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Section 24
Warning on the Dangers of Holding Therapy, Foster Care

Question 24 | Test | Table of Contents

Introduction
Attachment theory and attachment therapy have gained considerable status in social science and social work, especially in fostering and adoption (Arredondo & Edwards 2000; Haight et al . 2003). Attachment theory is arguably the most popular theory for explaining parent–child behavior by professionals involved with child welfare services and is referenced in the abstracts of nearly 1000 articles retrieved in the Social Science Citation database of the Institute for Scientific Analysis (ISI) since 1996, and 1600 times in the American Psychological Association’s PsycInfo database since 1988. Attachment research is primarily conducted by developmental scientists but has more recently been adapted by clinicians. Attachment theory is cited as the basis for two practice innovations in recent decades: attachment-based therapy (ABT) and bonding studies (BS) and is the theoretical approach used to underpin the diagnosis of reactive attachment disorder (RAD). The impact on services has been profound: Hill et al.’s (1992) review of 100 Scottish cases in which children were freed for adoption found that the quality of parent–child attachment was referenced in every case (usually with reference to birth parents). The RAD diagnosis has led to the rapid growth of agencies and conferences for adoptive parents and is partially responsible for some of the dubious and even harmful therapies developed to treat it.

Yet, attachment-based therapies and studies are not nearly as well represented or regarded in the scientific literature as they are in contemporary children’s services practice (e.g. see O’Connor & Zeanah 2003). A search for papers citing attachment therapy including those concerned with ‘holding therapy’ yielded four such articles in ISI, with only one being a modest, albeit positive, evaluation of therapeutic outcomes (Myeroff et al. 1999). One of the papers was a warning about the dangers of holding therapy (Mercer 2001). Mary Dozier (2003), an American researcher of early childhood foster care and attachment, wrote a paper opposed to holding therapy. Her paper explains that holding therapy, sometimes known simply as ‘attachment therapy’, does not emanate in any logical way from attachment theory or from attachment research. In addition, the psychoanalytic underpinnings of attachment theory have generally not provided a strong basis for effective treatment of children (Weisz et al. 1987). Rutter’s (1996) review of the attachment literature also concludes with an argument to reject these traditional psychoanalytic theories of development, on which some proponents of attachment theory rely, and to reorient our current emphasis on ‘maternal bonding’ to infants and disorders of attachment.

However, as O’Connor & Zeanah (2003) recently summarized with regard to diagnosis and treatment interventions: ‘Despite more than 20 years since the establishment of "disorders of attachment" . . . there is still no consensual definition or assessment strategy; nor are there established guidelines for treatment or management’ (p. 241).

The Limits of What Attachment Theories Can Tell Us
Accounts of disordered attachment first appeared in the 1930s and 1940s when a number of scholars observed the unhealthy consequences of raising children in institutions (Levy 1937; Goldfarb 1943, 1945; Spitz 1946). A psychiatrist and Kleinian psychoanalyst John Bowlby (1951) then began to write about the adverse influence on development of inadequate maternal care and called attention to the acute distress of young children separated from their primary caregivers. This distress was viewed as a fundamental human response, and in the book he wrote two years later for non-professionals, Bowlby asserted that a close mother–infant relationship was essential for socio-emotional adjustment: ‘. . . what is believed to be essential for mental health is that the infant and young child should experience a warm, intimate, and continuous relationship with his mother (or permanent mother-substitute – one person who steadily mothers him) in which both find satisfaction and enjoyment’ (Bowlby 1953, p. 11). This presumption seems sound enough, although it marks the transition from observational studies of distress to inferences about the meaning of a child’s desire to avoid such distress.

The following half century has taken the concept much further, and endeavored to reify toddlers’ reactions to separation from their caregivers during controlled experiments into discrete types of secure and insecure attachment (Ainsworth 1989). This work was followed by predictions about how children classified as being securely or insecurely attached as toddlers would develop differentially in early childhood (Sroufe 1983) and later, classification of adults according to attachment types (Main & Hesse 1992). The challenges to attachment-based theories of development have come more recently, as the emergence of longitudinal studies offers a basis for checking the reliability of predictions based on attachment theory. Sroufe, Egeland, and colleagues (Roisman et al. 2002), following a sample of high-risk and maltreated children to adulthood, find substantial discrepancies between predictions based on early childhood assessments of attachment and adult relationship outcomes. They suggest that their results provide evidence that, although attachment has been found to be stable over time in other samples, attachment representations are vulnerable to difficult and chaotic life experiences and thus lack predictive power when considering the future life chances of the sorts of children needing child welfare services (Weinfield et al. 2000). Sroufe et al. (1999) summarized the difficulties in using attachment theory to make predictions:

Early experience does not cause later pathology in a linear way; yet, it has special significance due to the complex, systemic, transactional nature of development. Prior history is part of current context, playing a role in selection, engagement, and interpretation of subsequent experience and in the use of available environmental supports. Finally, except in very extreme cases, early anxious attachment is not a direct cause of psychopathology but is an initiator of pathways probabilistically associated with later pathology. (p. 1)

Other studies have found little or no evidence of a link between psychological problems in older adopted children and insecure attachment relationships in infancy. Singer et al. (1985) found a similar quality of attachment between adoptive and non-adoptive families. These researchers also found that for middle class families, lack of early contact with an adopted child does not predict anxious adoptive mother–infant attachment. In addition, the authors argue that higher rates of psychological and academic problems among adopted children cannot be traced to insecure attachment patterns between adoptive mothers and children in infancy. Juffer & Rosenboom (1997) found that 74% of the adopted infants were securely attached to their parents, irrespective of country of origin or whether parents also had biological children. These findings suggest that the adoption experience itself, and all that the pre- and post-adoptive experiences may mean for the child and caregiver, is not a predictor of negative parent–infant relations, outside of other factors such as early emotional or physical deprivation.

More generally, although much legitimate research evidence is accumulating about attachment in early childhood and adjustment in later childhood, these studies are characteristically short-term and descriptive, and mostly based on children in non-adoptive families. Attachment theory cannot be used with any confidence to predict how children will develop over longer periods of time. Those professionals who would convince parents that their children may have attachment impairments – and that these will vex their children and families forever – are not reading the caveats from developmental scholars. While attachment problems may predispose a child towards future behavior problems, these problems must be evaluated and treated within the context of the child’s current environment. Such scholars would also forewarn against confusing evidence of risk as a strong basis for prediction.
- Barth, Richard, Crea, Thomas, John, Karen, Thoburn, June & David Quinton; Beyond attachment theory and therapy: towards sensitive and evidence-based interventions with foster and adoptive families in distress; Child & Family Social Work; Nov 2005; Vol. 10; Issue 4.

Children Adopted from Foster Care: Adoption Agreements,
Adoption Subsidies, and other Post-Adoption Supports


- Office of the Assistant Secretary for Planning and Evaluation. Children Adopted from Foster Care: Adoption Agreements, Adoption Subsidies, and Other Post-Adoption Supports. Washington, DC: U.S. Department of Health and Human Services.

Personal Reflection Exercise #10
The preceding section contained information about beyond the attachment theory and therapy.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Measuring Success in Foster Care

- Abrams, Z. (March 1, 2023). Psychologists work to support children and parents in the child welfare system, but more is needed. Hope for Foster Kids, 2(54), 1-5.

Peer-Reviewed Journal Article References:
Kim, A. Y., Kim, O. M., Hu, A. W., Oh, J. S., & Lee, R. M. (2020). Conceptualization and measurement of birth family thoughts for adolescents and adults adopted transnationally. Journal of Family Psychology, 34(5), 555–565.

Levy, I., & Eckhaus, E. (2020). Rape narratives analysis through natural language processing: Survivor self-label, narrative time span, faith, and rape terminology. Psychological Trauma: Theory, Research, Practice, and Policy, 12(6), 635–642.

Messina, R., & Brodzinsky, D. (2020). Children adopted by same-sex couples: Identity-related issues from preschool years to late adolescence. Journal of Family Psychology, 34(5), 509–522.

QUESTION 24
What cannot be traced to insecure attachment patterns between adoptive mothers and children in infancy? To select and enter your answer go to Test.

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