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Attachment therapy is the most commonly used term amongst foster or adoptive parents, caseworkers and on the Internet for a controversial category of alternative child mental health interventions intended to treat attachment disorders. The term generally includes accompanying parenting techniques. Another common name for these therapeutic and parenting interventions is holding therapy . It is found primarily but not exclusively in the United States. This article describes this particular set of interventions although in clinical literature the term is sometimes used loosely to mean any intervention based, or claiming to be based, on attachment theory, particularly outside the USA.

Attachment therapy is a treatment used primarily with fostered or adopted children who have behavioral difficulties, including disobedience and lack of gratitude or affection for their caregivers. The children's problems are ascribed to an inability to attach to their new parents because of suppressed rage due to past maltreatment and abandonment. The common form of attachment therapy is holding therapy, in which a child is firmly held (or lain upon) by therapists or parents. Through this process of restraint and confrontation, therapists seek to produce in the child a range of responses such as rage and despair with the goal of achieving catharsis. In theory, when the child's resistance is overcome and the rage is released, the child is reduced to an infantile state in which he or she can be "re-parented" by methods such as cradling, rocking, bottle feeding and enforced eye contact. The aim is to promote attachment with the new caregivers. Control over the children is usually considered essential and the therapy is often accompanied by parenting techniques which emphasize obedience. These accompanying parenting techniques are based on the belief that a properly attached child should comply with parental demands "fast, snappy and right the first time" and should be "fun to be around". These techniques have been implicated in several child deaths and other harmful effects. Variant forms or particular techniques may also be known by names including "rage-reduction", "compression therapy", the "Evergreen model", "holding time", "rebirthing", "corrective attachment therapy" and Coercive Restraint Therapy.

This form of therapy, including diagnosis and accompanying parenting techniques, is scientifically unvalidated and is not considered to be part of mainstream psychology or, despite its name, to be based on attachment theory, with which it is considered incompatible. It is primarily based on Robert Zaslow's rage-reduction therapy from the 1960s and 70s and on psychoanalytic theories about suppressed rage, catharsis, regression, breaking down of resistance and defence mechanisms. Zaslow, Tinbergen and other early proponents used it as a treatment for autism, based on the now discredited belief that autism was the result of failures in the attachment relationship with the mother.

It has been described as a potentially abusive and pseudoscientific intervention that has resulted in tragic outcomes for children, including at least six documented child fatalities. Since the 1990s there have been a number of prosecutions for deaths or serious maltreatment of children at the hands of "attachment therapists" or parents following their instructions. Two of the most well-known cases are those of Candace Newmaker in 2000 and the Gravelles in 2003. Following the associated publicity, some advocates of attachment therapy began to alter views and practices to be less potentially dangerous to children. This change may have been hastened by the publication of a Task Force Report on the subject in January 2006, commissioned by the American Professional Society on the Abuse of Children (APSAC) which was largely critical of attachment therapy. In April 2007, ATTACh, an organisation originally set up by attachment therapists, formally adopted a White Paper stating its unequivocal opposition to the use of coercive practices in therapy and parenting, promoting instead newer techniques of attunement, sensitivity and regulation.

This form of treatment differs significantly from mainstream attachment-based therapies, talking psychotherapies such as attachment-based psychotherapy and relational psychoanalysis or the form of attachment parenting advocated by the pediatrician Sears. Further, the form of rebirthing sometimes used within attachment therapy differs from Rebirthing-Breathwork.

Treatment characteristics

The controversy, as outlined in the 2006 American Professional Society on the Abuse of Children (APSAC) Task Force Report, has broadly centered around "holding therapy" and coercive, restraining, or aversive procedures. These include 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 normal social relationships outside the primary 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 change frequently. They may be known as "rebirthing therapy", "compression therapy", "corrective attachment therapy", "the Evergreen model", "holding time", "rage-reduction therapy" or "prolonged parent-child embrace therapy". Some authors critical of this therapeutic approach have used the term Coercive Restraint Therapy. It is this form of treatment for attachment difficulties or disorders which is popularly known as "attachment therapy". Advocates for Children in Therapy, a group that campaigns against attachment therapy, give a list of therapies they state are attachment therapy by another name. They also provide a list of additional therapies used by attachment therapists which they consider to be unvalidated.

Matthew Speltz of the University of Washington School of Medicine describes a typical treatment taken from The Center's material (apparently a replication of the program 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."

According to the APSAC Task Force,

"A central feature of many of these therapies is the use of psychological, physical, or aggressive means to provoke the child to catharsis, ventilation of rage, or other sorts of acute emotional discharge. To do this, a variety of coercive techniques are used, including scheduled holding, binding, rib cage stimulation (e.g., tickling, pinching, knuckling), and/or licking. Children may be held down, may have several adults lie on top of them, or their faces may be held so they can be forced to engage in prolonged eye contact. Sessions may last from 3 to 5 hours, with some sessions reportedly lasting longer... Similar but less physically coercive approaches may involve holding the child and psychologically encouraging the child to vent anger toward her or his biological parent."

The APSAC Task Force 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. If the child is well-behaved outside the home this is seen as successful manipulation of outsiders, rather than as evidence of a problem in the current home or current parent-child relationship. The APSAC Task Force 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 it is impossible to establish a trusting relationship with them. They believe this is because children with attachment problems actively avoid forming genuine relationships. Proponents emphasize the child's resistance to attachment and the need to break it down. In rebirthing and similar approaches, protests of distress from the child are considered to be resistance that must be overcome by more coercion.

Coercive techniques, such as scheduled or enforced holding, also may serve the intended purpose of demonstrating dominance over the child. 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 atta

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