Therapeutic-Jurisprudence

http://www.thelizlibrary.org/therapeutic-jurisprudence/time-to-end-it.html




Parental Alienation Not A Mental Disorder, American Psychiatric Association Says
By DAVID CRARY 09/21/12 01:50 PM ET EDT Description: AP
NEW YORK -- Rebuffing an intensive lobbying campaign, a task force of the American Psychiatric Association has decided not to list the disputed concept of parental alienation in the updated edition of its catalog of mental disorders.
The term conveys how a child's relationship with one estranged parent can be poisoned by the other parent, and there's broad agreement that it sometimes occurs in the context of divorces and child-custody disputes.
However, an acrimonious debate has raged for years over whether the phenomenon should be formally classified as a mental health disorder by the psychiatric association as it updates its Diagnostic and Statistical Manual of Mental Disorders for the first time since 1994.
The new manual, known as DSM-5, won't be completed until next year, but the decision against classifying parental alienation as a disorder or syndrome has been made.
"The bottom line – it is not a disorder within one individual," said Dr. Darrel Regier, vice chair of the task force drafting the manual. "It's a relationship problem – parent-child or parent-parent. Relationship problems per se are not mental disorders."
Regier and his APA colleagues have come under intense pressure from individuals and groups who believe parental alienation is a serious mental condition that should be formally recognized in the DSM-5. They say this step would lead to fairer outcomes in family courts and enable more children of divorce to get treatment so they could reconcile with an estranged parent.
Among those on the other side of the debate, which has flared since the 1980s, are feminists and advocates for battered women who consider "parental alienation syndrome" to be an unproven and potentially dangerous concept useful to men trying to deflect attention from their abusive behavior.
Some critics of the concept say it's being promoted by psychologists, consultants and others who could profit if parental alienation had a more formal status in family court disputes.
"At its worst, it lines the pockets of both attorneys and expert witnesses by increasing the number of billable hours in a given case," wrote Dr. Timothy Houchin, a University of Kentucky psychiatrist, and three colleagues in an article earlier this year in the Journal of the American Academy of Psychiatry and the Law.
"It creates an entire new level of debate, in which only qualified experts can engage, adding to the already murky waters of divorce testimony," they wrote, arguing that courts could deal with parent/child estrangement without labeling the child as mentally ill.
Advocates of the concept of parental alienation had been braced for a decision by the APA not to classify it as a syndrome or disorder, but held out hope that it would be specifically cited in an appendix as an example of a parent-child relational problem.
Regier, in an e-mail Friday, said this is "very unlikely," even though the final draft of the DSM-5 remains incomplete.
Dr. William Bernet, a professor emeritus of psychiatry at the Vanderbilt University School of Medicine, is editor of a 2010 book making the case that parental alienation should be recognized in the DSM-5. He contends that about 200,000 children in the U.S. are affected by the condition.
Bernet's proposal to the DSM-5 task force defines parental alienation disorder as "a mental condition in which a child, usually one whose parents are engaged in a high conflict divorce, allies himself or herself strongly with one parent, and rejects a relationship with the other parent, without legitimate justification."
In a telephone interview, Bernet contended that the task force had made up its mind based on factors beyond the scientific evidence.
"I think they're being motivated not by the science, but being driven by friendships, by political forces," he said.
Parental alienation surfaced on the pop-culture scene several years ago as a consequence of the bitter divorce and child custody battle involving actors Alec Baldwin and Kim Basinger. Baldwin was assailed by some feminist groups for citing parental alienation syndrome as a source of his estrangement from his daughter.
"The truth is that parental alienation really is a dangerous and cleverly marketed legal strategy that has caused much harm to victims of abuse," said the National Organization for Women amid the controversy.
Bernet, in his proposal to the DSM-5 task force, said he agreed that "in some instances the concept of parental alienation has been misused by abusive parents to hide their behavior."
"However, we strongly disagree with throwing out the baby with the bathwater," he wrote, arguing that such abuse would be curtailed if diagnostic criteria for parental alienation were established.






ANALYSIS AND C O M M E N T A R Y


The Parental Alienation Debate
Belongs in the Courtroom, Not
in DSM-5
Timothy M. Houchin, MD, John Ranseen, PhD, Phillip A. K. Hash, DO, PhD, and Daniel J. Bartnicki, JD
The DSM-5 Task Force is presently considering whether to adopt parental alienation disorder (PAD) as a mental illness. Although controversy has surrounded PAD since its inception in 1985, pro-PAD groups and individuals have breathed new life into the push to establish it as a mental health diagnosis. In this analysis, we argue that it would be a serious mistake to adopt parental alienation disorder as a formal mental illness in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
J Am Acad Psychiatry Law 40:127–31, 2012
Parental alienation disorder (PAD),1 formerly and perhaps better known as parental alienation syn­drome (PAS), is one of the most controversial diag­noses under consideration for inclusion in the Diag­nostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Dr. Darrel Regier, vice-chair of the DSM-5 Task Force, told the Associated Press that he has received more mail regarding PAD than on any other proposed diagnosis.2 In this regard, groups for and against PAD’s inclusion in the DSM-5 have been gearing up for a battle that should have been over before it began.
A Note on Alienation
PAS advocates have argued unsuccessfully for de-cades that it is a mental illness and should be included in the DSM. More recently, parental alienation sup­porters have renamed PAS as PAD and have formally submitted it for inclusion in DSM-5. Semantics aside, the concept of parental alienation is neither unique nor particularly controversial. Alienation is defined by Merriam-Webster’s online dictionary3 as “a withdrawing or separation of a person or a person’s affections from an object or position of former attachment.” There are, of course, numerous situations in which persons who are angry with an individual might try to recruit others to their point of view. Politicians frequently engage in alienation tactics to win elections, yet there is little thought to labeling this process as a diagnosis.
Text Box: Volume 40, Number 1, 2012 127In the authors’ opinion, there is nothing wrong with using the term parental alienation to describe one parent’s “campaign of denigration” (see below) against another. However, there is no good purpose served in deciding to mold an arguably contentious, collateral process of divorce into a diagnosable men­tal illness. In this article, the reader will see that pa­rental alienation as a psychiatric diagnosis has arisen from emotions emanating from custody battles, pub­licity, and economics rather than from sound, scien­tific study.
The Origin of PAS
Richard Gardner, formerly a psychoanalyst and child psychiatrist on the clinical faculty at Columbia University, introduced the term parental alienation syndrome in his 1985 debut article on the subject.4 He would later strike a very academic tone in his refined definition of PAS5:
The parental alienation syndrome (PAS) is a disorder that
arises primarily in the context ofchild-custody disputes. Its 
primary manifestation is the child’s campaign of denigra-tion against a parent, a campaign that has no justification. It results from the combination of a programing (brainwash­ing) parent’s indoctrinations and the child’s own contribu­tions to the vilification of the target parent [Ref. 5, p xx; emphasis in the original].
Over the next decade, Gardner would go on to write prolifically. He founded his own publishing company, Creative Therapeutics, through which he published over 30 books. He used this venue not only to explain and expand his theories regarding PAS, but also to promulgate other problematic the­ories. For example, he openly supported abolishing child abuse reporting laws6 and controversially de-claredthat sexual abuse cases are “turn-ons” for those involved in the court process, including lawyers and judges.7 Despite these unusual claims, Gardner was highly sought as an expert witness, testifying in over 400 child custody cases before the end of his career.8
Previous Criticisms of PAS
Controversial since its inception, PAS has com-pelledmany scholars to write articles critical of Gard-ner’s theory. Kelly and Johnston have been notewor-thycritics of PAS, writing in their 2001 article, “The Alienated Child, A Reformulation of Parental Alien­ation Syndrome, ” that “PAS terminology has led to widespread confusion and misunderstanding in judi­cial, legal, and psychological circles” (Ref. 9, p 250). They also highlighted the lack of empirical support for PAS as a psychiatric diagnosis and the barring of PAS testimony in many courtrooms.
Although they vigorously refuted the validity of PAS as a psychiatric diagnosis, Kelly and Johnston acknowledged in their article that alienating behavior sometimes occurs during the course of child custody disputes. It was in this context that they actually re­worked the concept of parental alienation so that both practitioners and the courts could usefully ap­ply itwithout invoking a mental illness. As one might expect, Gardner took issue with Kelly and Johnston’s reformulation, writing a formal rebuttal.10 Tragi­cally, Gardner ended his own life before he could see this work published in 2004. Having the last word in a spirited series of published exchanges, Kelly and Johnston submitted a response to Gardner’s rebuttal that was published in tandem with it.11
Criticisms of PAS have not been limited to mental health professionals, as legal scholars have also been loath to accept the premise that parental alienation should be formally classified as a mental illness. For example, in her 2002 article, “Parental Alienation Syndrome and Alienation: Getting it Wrong in Child Custody Cases,”12 Carol S. Bruch, JD, voiced concern with Gardner’s tendency to cite his own, non-peer-reviewed books and publications on PAS. She noted that in one typical article, Gardner cited 10 sources: 9 writings of his own and 1 by Sigmund Freud. She further refuted Gardner’s suggestion that PAS was a generally accepted psychiatric phenome­non by pointing out that, when the validity of PAS was challenged in court, his testimony was often excluded.
Text Box: 128 The Journal of the American Academy of Psychiatry and the LawIn our opinion, Gardner’s approach of self-pub­lishing books and then citing himself as an authori­tative reference in the scholarly literature went be­yond simple self-aggrandizement; it was frankly misleading. We agree with Ms. Bruch that the inac­curate portrayal of PAS as an accepted and credible diagnosis gets it wrong on many levels.
Lack of an Empirical Basis for PAS
In Gardner’s 2004 posthumous publication,10 he countered critics who consistently pointed out the lack of an empirical basis for PAS as a psychiatric diagnosis. The term empirical, Dr. Gardner argued, could be interpreted to mean direct patient observa­tion and therefore did not have to involve scientific experimentation. He claimed that when the term empirical was interpreted this way, there was ample evidence that PAS stood as a legitimate diagnosis. He then acknowledged that there was only one PAS study (his own) at that time that had actually applied statistical analysis.
In our view, the argument over how one chooses to define the word empirical is semantic. It does not change the fact that there remains a paucity of scien­tific evidence that PAS (or PAD) should be a psychi­atric diagnosis.
Since Gardner’s death, others have taken up the crusade to crown his creation of PAS with acceptance in DSM-5. For example, the book, Parental Alien­ation, DSM-V, and ICD-11,13 was published in 2010, claiming to have dozens of professional-level contributors. The book contains the aptly named chapter, “Twenty Reasons Why Parental Alienation Should Be a Diagnosis,” in which the author sought to address the frequently criticized lack of quantifi­able, empirical research support for PAS as a psychi­atric diagnosis. In the chapter, the author cited two recent studies on the interrater reliability of making the diagnosis of PAS.14,15 Both studies made use of written clinical vignettes, asking mental health eval­uators to read them and determine whether PAS was or was not present. Based on these two studies, the author of “Twenty Reasons” concluded that PAS has achieved interrater reliability. We disagree.
First, only one of these studies was published in a peer-reviewed journal. Second, both studies relied exclusively on written vignettes, with neither study broadening the scope of evaluation to include videos, live patients, or even actors. Third, a combined total of only 45 evaluators actually returned the surveys of the more than 350 that were sent out. Of those sur­veys that were returned, only 34 were considered useable. In our view, labeling PAS a viable diagnosis based on these limited studies with minimal statisti­cal sway is misguided.
Many scholars of medicine, psychology, and the law have examined the literature regarding PAS. In short, they have consistently encountered a lack of empirical studies published in peer-reviewed jour­nals. Studies of PAS typically exhibit a low number of study participants, causing us to question how some have cited these studies as proof that PAS (or PAD) should be a diagnosis in DSM-5.
Economics of PAS
As with any heated controversy, one must examine the possible financial motivations that may influence the positions of those engaged in debate. Unfortu­nately, to get a good sense of PAS’s support, one has only to follow the money trail. Litigation stemming from the dissolution of marriage is estimated to be a $28 billion industry.16 It is no secret that the cost of divorce and custody litigation can add yet another facet of stress to all involved. Adding any further complexity to the problems involved in child custody only serves to compound the financial burden borne by the affected families. A formal diagnosis of PAS, with the obligatory dueling experts testifying at a custody hearing, can become a prime source of fee generation for everyone but the divorcing family.
The Associated Press article cited above2 went on to speak about how the diagnosis of PAS might gar­ner more business for those involved in the evalua­tion of child custody. The article highlighted the view of Elizabeth Kates, an attorney who litigates child custody cases. “It’s monetary,” Kates said. “These psychologists and therapists make huge money doing the evaluations and therapies.”


As Kates suggested, additional assessments would be a financial boon to evaluators who already oversee a complicated process with multiple variables that affect cost. In 2001, psychologist Dr. Ira Turkat wrote an article in which he, too, shed light on the economics of child custody evaluations:
Text Box: Volume 40, Number 1, 2012 129Custody evaluations can be pricey.... In 2003, the Florida Court of Appeal noted that one psychologist charged $20,000—an amount equal to the parties’ entire net worth, and questioned how it could be in a child’s best interest for the family’s resources to be depleted by fees of this magnitude [Ref. 17, p 8].
To abusiness-minded, professional child custody evaluator, the adoption of PAS or PAD as a bona fide psychiatric diagnosis in DSM-5 represents a poten­tial windfall opportunity to increase fee revenue. There would almost certainly be more interviewing and testing required by both parents seeking the ser­vices ofindependent experts to testify to the existence of PAS in their children.
It does not take much prognostication to see how inserting PAS into a custody situation may serve to further escalate an already tense situation, adding billable preparation time for lawyers and psychia­trists, while lowering the likelihood of an amicable settlement without a full hearing or trial.
PAS and Hollywood
Parental alienation has not only caught the atten­tion of mental health professionals, it makes for lively discussion among attorneys, social workers, parents, and even Hollywood celebrities. Actor Alec Baldwin wrote a book on fatherhood18 that contained the chapter, “Parental Alienation.” He also appeared on various talk shows detailing how he believed that his ex-wife, actress Kim Basinger, had alienated his daughter. While Baldwin’s alienation dialogue did not scientifically advance any of the theories of PAS, it did serve to bring PAS into mainstream discussion.
In 2010, PAS was the subject of the hit TV show Law and Order and was later described and quoted in The Huffington Post.19 In the episode, a defense attorney attempted to use PAS to exculpate a young man accused of murdering his father’s girlfriend after reportedly being alienated by his mother. The judge in the episode dismissed the PAS argument, but the American Psychiatric Association is clearly not dis­missing PAS(D), at least not for now, as it considers adding PAD as a diagnosis to DSM-5.

Current Status of PAS
As mentioned earlier, several individuals are lead­ing the charge to include parental alienation in DSM-5. In addition to contributing to Parental Alienation, DSM-V and ICD-11,13 many of these individuals have also been active in the Canadian Symposium for Parental Alienation Syndrome. Shortly after the book’s publication, this group held a massive pro-PAS forum at the Mount Sinai School of Medicine in New York City.20
A current opponent to PAS’s inclusion in DSM-5 is esteemed psychologist Lenore Walker, PhD, who was among the first to describe the battered-woman syndrome. In 2010, she published an article rebut­ting the assertion in Parental Alienation that PAS is a diagnosable mental illness.21 Echoing the criticism of PAS by other writers, Dr. Walker made the sound, if classic, argument that there is a paucity of empirical data to support a formal psychiatric diagnosis of PAS. Also published in 2010 was the textbook, Principles and Practice of Child and Adolescent Forensic Mental Health,22 which credited Drs. Kelly and Johnston with largely replacing Dr. Gardner’s PAS paradigm regarding parental alienation.
Conclusions
Arguments for and against parental alienation as a mental health diagnosis have been intense and ongo­ing for decades. Gardner started the PAS movement, citing his own, self-published works as evidence that PAS is a mental illness. Gardner’s critics have consis­tently cited the lack of empirical research to support such a diagnosis. Nevertheless, PAS supporters have recently demonstrated a high level of organization, vocalization, and cohesiveness. They have garnered much press and have even received support from Hollywood celebrities.
There is little question that codifying the common phenomenon of alienation as a formalized mental disorder would further complicate many custody dis­putes, thereby increasing the time and money re­quired to evaluate these already complicated situa­tions. One has to wonder if some of the interest on the part of mental health practitioners supporting the inclusion of PAS or PAD in DSM-5 has more to do with economic self-interest than with any belief that it would lead to improved clinical practice.
Do we believe that alienation by a parent occurs in some cases of child custody? Of course! Divorce is an intense and emotionally charged situation, often bringing out the worst in all parties. Having said this, we believe the courts are quite capable of dealing with this type of scenario without invoking a mental ill­ness to explain a child’s malignity against a parent.
Text Box: 130 The Journal of the American Academy of Psychiatry and the LawAt its best, adopting PAS or PAD as a formal di­agnosis in the DSM-5 serves only to further confuse mental health practitioners and the courts. At its worst, it lines the pockets of both attorneys and ex­pert witnesses by increasing the number of billable hours in a given case. It creates an entire new level of debate, in which only qualified experts can engage, adding to the already murky waters of divorce testi­mony. We believe PAS(D) has neither the empiric support nor the clinical relevance to justify its adop­tion as amental illness. By all means, each side should be allowed to present a robust argument to gain cus­tody in court, but these conflicted children, caught in the middle, should not be labeled as mentally ill.

References
1.   American Psychiatric Association: DSM-5 Development. Condi­tions Proposed by Outside Sources. Available at http:// www.dsm5.org/ProposedRevisions/Pages/ConditionsProposed-byOutsideSources.aspx. Accessed February 23, 2011
2.   Crary D: Is Parental Alienation a Mental Disorder? MSNBC. com. Available at http://www.msnbc.msn.com/id/39463768/ns/ health-mental_health. Accessed February 23, 2011
3.   Merriam-Webster Online Dictionary. Available at http://www. merriam-webster.com/dictionary/alienation. Accessed March 16, 2011
4.   Gardner RA: Recent trends in divorce and custody litigation. Academy Forum, 29:3–7, 1985
5.   Gardner RA: The Parental Alienation Syndrome (ed 2). Cresskill, NJ: Creative Therapeutics, 1992, p xx
6.   Gardner RA: Revising the child abuse prevention and treatment act: our best hope for dealing with sex-abuse hysteria in the United States. Issues Child Abuse Accus 5:25–7, 1993
7.   Gardner RA: Sex Abuse Hysteria: Salem Witch Trials Revisited. Cresskill, NJ: Creative Therapeutics, 1991, p 31
8.   Lavietes S: Richard Gardner, 72, dies; cast doubt on abuse claims. The New York Times. June 9, 2003. Available at http://query. nytimes.com/gst/fullpage.html?res=9F05E0DB1539F93AA35 755C0A9659C8B63. Accessed March 16, 2011
9.   Johnston JR, Kelly JB: The alienated child: a reformulation of parental alienation syndrome. Fam Court Rev 39:249–66, 2001
10.            Gardner RA: Commentary on Kelly and Johnston’s ‘The Alien­ated Child: A Reformulation of Parental Alienation Syndrome.’ Fam Court Rev 42:611–21, 2004
11.            Johnston JR, Kelly JB: Rejoinder to Gardner’s “Commentary on Kelly and Johnston’s ‘The Alienated Child: A Reformulation of Pa­rental Alienation Syndrome.’ ” Fam Court Rev 42:622–8, 2004
12.            Bruch CS: Parental alienation syndrome and alienated children: getting it wrong in child custody cases. Fam Law Q 35:527, 2001

13.  Bernet W: Parental Alienation, DSM-V and ICD-11. Springfield, IL: Charles C Thomas Publisher, Ltd., 2010
14.  Rueda CA: An inter-rater reliability study of parental alienation syndrome. Am J Fam Ther 32:391–403, 2004
15.  Morrison SL: Parental Alienation Syndrome: An Inter-Rater Re-liabilityStudy. Doctoral dissertation, University of Southern Mis­sissippi, Hattiesburg, MS, 2006
16.  Hoffman L: To have and to hold on to. Forbes.com. Available at http://www.forbes.com/2006/11/07/divorce-costs-legal-biz-cx_ lh_1107legaldivorce.html. Accessed January 18, 2012
17.  Turkat ID: On the limitations of child-custody evaluations. Court Rev 48:8–13, 2005
18.  Baldwin A: A Promise to Ourselves: A Journey Through Father­hood and Divorce. New York: St. Martin’s Press, 2008


19.  Wilson S: Parental Alienation: Law &Order Tackles the Topic. Huffington Post. December 2, 2010. Available at http:// www.huffingtonpost.com/2010/12/02/parental-alienation-law-o_n_791401.html. Accessed February 23, 2011
20.  Text Box: Volume 40, Number 1, 2012 131Canadian Symposium for Parental Alienation Syndrome: Ameri­can Psychiatric Association Considers Parental Alienation for the DSM-V. Available at http://cspas.ca/press_release_aug_2010. shtml. Accessed February 23, 2011
21.  Walker LE, Shapiro RL: Parental alienation disorder: why label chil­dren with a mental diagnosis? J Child Custody 7:266–86, 2010
22.  Ludolph PS: Child custody evaluation, in Principles and Practice of Child and Adolescent Forensic Mental Health. Edited by Benedek EP, Ash P, Scott CL. Washington, DC: American Psy­chiatric Publishing, 2010, p 154




No comments: