Is holding therapy a recommended treatment for attachment disorders in children?

Holding Therapy is Not Recommended for Attachment Disorders in Children

Holding therapy is not recommended for the treatment of attachment disorders in children and is considered potentially dangerous, with no empirical evidence supporting its use. 1

Understanding Holding Therapy and Its Risks

Holding therapy (sometimes called "rebirthing therapy") is a controversial intervention that involves physically restraining a child, often against their will, purportedly to promote attachment. This approach carries significant risks:

• Physical restraint has been associated with multiple deaths in children and adolescents, with 45 deaths attributed to restraint use in psychiatric facilities between 1993 and 2003 2

• Medical complications can include:

  • Airway obstruction and asphyxia
  • Skin breakdown and neurovascular damage
  • Rhabdomyolysis leading to kidney failure
  • Accidental strangulation
  • Brachial plexus injuries 2

• Psychological risks include:

  • Traumatization, especially for children with history of abuse
  • Promotion of an aggression-coercion cycle
  • Potential to inflame rather than reduce aggressive behavior 3

Evidence Against Holding Therapy

The American Academy of Child and Adolescent Psychiatry has explicitly stated in their practice parameter that "coercive treatments with children with attachment disorders are potentially dangerous and not recommended" 1. This position is supported by:

1. Lack of empirical evidence supporting efficacy
2. Significant risk of physical and psychological harm
3. Ethical concerns about forcing physical restraint on vulnerable children

Appropriate Approaches to Attachment Disorders

For children with attachment disorders, evidence-based approaches should focus on:

• Establishing a secure attachment relationship when none exists
• Ameliorating disturbed attachment relationships with caregivers 1
• Using psychodynamic psychotherapy approaches that respect the child's autonomy 3

The British Association for Adoption and Fostering has developed a position statement against holding therapy, emphasizing the importance of finding space to think and feel what the child is communicating without resorting to dangerous interventions 4.

When Physical Restraint May Be Appropriate

It's important to distinguish between therapeutic holding therapy (not recommended) and emergency physical restraint:

• Emergency physical restraint should only be used:
  • As a last resort when less restrictive measures have failed
  • When there is immediate risk of harm to the child or others
  • With proper training and monitoring
  • For the minimum time necessary (typically averaging 20-30 minutes) 5
  • With continuous monitoring of vital signs 2

Conclusion

The National Association of State Mental Health Program Directors emphasizes that restraint should be considered a security measure, not a form of treatment, and should only be used as a last resort 2. For children with attachment disorders, treatment should focus on evidence-based approaches that promote secure attachment without coercion or force.