Carol put an alarm on her daughter's door, terrified that one night Stephanie will slip out of her room and kill her while she sleeps. Stephanie's older brother and sister both lock Stephanie out of their bedrooms. Stephanie steals her sister's jewelry and ruined 30 of her CDs.
Stephanie nearly drowned her foster brother and sister, ages two and five, in the backyard pool. She can't be left alone with the family's kittens, either.
Stephanie is seven years old.
Stephanie (not her real name) has been diagnosed with reactive attachment disorder (RAD). Therapists say that because of abuse and neglect in the past, Stephanie is unable to form attachments and bond with other people. She doesn't know how to love or trust, and she doesn't have a conscience, says her adoptive mother, Carol. Stephanie tells lies and is self-destructive, picking at scabs until they bleed and then smearing the blood on her bedroom wall and carpet.
Once a week, Carol (not her real name) drives Stephanie two and a half hours each way to attachment specialist Gabrielle New's office in Bellaire. In a room filled with afghans and teddy bears that sport I-survived-my-dysfunctional-family T-shirts, New works with Stephanie.
"Our goal is to get these kids to fall in love with their parents," explains New, a licensed professional counselor.
She says there are only a few other therapists in Texas that specialize in attachment therapy. Kids aren't getting the help they need because it isn't available, New says, and because RAD is often undiagnosed or misdiagnosed. Traditional talk and play therapy don't work with kids like Stephanie, New says, because they aren't able to trust and connect with the therapist. Without treatment, these kids can turn into psychopaths and serial killers, New and several other attachment therapists predict.
New talks to Stephanie about her past, her feelings and her plans for the future. She tries to teach Stephanie to be "responsible, respectful and fun to be with." New says that developmentally, kids like Stephanie get stuck before they learn to bond, so her job is to pull Stephanie out of her "developmental stuckness." Most of the therapy is done while Stephanie lies on New's lap looking directly into her eyes. As described by New, holding therapy, as the technique is called, sounds loving and nurturing.
But holding therapy also has a long, controversial history because children have died during treatment.
Horror stories have emerged about children being held down, screamed at, cussed at, punched, pinched, suffocated, smothered and even killed -- all in the name of therapy.
Critics say that attachment therapists are overdiagnosing RAD and overpromising parents results from unproven techniques. Fear tactics are used to pressure parents into believing that if holding therapy isn't done, the child will become the next Charles Manson, critics say.
After a ten-year-old girl was suffocated during an attachment-therapy session, Colorado outlawed a form of holding therapy called rebirthing. Lawmakers across the country are considering following suit.
Still, supporters say that attachment therapy is the only way to effectively treat these kids. They claim that the dangerous techniques that have killed kids have been abandoned.
Neither side has solid statistics that show any rate of success. All they have to offer is anecdotes, most of them horrific on either side.
"People think that if you treat a kid with attachment issues you're going to hurt that child, and it's not true," New says. "We go back and help the child understand what happened to them. We help them understand their hurt and live in the present."
Thirty years ago, psychiatrist Foster Cline founded The Attachment Center at Evergreen, about 30 miles outside Denver. Cline's theory was that abused, neglected children internalize rage that needs to be released. Using techniques he witnessed at rehab clinics, Cline would provoke a child until he vented his pent-up anger. The idea was to disturb the disturbed. Then the parent comforted and cuddled the child, and bonding began.
"The more difficult the person, generally, the more difficult the therapy," says Cline. "The more disturbed the individual, generally, the more disturbing the corrective experiences they need to go through."
In 1993, attachment therapist Neil Feinberg released a videotape demonstrating techniques used at Evergreen institute. The tape is difficult to watch. A ten-year-old boy lies on Feinberg's lap crying, his arms held down as Feinberg screams at him.
"I'll yell at you, I'll piss you off, I'll sit on you, I'll lick your goddamn face, but I'm not gonna hurt you," Feinberg yells at the boy. "Who thinks about hurting other people all the time?"
"Me," the boy says softly.
He asks the boy how he's feeling. Scared, the boy says.
"You ought to be scared!" Feinberg shouts. "Scared of the killing rage inside you."
If the boy doesn't deal with his rage, he's going to kill somebody someday, Feinberg says. He intermittently covers the boy's mouth and nose so he can't breathe, orders him to kick violently and stare into his eyes. Like a crazed drill sergeant, Feinberg forces the boy to repeat after him that he often thinks of killing his mother.
Therapy like this, and other videos that show children bundled in blankets and pinned down by adults three times their size, are examples of old-school, outdated attachment therapy that has been phased out and largely eliminated, says Forest Lien, a licensed certified social worker and director of training at the same center where Feinberg filmed his tape.
"That wasn't attachment therapy -- that was terrorism," Lien says. "You can terrorize anybody into compliance. That's what the old therapy did. If you're bigger and stronger and more powerful than the kid, they'll comply with you. But it's not gonna last."
In 1995, Lien says, he restructured and reorganized the institute's treatment protocol and told people who wanted to yell at children and forcibly hold kids down that they had to leave. Feinberg is no longer employed at the institute. The program changed, because therapists discovered that instead of internalizing rage, abused children often internalize sadness and fear, Lien says. Yelling at sad, scared kids didn't improve their behavior, it worsened it. And kids got hurt.
"There's unorthodox techniques, and then there's dangerous techniques," Lien says. "The old attachment therapy looked abusive, and I think it was."
Lien says the goal of the institute's intensive, two-week program is to get kids to learn to be vulnerable, trust their parents and deal with their scared, mad emotions. "We try to normalize the kids' behaviors." With both the parents and the child's hometown therapist in the room, Lien sits on the couch, puts a pillow on his lap, and the child lies down and looks into Lien's eyes.
"We hold kids in a cradling way so that they feel safe and at the same time feel vulnerable," Lien says. "They can't stay in their head."
If a child doesn't want to participate in therapy, Lien tells him he made a bad choice and fires him from therapy. Then he and the child's parents discuss how sad it is that the child doesn't want to change his life and make it better. Usually, Lien says, the child asks if he can rejoin therapy.
Still, attachment therapy doesn't work for every kid, Lien concedes. In those instances, parents have to decide if they want the child to come home, enroll in military school or -- worst-case scenario -- live in an institution. "These kids light your house on fire, they kill your animals, they do some pretty atrocious things," Lien says. "If kids continue to behave like that, then they're not family material. Is it normal to have a psychopath in your home? Where do psychopaths belong? Not in a family. Parents become prisoners in their own home with these little monsters."
Ten years ago, Lieutenant Governor Bob Bullock appointed the Senate Health and Human Services Committee to investigate private psychiatric hospital abuse. Senator Judith Zaffirini (D-Laredo) says the committee members were shocked and horrified when they witnessed rage-reduction and holding therapy.
"It was so cruel," Zaffirini says. "Sometimes people believe that things have to get worse before they get better. They had to completely break down a person's emotional state and have a form of regression and then rebuild. That just seemed cruel and unusual therapy to me -- and potentially harmful."
The Senate interim committee recommended that rage-reduction therapy be banned.
Senate Bill 210 included a ban on holding and rage-reduction therapy as part of an eight-point mental-health reform package. But before passing in the full Senate in the 1993 legislative session, the rage-reduction portion was removed to cut legislative program costs, Zaffirini says. The Treatment Methods Advisory Committee was established to review the technique. In 1994, the committee released a statement saying it did not endorse or recommend rage-reduction or trust-development therapy.
A year later, more than 30 former patients filed suit against Fort Worth psychiatrist Robert H. Gross, whom Cline trained in rage-reduction techniques. Cline was named as a co-defendant. In October 1996, Tarrant County state District Judge Ken Curry awarded Gross's former patient Jeannie Warren $8.4 million. Warren's Dallas attorney, Ken Jenson, says that when Warren was 15, she went through two dozen, five-hour therapy sessions where she was held down by four technicians who covered her mouth and nose, screamed obscenities at her and mashed knuckles into her stomach.
In a renewed effort to ban holding therapy, Warren spoke to the legislature with Jerry Boswell, the Austin-based president of the Citizens Commission on Human Rights of Texas. Boswell hoped that the multimillion-dollar judgment would show the legislature that rage-reduction and holding therapy are abusive. "They're brutalizing," Boswell says. "It should be outlawed."
No new laws were written, but Don Rogers, communications director for the Texas Department of Mental Health and Mental Retardation, says holding therapy is not sanctioned by his agency.
"It's not accepted. It's not something we promote or recommend," Rogers says. "Anytime somebody is restrained, it's not therapy."
Zaffirini is still considering writing a bill to ban all forms of holding therapy. A difficulty in writing legislation that outlaws holding therapy is that it has no standard, textbook definition. Four Houston-area therapists the Houston Press interviewed each define holding therapy differently and employ different techniques. One encourages kids to release rage, another swaddles children, another has kids lie across her lap, and another hugs and holds children.
Family therapist Elaine Litsey trained with Cline and used his rage-reduction techniques for seven years at the Southwest Attachment Center in Houston. She and another therapist sat on a couch, held a child across their laps, patted the child's chest and jiggled his arms to irritate and annoy the child into a rage. Litsey says she stopped practicing rage-reduction holding therapy in 1997 when she moved to an office by herself. "It's difficult to do alone," she says. "It's very exhausting for everybody."
Today, she does predominantly family talk therapy and encourages parents to hold children at home, baby-talk, bottle-feed and play patty-cake with kids. Attachment therapists teach regressive parenting because children bond to parents in the first two years of life. Therapists tell parents to nurture and baby kids to redo the developmental stages that were missed.
If a child gets upset and starts screaming and yelling during a therapy session, Litsey restrains the child and encourages him to "get the mad out."
She has patients make life-size dolls with Styrofoam heads and newspaper-stuffed scarecrow bodies that look like the person who abused, abandoned or attacked them. The child gets to yell and scream at the doll, then slice out its heart and brain with a butter knife. Afterward, the child stuffs the doll's remains in a trash bag and tosses it into the Dumpster. Litsey tells the child that his anger is all contained in the bag, and he's thrown it away.
Nancy Hart Hernandez, a licensed clinical social worker, says the safest way to do holding therapy is by swaddling children shoulders-down in a stretchy, loose-weave blanket. She's even wrapped a six-foot-two, 17-year-old boy. "It's like having them cornered," Hernandez says. "They need to be contained." She says the child feels helpless, like an infant, and can't use normal defense mechanisms (or arms) to push her away. "Being confronted and not having anywhere to go to hide from it, the feelings come up and break through," Hernandez says.
But first, kids often violently protest, kick, scream, bite and head-butt her. "They say, 'I'm suffocating, I can't breathe, I'm gonna die' -- everything they can think of to dodge. And then they break through," Hernandez says.
Gabrielle New emphasizes that when she performs holding therapy, she is never actually holding or constraining the child. She sits on the sofa, places a pillow on her lap and keeps her arms on the back of the couch. The child puts an arm around her back and looks into her eyes while she talks in a smooth, soft, relaxation-tape voice.
Beth Powell, a licensed psychotherapist, runs The Attachment Center of Texas based in Austin, and has a satellite office in Columbus, 40 minutes west of Katy. Her version of holding therapy looks like a visit to a loving grandmother: She hugs the child, holds him chest-to-chest and rocks back and forth, whispering that she loves him.
On a rainy Thursday afternoon, a six-year-old girl named Lamiracle Schreck walks into Powell's office. Her dark brown eyes are directed downward, and she has a permanent my-dog-got-ran-over-five-minutes-ago expression. Smile at her and she doesn't smile back. A child of an alcoholic drug user who abandoned her (but occasionally visits), the girl constantly lies and steals. "Her behavior improves ten-fold when she's being held," Powell says.
Powell pats her lap and the girl crawls on, wraps her arms around Powell and nuzzles her face into Powell's neck. "She could probably be held forever. She's starved for it," Powell says. "This one would be happy if you were covered in Velcro and she could just stick to you."
Powell gently rocks, while patting Lamiracle's back, telling her, "I love to touch you. I love to hold you."
"A lot of therapists don't think you're supposed to touch children," Powell says. "They're already isolated. Touch is healing. If I can put me inside of her, if my heart can touch her heart, then it'll help her heal faster."
Two-year-old Krystal Ann Tibbets threw herself out of her crib and scratched her private parts until they bled. After Krystal was diagnosed with both RAD and attention deficit disorder, therapists at the Cascade Center in Salt Lake City recommended holding therapy.
"They said that no other therapy would work," says her foster father, Don Tibbets Jr. Without holding therapy, Tibbets says he was told, Krystal could end up a strung-out, drug-addicted teen prostitute, or another Ted Bundy.
During nearly a year of state-paid twice-a-week two-hour holding-therapy sessions, Krystal screamed, spit, scratched and bit. What disturbed her foster dad, a registered nurse, is that after she stopped fighting, Krystal's eyes rolled back into her head and she held her breath. Eventually she started breathing again, was exhausted, and Tibbets held her, fed her a bottle and rocked her to sleep.
Around 9 a.m. on July 8, 1995, Krystal was hanging on the bathroom door throwing a temper tantrum. Tibbets placed her on the floor, lay on top of her chest-to-chest, stared into her eyes and placed his fist on her stomach -- as therapists had instructed him. As usual, Krystal stopped breathing.
But this time, she didn't start again.
Tibbets performed CPR and called 911, but it was too late. He served a five-year prison sentence for child-abuse homicide, a third-degree felony. Released this year, he lives in Wyoming with his parents, volunteers as a truck-stop preacher and actively speaks out against holding therapy.
Across the Colorado state line, another child died during a holding-therapy session. In April 2000, attachment therapists Connell Watkins and Julie Ponder performed rebirthing therapy on ten-year-old Candace Newmaker. Rebirthing basically took regressive therapy one step further; the idea was that Candace would be reborn and have a fresh start with her adoptive mother. The New York Times reported that to simulate the womb, Candace was wrapped in a flannel sheet and therapists pressed against her with couch cushions to replicate contractions.
Candace said seven times that she couldn't breathe and six times that she was going to die. Therapists called her a quitter and told her to fight for air.
After 40 minutes Candace stopped responding. Thirty minutes later the sheet was removed and therapists discovered that she was dead.
The two therapists were each sentenced to 16 years in prison, and the state of Colorado passed "Candace's Law," which outlawed rebirthing therapy. Last year, a bill was passed in the Utah House of Representatives prohibiting licensed therapists from doing rebirthing and holding therapy, but it failed in the Senate. In June, The Salt Lake Tribune reported that a four-year-old girl's death might have been caused by holding therapy. Representative Mike Thompson (R-Orem) says he plans to refile the bill in the next legislative session.
Legislative hearings are being held in California, and in mid-July, North Carolina Representative Sue Myrick (R-Charlotte) proposed a resolution to ban rebirthing therapy and encouraged all states to do the same.
"The thing that upsets me the most is that it is child abuse," Thompson says. "You are taught by a professional that this type of child abuse is good."
This summer, the American Psychiatric Association released a position statement saying there is no scientific evidence that holding therapy or rebirthing techniques are effective but that clinical data shows they can be deadly. "Recent events have made it quite clear that some of these unproven techniques can be extremely dangerous and even fatal," says psychiatrist David Fassler, who chaired the committee that wrote the statement. "Deaths have occurred in the course of the implementation of these so-called treatments."
Attachment therapy is the current psychological fad, Fassler says, and attachment therapists are overdiagnosing kids who don't actually have the disorder. He says a very small number of children have RAD. "If you focus on a particular kind of treatment, you tend to look at a lot of problems through that lens," says Fassler, clinical associate professor in the Department of Psychiatry at the University of Vermont College of Medicine. Fassler is writing guidelines for parents and therapists treating RAD.
Just because a kid has attachment issues doesn't mean he has RAD, Fassler maintains. Attachment issues can be a symptom of a learning disorder, anxiety disorder or affective disorder, he says. Symptoms that look like RAD can really be a developmental ailment, such as autism.
"This can be a very complex and frustrating disorder," Fassler says. "It's also a very difficult and challenging disorder to treat, and I think there are no easy answers or magic solutions."
No single form of therapy will treat RAD, Fassler says. He thinks a variety of approaches -- including individual, family and behavioral therapy and psychotropic medication -- need to be tried to treat different aspects of the disease.
He doesn't endorse even the kinder, gentler forms of holding therapy, where a child is hugged or held on a therapist's lap. "There's no evidence that it is helpful. There's no consistent scientific evidence," Fassler insists. "Parents need that information. It has to be considered far out of the mainstream and not something we can really recommend."
Attachment therapy is nothing more than an overpriced exorcism, says Jean Mercer, professor of psychology at Richard Stockton College in Pomona, New Jersey. "That's not modern psychotherapy. That's not any kind of psychotherapy. What they do is a magic ceremony. It's like the laying on of hands."
She says attachment therapists use scare tactics in declaring that children will become mass murderers if they aren't treated. "Very, very few people do grow up to be that way."
Mercer says she's not convinced that RAD is a real disease. The behaviors on the RAD diagnostic checklist could apply to many not-so-well-behaved children. Mercer says that desperate parents start seeing everything a child does as a symptom of the disease. Labeling the bad behavior as an illness takes the blame off the parents, she says, so parents can say that they have a sick kid and not deal with their own emotional issues.
Karen Whitfield from Lakewood, Colorado, was a defiant child who didn't obey orders or follow rules, so her parents beat her with belts. Diagnosed with RAD when she was nine, Whitfield spent three years in therapy in Evergreen where she was held down, shouted at and poked in the ribs. "It was absolute hell," she says. "To me, it was no different than the abuse that I suffered at home -- it was just under the name of therapy."
A 26-year-old mother of twins, Whitfield still screams in her sleep, dreaming that she's reliving therapy sessions. She doesn't believe RAD is a legitimate disease -- she says it's a catch-all to label misbehaving kids.
"I was a child with a lot of problems that needed help -- not what they put me through," she says.
As a psychiatrist, Cline says, he understands why the American Psychiatric Association is reluctant to endorse attachment therapy. They don't want to get sued, he says. He argues that most forms of non-drug-related psychology and psychotherapy -- like play therapy -- are experimental and have not been scientifically proven. He says there's little documented proof of the life-improving factors of many things, like watching a sunset or a father playing with his kids.
For therapy to be considered scientifically proven, double-blind studies need to be conducted, Cline says, with a "statistically large enough control group."
That isn't going to happen, he says.
Studies would be costly and wouldn't be backed by drug-company money, because there isn't a magic RAD-reduction pill. Since kids have died, he doubts teaching hospitals and universities will fund studies. Front-line therapists, he says, are not keen on the idea of control groups, because they want to try to treat children they think they can help.
"Everyone recognizes (although there may be no scientific proof) that when an infant is in a rage, the mother's holding of the infant is essential to help the infant learn to cope, work things through and self-soothe," Cline says. "Is it really such a leap of faith to believe that exactly the same thing is needed with older children and adults who experience the same rage from unresolved early abuse and neglect?"
The therapy seemed to be working. Every night, Carol fed her daughter a bottle and they had cuddly, quiet time. Stephanie seemed to be falling in love with her, Carol says. But as therapy progressed, Stephanie's behavior worsened. "I don't see improvement," Carol says. Stephanie can't go an hour without having a temper tantrum. The week school started, Stephanie got so upset she pulled out one of her teeth. "It was not loose," Carol says. "I don't know how she had the strength."
Therapists assure Carol that Stephanie's behavior has to get worse before it can get better. They say that change is scary and Stephanie is frightened because she isn't in control anymore. But sometimes Carol wonders if they're doing the right thing, or if she's even the right parent. She's 41 years old, and the therapists want her to change her entire parenting style and not yell at Stephanie when she does something bad, doesn't obey or doesn't come when called. The soothing, well-looks-like-you-made-a-bad-decision therapeutic parenting works for a while, but at the end of the day, she's tired and she can't keep it up.
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Sometimes Stephanie makes her so mad she doesn't want to touch her. "It's very difficult to do the bonding work," Carol says. She doesn't feel like Stephanie's mommy. She feels like a disliked nanny.
Carol's insurance won't foot the $7,000 bill to send Stephanie to the two-week intensive program in Evergreen because she hasn't seriously harmed or hurt anyone. And the outpatient psychiatric clinic Carol was referred to a month ago doesn't take children under eight. Carol stood in the parking lot and cried. "Ted Bundy had this," Carol says. "If I don't get help soon helping this child, something bad is going to happen."
Her friends tell her she's crazy for putting up with Stephanie's behavior. If she terminates the adoption, Carol says, she's setting Stephanie up for failure because that's one more bond she failed to make.
"One minute we say we're never gonna give up on her -- the next minute I think, 'I can't live the next ten years like this -- my family can't live the next ten years like this,' " Carol says. "Right now we're keeping her. Ask me again in five months, and it may be a different story."