Treatment Discussion Response to Jean Mercer

This is my response to Dr. Mercer regarding her desire to discuss treatment.

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Hello Dr. Mercer,

First, let me say it’s a pleasure to meet you and to engage you in this professional dialogue. Thank you for your response to my previous post.

Second, let me say, I am not a fan of the Gardnerian PAS model. I will in no way defend the Gardnerian PAS model. Needless to say, I suspect my criticisms of the PAS model have left me few friends among the current PAS advocates. Don’t care. The PAS model isn’t very good.

I’m a conservative clinical psychologist, and I believe we should remain within scientifically established psychological principles and constructs and work at the highest level of professional knowledge, based in the scientifically established literature.

Also, I’ve worked in the foster care system as the Clinical Director for a children’s assessment and treatment center, and I am experienced with authentic child abuse up close and personal. Whatever solutions we develop must protect 100% of children 100% of the time.

Based on your blog and Comment, I recognize your interest in moving into a discussion of treatment, but I would respectfully suggest that a discussion of treatment would be premature before we have an agreed understanding regarding the pathology we are trying to treat.

While I must plead ignorance regarding your work, I suspect you have a strong concern for protecting children from authentic child abuse and a strong reluctance to discount the reports from the children. If I’m correct in my assumptions, your position would be understandable and I would agree with it.

What I’m worried about is a very small population of children who are being parented by a narcissistic and/or borderline personality parent.

A 2008 study regarding the prevalence of Narcissistic Personality Disorder (Stinson, et al., 2008) estimates the prevalence of Narcissistic Personality Disorder at 6%.

A 2008 study regarding the prevalence of Borderline Personality Disorder (Grant, et al., 2008) estimates the prevalence of Borderline Personality Disorder at 6%.

I’m not going to quibble on numbers, but my point is it’s a small, but not insubstantial, group of families. This pathology, the narcissistic and borderline personality pathology, is also likely to be highly represented in high-conflict divorce. The association of this type of personality pathology with disorganized attachment would mean that these spouses/parents have no organized strategy for repairing relationship breaches, such as encountered in the divorce. In addition, the divorce hits dead center on the narcissistic vulnerability of primal self-inadequacy (rejection of the narcissistic personality spouse by the attachment figure of the other spouse), and dead center on the core borderline vulnerability of abandonment fears (by the attachment figure of the other spouse).

So a more florid display of narcissistic and borderline personality pathology surrounding divorce should be expected. So the clinical question becomes, what would that display look like?

In discussing the narcissistic and borderline personality structure, Otto Kernberg notes that,

“They are especially deficient in genuine feelings of sadness and mournful longing; their incapacity for experiencing depressive reactions is a basic feature of their personalities. When abandoned or disappointed by other people they may show what on the surface looks like depression, but which on further examination emerges as anger and resentment, loaded with revengeful wishes, rather than real sadness for the loss of a person whom they appreciated.” (Kernberg, 1977, p. 229)

The divorce experience is a loss, so it will produce a grief response. But if the narcissistic/borderline personality structure is characterologically unable to process sadness and grief, but instead translates it into “anger and resentment, loaded with revengeful wishes” then what we may be looking at is what Bowlby called disordered or pathological mourning.

“Disturbances of personality, which include a bias to respond to loss with disordered mourning, are seen as the outcome of one or more deviations in development that can originate or grow worse during any of the years of infancy, childhood and adolescence.” (Bowlby, 1980, p. 217)

I don’t want to go too technical in our discussion at this point, but I don’t feel I’m cherry-picking Bowlby. It think that attachment theory and personality disorder pathology can add considerably to the quality of the discussion that has thus far been dominated by a woefully inadequate proposal of PAS. Personally, I’m going to be leaving the construct of PAS behind as an interesting historical curiosity, and I intend to engage in a more scientifically and clinically anchored discussion of the pathology.

As I said in my post Cats Are Not Dogs, there is a genuine pathology, and it is linked to the pathology of a narcissistic and borderline personality parent. That’s the group of parents and their children that I am concerned about. Not all animals are cats. Not all animals are dogs. And the existence of cats does not discount the existence of dogs. Both cats and dogs have four legs, fur, and a tail. So we don’t want to get them confused. But there are also differences; cats have retractable claws, dogs don’t; dogs bark, cats meow. So once we know what we’re looking for, then we can begin to identify the specific features that clinically differentiate cats and dogs.

Recognizing that you may reasonably disagree with the order of my listing of extremely bad parenting, I would rank order my list of worst possible parents as:

1. Sexual abuse – incest
2. Narcissistic and borderline personality parent
3. Physical abuse
4. Neglect and depression
5. Actively bipolar and schizophrenic

Reasonable people can disagree on the specific order of this list, and even trying to develop a list at this extreme level of pathology may be a fool’s errand. But my point is that narcissistic and borderline personality parents are extremely bad parents.

In this regard, you may also be interested in a wonderful study by Moor and Silvern (2006) regarding the mediating role of parental empathic failure in the subsequent outcome from various forms of childhood trauma exposure. They describe in their study that,

“Only insofar as parents fail in their capacity for empathic attunement and responsiveness can they objectify their children, consider them narcissistic extensions of themselves, and abuse them. It is the parents’ view of their children as vehicles for satisfaction of their own needs, accompanied by the simultaneous disregard for those of the child, that make the victimization possible.” (p. 104)

“An empathically responsive environment precludes abuse and objectification of children. Correspondingly, the act of child abuse by parents is viewed in itself as an outgrowth of parental failure of empathy and a narcissistic stance towards one’s own children. Deficiency of empathic responsiveness prevents such self-centered parents from comprehending the impact of their acts, and in combination with their fragility and need for self-stabilization, predisposes them to exploit children in this way.” (p. 94-95)

“The indication that posttraumatic symptoms were no longer associated with child abuse, across all categories, after statistically controlling for the effect of perceived parental empathy might appear surprising at first, as trauma symptoms are commonly conceived of as connected to specifically terrorizing aspects of maltreatment (e.g., Wind & Silvern, 1994). However, this finding is, in fact, entirely consistent with both Kohut’s (1977) and Winnicott’s (1988) conception of the traumatic nature of parental empathic failure. In this view, parental failure of empathy is predicted to amount to a traumatic experience in itself over time, and subsequently to result in trauma-related stress. Interestingly, even though this theoretical conceptualization of trauma differs in substantial ways from the modern use of the term, it was still nonetheless captured by the present measures.” (p. 197)

The characterological incapacity for empathy and the role-reversal violation of psychological boundaries associated with the narcissistic/borderline personality pathology is what has me so deeply concerned for the children of these parents (Fonagy, Luyten, & Strathearn, 2011).

Splitting and Triangulation Through the Cross-Generational Coalition

Returning to the narcissistic/borderline parent’s response to divorce, what happens when the splitting pathology of the narcissistic/borderline parent is added to a role-reversal cross-generational coalition as defined by Minuchin (1974) and Haley (1977)? The pathology of splitting cannot accommodate to ambiguity (Juni, 1995). It polarizes perceptions into extremes of all-good or all-bad. This polarization does not involve an actual physical separation of brain networks, but rather a neurological cross-inhibition of these networks.

The borderline personality structure has its origins in disorganized attachment involving incompatible motivational directives for attachment bonding and avoidance. According to Aaron Beck and his colleagues (2004),

“Various studies have found that patients with BPD are characterized by disorganized attachment representations (Fonagy et al., 1996; Patrick et al, 1994). Such attachment representations appear to be typical for persons with unresolved childhood traumas, especially when parental figures were involved, with direct, frightening behavior by the parent. Disorganized attachment is considered to result from an unresolvable situation for the child when “the parent is at the same time the source of fright as well as the potential haven of safety” (van IJzendoorn, Schuengel, & Bakermans-Kranburg, 1999, p. 226).” (p. 191)

The pathology of splitting arises to resolve the simultaneous activation of attachment bonding motivations (“haven of safety”) and avoidance motivation (“source of fright”) created by a parent who is “at the same time the source of fright and the potential haven of safety” (creating the disorganized attachment).

Splitting involves the intense neurological cross-inhibition of attachment bonding and avoidance motivations, so that a single coherent motivational directive can be achieved. When one motivating system is on, the other motivating system is entirely turned off (cross-inhibited), so that only one or the other of these motivational systems can be active at any given time, which produces the characteristic polarization of perception into extremes of idealization or devaluation, and the complete absence of ambiguity (i.e., of both networks being on simultaneously which would modulate the perception of the other person).

With the divorce, the spouse becomes an ex-spouse, i.e., the representational networks for the spouse switch from the attachment bonding motivational system to the avoidance motivating system. Since the pathology of splitting cannot accommodate to ambiguity, only one of these motivational networks can be active at any given time, and with the divorce that network for the other spouse/(parent) is the avoidance motivating system. The attachment-bonding networks are entirely turned off (neurologically inhibited). Which means that the narcissistic/borderline parent cannot perceptually register the continuing attachment bond between the child and the other parent because the attachment bonding system in the brain of the narcissistic/borderline parent is being entirely shut down (cross-inhibited by the avoidance system).

This leads to a characteristic feature of this pathology, that the narcissistic/borderline parent cannot recognize, cannot perceptually register, that a normal child’s attachment system would want a relationship with the other parent (the parent who the narcissistic/borderline parent now perceives as being the embodiment of evil because of the splitting pathology).

With the divorce, the spouse has become an ex-spouse, so they must also become an ex-parent. There is no other possibility allowed by the neural networks of the splitting pathology. The ex-husband MUST become an ex-father; the ex-wife an ex-mother. This is a neurologically imposed imperative created by the splitting pathology.

The narcissistic/borderline personality parent accomplishes this goal by engaging the child into a cross-generational coalition (i.e., a role-reversal relationship as a “regulatory object” for the parent) in which the child is induced into rejecting the other parent (actually, the child is induced into adopting a trauma reenactment role of “victimized child” but I don’t want to get too far afield; I describe the symptom induction process in Foundations).

What we’re essentially looking at in the pathology traditionally called “parental alienation” is the manifestation of narcissistic and borderline personality pathology into the family relationships as a consequence of the divorce.

This whole dynamic is much more involved and complex, and I would refer you to Foundations for a complete description of the pathology. My point is that the pathology exists. The pathology of narcissistic and borderline personality disorder exists. And it is this pathology that is creating the child’s symptom display which is traditionally called “parental alienation.” The legions of parents who are claiming that they have been completely cut off from relationships with their children because of the pathological parenting of their ex-spouse are not delusional. The pathology exists as a manifestation into the family processes of narcissistic and borderline personality disorder pathology of the allied and supposedly “favored” parent.

That’s not to say that children do not also reject relationships with parents because of authentic child abuse and domestic violence. Just because cats exist doesn’t nullify the existence of dogs. Both cats and dogs exist.

But right now, I’m discussing cats, not dogs. We can discuss dogs once we recognize the existence of cats. The existence of dogs, while actual, does not nullify the existence of cats. Cats exist. Narcissistic and borderline personality pathology exists.

Treatment

So, returning to your initial desire to discuss treatment, the question becomes what is the treatment for a child’s role-reversal pathology as a regulatory object for a narcissistic/borderline parent? In this regard, my primary concerns would include both the “invalidating environment” described by Linehan (1993) and the role-reversal pathology (Kerig, 2005) in which the child is used as a regulatory object to stabilize the parent’s pathology, both of which are associated with narcissistic and borderline psychopathology.

Linehan and Koerner (1993) describe the invalidating environment,

“A defining characteristic of the invalidating environment is the tendency of the family to respond erratically or inappropriately to private experience and, in particular, to be insensitive (i.e., nonresponsive) to private experience… Invalidating environments contribute to emotional dysregulation by: 1) failing to teach the child to label and modulate arousal, 2) failing to teach the child to tolerate stress, 3) failing to teach the child to trust his or her own emotional responses as valid interpretations of events, and 4) actively teaching the child to invalidate his or her own experiences by making it necessary for the child to scan the environment for cues about how to act and feel.” (p. 111-112)

In their description of the invalidating environment, Fruzzetti, Shenk, and Hoffman, (2005) note the nullification of the child’s self-authenticity,

“In extremely invalidating environments, parents or caregivers do not teach children to discriminate effectively between what they feel and what the caregivers feel, what the child wants and what the caregiver wants (or wants the child to want), what the child thinks and what the caregiver thinks.” (p. 1021)

In the Journal of Emotional Abuse, Kerig (2005) describes the pathology of the role-reversal relationship and notes the nullification of the child’s self-authenticity,

“Rather than telling the child directly what to do or think, as does the behaviorally controlling parent, the psychologically controlling parent uses indirect hints and responds with guilt induction or withdrawal of love if the child refuses to comply. In short, an intrusive parent strives to manipulate the child’s thoughts and feelings in such a way that the child’s psyche will conform to the parent’s wishes.” (p. 12)

“In order to carve out an island of safety and responsivity in an unpredictable, harsh, and depriving parent-child relationship, children of highly maladaptive parents may become precocious caretakers who are adept at reading the cues and meeting the needs of those around them. The ensuing preoccupied attachment with the parent interferes with the child’s development of important ego functions, such as self organization, affect regulation, and emotional object constancy.” (p. 14)

Rappoport (2005) describes the parenting of a narcissistic personality,

“To the extent that parents are narcissistic, they are controlling, blaming, self-absorbed, intolerant of others’ views, unaware of their children’s needs and of the effects of their behavior on their children, and require that the children see them as the parents wish to be seen. They may also demand certain behavior from their children because they see the children as extensions of themselves, and need the children to represent them in the world in ways that meet the parents’ emotional needs.” (p. 2)

In describing the co-narcissist’s relationship with a narcissistic personality, Rappoport (2005) describes the nullification of the other person’s self-experience,

“In a narcissistic encounter, there is, psychologically, only one person present. The co-narcissist disappears for both people, and only the narcissistic person’s experience is important.” (p. 3)

In the family systems literature, the construct would be psychological enmeshment. In the child development literature it would involve the construct of shared “intersubjectivity.”

Ultimately, the role of intersubjectivity is going to become central to understanding the pathology, and the works of Stern, Tronick, Trevarthan, Fonagy, and others is going to become prominent to understanding the pathology and important for understanding treatment.

Stern (2004), for example, describes the neurological underpinnings of shared psychological experience,

“Our nervous systems are constructed to be captured by the nervous systems of others. Our intentions are modified or born in a shifting dialogue with the felt intentions of others. Our feelings are shaped by the intentions, thoughts, and feelings of others. And our thoughts are cocreated in dialogue, even when it is only with ourselves. In short, our mental life is cocreated. This continuous cocreative dialogue with other minds is what I am calling the intersubjective matrix… The idea of a one-person psychology or of purely intrapsychic phenomena are no longer tenable in this light.” (p. 76)

Tronick (2003) refers to this shared psychological state as a “dyadic state of consciousness,”

“When mutual regulation is particularly successful, that is when the age-appropriate forms of meaning (e.g., affects, relational intentions, representations; see Tronick 2002c, d) from one individual’s state of consciousness are coordinated with the meanings of another’s state of consciousness — I have hypothesized that a dyadic state of consciousness emerges.” (p. 475)

The mirror neuron network represents the neurological substrate for this shared psychological state (Iacoboni, et al, 2005; Kaplan & Iacoboni, 2006).

The concern surrounding the pathological parenting of a narcissistic/borderline parent is that the child is being used in a role-reversal relationship as a regulatory object to stabilize the pathology of the narcissistic/borderline parent, and that this role-reversal pathology has nullified the child’s self-authenticity in order to meet the needs of the narcissistic/borderline parent.

So if you wish to begin a discussion of treatment, then I would pose the question to you as to what you propose the treatment to be for the role-reversal pathology of a child’s cross-generational coalition with a narcissistic/borderline parent in which the child is being used as a regulatory object to stabilize the pathology of the narcissistic/borderline parent?

In order to engage the discussion of treatment, we need to first understand what the pathology is that we are treating.

In my view, a discussion of treatment is a bit premature, but if you want a beginning orientation to my basic views, I would refer you to my blog post, On Unicorns, the Tooth Fairy, and Reunification Therapy in which I discuss a general orientation to therapy for this type of narcissistic/borderline personality pathology within the family from multiple perspectives.

In your blog you drew from one possible idea I’ve put foward, a strategic family systems intervention, for treating the pathology of a role-reversal relationship with a narcissistic/borderline parent in which the child is being used as a regulatory object to stabilize… you know that’s an awfully long sentence to write each time I have to refer to this pathology… isn’t there some shorter label we can give to this type of pathology?

Hmmm… people in the general population appear to be calling it “parental alienation.” The problem is, if I call it “parental alienation” then everyone is going to think I’m talking about a Gardnerian model of PAS, and I’m not. But if I label this pathology something different, then people won’t realize that I’m talking about the same type of pathology they are, of a child’s induced rejection of a parent which they’re calling “parental alienation.”

Okay, how about this. I’ll use the term “parental alienation” but I’ll put it in quotes to indicate that it’s not an actually defined pathology, and then I’ll add the words attachment-based to differentiate this description of the pathology from the Gardnerian PAS model.

So that’s what I’ve done. Going forward, Dr. Mercer, if you’d like to refer to the pathology of a narcissistic/borderline parent inducing a role-reversal relationship… on and on long sentence… by some other label, I’m open to that. My preference, based on my analysis of the pathology in Foundations, would be “attachment-trauma reenactment pathology.” But if you want to call it “Bob” – that’s fine by me.

I don’t care what we call it, we just need to recognize that narcissistic and borderline personality disorders exist and that this form of pathology becomes highly activated surrounding divorce (i.e., the loss of the attachment figure and direct hits on the core vulnerabilities of the narcissistic/borderline parent), and that a narcissistic/borderline parent has an extremely devastating impact on child development. Cats exist. Dogs exist. They both exist.

Parallel Process

One of the dangerous features of working with borderline personality pathology is the parallel process of splitting that can occur among the mental health professionals working with the borderline pathology. Marsha Linehan (1993) refers to this parallel process as “staff splitting.”

“Staff splitting,” as mentioned earlier, is a much-discussed phenomenon in which professionals treating borderline patients begin arguing and fighting about a patient, the treatment plan, or the behavior of the other professionals with the patient… arguments among staff members and differences in points of view, traditionally associated with staff splitting, are seen as failures in synthesis and interpersonal process among the staff rather than as a patient’s problem… Therapist disagreements over a patient are treated as potentially equally valid poles of a dialectic. Thus, the starting point for dialogue is the recognition that a polarity has arisen, together with an implicit (if not explicit) assumption that resolution will require working toward synthesis.” (p. 432)

I am concerned that the parallel process of splitting has infected previous discussions of this pathology surrounding the Gardnerian PAS model, in which hyperbolic exaggerations have been used to characterize reasonable and responsible mental health professionals as somehow being unethical and as seeking the abuse of children.

In moving forward with professionally responsible dialogue, I would desperately want to avoid the parallel process of “staff splitting” described by Linehan. “Sides” are a manifestation of the splitting pathology. There are no sides. We all want to protect children from child abuse. 100% of children 100% of the time. The critics of Gardnerian PAS want to protect children from an authentically abusive parent (dogs exist). The supporters of the “parental alienation” construct want to protect children from the pathology of a narcissistic/borderline parent – although they have not been describing it in this way – (cats exist).

In her wisdom, Marsha Linehan has pointed to the door out from the parallel process of splitting. Each side in the dialogue represents “equally valid poles in a dialectic” and “the starting point for dialogue is the recognition that a polarity has arisen, together with an implicit (if not explicit) assumption that resolution will require working toward synthesis.”

Working toward a reasonable, professionally sound, and scientifically supported synthesis for addressing all forms of emotional, psychological, physical, and sexual abuse of children is what I seek in proposing an attachment-based reformulation for the pathology traditionally called “parental alienation.”

Best wishes,

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

References

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Fonagy, P., Luyten, P., and Strathearn, L. (2011). Borderline personality disorder, mentalization, and the neurobiology of attachment. Infant Mental Health Journal, 32, 47-69.

Fruzzetti, A.E., Shenk, C. and Hoffman, P. (2005). Family interaction and the development of borderline personality disorder: A transactional model. Development and Psychopathology, 17, 1007-1030.

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Haley, J. (1977). Toward a theory of pathological systems. In P. Watzlawick & J. Weakland (Eds.), The interactional view (pp. 31-48). New York: Norton.

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Kaplan, J. T., & Iacoboni, M. (2006). Getting a grip on other minds: Mirror neurons, intention understanding, and cognitive empathy. Social Neuroscience, 1(3/4), 175-183.

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Linehan, M. M. & Koerner, K. (1993). Behavioral theory of borderline personality disorder. In J. Paris (Ed.), Borderline Personality Disorder: Etiology and Treatment. Washington, D.C.: American Psychiatric Press, 103-21.

Minuchin, S. (1974). Families and Family Therapy. Harvard University Press.

Moor, A. and Silvern, L. (2006). Identifying pathways linking child abuse to psychological outcome: The mediating role of perceived parental failure of empathy. Journal of Emotional Abuse, 6, 91-112.

Rappoport, A. (2005). Co-narcissism: How we accommodate to narcissistic parents. The Therapist.

Stern, D. (2004). The Present Moment in Psychotherapy and Everyday Life. New York: W.W. Norton & Co.

Stinson, F.S., Dawson, D.A., Goldstein, R.B., Chou, S.P., Huang, B., Smith, S.M., Ruan, W.J., Pulay, A.J., Saha, T.D., Pickering, R.P., and Grant, B.F. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV Narcissistic Personality Disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69, 1033-1045.

Tronick, E.Z. (2003). Of course all relationships are unique: How co-creative processes generate unique mother-infant and patient-therapist relationships and change other relationships. Psychoanalytic Inquiry, 23, 473-491.