, it was and is common for adults and even treatment providers to suspect that children who are attachment disordered are either lying about or faking various symptoms and complaints.

So, after devoting her career to working with high risk children, Connell Watkins served seven years of a sixteen year prison sentence.  The rest of us (Attachment Therapists) were more or less forced to stop “Intensive Therapies.”  This had the effect of preventing the possibility of scientifically examining the practice of Intensive Therapy, and developing accepted protocols for its use.

It is interesting to note that Connell Watkins was third in a line of therapists who were  sanctioned by governing bodies for use of high risk approaches to high risk patients.

The first was Robert Zaslow, a California psychologist who pioneered holding therapies through the advocacy of the “Z Process.”  Such was Zaslow’s popularity and acceptance within the treatment community, that he supervised scenes in the movie “Change of Habit” starring Elvis Presley (a young doctor) and Mary Tyler Moore (a nun).  In the movie a mother brings an unruly, out-of-control child to Presley who uses holding techniques (i.e., rage reduction) to work the child through the child’s aggression, and returns a “healed” child to his mother.  Zaslow had to surrender his license due to allegations of impropriety in treating a patient with his technique.

Following Zaslow was Foster Cline.  Cline dedicated his book Hope for High Risk Children to Zaslow indicating that Zaslow’s genius was not appreciated.  After founding and heading the Attachment and Bonding Center in Evergreen, Colorado, Cline was ordered to stop using [intensive therapy] methods as a result of allegations made against him.  He moved to Utah where he continued to write books and give lectures to up-and-coming therapists and parents of attachment disordered children.

Connell Watkins was Cline’s protége´ and supervisee at Evergreen; it is my understanding that she was, at one point, the clinical director of the Attachment Center.  She was mentioned as a practicing therapist in Cline’s book mentioned above.   She was never licensed by the state, but had a Masters degree in Social Work.  She left the Attachment Center and went into private practice.  She conducted intensive therapies in the basement of her home in Evergreen.

I worked with Connell Watkins on several cases in the mid-1990’s.  We worked intensive therapies together; I copied her technique and brought it back to Ohio.

Upon my return from Colorado I attempted to use intensive therapies with the Attachment cases I had been treating.  After a relatively short time, I abandoned the practice because I did not see the outcomes I believed should have been possible, nor did I feel comfortable deliberately antagonizing children into rage.  What I did do was this: I developed a treatment strategy that used a variation of the US Military model for training and transforming recruits.  I named it “modified intensive experiential therapy.”  I worked with children in individual and group therapies by employing the persona of a military Drill Sergeant with an empathetic heart (i.e., therapeutic sensitivity to thoughts and feelings).  This therapy gained me a local reputation of being a therapist who got results.  Children’s parents were calling years after treatment indicating that their children were thriving.  I received graduation announcements from kids who hated me at the time of their treatments.  Several of the kids I treated in the late 1990’s went on to serve in the military.  In early June of 2016 I was notified by one mother that her adopted son had the RAD diagnosis removed from his mental health profile.

The model included the use of written assignments, push-ups as penalties, physical discomfort, bold talk, and most importantly, empathy.  Parental involvement and education were mandatory.  The interventions brought forth emotions that became the springboard to the children’s inner worlds.  The goal was to humanize children who had no sense of conscience nor concern for anyone other than themselves, and to simultaneously give parents a more compassionate and confident way to view their damaged children.  Through the interventions, the children were coming alive.  It was a beautiful thing to do and see.

I quietly employed my techniques for nearly twenty years.

As fate would have it, in March of 2014 I became the fourth in that line of therapists who were sanctioned for the manner in which they treated High Risk Children.  A disgruntled, divorced father reported me to the State Board for employing a technique that had no empirical evidence to back up its use (i.e., push-ups as penalties for rule infractions).  The child had been asked to do five push-ups in the presence of his mother (the custodial parent) for forgetting to sign his summary for the previous session.  Fortunately for me, there were no formal actions brought by the Board, however, I was instructed to “cease and desist” the use of punitive push-ups in my treatment of children.

The efficacy of my treatments diminished immediately.  I petitioned the Board with testimonials from parents (current and past cases), and I provided various rationale for the continued use of the push-ups.  I asked the Board to allow me to develop and initiate a study of the practice.  In the end my pleas were futile.  Gym teachers, athletic coaches, martial arts instructors, and the USMC can continue doling out penalty push-ups, but, alas, I cannot, at least not without risking my license.  “Modified Intensive Therapy” is no more.

It is my belief that working with unconscionable children is a highly complex affair that requires knowledge and skill in the area of employing strong limits and controls in an attitude of compassion and acceptance.   Parents and providers must understand that these are damaged CHILDREN, not young criminals.

Reactive Attachment Disorder is a real malady in our society., and to date, there appears to be no science for implanting a conscience where none exists.    Standardized treatment protocols are needed to address the problem, and expertly skilled treatment providers are necessary for employment of such protocols.  As I see it, there should be no real difference for getting treated for a medical condition and receiving effective treatment for RAD.

I am nearing the end of my career.  It is my intention to generate enough practical and theoretical material that someone will contact me with a desire to formally develop treatment strategies that can be scientifically evaluated, then presented to the National Institute for Mental Health for universal implementation.  A treatment protocol for a childhood malady that is effective, and can be learned and applied with safety and confidence.

Reactive Attachment Disorder… A Systems Perspective

A More Encompassing View

by Ray Messer, MSW, LISW

Reactive Attachment Disorder (RAD) has been defined in the Diagnostic and Statistical Manual of Mental Disorders since 1980.  The current diagnostic criteria (DSM-5) can be found at http://behavenet.com/node/21499.  In all of my research, I have not been able to find how RAD got its name.  Also, it should be noted that little is said in the DSM about the nature of the interactions that result in the RAD situation. The diagnostic criteria listed in the DSM focus wholly upon the characteristics of the child with the disorder, not upon the system in which the child resides.  What follows is a developmental approach to Reactive Attachment Disorder as it exists within an adoptive environment.

An observational examination of the dynamics of RAD reveals the following:  The disorder presents as the undesirable interactions of a child with adult caretakers and authority figures.  These interactions become reactions between the child and the parent(s).  A severely corrosive and unhealthy feedback loop is established between the child and the caretakers that results in the ultimate assignment of the disorder to the child.  Yet, the disorder in the child is also revealed in the very deep negative feelings that are experienced by those who are charged with providing care.  Most non-attachment therapists are unaware of the reciprocal nature of the disorder, and often see the child as the sole problem.  Children who have been unloved, abandoned, abused and/or neglected by their biological mothers from birth (or very early in their lives) often find themselves living in homes with people who feel like hating, abandoning, abusing, and/or neglecting them in a manner similar to their birth mothers.  It can be supposed that the anger in the adoptive and surrogate parents somehow has been transferred to them by the children.

RAD children are often brought into the foster care system by way of Children’s Protective Services and are subsequently placed for adoption.  Many adults (couples and individuals) take in these children with the expectation of giving love and sustenance to a needy child (or children), and getting some measure of love in return.  These adults tend to believe that providing love and security will resolve whatever deficits or difficulties these children may have endured or experienced earlier in their lives. Often, although not always, these kind and caring adults find themselves at extreme odds with the very child they had attempted to take into their hearts.

Many of these parents discover parts of themselves they have not routinely experienced in their lives prior to the adoption experience.  They come to find themselves overwhelmed with extreme anger, emotional exhaustion, guilt and regret.  They lose their sense of personal freedom and sometimes they lose touch with their own identity.  Some of these parents become so disenchanted with raising these children that they give them back to the system, often having to pay the system monthly child support payments until the child is adopted by another unsuspecting, naive someone with a big heart.  One woman went so far as to put her adopted child on a jet airplane bound for Russia, and made international news by doing so.

The heart of Reactive Attachment is this:  It is a parent reacting to the undesirable behaviors exhibited by a child, and the child reacting to the parent.  These reactions resonate between both, and most often, it is the child who is blamed for the problems caused in the interaction, and it is the child who is “treated.”  In the final analysis, it is the child who has the ultimate control of the emotional interactions in the family, but it is the parent(s) who bear the responsibility to resolve them.  These parents want to love and be loved,  but the child wants what he or she wants, love be damned.  So when the child is not gratified, the goal is changed to something else, i.e., power in the form of emotional control.  By defying the parent, or by simply not returning the parent’s love, the child gains control of the emotional tenor of the interactions within the family.  Life becomes miserable for all.  The natural thing for a parent to do is to emotionally retaliate and attempt to control the child; this results in more of the same (only worse).

How does this happen?  Why doesn’t love reach these children?

The answer:  ANGER.  Internalized anger that has become part of the child’s character, and subsequently becomes central in the parent-child relationship.  This anger can be overt and openly aggressive or covertly passive-aggressive, but whatever style the child presents, it is hell for the parents.

In order to understand the abnormal development of the RAD child, it is important first to understand the development of a “normal,” healthy child.

“Normal” Healthy Child Development

In the vast preponderance of child births, at least in the United States, the mother is either nervously or excitedly awaiting the birth of her baby.  She begins to prepare for the arrival of her child during the early stages of pregnancy, and often falls in love with her baby months before birth.  When a mother is presented with her baby for the first the first time, she realizes her life will never be the same.  She is no longer an individual, she is mother with child; for most women this is a wondrous event; for some, it is the beginning of an inconvenience that will not go away.

The human infant is completely dependent upon the outer world for survival; usually this outer world is comprised of the mother.  The mother, or some mother substitute, must be available to the infant child on a continual basis for at least the first few years of the child’s life, and it is the first four years of the child’s life that lay the foundation for the rest of the child’s emotional existence.  If those years go well, the likelihood of a healthy emotional life is greatly improved over that of the converse.

Attachment and bonding occur during the first crucial months of a child’s life.  During the first year a cycle is enjoined that results in the emotional attachment of the child to the mother; successful completion of attachment in infancy results in the internalization of trust.  (Consider Erickson’s stages of emotional development.)

This cycle is usually represented as:  Biologic needs give rise to pain or discomfort, this discomfort is expressed by crying (anger, if not gratified soon enough); the crying alerts the caretaker (mother) to the need of the child; the need is gratified and the child experiences relief.  When this cycle is repeated throughout infancy, the child learns that crying will bring relief, which brings forth trust, which is internalized in an attitude of love, and the child becomes bonded to the mother.  As the infant’s cognitive abilities develop, the child is able to recognize the external presence of the mother.  The mother becomes the object of the child’s internalized trust and, eventually, the child’s love.  Naturally, all of this presupposes that mother loves her baby.

Yet, the end of infancy presents an apparent paradox: the more securely bonded, the more likely it is that  the child will separate during the second stage of development, toddlerhood.

Operant conditioning perspective… healthy development

The above process can be viewed as a process of Operant Conditioning in which the child is “conditioned” by way of repetitive experiences of crying and relief.  If one takes this view, it can be seen that, as with any organism with a brain, the infant child is trained to expect the “operator” (i.e., the mother) to continue this regimen indefinitely (consider the process of infancy to be analogous to the conditioning of a pigeon placed in a Skinner’s Box, or a canine who learns to sit for a morsel of kibble).

Operant conditioning proponents don’t really talk about “trust” as an outcome of the training process, but rather they see this as conditioning or training.  In the animal world, there is no concept of trust; there is only stimulus, response and “learned” survival behaviors.  Animals instinctively respond to their environments according to their natures and genetic loading.  It is primarily within the human mind that the product of this process is known as trust.

Thus, it is possible to conclude that the process of trust development is a process of conditioning, and that the internalization of trust is a result of the mother’s unwavering rewarding of the act of the infant’s crying throughout infancy.

Simply stated, healthy infants are trained to cry; crying brings relief; relief yields trust.

However, as infancy gives way to toddlerhood, this conditioning is interrupted by the advent of refutation.

Healthy Toddlerhood

As noted earlier, the paradoxical outcome of healthy attachment is the experience of separation.  The toddler child, now fully attached and expectant of continued love and sustenance from the mother, begins to venture into the world on two legs that now hold the child upright and mobile.

Toddlerhood can present a conundrum for the mother.  She has to be able to gradually let go of her child so that the child can explore its world, yet mother, at the same time, has to deal with the loss of the pleasure that was experienced with her newborn.    She also is taxed with the newfound stress of having to “chase” after her child for the years remaining before the child goes to school, and she has to learn to tame her child when necessary.

Toddlerhood is a time of recognizing, on the part of the child and the mother, that each is separate from the other.  This recognition takes place over time and most often, and most desirably, takes place in an attitude of love.  The emerging toddler, as an infant, had been conditioned to expect that the act of crying would produce the same results as it had in the past, (i.e., gratification/relief), but things are changing for the toddler, and these changes produce a new kind of pain for the child, i.e., emotional pain.  The experience of emotional pain produces crying, as did physical pain in infancy, and the mother (as well as others who care for the child) must be able to deal with these repeated episodes of crying (and angering) so that the child can learn to tolerate the inner feelings that give rise to the anger which is experienced in the refutation process.

Simply stated, the child expects mother to give in to the crying as she had in the past, when this does not happen, the child will unleash aggression upon the mother.  When mother contains this aggression within an attitude of love without retaliating, abandoning or indulging the child, the child will eventually accept the futility of crying and angering, and  move on to whatever is next.  The incident that precipitated the crying, whatever it was, will have passed and the child’s emotional balance is restored.  The end result of this process (i.e., ongoing aggression toward mother met with compassionate limits) will ultimately produce guilt and a sense of conscience within the child.  The child learns that anger does not beget anger, but rather compassion and containment from the mother.

It is the process of loving refutation that gives rise to formation of the child’s ability to tolerate stress and also gives rise to the formation of the human conscience.  By the time most children are four or five years old, they have learned to accept the basic limits imposed by parents, and have developed some measure of empathy and concern for others.

Effectively, with regard to Operant Conditioning, toddlerhood is the “breaking” of the conditioning that was instilled during infancy.  When this process is healthily achieved, the child goes on to participate in adaptive relationships with peers and adults.  When this process is not healthily achieved, a variety of emotional and psychological consequences can occur.

Reactive Attachment

The gratification of instincts is happiness, but when the outer world lets us starve, refuses us satisfaction of our needs, they become the cause of very great suffering… Sigmund Freud, Civilization and its Discontents.

What follows is a likely series of events that unfold for a child who is brought into a world in which he or she is not wanted, appreciated, or loved.  The conclusions set forth are based upon primary suppositions which are based in observations of real life case histories for children with the Reactive Attachment diagnosis.

Infancy

It is assumed the mother of an unwanted child will tend to her child in a manner wholly different from that of a loving and caring mother.  This mother will grudgingly care for her child; usually she will tend to the child in an effort to “shut the child up.”  This mother will likely ignore her child until the child screams loudly enough to get her attention so that the child can gain relief from whatever need arose (many times, this occasion of gratification is accompanied with physical or emotional abuse). This implies (one can infer) that this is a process of angering to gain attention.  Thus, over time, the child will be conditioned to get angry in order to be noticed.  (It can be noted here that there is a parallel system that will be experienced by a child who is inhibited {i.e., non-aggressive}, a system that promotes lethargy and disinterest on the part of the child; this system is not the focus of this blog.)

Unlike the loved and wanted child, this child has to get angry to simply be noticed.  Thus, the child is learning to trust anger to gain the necessary attention to get basic physical needs met, as well the human need for affiliation.  However, the affiliation is not by way of love and satisfactory attachment, but rather by way of attention from the caretaker in the form of  anger and resentment (i.e., the Reactive Attachment).  This notion helps to explain why these children are willing to settle for any kind of attention, and seem to have no real preference for loving attention.  The child is accustomed (trained) to use anger to get attention (as well as gratification) in return.  By the time the child is removed from his or her biological parent(s), this process of attention getting is well in place.  The child has been trained to be angry; the anger is internalized.

“Reactive” Toddlerhood: The Adoptive Home

If one accepts the above as a typical illustration of what goes on in the infancy of the unwanted child, then what happens in Toddlerhood will be a much different process than is experienced by the well attached child.   Many children are removed from their derelict birth mothers in or around early toddlerhood.  These children suffer, not only the breaking of what little bond had been formed with the birth parent, but an existence which will be marred by the internalized anger noted above.

It is accepted that the adoptive parent adopts a child out of the desire to love and nurture that child.  Yet, in many families, the parent(s) quickly learn that attempts to soothe, mollify and comfort a child by way of gift of love is rejected.  The child does not accept the parent’s efforts to guide and direct, and the parent begins to feel the pain of failure. Now instead of loving containment, the parent resorts to attempts to get the child to conform (often resorting to anger), and child experiences a process of mutual angering with the mother (or other caretakers).  Whereas in the well-loved situation, the crying child is tolerated, accepted and even soothed, the Reactive Attachment situation sees the crying/angering child receiving ever more anger from the caretakers.  Therefore, instead of learning that the mother or caretaker is accepting of and compassionate toward the child when angry, the child learns that the mother or caretakers are hostile and harsh.   The goal of the parent in the RAD situation becomes similar to that of the mother in the original situation: to get the child to stop being a nuisance.

Probably one of the worst aspects of this process is that the child, who is NOT developing in an attitude of love and acceptance, will acquire more anger from the parent(s), and fail to develop a conscience.  This has consequences, not only for the child and his or her adoptive family, but in a larger sense for society as a whole.  For, if the child has no conscience, the resulting adult will have none as well.  If the child learns that he or she has the power to disrupt the emotional balance of the parent(s), the resulting adult will learn to do the same with intimates and peers.   These conclusions are supported in the case studies of persons who find themselves in marital therapy, mental hospitals, jails and prisons.

Conclusion

Reactive Attachment Disorder is prevalent throughout our society and appears to be ever more on the rise.  The increased numbers of mothers of lower socioeconomic backgrounds who become addicted to drugs and alcohol will produce more children with the makings of the disorder.    The more children with the disorder, the more offspring they will produce.

Those who wish to adopt these children as part of their desire to “give back” or “make up for deficits” in their lives should be mindful of the potential for difficult and miserable times ahead of them.  They should endeavor to get expert assistance from therapists and counselors who are familiar with Reactive Attachment in order to gain insight and skills to manage the difficult days ahead of them.

The intent of this blog has been to give a reasonable explanation for the dynamics of the Reactive Attachment situation with regard to anger and aggression toward adoptive parents and temporary caretakers (i.e., foster parents).  It has been posited that healthy infants are trained to cry to gain relief throughout infancy, whereas poorly attached children are trained to use anger and disruptive behaviors to gain attention.  When infants become toddlers they must be “retrained” to not use crying and emotion to get needs met.  The healthy toddler is typically refuted with a loving attitude from parents, and learns to acquiesce to parental wishes.  However, the poorly attached toddler, craving attention and control, experiences caregivers who become frustrated, rejecting, and hostile; thus, establishing the Reactive Attachment.  Initially, these parents and caregivers put themselves in a position to try to “save” these children from doom, but in the end find themselves suffering their own versions of despair in their failed attempts to love and receive love in return.

References and resources:

Object Relations: A Dynamic Bridge Between Individual and Family Treatment, Samuel Slipp, M.D.,  Jason Aronson, 1991 (Paperback edition)

The Psychological Birth of the Human Infant, Mahler et al,  Basic Books, Inc, NY,  1975

Hope for High Risk and Rage Filled Children: Reactive Attachment Disorder, Theory and Intrusive Therapy, EC Publications, Evergreen CO,  1992

Principles of Psychology: A Systematic Text in the Science of Behavior
Fred S. Keller; William N. Schoenfeld, Appleton-Century-Crofts, 1950

Healing the Hurt Child,  Helping Adoptive Families Heal and Grow, Gregory Keck and Regina Kupecky,  NAVPress, 2002