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More Questions for Dr. Ronald Federici

April 30, 2010

Dr. Federici and his supporters have put forth a number of arguments defending his recommended interventions. In response to concerns about his restraint methods, he has essentially stated that the methods he recommends are solely for safety and protection. What this should mean, as I understand it, is that the restraints would be used only when the child is presenting an immediate threat to the physical safety of others or self. If that were the case, the restraint methods would still have to be shown to be safe and based on the literature I have examined, my understanding is that the face-down, prone restraint method with two adults on top of the person is not considered safe, regardless of purpose. However, the other issue is the immediacy of the danger. The danger must be imminent to justify use of restraints, meaning an immediate threat.

What I would like to ask Dr. Federici about is the points in his writings or public appearances that depict situations where the threat was not immediate. For example, in his book, he advises caregivers to go ahead and restrain the child, even if the child has backed down and promised to be good. Please help me to understand, Dr. Federici, how is that the sort of immediate threat to safety that would justify the use of restraints? If the child is backing down, he/she is no longer an immediate danger. There could be long-term consequences, as Dr. Federici points out, but in order to be justified, there must be an immediate threat. Another example was in the Dateline NBC segment, Saving Dane, the parents restrained the child because they asked him to go to the bathroom and he refused. Again, where is the imminent danger? Are the restraint methods only for safety or are they also being proposed to show the child who is boss, who is in control (namely the caregivers)? If the latter factors into these methods, then it would seem to me that this has gone beyond the use of restraints solely for physical protection and safety. I have read Help for the Hopeless Child and it is my understanding that the purpose of phase 1 is to show the child that the parents, not the child, are the ones in control and that the sequence one hold is part of this process. Have I understood you correctly, Dr. Federici? If not, please do feel free to clarify. I will post your response here if you wish to respond, as long as your response is free from any kind of personal attacks on me or my colleagues. I want to discuss the issues, so please help me to understand.

Dr. Federici, I realize that you argue you are an expert with years of hands-on clinical experience working with this population, but I have asked other experts who are also fully licensed, also have years of experience working with this population and do not agree with your methods. Additionally, for five years, I worked for a Neuropsychologist who has credentials very similar to yours and was one of the “go to” people in his area for highly troubled children with serious behavior problems. He has 30+ years of clinical experience and I witnessed his work with literally thousands of children and adolescents. I never discussed your particular methods with him, but I have to say that I never even once, saw him resort to or recommend restraints or anything even remotely resembling your intervention, yet he had a great deal of success. He has an eclectic approach and uses a number of different techniques, including behavioral interventions that have strong research support.

So you see, I am not just some researcher sitting in some ivory tower and commenting from afar.

I also need to note that recently this person who I used to work for has been trashed on another WordPress blog, when the main part of his treatment involves behavioral interventions and he is a very highly respected Neuropsychologist who constantly gets referrals from schools and the court system in his area and has a real gift for communicating with children. Observe the blatant hypocrisy where I am taken to task for daring to criticize licensed professionals, yet this particular licensed professional who has never been in trouble with his state board, who has dual doctorates (including a PhD in Psychology from SUNY Buffalo, as opposed to a PsyD) and 30+ years of experience is being trashed and his work unfairly misrepresented by having only a small fraction of what he does made to seem as if it were the totality of what he does. The take-home message here seems to be: it’s okay to attack licensed professionals if it fits the propagandist’s agenda but not okay if it doesn’t.

Although it is well known that I no longer endorse or support TFT/VT and in fact have been highly critical of it in numerous publications, I also need to point out that no one has ever died as a result of TFT/VT. Many, however, have died from face-down prone restraint procedures which are completely banned in some states such as Ohio where no one, no matter how safe they think they are or how “correctly” they think they are doing the procedure, is allowed to use them. Dr. Federici has argued that the face-down prone restraint procedure he recommends in his book is safe, if done correctly, but where is the evidence showing it to be safe? “Done correctly” has little meaning if the correctness has not been empirically tested with properly designed controlled studies. I mean actual randomized controlled trials, not clinical anecdotes and the fact that no one in his practice has died from them. The facilities that had deaths from restraints could have made the same type of claims, prior to the deaths.

I’ve done a literature search on safety of restraints and the conclusions all of the reviews I have examined come to is that there is no valid empirical evidence on the safety and efficacy, particularly of the take down and prone face-down restraint methods used with children — it is almost all authority-based and given the risk for asphyxiation and the deaths that have been well-documented to have occurred, even in residential facilities where supervision is much greater than it would be with two parents, “trained” by a therapist and left alone, that is concerning. Federici recommends that parents consult with a therapist who has had experience working in a residential facility that used his recommended methods, but again, reviews I have read state that there is no evidence that just because people work in such facilities, they are properly trained. The days of authority-based mental health practice are fortunately, coming to an end since proponents of evidence-based practice are questioning these “authorities” who insist on practices that lack evidence for their safety and efficacy. Some of these authorities are not happy about this, however and are fighting back with yet more bald assertions from authority and anecdotes of clinical experience, rather than evidence.

My expertise is in evaluating empirical evidence for therapeutic interventions and because the intervention proposed in Help for the Hopeless Child does not have randomized clinical trials to support its efficacy, and by your own description is quite aggressive, I have serious concerns about it.

Again, normally I would have contacted Dr. Federici privately first and asked him these questions. However, since in a communication to me in August, 2009, he explicitly told me not to contact him directly after I had e-mailed him and made an attempt to have a reasonable dialogue with him and clear up some misunderstandings he had about me, that is not an option, hence my need for an open letter style communication.

I have also noted that Dr. Federici does not wish to be labeled as an “attachment therapist” and so I will not label him in this manner. To me it’s the issues rather than the labels that are important, so if he doesn’t wish to be identified in that manner, I won’t. He has also made distinctions between his holding methods and those recommended by attachment therapists. In his book, as I understand it, he points out that their purpose is not to take a calm child and force that child to relive painful trauma by holding them, but rather to provide safety and security and to show the child who is in control, namely the parents. He has stated that he is opposed to the sort of holding therapy done by attachment therapists so at least there, we agree in terms of what we are opposed to.

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