Attachment therapy

Attachment therapy is the popular (lay) name collectively applied to a loosely identified category of mental health interventions, including parenting techniques or methods, which purport to treat a child for an attachment disorder, problem, disruption or difficulty, or for the behavioral sequelae to such an attachment disorder, problem, disruption or difficulty.

While there are attachment-related interventions based on generally accepted theory and using generally supported techniques, attachment therapy has primarily come to public notice because of the 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^[1])

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".^[1]

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 persistent disregard for the child's basic attachment needs. There are a variety of attachment 'styles', some of which are more problematic than others.

Attachment therapy which purports to treat disorders of attachment came to the attention of professional bodies and the wider public following a series of prosecutions for deaths or serious maltreatment of children allegedly at the hands of "attachment therapists" or parents following their instructions, two of the most well known cases being that of Candace Newmaker in 2001 and the Gravelles in 2003-5.

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,^[2])

In 2003 an issue of Attachment & Human Development, was devoted to the subject with articles by well known experts in the field.^[3] 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 laid down guidelines for the diagnosis and treatment of attachment disorders. (Chaffin et al, 2006, p83^[1]) 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^[4]) 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)^[5][6][4][7]). 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^[1])

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.^[8]

Prior and Glaser (2006) describe attachment therapy as a variety of treatments offered to desperate caregivers of troubled, maltreated children which often include variants of holding, e.g. holding time (Welch, 1989^[4]), therapeutic holding (Howe and Fearnley 2003), rage reduction therapy (Cline, 1992^[7]) and rebirthing.^[9]

The advocacy group Advocates for Children in Therapy 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." [10] 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." [11] 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 invalidated.[12]

Speltz (2002)^[2] states that the roots of attachment therapy are traceable to Robert Zaslow in the 1970s.^[10] 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.^[2] 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".^[11]

Speltz cites Martha Welch and "holding time" (1984 and 1989^[4]) 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.^[2] A number of clinics later arose in Evergreen, Colorado, 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). [13]

Metaphors based on Zaslows original misapplication 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.^[8] 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^[7])" 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^[12])p263^[9]

Cline's privately-published work "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.^[7][13] 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 misapplied metaphors deriving from Zaslow and psychoanalysis, not attachment theory.^[8]

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^[1]).

The APSAC Task Force (2006) describes how the conceptual focus of these treatments is the child's 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, including those who recommend other controversial techniques (Federici, n.d.). Similar but less physically coercive approaches may involve holding the child and psychologically encouraging the child to vent anger toward her or his biological parents. Coercive techniques, such as scheduled or enforced holding, also may serve the intended purpose of demonstrating dominance over the child, and provoking catharsis or ventilation of rage. Establishing total adult control, demonstrating to the child that he or she has no control, and demonstrating that all of the child's needs are met through the adult, is a central tenet of many controversial attachment therapies. Similarly, many controversial treatments hold that children described as attachment disordered must be pushed to revisit and relive early trauma. Children may be encouraged to regress to an earlier age where trauma was experienced (Becker-Weidman, n.d.-b) or be reparented through holding sessions…" (Chaffin et al, 2006, p78^[1])

Speltz describes a typical treatment taken from The Center's material (apparently a replication of the programme at the Attachment Center, Evergreen) as follows:

"Like Welsh (sic)(1984, 1989), The Center induces rage by physically restraining the child and forcing eye contact with the therapist (the child must lie across the laps of two therapists, looking up at one of them). In a workshop handout prepared by two therapists at The Center, the following sequence of events is described: (1) therapist "forces control" by holding (which produces child "rage"); (2) rage leads to child "capitulation" to the therapist, as indicated by the child breaking down emotionally ("sobbing"); (3) the therapist takes advantage of the child's capitulation by showing nurturance and warmth; (4) this new trust allows the child to accept "control" by the therapist and eventually the parent. According to The Center's treatment protocol, if the child "shuts down" (i.e., refuses to comply), he or she may be threatened with detainment for the day at the clinic or forced placement in a temporary foster home; this is explained to the child as a consequence of not choosing to be a "family boy or girl." If the child is actually placed in foster care, the child is then required to "earn the way back to therapy" and a chance to resume living with the adoptive family." (Speltz 2002 p5^[2])

According to O'Connor and Zeanah (2003, p. 235^[14]), 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 descriptions of attachment therapy, 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 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."[14]

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^[15]).^[16]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. As part of attachment parenting, parents may be counseled to keep their child at home, bar social contact with others besides the parent, favor home schooling, assign children hard labor or meaningless repetitive chores throughout the day, require children to sit motionless for prolonged periods of time, and insist that all food and water intake and bathroom privileges be totally controlled by the parent (for an example of some of these types of recommendations, see Federici, 2003). … Children described as being attachment disordered are expected to comply with parental commands 'fast and snappy and right the first time,' and to always be 'fun to be around' for their parents (see, e.g., Hage, n.d.-a). Deviation from this standard, such as putting off chores, incompletely executing chores, or arguing, is interpreted as a sign of attachment disorder that must be forcibly eradicated. From this perspective, parenting a child with an attachment disorder is a battle, and winning the battle by defeating the child is paramount." (Chaffin et al, 2006, p79^[1])

Other features of attachment therapy are the 'two week intensive' course of therapy, and the use of 'therapeutic foster parents' with whom the child stays whilst undergoing therapy. See ACT page of quotations from Thomas for what may be required of such foster parents, and a description of parenting techniques.[15][16]

In contrast:

"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^[17] Nichols, Lacher & May, 2004^[18])." (Chaffin et al, 2006, p76^[1])

The APSAC Task Force stated that proponents correctly point out that most critics have never actually observed any of the treatments they criticize or visited any of the centers where the controversial therapies are practiced. They argue that their therapies present no physical risk if undertaken properly and that critics concerns are based on unrepresentative occurrences and misapplications of techniques, or misunderstanding by parents. Holding is described as gentle or nurturing and it is maintained that intense, cathartic approaches are necessary to help children with attachment disorders. Their evidence for this is primarily clinical experience and testimonial. (Chaffin et al, 2006, p78^[1])

There are controversies within the attachment therapy community about coercive practices. There has been a move away from coercive and confrontational models towards attunement and emotional regulation amongst some leaders in the field. A number of therapies are quite different to those that have lead to the abuse and deaths of children in much publicised court cases. However, the Taskforce point out that all the therapies, including those using frankly coercive practices, present themselves as humane, respectful and nurturing therefore caution is advised. Some practitioners condemn the most dangerous techniques but continue to practice other coercive techniques. Others have taken a public stand against coercion. The Taskforce was of the view that all could benefit from more transparency and specificity as to how the therapy is behaviourally delivered.^[19]

In 2003 and 2006, ATTACh, an organisation associated with attachment therapy, issued a series of statements the latter of which, in their own words "unequivocally state(s) our opposition to the use of coercive practices in therapy and parenting." They acknowledge ATTACh's historical links with catharsis, provocation of rage, and intense confrontation, among other overtly coercive techniques (and indeed continue to offer for sale books by controversial proponents) but state that the organization has evolved significantly away from earlier positions. They state that this is due to a number of factors including tragic events resulting from such techniques, an influx of members practicing other techniques such as attunement and a "fundamental shift ... away from viewing these children as driven by a conscious need for control toward an understanding that their often controlling and aggressive behaviors are automatic, learned defensive responses to profoundly overwhelming experiences of fear and terror."^[20][21]

Evidence based medicine is a term used to mean that proposed medical and psychological treatments should be based upon rigorous testing and independent peer review of findings by the medical community and reviewers using meta-analysis of medical literature, risk-benefit analysis, and randomized controlled trials. There have been a number of reports on the evidence base for attachment therapy and holding therapies in general.

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^[1]) 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.^[22] Nor did it accept recent claims to evidence base in its November 2006 Reply.^[1][19]

Two approaches on which published studies have been undertaken are holding therapy, Myeroff et al (1999)^[23] and Dyadic Developmental Psychotherapy, Becker-Weidman (2006).^[24] Each study claims the treatment method studied was effective.

Both the APSAC Task Force and Prior and Glaser cite and criticize the one published study on "holding therapy" by Myeroff et al (1999) which "purports to be an evaluation of holding therapy".(Chaffin et al, 2006, p85^[1])(Prior & Glaser 2006, p264^[9])^[23] 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."^[25] 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^[9])

Dyadic Developmental Psychotherapy was developed by Daniel Hughes with the express intention of developing a therapy away from notions of physical coercion, obedience and control. Hughes states that it is based on Bowlby's principles of attachment theory.[17]^[26] Hughes website also gives a list of attachment therapy techniques specifically forsworn by him. Two studies on Dyadic Developmental Psychotherapy have been published by Dr Becker-Weidman, the second being a 4 year follow up of the first. (Becker-Weidman 2006)^[24] Opinion is divided as to whether Dyadic Developmental Psychotherapy is in fact an attachment therapy with Prior and Glaser stating Hughes' therapy 'reads' as good therapy for abused and neglected children, though with 'little application of attachment theory' (p 261), but the advocacy group ACT and the Taskforce placing Hughes within the attachment therapy paradigm.^[9][18]

Craven & Lee (2006) undertook a literature review of 18 studies and classified them under the controversial Saunders, Berliner, & Hanson (2004) system.^[27][28][29] They considered both Dyadic Developmental Psychotherapy and holding therapy.^[30][23] They placed both in Category 3 as "supported and acceptable". This categorisation has been criticised as unduly favourable (Pignotti & Mercer 2007) which Craven and Lee refute in their reply.^[31][32] Both Myeroff et al (1999) and Becker-Weidman's studies (published after the main Report) were examined in the Taskforce's November 2006 Reply to Letters. Becker-Weidman (2006) was described as "an important first step toward learning the facts about DDP outcomes" but considered to fall far short of the criteria necessary to constitute an evidence base.^[19]

Some studies are still being undertaken on coercive therapies. A 2006 pilot study by Welch (the progenitor of 'holding time') et al on Welch's 'prolonged parent-child embrace therapy' was conducted on children with a range of diagnoses for behavioral disorders and claimed to show significant improvement.^[33]

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).^[9]

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).^[34]

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.^[35]

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".^[9] The Internet is considered essential to the popularization of holding therapy as attachment therapy.^[8]

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^[1])

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^[10]) and Cline (1992^[7]). (Chaffin et al, 2006;^[1] Prior & Glaser, 2006^[9]) 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^[1]) 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.^[9]

A commonly used diagnosis checklist in attachment therapy is the Randolph Attachment Disorder Questionnaire or "RADQ", emanating from the Institute for Attachment in Evergreen.^[36] 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.^[37] 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.^[38] 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.^[39]

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^[1]).

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^[9]) 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. [19]

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.[20] See: American Psychological Association (Division on Child Maltreatment) [21], National Association of Social Workers [22] (and its Utah Chapter[23]), American Professional Society on the Abuse of Children,^[1] American Academy of Child and Adolescent Psychiatry,^[34] and American Psychiatric Association[24]. 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.^[40][41]

• Association for Treatment and Training in the Attachment of Children (ATTACh) - Self-described as "an international coalition of professionals and families dedicated to helping those with attachment difficulties by sharing our knowledge, talents and resources"
• Advocates for Children in Therapy - Advocacy group opposing attachment therapy
• "Be Wary of Attachment Therapy" from Quackwatch - medical watchdog website