Updated by:
Jacquelin Medrano, MS, and Natalie Wilcox, BA
University of Oregon

Description:

Autism Treatments SummaryHolding therapy (HT) was a method developed to address behavior(s) in children and adults based primarily on alternative theories and attachment theories. Alternative theories are the belief that personality characteristics can be transformed by forceful physical means (Pignotti & Mercer, 2007). Attachment theory, created in the mid-1900s, emphasized the importance of the caregiver-child attachment and claimed that the level of this attachment correlated with a child’s behavior (Haney, 2021). Bringing these two theories together, HT was developed with the purpose of building or restoring a patient’s attachment to their caregivers, via physical means, when the patient’s behavior was believed to indicate a deficit in the relationship. Most commonly, these behaviors involve disobedience and unwillingness to express affection as parents desire, such as refusing to be held or outbursts when asked to show affection (Mercer, 2015). Due to the nature of the behaviors targeted by HT, it has often been used with adoptive and foster children, as well as those diagnosed with reactive attachment disorder (RAD) and autism spectrum disorder (ASD) (Mercer, 2014). These populations are either characterized by their lack of traditional affectionate behavioral displays (e.g., RAD, ASD), commonly lacking these behavioral displays due to their past experiences (e.g., adoptive and foster children), or a combination of both.

HT includes physical restraint by several therapists or by parents, with the goal of improving the attachment between the caregiver and child (Mercer, 2014). HT methods may include limiting diet and toilet use, as well as face-to-face restraint of children by parents (Mercer, 2014).  Generally, younger children will be placed on the caregiver’s lap, whereas for older children, the parent will lie face down on the older child who is lying face up. In both positions, the child will be made to face the caregiver and will be restrained until they reciprocate eye contact, which HT supporters claim will achieve attachment to the caregiver (Lilienfeld, 2007; Mercer 2013). Patients are expected to actively resist. Although the caregiver is primarily the person administering the hold, the caregiver may be assisted by one or two therapists to restrain the child. Due to the physical restriction and extreme pressure, HT has been associated with a number of child deaths (Mercer et al., 2003).

Other common names for HT include rebirthing therapy and rage reduction therapy (Buckner et al., 2008). Both rebirthing therapy and rage reduction therapy are used for the same purposes as HT with the same primary populations. Rebirthing therapy more specifically describes a breathing technique, with variations of the technique including wrapping the child in swaddling items, such as blankets and pillows and pushing on the child in a way that is meant to simulate uterine contractions (Josefson, 2001). Following the death of a child, a congressional resolution in the United States rejected the use of rebirthing therapy techniques. Following this decision, numerous professional organizations such as the American Psychological Association, the American Psychiatric Association, and the National Association of Social Workers joined in this opinion or rejected HT as a whole, and numerous states have outlawed the use of any psychotherapy involving the use of active restraint (Mercer, 2013; O’Connell-Sussman & Weiss, 2021).

Research Summary:

The only known published trial attempting to prove the validity of HT (Myeroff et al., 1999) has since been rejected due to confounding causes of improvement seen in patients (Buckner, et al., 2008; Chaffin, et al., 2006; Lilienfeld, 2007; Mercer et al., 2003; Pignotti & Mercer, 2007). More specifically, HT cannot be verified as effective because other circumstances in a patient’s life may account for their behavioral changes. For instance, in adopted patients, researchers have found that improved symptoms of RAD will be seen if the patient receives adequate care the first two to three years after adoption. Therefore, in patients with RAD who have received HT within their first few years of being adopted, it is not possible to identify if changes to their behavior are a result of HT or the adoption (Zeanah & Gleason, 2015). These potential alternative causes for improvement are commonly found in patient populations who receive HT, preventing HT from being verified.

Recent systematic reviews of the literature have led professionals to conclude that HT is not supported by scientific evidence and is potentially harmful (Pignotti & Mercer, 2007). The lack of research support has led HT to be left out of task reports that evaluate evidence-based treatments for those with autism, such as the National Standards Project (National Autism Center, 2015). In addition to a lack of research support, HT has resulted in patients requiring subsequent treatment for anxiety and post-traumatic stress disorders, the creator of HT surrendering their professional license following a serious injury to an adult patient, and the death of multiple patients (Mercer, 2014). Studies have shown that HT causes harm (Lillienfeld, 2007; Mercer, 2014; Mercer, 2013), and the use of HT practices by families and clinicians has been observed to be abusive and dangerous, cause long-lasting harm, and even death (Chaffin, et al., 2006; Lilienfeld, 2007; Mercer, 2003; Pignotti & Mercer, 2007). Currently, HT is not legal in the United States (Mercer, 2014).

Recommendations:

Current research and legal mandates emphasize that neither holding therapy nor rebirthing therapy are effective treatments. As such, they are not recommended. Given the dangers associated with HT, caregivers and consumers are strongly advised against using these methods for treating various behaviors in individuals with autism or any individual demonstrating behavioral issues. Rather than attempting HT, caregivers should seek treatment supported by research and professional organizations. Professionals in relevant positions, such as social workers or physicians, should recommend and provide resources to families to help them seek empirically supported treatment methods and to take steps to maximize the consent of those receiving such interventions. Evidence-based practices for promoting meaningful behavior change include practices informed by Applied Behavior Analysis (ABA). For those in need of services that address behavioral challenges, connecting with clinicians who utilize practices informed by ABA will likely be an informative and worthwhile endeavor (Behavior Analyst Certification Board, n.d.). For those seeking more information on building or establishing relationships, empirically supported information on rapport building (i.e., pairing) and improving engagement can be accessed on the ASAT website. Links to this information can be found below.

References

Systematic Reviews of Scientific Studies

National Autism Center. (2015). Findings and conclusions: National standards project, phase 2. Author

Zeanah, C. H., & Gleason, M. M. (2015). Annual research review: Attachment disorders in early childhood–clinical presentation, causes, correlates, and treatment. Journal of Child Psychology and Psychiatry, 56(3), 207–222. https://doi-org.uoregon.idm.oclc.org/10.1111/jcpp.12347

Selected Scientific Studies

Myeroff, R. L., Mertlich, G., & Gross, G. (1999). Comparative effectiveness of holding therapy with aggressive children. Child Psychiatry and Human Development, 29(4), 303-313.

Selected Reports of Side-effects 

Josefson, D. (2001). Rebirthing therapy banned after girl died in 70 minute struggle. BMJ Publishing Group, 322(7293).

Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53–70. https://doi.org/10.1111/j.1745-6916.2007.00029.x

Position Statements and Warnings

Chaffin, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., Zeanah, C., Berliner, L., Egeland, B., Newman, E., Lyon, T., LeTourneau, E., & Miller-Perrin, C. (2006). Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. Child Maltreatment, 11(1), 76–89. https://doi.org/10.1177/1077559505283699

O’Connell-Sussman, E., & Weiss, M. J. (2021). A non-exhaustive list of current position statements related to autism treatment. Science in Autism Treatment, 18(11).

Other Cited Articles

Behavior Analyst Certification Board. (n.d). About Behavior Analysis. Behavior Analyst Certification Board. https://www.bacb.com/about-behavior-analysis/#ABAFactSheets

Buckner, J. S., Lopez, C., Dunkel, S., & Joiner, T. E. (2008). Behavior management training for the treatment of reactive attachment disorder. Child Maltreatment, 13(2), 289-297. https://doi.org/10.1177/1077559508318396

Haney, K. M. (2021). Attachment therapy: Are we truly doing “no harm”? Clinical Psychology (New York, N.Y.), 28(1), 72–80. https://doi.org/10.1111/cpsp.12379.

Mercer, J. (2013). Holding therapy: A harmful mental health intervention. Focus on alternative and complementary therapies, 18(2), 70-76.

Mercer, J. (2014). International concerns about holding therapy. Research on Social Work Practice, 24(2). https://doi.org/10.1177/1049731513497518

Mercer, J. (2015). Attachment therapy. In S. O. Lilienfeld, S. J. Lynn, & J. M. Lohr (Eds.), Science and Pseudoscience in Clinical Psychology (2nd ed., pp. 466–499). The Guilford Press.

Mercer J., Sarner L., & Rosa L. (2003). Attachment therapy on trial. Westport, CT: Praeger.

Oliveira, J., & Shillingsburg, A. (2023). Clinical Corner: Building rapport with students using specific strategies to promote pairing. Science in Autism Treatment, 20(12).

Pignotti M., & Mercer J. (2007). Holding therapy and dyadic developmental psychotherapy are not supported, acceptable social work interventions. Research on Social Work Practice, 17(4), 513–519. https://doi.org/10.1177/1049731506297046

Citation for this article:

Medrano, J., & Wilcox, N. (2024). A treatment summary of Holding Therapy. Science in Autism Treatment, 21(11).

Related ASAT Articles

Related ASAT Reviews:

#EIProviders #MedicalProviders #Multidisciplinary  #Researchers #SocialWorkers

Print Friendly, PDF & Email