Parental Alienation Not A Mental Disorder, American
Psychiatric Association Says
By DAVID CRARY 09/21/12 01:50 PM ET EDT 
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.
In 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.
In 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.
Custody 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].
At 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.
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.
In 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].
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.
In 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:
Custody 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.
At 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
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