Identifying Pathology

I recently heard (secondhand) a critique by a mental health professional about an attachment-based model of “parental alienation.”  This mental health professional was apparently concerned about “labeling” the alienating parent’s pathology as being related to personality disorder processes (“Why do we need to “label” the parent as having a personality disorder?”)

I wish to take this opportunity to address this concern for “labeling” the pathology of the allied and supposedly favored parent.


Identifying pathology is the central and primary function of mental health professionals.

To say that we shouldn’t identify the nature and severity of psychological pathology is like saying the legal system shouldn’t identify the nature and severity of the violations of the law.

Judge: “I really feel uncomfortable labeling someone as a murderer. Can’t we just say they’re a doer of bad things?”

Psychologist: “I know the person has prominent hallucinations, delusions, and conceptual disorganization, but why do we need to label the person as having schizophrenia?  Is that really necessary?  Can’t we just say they have different thoughts and experiences?”

Social Worker: “Just because someone sexually molests a child, do we really need to label that person as a pedophile?  Can’t we just say the person has unusual sexual desires?”

Our job in mental health is to understand the nature and variety of psychopathology, to assess persons and situations, and then to apply this knowledge of psychopathology to the person and situation based on standard principles of professional psychology, including the DSM diagnostic system of the American Psychiatric Association.

Personality disorders, and in this context I am speaking specifically about narcissistic and borderline personalities, are acknowledged and fully described forms of psychological pathology by preeminent figures in mental health, including Otto Kernberg (1975), Theodore Millon (2011), Arron Beck (2004), and Marsha Linehan (1994).

Narcissistic and borderline personality disorders are also recognized mental health pathology in the DSM-5 diagnostic system of the American Psychiatric Association with established diagnostic criteria.

In addition, the pathology of personality disorders is recognized as presenting along a “dimensional” continuum of severity (Widiger & Trull, 2007), meaning that a person can present some traits or features of a personality disorder without necessarily meeting the full diagnostic criteria for a personality disorder.

Furthermore, blends of personality disorder traits are acknowledged as more the norm than the exception. For example, the renowned psychiatrist, Arron Beck, describes that,

“Patients with BPD [borderline personality disorder] consistently meet criteria of one to five other personality disorders.” (Beck et al., 2004, p. 196)

And the preeminent expert in personality disorders, Theodore Millon (author of the Millon Clinical Multiaxial Inventory, which is considered the gold-standard for the assessment of personality disorders), describes the overlap of personality disorder traits for the narcissistic personality;

“Several personality disorders often covary with the narcissistic spectrum. Most notable among these are the antisocial and histrionic spectrum variants. Also listed are covariations seen with the sadistic, paranoid, negativistic personality spectra, as well as borderlines.” (Millon, 2011, p. 406)

The renowned expert in personality disorders, Otto Kernberg, identified the core structure of the narcissistic personality as representing a “subgroup of borderline patients,”

“One subgroup of borderline patients, namely, the narcissistic personalities…” (Kernberg, 1975, p. xiii)

In addition, both narcissistic and borderline personalities have been prominently associated with the collapse of thinking into delusional belief systems when under stress. The label of “borderline” personality was given to this personality style in the 1930s because this personality structure was considered to be on the “borderline” between neurotic and psychotic, and Theodore Millon has specifically described the collapse of the narcissistic personality disorders into delusional beliefs:

“Under conditions of unrelieved adversity and failure, narcissists may decompensate into paranoid disorders. Owing to their excessive use of fantasy mechanisms, they are disposed to misinterpret events and to construct delusional beliefs. Unwilling to accept constraints on their independence and unable to accept the viewpoints of others, narcissists may isolate themselves from the corrective effects of shared thinking. Alone, they may ruminate and weave their beliefs into a network of fanciful and totally invalid suspicions. Among narcissists, delusions often take form after a serious challenge or setback has upset their image of superiority and omnipotence. They tend to exhibit compensatory grandiosity and jealousy delusions in which they reconstruct reality to match the image they are unable or unwilling to give up. Delusional systems may also develop as a result of having felt betrayed and humiliated. Here we may see the rapid unfolding of persecutory delusions and an arrogant grandiosity characterized by verbal attacks and bombast. Rarely physically abusive, anger among narcissists usually takes the form of oral vituperation and argumentativeness. This may be seen in a flow of irrational and caustic comments in which others are upbraided and denounced as stupid and beneath contempt. These onslaughts usually have little objective justification, are often colored by delusions, and may be directed in a wild, hit-or-miss fashion in which the narcissist lashes out at those who have failed to acknowledge the exalted status in which he or she demands to be seen.” (Millon, 2011, pp. 407-408; emphasis added)

A delusion is an intransigently held, fixed and false belief that is maintained despite contrary evidence. The shared belief by the allied and supposedly favored narcissistic/(borderline) parent and child that the targeted-rejected parent is an emotionally or psychologically “abusive parent,” whose parenting practices present a risk to the child, represents an intransigently held, fixed and false belief which is held despite contrary evidence that the parenting practices of the targeted parent are entirely normal-range. The belief that the targeted parent is an “abusive parent” who presents a danger to the child is delusional. It is not true.

This intransigently held, fixed and false belief (i.e., a delusion) is created by the collapse of the organized cognitive structures of the narcissistic/borderline personality into delusional beliefs, as specifically described by Millon (2011), in response to the psychological stresses triggered by the “unrelieved adversity and failure” surrounding the divorce experience (i.e., the public rejection and abandonment of the narcissistic/(borderline) parent by the attachment figure of the other spouse).

The pathology of attachment-based “parental alienation” is extraordinarily severe. To miss making the diagnosis of this extremely severe psychopathology is, to me, stunningly incompetent. I can only attribute this level of professional incompetence to professional ignorance regarding the nature of personality disorder pathology, which would then likely represent practice beyond the boundaries of professional competence if the mental health professional is then diagnosing and treating personality disorder pathology.

If a patient has the characteristic symptoms of cancer, the physician diagnoses cancer.

If a patient has the characteristic symptoms of heart disease, the physician diagnoses heart disease.

The physician does not say, “Cancer is such a serious disorder, why do we need to label the patient as having cancer? Can’t we just say the patient has some “uncomfortable pains”?

According to the DSM-5, if the patient has hallucinations and delusions, then the patient is diagnosed with schizophrenia. If the patient has mania and depression, the patient is diagnosed with bipolar disorder. Personality disorder pathology exists within the DSM diagnostic structure. Delusional disorders exist within the DSM diagnostic structure.

The purpose of identifying the nature of the parental personality pathology in attachment-based “parental alienation” is NOT to diagnose the parent. The diagnosis of attachment-based “parental alienation” is made SOLELY on the CHILD’s symptom display, not the parent’s.

The purpose of identifying the nature of the parental psychopathology is to gain an accurate conceptual understanding for the nature of the pathology being displayed by the child in attachment-based “parental alienation.” The key feature of this conceptual understanding is that the pathology of the parent is being TRANSFERRED TO THE CHILD through the distorting influence on the child’s belief systems of the narcissistic/(borderline) parent’s pathology. As a result of this transfer of pathology from the parent to the child, we will see evidence in the child’s symptom display of the distorted parental influence from the narcissistic/(borderline) parent’s psychopathology.

The pathology of the parent is creating the child’s pathology, and as a result, features of the parental pathology will be evident in the child’s symptom display (I refer to these symptom features as “psychological fingerprints” of parental influence by a narcissistic/(borderline) parent).

This “psychological fingerprint” evidence in the child’s symptom display represents Diagnostic Indicator 2 for an attachment-based model of “parental alienation,” i.e., the presence of five specific a-priori predicted narcissistic/(borderline) personality traits in THE CHILD’S symptom display (I’ll defer discussion of the anxiety variant).

Q: How does a child acquire this specific set of narcissistic/(borderline) personality characteristics that are being expressed selectively just toward the targeted-rejected parent?

A: Through the psychological influence on the child’s symptom formation from the pathology of a narcissistic/(borderline) parent.

Failure to acknowledge the nature of the pathology will lead to a MISDIAGNOSIS of the personality disorder pathology displayed in the child’s symptoms as falsely representing diagnostic indicators of either oppositional-defiant behavior by the child, or problematic parenting by the targeted-rejected parent.

No. This is the wrong diagnosis.

Let me be abundantly clear… this would be the WRONG diagnosis.

The child’s symptom display is NOT oppositional-defiant behavior and is NOT the result of problematic parenting from the targeted-rejected parent. The child’s symptom display directed toward the targeted parent represents a set of specific narcissistic and borderline personality traits that are being acquired by the child through the distorted pathogenic parenting practices of the allied and supposedly favored parent. The source for this child symptom set is the narcissistic/(borderline) personality pathology of the parent that is creating the pathology of attachment-based “parental alienation” as expressed by the child.

If a mental health professional makes the WRONG diagnosis as a consequence of the personal discomfort of this mental health professional with the correct diagnosis, it would be analogous to a medical doctor making an incorrect diagnosis of cancer as instead representing high blood pressure because the physician was personally uncomfortable with the seriousness of the cancer diagnosis. The physician would then treat the patient for high blood pressure, and the patient would die from cancer.

When mental health professionals make the WRONG diagnosis concerning the pathology of attachment-based “parental alienation” as incorrectly being the product of the child’s oppositional-defiant behavior or as being caused by the problematic parenting of the targeted-rejected parent, this leads to incorrect and entirely ineffective treatment, and the patient (i.e., the child’s healthy development and the child’s healthy loving relationship with a normal-range and affectionally available parent) dies as a direct consequence of the misdiagnosis by the mental health professional.

If a physician were to ignore the symptom indicators of cancer and instead misdiagnose a patient’s cancer as being high blood pressure because of a motivated desire by the physician to avoid the correct diagnosis of cancer, and as a result of this motivated misdiagnosis the patient dies from untreated cancer, this would seemingly represent professional malpractice.

So why doesn’t the same apply to mental health? Actually, it does.

The central defining role for the mental health professional is to correctly identify psychological psychopathology.

The central defining role for the medical professional is to correctly identify the nature of physical pathology.

The central defining role for the legal professional is to correctly identify violations of the law.

Failure in any of these areas represents a fundamental failure in the primary professional obligation of the mental health, medical, or legal professional.

Personality disorder pathology exists. Delusional pathology exists, particularly in association with specific types of personality disorder pathology. It is the central professional obligation of mental health professionals to CORRECTLY identify the nature of the pathology in every single case.

Failure to do so would represent a foundational failure in the professional’s “duty of care” for the patient.

To then also assert a professional reluctance to correctly diagnose the nature of the psychopathology because of an unwillingness to apply a professionally established and defined professional label regarding the nature of the pathology runs perilously close to a motivated misdiagnosis of the psychopathology, which may then represent professionally negligent practice rather than simple incompetence.

The issue is NOT diagnosing the parent. An attachment-based model for the construct of “parental alienation” DOES NOT diagnose the parent.

The diagnosis of the pathology associated with an attachment-based model of “parental alienation” remains solely and completely focused on the symptom indicators in the child’s symptom display.

The correct clinical term for “parental alienation” is “pathogenic parenting” (patho=pathology; genic=genesis, creation). Pathogenic parenting is the creation of significant pathology in the child through highly aberrant and distorted parenting practices.

The issue is NOT the parent’s pathology. It is the transfer of this parental psychopathology to the child through highly aberrant and distorted pathogenic parenting practices, as evidenced in the specific features of the child’s symptom display.

The reason for identifying the nature of the parental psychopathology is to ground the diagnosis in an underlying theoretical understanding regarding the nature of the psychopathology, which then allows us to identify specific diagnostic indicators in THE CHILD’s symptom display that represent definitive diagnostic evidence of the psychopathology.

At its fundamental core, attachment-based “parental alienation” represents the trans-generational transmission of attachment trauma from the childhood of the allied and supposedly favored narcissistic/(borderline) parent to the current family relationships. This trans-generational transmission of attachment trauma is mediated by the distorted personality pathology of the parent. The personality pathology of the parent is, in turn, the consequent product of the attachment trauma (i.e., of disorganized attachment patterns) from the childhood of the allied and supposedly favored narcissistic/(borderline) parent.

The professional issue is NOT labeling the parent, the issue is correctly identifying the nature of the psychopathology being expressed in the child’s symptom display.

Craig Childress, Psy.D.
Clinical Psychologist, PSY 18857

References:

Beck, A.T., Freeman, A., Davis, D.D., & Associates (2004). Cognitive therapy of personality disorders. (2nd edition). New York: Guilford.

Kernberg, O.F. (1975). Borderline conditions and pathological narcissism. New York: Aronson.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford

Millon. T. (2011). Disorders of personality: introducing a DSM/ICD spectrum from normal to abnormal. Hoboken: Wiley.

Widiger, T.A. and Trull, T.J. (2007). Plate tectonics in the classification of personality disorder: Shifting to a dimensional model. American Psychologist, 62, 71-83.

 

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