Kim J. Masters, M.D.

Therapeutic Holding is defined as an adult physically holding a child for therapeutic benefit. Its use includes: comforting hugs that a child seeks out, playfully holding a child to stimulate the improvement of emotional bonds, holding an out of control child until he calms down, and provoking a child into an angry outburst and restraining him/her until he acquiesces to the adult’s wishes. While the procedure is intended for prepubescent children, it is also sometimes used with teenagers.

Because of restraint related deaths, in 1999, the Center for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) limited physical holding in accredited hospitals and residential treatment centers to crisis behavior control. Before then, holding children was justified as therapeutic on psychological grounds. Medical risks were not generally considered.

This rationale is well described in a text of the period: “Physical holding conveys the message that a person can and will control children when they cannot control themselves. Most children will not work with you on the exploration and expression of intense negative and frightening feelings unless you have convinced them that you are willing and able to provide them with external controls when they lose their internal controls” (Cotton 1993).

Holding also became part of the armamentarium of attachment therapists and attachment therapy centers. It was in these practices that fringe uses of holding were sometimes employed, which included holding teenagers, provoking children to rage while in a hold until they submitted, and performing rebirthing therapy. The Colorado State Medical Board censored a practitioner for using holding for rage reduction. Recently, criminal charges were brought after a child died during a hold in a rebirthing therapy. Adverse experiences have not stopped the general practice of using holding for attachment purposes, even though it is not mentioned in a recent authoritative compendium (Cassidy, Shaver 1999). For instance, Martha G. Welch, M.D. has written in her popular book, Holding Time, “holding time is a practical way for you as a mother to achieve a closer, more satisfying, and truly wonderful relationship with your child.” (Welch 1988).

There are vocal detractors, too. Some, like me, base our objections to holding mainly on the medical risks, and some, like Jan Hunt, M.Sc., Director of the Natural Child Project and Coordinator for British Colombia for the Canadian Society for the Prevention of Cruelty to Children, base their objections on psychological grounds: “I consider this practice to be completely at odds with attachment parenting, which is above all a relationship based on mutual trust. It can be immensely difficult for a child to regain full, genuine trust after being forcibly held–regardless of the parent’s ‘good intentions’ or the resulting surface behavior” (Hunt 2004).

Physical holding is promoted as part of attachment therapy for RAD (Reactive Attachment Disorder), practiced in attachment centers and taught by the therapists to patients and parents as a useful bonding treatment (Thomas 1997). Presumably these places operate without CMS and JCAHO surveillance. I don’t know whether they have medical equipment, such as pulse oxymeters, blood pressure or pulse measuring devices, or medical personnel trained in their use.

The media has weighed in on both sides of the holding question. On 60 Minutes II, CBS televised the inappropriate holding and restraint of a child in its exposé on Charter Hospitals (AACAP 2002). NBC’s Dateline, on the other hand, recently followed Dr. Ron Frederici’s work with parents of a severely emotionally damaged adopted child. Dr. Frederici is a well respected neuropsychologist who is known internationally for his extensive experience helping American families who adopt children raised in orphanages, particularly those in Romania. (Frederici 2004, 1998). Dateline televised some of the holding time for the child, who was held prone for 6-12 hour stretches, until his aggressive behavior stopped. Amazingly, as a result, he became much more cheerful and more respectful to family members and attentive to rules.

What is going on here? Obviously, there are different schools of thought about holding, based on personal feeling, beliefs and experience. Both may be influenced by a genetic predisposition for (or against being held). In its extremes, for example, some borderline individuals might feel holding is essential, while some autistic individuals would likely be distressed by it. Most of us are probably somewhere in this continuum, based on our own biology, early nurturing, and learning experiences.

Those favoring holding often cite the work of Dr. John Bowlby on attachment and that of Dr. Harry Harlow, who showed that monkeys raised with wire mesh mothers were immature, aggressive, and unsocialized when compared with those raised by cuddling biological mother monkeys. However, neither of these sources focuses on holding experiences that are unwanted or resisted.

Those opposed to holding cite the posttraumatic stress disorder (PTSD) literature about potential trauma from holding which results from being controlled, overpowered, and helpless in the hands of an adult captor “masquerading” as a therapeutic parent. They would see holding as an example of authoritarian and coercive parenting, i.e., “You will do it my way now or stay in my lap until you submit.” Repetitive experiences with this procedure might then lead to its internalization as a traumatic experience with PTSD sequelae.

Furthermore, since authoritarian parenting is seen as the seed bed for promoting conduct problems in children, and authoritarian styles as the basis for troubles in professional child care staff, holding is seen as sending the wrong disciplining and parenting message.

So, is therapeutic holding dead? No. Not by a long shot! It is just not allowed in JCAHO and CMS facilities. I suspect the conflicts over the uses of holding are likely to remain emotionally charged topics as long as raising children is part of human experience, particularly among those whose personal experiences lead them into work with children who have attachment and trauma issues. A Masters from page

Dr. Masters is Executive Medical Director for ABS Midlands, ABS Charleston, and New Hope Treatment- Carolinas. He is also Assistant Clinical Professor of Health and Behavior at the Medical College of Georgia and co-author of AACAP’s Practice Parameter on the Prevention of Aggressive Behavior.

AACAP (2002) Practice Parameter on the Prevention and Management of Aggressive Behavior in Psychiatric Institutions, with Special Reference to Seclusion and Restraint, 4 (2Supplement) 9S.

Cassidy J, Shaver PR (1999) Handbook of Attachment. New York: Guilford.

Cotton, N (1993) Lessons from the Lion’s Den. San Francisco: Jossey-Bass, 210.

Frederici, R (2004) Interview. Dateline, June 29.

Frederici, R (1997) Help For the Hopeless Child. Alexandria, VA: Hennage, 93-126.

Hunt Jan, (2004) The Dangers of Holding

Thomas, N (1997) When Love is Not Enough. Evergreen, CO: Families by Design.

Welch, M (1988) Holding Time New York: Fireside, 17.