RE: behavior modification "specialty programs" for "troubled teens"

[<F.Schultz@xxxxxxxxxxxxxxxxx>]

Rick,

All I can say is that you might wish to read the Fonagy papers.  His
recent short works are posted, free online at
http://www.psychematters.com.  Naturally, the likelihood of a good
outcome depends to a large degree on matching the problem with the
intervention. If the decision to place is the parents', parents with
problematic attachment issues themselves are notoriously wrong in
describing the real issues their child is confronting.  Some of the
beneficial results of an out of home placement may come from
substituting a more emotionally available and reliable caretaker or
therapist for the otherwise inept and unhelpful interactions the child
experiences at home, rather than the "type" of therapy the out of home
placement offers.  That can be construed as an "attachment-based"
effect.

Jeremy Holmes is another distinguished British clinician who has written
specifically about an attachment-theory-informed practice of adult
therapies, and discusses what is different in terms of method and
perspective.  If you relate, in turn, what he says to the very
practically-oriented material put out by James Masterson on therapy for
personality disorders, a lot of things click.  Holmes is very eloquent
on what seems to go wrong when "skill-based" interventions do not seem
to "stick".  He says it is because the emotional underpinnings around
"containing" mood can be so disrupted or undeveloped that the relative
"calm" needed to learn and correctly apply the "skill" simply doesn't
hold long enough, and the person resorts to old defensive strategies
which provide IMMEDIATE relief in the short run, no matter how socially
dysfunctional over all.

Naturally I was not advocating for any of the pop therapies which claim
an "attachment" basis, like "holding therapy" which involves physical
restraint or "rebirthing" or any of the other highly peripheral, "pop"
ideas out there.  They offer more risk of harm than help, in what I have
read, and the reasons seem obvious to me.

As the parent of a young adult with autism who has been hospitalized for
acute emotional issues more than once,  I am particularly averse to any
physical holding/restraint approaches to interventions, including more
than the briefest trial with chemical "restraints".  My son, by the way,
by all appropriate measures, has been found to be securely attached, in
spite of his proprioceptive and emotional/perceptual issues, and so are
many kids like him with autism who also have crossed that developmental
threshold successfully.  Autistic kids, like other kids, DO eventually
form secure attachments under the right circumstances, but that only
helps, and does not "cure" their other emotional issues (chronic anxiety
from a biological shortage of GABAA production in the cerebellar vermis,
for instance) or issues of relating, since they cannot "read" other
people's faces for emotion, especially under stress or in a group
context.  Not reading faces also means that their perception of mother's
non-verbal "mirroring" in infancy is also flawed and restricted, so
things can go wrong there, too. We have agencies and therapists in our
community who work well with young children and their parents in
overcoming these kinds of barriers to effective emotional maturation.

And, Fonagy points out that clinical depression or anxiety "swamp" the
beneficial effects of secure attachment. 

Professionally, I specialized in the study of autism in grad school
under an NIMH fellowship to study primate social behavior almost 40
years ago because I was interested in the "natural" failure to develop
normal social relating, and have learned a great deal from my personal
experiences with my son and other children about what is really tied to
what in development.

I believe one of the researchers at SUNY Stoneybrook has a NIMH grant to
develop and evaluate a short term attachment-based intervention for
adolescents and adults, and I believe that is well underway.  You might
want to look at the Stonebrook site for more information.

Freya

Freya J. Schultz
Staff Analyst
Santa Barbara County Social Services
234 Camino del Remedio
Santa Barbara, CA 93110
805-681-4626
Fax 681-4403
email f.schultz@sbcsocialserv.org

-----Original Message-----
From: owner-CHILD-MALTREATMENT-RESEARCH-L@cornell.edu
[mailto:owner-CHILD-MALTREATMENT-RESEARCH-L@cornell.edu] On Behalf Of
Rick Barth
Sent: Wednesday, October 13, 2004 7:02 AM
To: Child Maltreatment Researchers
Subject: Re: behavior modification "specialty programs" for "troubled
teens"

Freya: Since I often read your posts with great interest, I want to
thank you for your many sterling contributions.  But, I must raise
concern about the conclusion that "attachment-based" therapies are more
effective than cognitive-behavioral treatments (I added the cognitive to
your original reference to behavior modification, because most such
interventions are now combined efforts, addressing information
processing as well as social learning).

I have not seen the Fonagy and Roth works, but the single type of
therapy judged to be harmful in the review by Saunders, et al, was an
"attachment based therapy".

Saunders, B. E., Berliner, L., & Hanson, R. F. E. (2003). Child physical
and sexual abuse: Guidelines for treatment (Final report: January 15,
2003). Charleston, SC: National Crime Victims Research and Treatment
Center.

Also,John Weisz, at UCLA, arguably the nation's leading scholar in the
area of child and adolescent interventions has long found--and continues
to find, in rigorous research syntheses that psychodynamic based
interventions--which would include atttachment based interventions--are
less effective than skill based interventions.  THis is an older
citation,but his more recent work is confirmatory.

Weisz, J. R., Weiss, B., Han, S. S., Granger, D. A., & Morton, T. 
(1995). Effects of psychotherapy with children and adolescents
revisited: A meta-analysis of treatment outcome studies. /Psychological
Bulletin, 117/, 450-468.

I know that your post was on a slightly different tack, but I wanted to
clarify that there is strong evidence that we should not be promoting
the effectiveness of attachment based therapies over other more evidence
based interventions.

Rick



F.Schultz@SBCSocialServ.org wrote:

> This may not be entirely what you are looking for, but I would suggest

> you look at "What Works for Whom", a new summary of studies for 
> evidence of efficacy for various forms  psychotherapy or psychological

> interventions by Fonagy and Roth.  Peter Fonagy is a research director

> for the Menninger Clinic and is a leading researcher on attachment 
> theory and attachment-based interventions.  The book is divided into 
> two sections, one for adults and one for children and adolescents.  I 
> seem to recall that it finds lasting benefits for "attachment-based"
> therapies over behavior modification treatments.
>  
> The book does not comment on the legal issues regarding behavior mod, 
> just that it doesn't seem to have long-lasting beneficial results, 
> whereas other therapies DO, depending on the issues presented by the 
> child.
>  
> It would seem to me that in any legal challenge to placement in a 
> behavior mod program, efficacy of the intervention and whether the 
> restrictions on the child are warranted in order to insure a lasting 
> beneficial outcome would be an issue.
>  
> I looked at the web site you cited as your "agency" and did not find 
> anything that tells me anything about the group or agency you may 
> represent.
>  
> Freya Schultz
> Santa Barbara County Social Services
>
> ----------------------------------------------------------------------
> --
> *From:* owner-CHILD-MALTREATMENT-RESEARCH-L@cornell.edu
> [mailto:owner-CHILD-MALTREATMENT-RESEARCH-L@cornell.edu] *On Behalf Of

> *Elisabeth Feldman
> *Sent:* Tuesday, October 12, 2004 8:32 AM
> *To:* Child Maltreatment Researchers
> *Subject:* behavior modification "specialty programs" for "troubled
teens"
>
> Is anyone aware of outcome studies on private/nonadjudicated behavior 
> modification based "specialty" wilderness, boarding school and/or 
> residential treatment centers for "troubled" teens?
>  
> Is there anyone out there who is or knows of someone researching this 
> topic from the perspective of parental vs. minors rights (as most of 
> these programs deny constitutional rights of minors in favor of 
> parental rights, i.e. minors in these facilities have no right to 
> contact an attorney, sometimes no right to contact anyone except 
> parents, and even then, contact is monitored.)
>  
> Thank You,
>  
> Elisabeth Feldman
> The Troubled "Troubled" Teen Industry Research Group 
> <http://www.troubledteenindustry.blogspot.com>