- Timothy M. Houchin, MD,
- John Ranseen, PhD,
- Phillip A. K. Hash, DO, PhD and
- Daniel J. Bartnicki, JD
Address correspondence to: Timothy M. Houchin, MD, Department of Psychiatry, University of Kentucky, 3470 Blazer Parkway, Lexington, KY 40509.
Abstract
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).
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 decades 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 of child-custody disputes. Its primary manifestation is the child's campaign of denigration 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 declared that 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
compelled many scholars to write articles critical of Gardner's theory.
Kelly and
Johnston have been noteworthy critics 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 it
without 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 (The Liz Library!). “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 a business-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 of independent 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 a mental 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.
Acknowledgements
The authors thank University of Kentucky medical librarian Ms. Tag Heister, MSLS, for her collaboration in this effort.
Footnotes
-
Disclosures of financial or other potential conflicts of interest: None.
- © 2012 American Academy of Psychiatry and the Law
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