The evening of June 9, 2002, Springville emergency medical technicians responded to the home of Richard and Jennete Killpack. When they arrived, they found the couple's 4-year-old daughter lying on the floor, her belly swollen, her breathing sporadic. Pink foam spilled from her mouth.
"It was coming out so fast I couldn't suction it," medical technician Terri Shuler testified at a court hearing the following May. She used four towels to soak up the foam.
"Three of the towels, I could wring water out of," Shuler testified.
The girl suffocated on her own vomit shortly after arriving by helicopter at Primary Children's Medical Center.
Her drowning was well under way hours earlier.
The girl's hands were tied behind her back with rope by her adoptive mother, and she was forced to drink water, according to videotaped testimony from a 7-year-old sister. When her father came home, the sister testified, he held the 4-year-old's head back as the couple forced more water down her throat.
She was being disciplined for taking a soft drink from a younger sibling.
"They make her drink a glass of water until she pukes," the sister told police.
Pathologists at the medical center listed the cause of death as water intoxication. The overdose of water caused the girl to vomit water and then breathe it into her lungs.
During the flight to the medical center, Cassandra Killpack also excreted and urinated large quantities of fluid.
When her parents go to trial next September, they are expected to blame Cassandra's death on the Cascade Center for Family Growth, a child behavior modification clinic in Orem that provides both traditional and unorthodox treatments.
The Killpacks claim they learned the bizarre hydrotherapy discipline method there.
A three-month investigation by the Utah County Attorney's Office cleared the center of any responsibility in Cassandra Killpack's death.
But the incident is proving fatal to the clinic. For several years, public and government scrutiny has been closing in on the state's lone provider of "holding therapy," a behavior modification treatment for severely traumatized or abused children that is reviled by some traditional child therapists but revered by many parents.
Social workers have stopped referring clients. The state Division of Child and Family Services no longer helps pay for treatment at Cascade. Directors Larry VanBloem and Jennie Gwilliam still have licenses to practice, but the state may revoke them in January.
VanBloem is nearly bankrupt. His family doctor buys his children shoes. His children must work to buy the family groceries.
"They've broken us," VanBloem says of those who have tried to shut the center down. "We're just barely hanging on."
VanBloem's critics call him a cult leader who brainwashes his clients and the dozens who passionately defend him. They say the strain of therapy he practices can result in death.
In 1999, a 10-year-old Colorado girl who weighed 68 pounds was asphyxiated during a holding therapy session called a "rebirthing" that went too far. The therapy, which is an extreme form of holding therapy, and which VanBloem strongly denies ever using at the Orem center, involves wrapping and holding a child tight in a blanket. Immobility and pressure induce panic from which the child is rescued by the parent.
Proponents believe the act creates an emotional bond that was missing between the two.
In 1997, a Midvale father suffocated his 4-year-old daughter in what he described as a holding therapy session gone wrong. He claims he was trained at the center, but prosecutors say he was using the therapy in an attempt to cover abuse of the child.
VanBloem says few understand what he does because few have seen it. They have heard stories and seen videos of terrified children pinned to the floor by several adults, screaming and pleading for help, but this is not the kind of holding therapy he practices.
It is a cold Wednesday afternoon in late October and the clouds are rolling slowly across Utah Lake, gray and heavy. In Eagle Mountain, elementary school children are walking home from school. Some are still in Halloween costumes.
Cinderellas in red velvet dresses, boys dressed as soldiers and tigers.
Inside the home of Kristi Hutchings, a frizzy-haired girl wearing a powder blue dress is asking for holding therapy. She looks up at VanBloem, her small hands held gently in his, and asks when it will be her turn.
"Not today," he says with a small smile. Then he looks up. "Do these look like terrified kids to you?" he asks.
VanBloem has treated many of these children, who suffer from what he calls "reactive attachment disorder," a malady that most often affects adopted children who have suffered severe abuse, either physically or emotionally, by a previous primary caregiver.
If a child does not form an attachment during the first three years of life, he or she will not "think and feel like a normal person," says Nancy Thomas, a Colorado therapist and advocate of holding therapy, and will often feel "a deep-seated rage, far beyond normal anger."
On this fall day, VanBloem, a licensed clinical social worker, is making a house call to treat one of Risenmay's daughters. The teenager has bony hips and light brown eyes that never seem more than halfway open. She leans into VanBloem when he calls her and tucks her head as she softly reports what got her sent home from school. They have some things to work out, he says, their foreheads touching. She smiles shyly and nods.
The bills are stacking up. Since the DCFS terminated its contract with Cascade in October 2002, parents like Risenmay have had to pay for VanBloem's services on their own. Treatment at community mental-health centers, such as Wasatch Mental Health in Utah County, is fully covered by Medicaid, while half the treatment costs at private clinics are paid for by DCFS for children adopted through the state agency.
When the state still recognized Cascade as a viable mental health option for troubled children, Risenmay sometimes took her kids there four days a week for therapy sessions that lasted from 9 a.m. to 4:30 p.m. VanBloem says approximately 95 percent of therapy sessions last two hours, and holding therapy typically lasts for 15-20 minutes. Cascade also put a "tracker" in the home to monitor the child's behavior and administer holding therapy if necessary. Overall, Cascade charged $2,000 a month.
Because most parents can't afford that on their own, two things have happened: VanBloem's business has suffered and, according to Risenmay, children who need holding therapy have regressed. Now VanBloem comes to Risenmay's house every few months. Some of her children are faring well, with occasional outbursts, while others have suffered dramatically from the decrease in contact with Cascade, she says. Risenmay's 9-year-old adopted daughter, for example, is at the Utah State Hospital, the state's mental institution.
"She needed a safe, nurturing and contained situation to even begin to deal with the things she was dealing with, and when she didn't have that, she couldn't cope," Risenmay says.
"I respect what the hospital is doing, but I don't know if they can treat her," VanBloem says, shaking his head.
Reactive attachment disorder is a disease few understand, manifesting itself in monstrous ways that would shock most parents, VanBloem says. Risenmay's 13-year-old, for example, ripped doors off their hinges as a 5-year-old, smacked her mother upside the head with a baseball bat and came after a sister with a pipe. Her daughter living at the mental hospital, adopted as a 2-year-old, smeared feces on the walls, put plastic bags over her head and once attacked her mother, cracking a rib. Her first word was the F-word.
Stories like these are common for those who have sought VanBloem's services. Tales of abuse that emerge during therapy are often so hideous VanBloem has to take breaks and walk around the Cascade building. Risenmay has vomited in a bucket.
"It is gut-wrenching what we do, but if we can't witness it and be there emotionally for the child, how can they trust us?" VanBloem asks.
"We had to design our therapy to meet the needs of these families. If that meant we had to create new programs, we created new programs. If that meant we had to come out on a Sunday, we did. Typical programs are not flexible enough to do that. The child's needs have to be addressed."
At first, Risenmay took her adopted daughters to conventional therapists, who told her what she already knew: Her girls were angry. Much of the blame for the child's condition came back to her.
With VanBloem it was different. He didn't make Risenmay sit out in the waiting room; he involved her in the therapy process. And he listened to her, without placing fault.
"I saw more progress in one therapy session than I saw in months of conventional therapy," Risenmay says.
She was not alarmed when her children screamed during therapy sessions, because it was emotion she saw every day.
"They say we incite these kids? They are already there," she says. "I can count on one hand the number of times Larry had to physically restrain my child. Yeah, you see the emotion, but you're seeing it every single day of your life, and it's uncontrolled."
Risenmay puts down her bills and leans across her daughter; VanBloem places the heel of his hand on the child's stomach and begins pressing.
"It's time to get your mad out," Risenmay says.
"I'm scared," the girl says flatly.
VanBloem places his hand on her forehead, trying to maintain eye contact.
"Stay with me," he says.
VanBloem says he was trained to practice a more intrusive form of therapy than the kind he now administers. In a CBS "48 Hours" special on the therapy, therapists at a treatment center where VanBloem worked are shown lying on top of children, yelling at them inches from their face. The boy in the video, who has since said holding therapy helped him, appears terrified.
The state's Division of Occupational Licensing, which monitors licensed therapists in Utah, began investigating Cascade in 1997, according to VanBloem, when a former client, Johanna Everett, complained of abuse at Cascade. That set off an investigation that culminated in September 2002 with a petition filed by the state Attorney General's Office seeking to revoke VanBloem's license.
The petition, which was based on interviews with former Cascade clients, detailed five cases in which VanBloem and another therapist, Jennie Gwilliam, lay on top of children face-to-face to induce "belly breathing." VanBloem and other therapists would then restrain the child by "methods including sitting on the child's legs or wrapping the child in a blanket," the petition states.
The state alleged that VanBloem then used his hands and knuckles to press into the child's abdomen and ribs, causing pain. One mother of an 8-year-old patient reported finding bruises on her daughter after therapy sessions.
Since the petition was filed, VanBloem and his supporters have vehemently disputed it. VanBloem has videotaped testimony from eight parents who say state investigators have twisted their words, that Cascade never abused their children and that holding therapy was an effective treatment.
Everett, who spurred the probe, has since recanted her story and now campaigns in support of Cascade. Everett told the Deseret Morning News in September 2002 that state investigators misled her during interviews.
"They took my statements totally out of context," she said. "Most of what I said was true, but they put little spots of lies into it. They made it sound like it was torture, and it wasn't."
Dee Thorell, an investigator with the state license division assigned to the Cascade case, declined comment.
In June, Cascade was sued by Cheryl Denise Ely Haws, who said that during therapy sessions she was led to believe she was lesbian and that she had been the victim of ritualistic, satanic abuse as a child. The lawsuit also alleges that Gwilliam recommended Haws discipline her seven children with physical restraint, and that if they failed to obey her, she could make them drink a large glass of water.
Haws was seeking counseling for depression and marital problems, but she said the sessions made her suicidal and destroyed her 20-year marriage. VanBloem said he would like to comment on the lawsuit but cannot because the matter is still in court.
Then there is a Web site www.kidscomefirst.info that implies holding therapy has caused the death of seven children and suggests that Cascade is at least partly to blame for the deaths of two of those children, including Krystal Tibbets, a 3-year-old Midvale girl who was suffocated by her father in 1997.
Her father, Donald L. Tibbets, who says he was trained by VanBloem, was released in 2002 from prison after serving a five-year sentence for child-abuse homicide.
VanBloem says he never told Tibbets to practice holding therapy in the home and says the man suffers a history of violence. He has sued the creators of the Web site for defamation.
"They want to stop us because they think we are akin to something evil. They fully believe we are doing harm to kids," he says.
VanBloem insists he doesn't lie on top of children and restrains only those children who kick and punch. Sometimes, his therapy sessions don't include holding at all. He has never hurt children, he says, or instructed others to.
"We were trained to be kind of harsh in our words, and I never did that well because I thought it wasn't that great," VanBloem says. "I never liked it because it was hard on kids. We don't do that anymore.
"We didn't leave that therapy because it wasn't working. We left it because there were less intense ways to accomplish the same thing. We wanted to make it as easy as possible on the kids. Now we approach kids in a more loving way."
On the floor, the therapy session is intensifying. Risenmay leans closer to her daughter and asks her how she feels about the man who abused her.
"Mad?" the girl whimpers.
"Well, you don't sound mad," Risenmay says sternly.
"I'm mad," the girl growls.
VanBloem holds his hand above her face.
"This is (the person who abused her) how do you feel?"
"I'm mad!" the girl screams. Risenmay screams with her, and soon the two are chanting in unison: "I'm mad! I'm mad!" at an increasing volume for 30 seconds or so, until the girl's voice begins to crack and tears bubble up from her eyes.
Once she has released her repressed rage, VanBloem and Risenmay speak to her in soothing tones about appropriate ways to deal with anger. When they are finished she hugs VanBloem. Risenmay sits on the couch, and her lanky daughter curls up in her arms like an infant.
"I'm sorry you have to carry so much inside you," Risenmay says, stroking the girl's forehead. "You're such a beautiful girl. I love you."
As part of the continuing fight to keep his license, VanBloem will present his therapy to a state regulatory board in January. He will argue that the physical prodding he does is an approved method of massage therapy and that holding therapy is supported by scientific research.
It will be a tough argument to make. According to both the American Psychiatric Association and the Utah Psychiatric Association, there is no scientific evidence to support holding therapy.
There is some debate within the mental health field over whether reactive attachment disorder even exists.
"I'm very skeptical of the way RAD is diagnosed. Therapists use a checklist that has no scientific basis, and every kid with a history of abuse gets diagnosed with it," says Jean Mercer, a psychology professor at Richard Stockton College in New Jersey and an outspoken critic of holding therapy. "It's very rare, but there are some cases of children who are psychotic from a very early age, but that's not RAD; that's early onset schizophrenia, and nothing but medication is going to help them. This idea that sitting on someone is the answer, it's just bizarre."
Both Mercer and Matthew Speltz, director of the Child Psychiatry Outpatient Clinic at the University of Washington, agree that RAD is often misdiagnosed for children who suffer obsessive compulsive disorder, anxiety, severe depression and other mental illnesses.
Therapists who treat it often describe RAD as a disease so horrific most people are unaware it exists, a disease caused by pre-birth trauma, abuse by their birth parents or even satanic rituals. Unlike conventional therapists, who view current family relationships as at least part of the problem, attachment therapists focus solely on the child, which appeals to some parents.
"Parents with a difficult child are fighting the implication that they are to blame," Speltz says. "It's appealing to listen to a therapist who says the problem resides in the child, that there is something evil in them, and without serious intervention they will become the next Ted Bundy.
"The parents are as much a victim as the kids. They are desperate for help, and they are willing to consider anything; they are so vulnerable. These are kids who have learned to survive, they can change a family, they can drive a wedge between parents, and this gives parents the power back.
"These parents are easy marks for those who are selling an idea with no scientific validation," Speltz says.
Holding therapy also pleases parents because it involves them in the process. Indeed, during the therapy session at Risenmay's house, she was as much the therapist as VanBloem. For those who believe attaching with the mother is the key to solving a child's mental-health problems, it makes sense that the mother would be involved in the session.
Speltz and Mercer compare holding therapy to brainwashing. They say it bonds a child to his or her parents in the same way boot camp bonds soldiers to their military units.
Cult leaders, fringe-rehabilitation programs and religious organizations have long used intense psychological methods to "destabilize a sense of self in order to promote compliance with an ideology or organization," Speltz wrote in a 2002 study on holding therapy.
"What's totally unscientific and a figment of imagination is that when it does work it's working for the reasons holding therapists say it works," Speltz says. "This idea that you can reduce a kid to tears, and you are bringing them back to early infancy, it's pure nonsense. Or this idea that pent-up anger is stored in the gut it's pretty primitive thinking. And it's kind of scary, because it suggests that the therapist has no training in physiology or anatomy."
"There's not a lot of difference between that and ancient theories that lumps in the head were indicative of personality, and that by moving those lumps you could change personality."
Speltz thinks holding therapy should be outlawed, and it baffles Mercer why many states still allow it. A bill sponsored by former state Rep. Mike Thompson, R-Orem, that would have banned holding therapy in Utah died from lack of support in the 2003 Legislature.
VanBloem has heard the attacks on holding therapy so many times he has them memorized. He can laugh at most of them, but what hurts is what the attacks have done to his business, his family and the children who he says need his help.
"They say I'm a cult leader. They say I brainwash people. It would be funny if it wasn't so serious," VanBloem says, sitting on the floor of Risenmay's house.
"Yeah, we've been brainwashed," Risenmay scoffs. "I have books and books, boxes and boxes stacked in my basement of research on holding therapy."
"Almost all the therapy out there has no more research than this. Our therapy has been supported by a peer-reviewed study published in an academic journal," VanBloem says. "What more do they want?"
He looks tired. His eyes are surrounded by dark circles. He has nearly gone broke fighting for the right to keep practicing. A year ago, he thought he was going to have to shut his business down.
"It's moment to moment. We're just staving off disaster," he says. "But you look at the kids, you look in their eyes, and you've got to do it."