Advocates for Children in Therapy, Attachment Therapy, Bryan Post, Evidence-Based Practice, Heather Forbes, Iatrogenic Therapies, Monica Pignotti, not-for-profit, prone restraints, Randomized Controlled Studies, Ronald Federici, straw man fallacy
Misrepresentation of Advocates for Children in Therapy’s Position on Attachment Therapy and Restraints
Recently I discovered a blog and also similar postings online where this posting is repeated, that are engaging in an egregious misrepresentation of the position of Advocates for Children in Therapy. This particular blog, written by someone who identifies himself as Jon Goodman, a parent, either has an honest misunderstanding or is engaging in straw man argumentation. The straw man fallacy is one in which a person misrepresents an argument, putting it into a form that is very easy to refute rather than addressing the actual statements and arguments being put forth. The blog in question stated:
[this is a quote of misrepresentation] ACT, also known as Advocates for Children in Therapy… recently made a rather large public statement saying they can prove that Attachment Therapy, Holding Therapy and Therapeutic restraints always hurt kids and always are lethal.
First, just to correct a major falsehood, ACT was falsely portrayed in that posting as for-profit when it is a not-for-profit organization, so he got this wrong. There is a difference between not-for-profit organizations (aka non-profits) and charities. All charities are non-profit, but not all non-profits are charities which are known as 501(c) and 501(c)(3) organizations. A 501(c)(3) is an organization that can accept tax-deductible contributions, but not all non-profits have that status. ACT is a non-profit that does not have 501(c) or 501(c)(3) status; it does not have the status where it can accept tax-deductible contributions but it is still a non-profit. That is why ACT is not listed with Guidestar. Guidestar only lists 501(c)(3) charities, not all non-profits. Same with the IRS. The IRS has a list of charities, but not all non-profits.
The fact something comes up on a Google search, does not mean it is true. Additionally, Mr. Goodman never gives any kind of reference to substantiate that such a “big public statement” was made, other than claiming it was a “headline on Google” which means nothing. Where is the “big public statement”, Mr. Goodman? Is it on the ACT website? No, it is not. The fact is that there have been no such statements from ACT, from me, or anyone else maintaining that “holding therapy and therapeutic restraints always hurt kids and are always lethal”. That would be an idiotic statement to make and of course this is a classic straw man argument because all one needs to do to refute it is produce one child who did not die from holding therapy or therapeutic restraints. No one from ACT has ever stated this, nor have I and I challenge the blogger to point to a verifiable statement made by any representative of ACT and yes, I mean something that is verifiable, not a statement from an anonymous person intent on misrepresenting ACT’s position. [Mr. Goodman then goes on to engage in a passionate defense of what he calls attachment therapy (his words, not mine), defend the work of Ronald Federici, Bryan Post and Heather Forbes and make a number of other claims and statements I disagree with but are beyond the scope of this particular posting (for example the statement that ACT recommends people do nothing is patently false and another straw man argument), some of which I have addressed elsewhere. For now I will focus on the problem with this one statement.]
Additionally, Mr. Goodman is reversing the burden of proof. The burden of proof is not on ACT to prove restraints or AT is always harmful. The burden of proof is on the people who deliver these treatments to prove they are safe and effective. The default position is first, do no harm. If a doctor were prescribing an untested drug, people opposing this would not have to prove the drug is harmful. The doctor would need to prove it is safe and effective. The same goes for mental health practices, especially physically invasive ones.
That being said, there also could be an honest misunderstanding of ACT’s position on the part of parents so making the most generous interpretation possible, I will attempt to clear this up. Perhaps the confusion is that people are equating the statement that something is dangerous with the statement that it is always harmful and/or lethal. Stating that something is dangerous is not the same thing as saying it is always fatal or even always harmful. Here’s an analogy you might find helpful. Most of us would agree that riding a motorcycle without a helmet is dangerous. There really is no controversy about that statement because it is a well documented fact that deaths and serious brain injuries have been caused by riding motorcycles without helmets. Is that the same thing as claiming that riding a motorcycle without a helmet is always fatal or harmful? Of course not. The vast majority of people who ride motorcycles without helmets do not get killed or even injured, but it’s still dangerous because each individual human life is valuable and even if only a minority get injured, that makes it valid to state that it is dangerous to ride a motorcycle without a helmet. Would multiple people coming forward and blogging that when they rode a motorcycle without a helmet they felt really great and did not get injured be a sensible rebuttal to the fact that riding a motorcycle without a helmet is dangerous? Of course not.
The same is the case with prone restraints. Do prone restraints always kill people? Of course not. Do they always injure people? Of course not. Do some people say they benefited from their use? Yes, I’m sure that some people would attest to the fact that using such a restraint was helpful in their particular case. Is that a rebuttal to the evidence they are dangerous? No, it is not. No more than a positive testimonial about riding a bike without a helmet would be.
What, then, constitutes evidence that an intervention is safe? Does a parent’s testimonial of a good experience constitute evidence? No, for the reasons I discussed above. Does the therapist’s claim that no one he has done it with has been harmed constitute evidence? No, because to be designated as safe and efficacious, an intervention needs to be systematically tested, before it is put out on the market, preferably by people who have no vested interest in the intervention.If a doctor wanted to give our child a drug based on positive testimonials from other parents, would you give that drug to your child? Would you give your child a drug, based solely on your doctor’s word that in his clinical experience it helped people and he has not seen anyone harmed by it? I sure hope not.
The proper way to test an intervention for safety and efficacy is to conduct randomized clinical trials. To determine whether an intervention is safe, a group receiving the treatment needs to be compared to a group that had no treatment. If the no treatment control group is better than the treatment group at the end of the study, it means that the treatment is harmful. Another way that harm for a minority of people can be determined is during such a study, keep a careful record of all adverse events. That way, even if a the treatment group, on average, did better than the control group, adverse events can be identified. No clinician, no matter how skilled, can be a substitute for such a study. For one thing, people can drop out of treatment and not be accounted for whereas in well-designed studies drop outs are accounted for. Additionally, even the most honest clinician can have biases and tend to see results that confirm what he believes and discount results that disconfirm what he believes. This is called confirmation bias and as Paul Meehl points out, it is arrogant for any clinician to think he is exempt from confirmation bias.
The bottom line for any treatment is that before it is put on the market, it needs to be determined through well-designed randomized controlled clinical trials that the benefits outweigh the risks. Through such studies, the adverse events, if any, are documented and so people who decide to do the treatment can be properly informed of the risks and the benefits and make an informed choice. Again, this is not possible when treatments are put on the market prior to such testing. As Peter Fonagy pointed out in the BBC documentary I discussed in an earlier posting:
PETER FONAGY: Because it’s such an unusual intervention I would really want to know in a properly conducted randomised control trial that the treatment is (a) safe and (b) effective in the long run.
The principle here is first, do no harm and there is a great deal of evidence that prone restraints are dangerous. Again, note that I am not saying that they are always lethal or injurious. Neither is riding a motorcycle without a helmet. Neither is driving while under the influence of alcohol, but nevertheless, a reasonable people would consider these acts dangerous. This isn’t just me, Monica Pignotti, giving an off the cuff statement here about the danger of prone restraints. My colleagues and I are being misportrayed as lone, fringe mavericks against the establishment when this is far from being the case. Much of the establishment agrees with us. The State of Ohio and some other states have made the decision to ban prone restraints after doing a careful review of the evidence. The order states:
Research has shown that the Prone Position is a Hazardous and Potentially Lethal Restraint Position. Accepted research has shown that there is a risk of sudden death when restraining an individual in the prone position. The prone position occurs when an individual is face-down. The research has led other states to prohibit the use of this restraint technique.
That isn’t me or some anonymous person. That is the State of Ohio and you can read the order yourself on the Governor of Ohio’s website, by clicking here. Responding to me by using an argument that I am not an expert is not a proper rebuttal because the State of Ohio and other states that made similar decisions to ban prone restraints obviously consulted not only legitimate, mainstream experts but also and more importantly, the research literature, so whether or not you want to consider me a legitimate expert is a moot point. I have no problem at all deferring, when appropriate, but my ultimate deference is to evidence and the facts of reality. I engage in due diligence by examining the latest research, not polemical opinion papers attempting to sell people on their point of view, but actual evidence.
I have never expected people to believe something because I said so, because ACT says so or anyone else. I argue from evidence that people can examine and decide for themselves. When actual evidence is presented, it matters not whether the person who is the messenger of that evidence is an “expert”. The issue is whether the evidence is sufficient and when it comes to prone restraints, there is no need to just take my word for it.
I urge people to examine the evidence for themselves (not anecdotes or claims that have no research to support them) that shows that the treatment being proposed is helpful and that the benefits outweigh the risks. Anyone who has any kind of ability to gain rapport with another person can produce positive testimonials or friends who can give personal references about what a great person the individual is, but that’s not the issue. Just surf the internet and you will find literally thousands of treatments that have glowing testimonials that have no evidence and may well be completely worthless. Scientology can and has provided many thousands of success stories, signed by people with real names and the current leader, David Miscavige recently brought several people on CNN to talk about what a great person he is and how every negative thing uttered about him by defectors and critics is a lie. Defectors who speak out against Scientology often get labeled as psychotic or criminal. Does this prove that Scientology is valid and does what it claims? I don’t think so, nor is trying to label me or other critics of certain therapies as being not of sound mind or a lying that I am a criminal (when in fact I have no criminal record at all), compelling evidence for those therapies. Again, we come back to my oft-repeated bottom line, which is that legitimate therapies do not need to conduct smear campaigns against their critics. Instead, they produce valid evidence, they do randomized controlled clinical trials.
I hope this clarifies any genuine misunderstandings people may have about ACTs or my position.