In my afternoon talk in Dallas, I began to more fully unpack the diagnosis of AB-PA.
Professional diagnosis is more than simply the identification of symptoms. Diagnosis involves recognizing the underlying causal origin of the pathology that leads to the pattern of symptoms.
In my Dallas talk, I drew the analogy of diagnosis to putting together the pieces of a puzzle. The symptoms are the variously shaped and colored puzzle pieces. The diagnosis is the completed picture that’s made when all the puzzle pieces are put together.
Imagine different types of puzzles (analogous to different types of pathology). There’s the puzzle Cats in the Garden that depicts three cats playing in a garden among flowers and butterflies. There’s a different puzzle depicting a train traveling through the mountains, and there’s another type of puzzle of boats sailing on a lake.
With each puzzle there are a set of characteristic puzzle pieces (diagnostic indicators) that can be used to identify the puzzle. But the puzzle is more than this limited set of characteristic pieces. The type of puzzle (the type of pathology) is the actual picture that’s made when ALL the puzzle pieces are put together.
Diagnosis of pathology is knowing how the puzzle pieces fit together to create a picture when all the puzzle pieces are assembled. It’s the puzzle Cats in the Garden because the puzzle pieces create a picture of three cats playing in the garden. It’s not a picture of a train in the mountains. It’s not a picture of boats on a lake.
Sometimes the puzzle Cats in the Garden has four cats instead of three. And sometimes there’s a watering can over in this area, and sometimes there isn’t. The cats can even be different colors sometimes. But the puzzle Cats in the Garden is always a picture of cats playing in the garden. In Cats in the Garden, there’s always flowers in this area, there’s always a couple of butterflies over here, and there’s always a wooden fence along this side.
When the entire symptom picture is put together, Cats is the Garden is never a picture of a train, and Cats in the Garden never depicts boats sailing on a lake.
In addition, the puzzle Cats in the Garden ALWAYS has three characteristic puzzle pieces that always show up in the puzzle Cats in the Garden, and that NEVER show up, all three together, in any other puzzle (in any other form of pathology). In the puzzle Cats in the Garden, there is always a yellow piece in this location, a blue piece in this location, and a red piece in this location. None of the other puzzles have these three specific pieces in these specific locations.
So if these three specific puzzle pieces are present (these three specific symptoms), then the puzzle MUST be Cats in the Garden, because no other puzzle has all three of these pieces (all three of these symptoms) in these specific locations.
But at the professional level of diagnosis, the puzzle isn’t Cats in the Garden simply because of these three pieces alone. It’s the puzzle Cats in the Garden because when you put ALL the puzzle pieces together they create a picture of three cats playing in the garden, with butterflies over here, and a fence over here. It’s not a picture of a train in the mountains, and it’s not a picture of boats on a lake.
In my descriptions of the diagnosis of AB-PA up until now, I have limited my discussion to the three definitive diagnostic indicators of AB-PS:
1.) Attachment System Suppression: The suppression of the child’s attachment bonding motivations toward a normal-range and affectionally available parent;
2.) Narcissistic Personality Traits: The presence in the child’s symptom display of five specific narcissistic personality traits;
3.) Encapsulated Persecutory Delusion: A fixed and false belief evidenced in the child’s symptom display regarding the child’s supposed “victimization” by the normal-range parenting practices of the targeted-rejected parent (an encapsulated persecutory delusion).
Up until now, I’ve not wanted to extend the discussion into the 12 Associated Clinical Signs of AB-PA because I didn’t want to confuse the issue of diagnosis. The DSM-5 diagnosis of V995.51 Child Psychological Abuse, Confirmed is based solely on the presence of the three characteristic and definitive diagnostic indicators of AB-PA. No other pathology in all of mental health (no other type of puzzle) will create this specific set of three symptoms other than AB-PA as described in Foundations. If these three symptoms are present in the child’s symptom display, the puzzle must be Cats in the Garden.
However, it’s not a clinical diagnosis of AB-PA simply because of these three puzzle pieces. It is a clinical diagnosis of the attachment related, personality disorder, family system pathology of AB-PA because when all the puzzle pieces are put together they create a picture of three cats playing in the garden. The 12 Associated Clinical Signs represent some of the other puzzle pieces that are often present in the attachment-related pathology of AB-PA (the butterflies, the flowers, the watering can).
Sometimes the puzzle of Cats in the Garden has a watering can over here, and sometimes it doesn’t. So sometimes one of these Associated Clinical Signs may be present, and sometimes not. But the puzzle Cats in the Garden (the pathology of AB-PA) ALWAYS has three specific puzzle pieces (the three definitive diagnostic indicators of AB-PA).
The Associated Clinical Signs
The time has come for me to now start unpacking and describing the 12 Associated Clinical Signs of AB-PA.
In addition to the three definitive diagnostic indicators of AB-PA and the 12 Associated Clinical Signs, there are also other diagnostic features that also create the overall picture of the pathology, such as the construct of “stimulus control” drawn from behavioral psychology that can be used to differentiate authentic from inauthentic parent-child conflict, and the construct of the “inverted family hierarchy” drawn from structural family systems therapy that identifies the presence of a cross-generational coalition within the family,
Foundations provides an overarching description of the origins of the pathology and its symptoms from within and across three distinct and separate levels of analysis (the family systems level, the personality disorder level, and the attachment system level). This overarching description of the pathology serves as the foundation for understanding the complex origins of the pathology that lead to the diagnostic symptom pattern. In my upcoming book, Diagnosis, I will more fully describe the professional assessment process and the complete diagnostic picture created by AB-PA. Beginning with this blog post though, I want to begin describing the 12 characteristic Associated Clinical Signs of AB-PA.
ACS-1 Use of the Word “Forced”
This is a very common associated clinical feature of AB-PA. It is a symptom feature most often displayed by the allied narcissistic/(borderline) parent, although the child will often evidence this symptom feature as well. In its most common form, the allied narcissistic/(borderline) parent will characterize the situation surrounding the child’s relationship with the targeted parent using the specific word “forced,” such as:
N/(B) Parent: “I can’t force the child to go on visitations with the other parent.”
N/(B) Parent: “I can’t force the child to get in the car.”
N/(B) Parent: “The child shouldn’t be forced to have a relationship with the other parent.”
This latter statement is often accompanied by ACS-2 of empowering the child:
N/(B) Parent: “The child shouldn’t be forced to have a relationship with the other parent. The child should be allowed to decide whether the child wants to go on visitation with the other parent.”
This symptom of characterizing the child as being “forced” to be with the other parent represents a sophisticated manipulative control of language to both define the other parent as “abusive” and to disempower therapeutic efforts to create a positive relationship of the child with the targeted-rejected parent.
Narcissistic and borderline personalities are masters at manipulation. There is none better.
By manipulatively characterizing the child as being “forced” to go on visitations with the targeted parent, this subtly but clearly defines the targeted parent as being an “abusive parent” and the child as being a “victimized child” within the false trauma reenactment narrative.
Why else would the child need to be “forced” to be with the other parent if it weren’t for that parent being a bad and “abusive” parent? We don’t have to “force” children to be with a loving and kind parent. If we are having to “force” the child to be with the other parent, it must be because of the bad and “abusive” parenting practices of the other parent.
In addition, mental health professionals are typically respectful of people’s autonomy and decision-making rights. Mental health professions don’t want to “force” someone to do something. By characterizing treatment-related efforts to foster the child’s development of a positive relationship with the targeted parent as “forcing the child,” this disempowers the mental health professional’s ability to encourage the child’s involvement and contact with the targeted-rejected parent.
When this symptom feature is displayed by the child, it is often accompanied by the phrase “I’m not ready” and occasionally with the offer of a possible future reconciliation if the child is allowed to reject the parent now:
Child: “I shouldn’t be forced to spend time with the other parent if I don’t want to. I’m not ready to be with that parent. Maybe if the other parent listens to me and lets me stop visiting now, then maybe in the future I’ll be ready at some point.”
This offer of possible future relationship if the child is allowed to reject the targeted parent now represents bait for the naïve and ignorant mental health professional. When combined with the characterization of the child’s relationship with the targeted parent as the child being “forced” to be with the targeted parent, the ignorance and naivete of an incompetent mental health professional will lead them into becoming an ally of the narcissistic/(borderline) parent in enacting the pathology:
MH Professional: “The child “isn’t ready” for visitations yet. The child needs more time become “ready.” The child should receive additional individual therapy to help the child become “ready.”
Narcissistic and borderline parents are masters at recruiting allies. The narcissistic personality recruits allies with the presentation of powerful self-assurance and a gregarious self-confidence. The borderline personality recruits allies through the presentation of helpless vulnerability and victimization that manipulatively elicits nurturance and “protection” from ignorant and naïve mental health professionals.
Once this manipulative ploy of “not being ready” is accepted by the naïve and incompetent mental health professional, the child will never be “ready,” and the pathology of a child rejecting a normal-range and affectionally available parent will be locked into place by the ineffective and pointless therapy conducted by an ignorant and incompetent therapist.
Sharing and receiving love between a parent and child is always a good thing. The targeted parent simply wants to love the child. There is nothing at all wrong about a child receiving love from a parent. That’s a good thing. Children want to be loved by parents. For a child not to want to be loved by a parent is really weird and it is a prominent indicator of significant pathology, either from the targeted parent (i.e., child abuse) or from the child (AB-PA).
In assessing this symptom feature, since the characterization of “forcing” the child to be with the targeted parent carries the implication of child abuse by the targeted parent, it is important to first rule out actual child abuse by the targeted-rejected parent as the source of this symptom feature.
Q: Is there any credible indication that the targeted parent presents a risk of physical or sexual abuse of the child?
If the targeted parent does present a credible risk of physical or sexual child abuse, or of severely problematic parenting (Categories 1 or 2 on the Parenting Practices Rating Scale), then this parental risk to the child needs to be fully and appropriately addressed, and the family pathology is not likely to be AB-PA because the targeted parent is not a “normal-range” parent required to meet diagnostic indicator 1 for AB-PA and the child’s belief in victimization has a reality base and is not delusional, so the child will not meet diagnostic indicator three either.
As part of all clinical assessments, the parenting practices of the targeted parent should be documented using the Parenting Practices Rating Scale. The documentation chart notes in the patient record that accompany the clinician’s ratings on the Parenting Practices Rating Scale should include examples of the parenting practices that justify the rating made by the clinician. In all cases of clinical assessment for AB-PA, the problematic or normal-range parenting by the targeted parent should be documented on the Parenting Practices Rating Scale.
If the clinical assessment of the parenting practices of the targeted parent – documented with the Parenting Practices Rating Scale – indicates that the parenting practices of the targeted parent are broadly normal-range, then the characterization by the allied parent of the child being “forced” to be with a normal-range and affectionally available targeted parent represents a clinical sign of a manipulative use of language consistent with narcissistic and borderline manipulation, and consistent with an effort to implicitly create the false trauma reenactment narrative of AB-PA pathology (“abusive parent”/”victimized child”/”protective parent”).
When the narcissistic/(borderline) attempts to manipulatively characterize the child as being “forced” to have a relationship with the normal-range and affectionally available targeted parent, the immediate response from mental health and legal professionals should be to reframe this characterization into a normal-range and accurate characterization of the child having “the opportunity” to have a positive relationship with both parents.
N/(B) Parent: “What can I do? I can’t force the child to go on visitations with the other parent.”
MH/Legal Professional: “The child isn’t being ‘forced.’ The child is being given the ‘opportunity’ to have a loving and bonded relationship with both parents. That’s a good thing.”
Resistance by the N/(B) Parent
While normal-range parents have empathy for their children and will recognize that it is emotionally and psychologically healthy for children to have a positive relationship with both parents, the narcissistic/(borderline) parent is completely absent of authentic empathy for the child, and the narcissistic/(borderline) parent will therefore be unable to recognize that the child’s having a positive relationship with both parents is emotionally and psychologically healthy for the child. Instead, the narcissistic/(borderline) parent will characterize the loss of the child’s relationship with the other parent as being a good thing because the other parent “deserves” to be rejected (ACS-11).
In an appropriately skilled interview, the mental health (or legal) professional can elicit additional Associated Clinical Signs by pressing the issue of the child being given the “opportunity” to have a loving and bonded relationship with the targeted parent. When it is suggested that the child be provided with an opportunity to bond to the targeted parent, this activates both the abandonment anxiety and the childhood trauma anxiety associated with the underlying borderline personality processes of the narcissistic/(borderline) parent. With skilled clinical questioning, the interviewer can elicit a variety of additional AB-PA features emanating from these core parental anxieties.
If the issue of providing the child with the “opportunity” to bond to the targeted parent is pressed by the mental health professional who is conducting the interview, two of the most common Associated Clinical Signs to emerge are:
ACS-2 Empowering the Child: The narcissistic/(borderline) parent will respond in a way that empowers the child to reject the targeted parent (“the child should be allowed to decide“);
ACS-10 Role-Reversal Use of the Child: The narcissistic/(borderline) parent abdicates parental authority and hides their manipulative parental influence of the child behind the child’s supposed “decision” (“I encourage the child to go, but what can I do? I can’t force the child to go on visitations. It’s not me, it’s the child who…).
Additional Associated Clinical Signs that may emerge if the issue of “opportunity” to bond is further probed in skilled questioning are:
ACS-5 The Unforgivable Event: The narcissistic/(borderline) parent justifies the child’s rejection of the targeted parent by citing a past “unforgivable event” or incident between the child and targeted parent.
ACS-7 Themes for Rejection: The narcissistic/borderline parent will offer of one of the characteristic themes for the child’s rejection of the targeted parent, such as the targeted parenting being “too controlling” or that the targeted parent’s relationship with his or her new spouse takes away from the child’s special time with just the targeted parent.
In some cases, the narcissistic/(borderline) parent will offer a clear display of psychological boundary dissolution between the experience of the parent-as-a-spouse and the experience of the child by offering a supposedly supportive statement that, “I know just what the child is going through. The other parent was just like that with me during our marriage.”
ACS-8 The Unwarranted Use of the Word “Abuse”: Sometimes, if the clinical interviewer presses the reframing of “forced” into the child being given the “opportunity” to bond to the other parent, the abandonment anxiety and childhood trauma anxiety of the narcissistic/(borderline) parent will be revealed in the unwarranted use of the word “abuse” to characterize the parenting of the targeted parent (ACS-8). All allegations of abuse must always receive a full and proper assessment. In addition, borderline personality pathology frequently characterizes the actions of other people as being “abusive.” When the word “abuse” is used to characterize someone’s behavior, two differential diagnoses immediately emerge, 1) authentic abuse, 2) borderline personality processes. Both differential diagnostic possibilities should receive full and appropriate assessment whenever the word “abuse” is used to characterize the actions of another person.
ACS-11 Targeted Parent “Deserves” to be Rejected: This is also a very common response from the narcissistic/(borderline) parent in response to being pressed on providing the child with an “opportunity” to bond to the other parent. The narcissistic/(borderline) parent will not display an understanding for the important emotional and psychological benefits to the child from an affectionally bonded relationship to the other parent, but will instead advance the theme that the targeted parents “deserves” to be rejected.
Providing the child with an opportunity to form an affectional attachment bond to the targeted parent directly activates substantial anxiety in the narcissistic/(borderline) parent for a variety of clinical reasons (Foundations). As a result, clinical interviewing that presses this reframing of the child being given the “opportunity” to bond to the targeted parent will often result in a wide display of Associated Clinical Signs and other characteristic features of the pathology, such as the almost obsessive need of the narcissistic/(borderline) parent to be the “protective parent.” In addition, a skilled clinical interviewer can often draw out a complete display of the false trauma reenactment narrative of “abusive parent”/”victimized child”/”protective parent” just in the skilled exploration and elaboration of ACS-1 Use of the Word “Forced.”
Skilled clinical interviewing will also often elicit a highly characteristic triad combination of Associated Clinical Signs: ACS-1 – ACS-2 – ACS-10, often beginning with the abdication of parental power and authority:
N/(B) Parent: “What can I do? I can’t force the child to go on visitations with the other parent. I encourage the child to go, but it’s not me, it’s the child who doesn’t want to go, and I’m merely respecting the child’s decision. The child should be allowed to decide whether to go on visitations with the other parent. I’m just listening to the child. Ask the child. We need to listen to the child.”
A professional-level diagnosis is based on the entire picture that’s created when all the symptom features are put together. The picture that’s created is of three cats playing in the garden, with a watering can over here, and butterflies over here above these the flowers. Sometimes there are four cats instead of three, and sometimes the flowers are blue instead of yellow. But the picture is always of cats playing in the garden. It’s not a picture of a train in the mountains, and it’s not a picture of boats on a lake.
And the picture will ALWAYS have three specific pieces (three definitive diagnostic indicators) in specific locations:
1.) Attachment System Suppression toward a normal-range and affectionally available parent (diagnostic evidence of an attachment-related pathology created by pathogenic parenting);
2. ) Narcissistic Personality Traits in the child’s symptom display (representing the “psychological fingerprints” in the child’s symptoms of the coercive psychological control and influence on the child by a narcissistic parent);
3.) An Encapsulated Persecutory Delusion regarding the child’s supposed “victimization” by the normal-range parenting of the targeted parent (diagnostic evidence for the false trauma reenactment narrative of AB-PA).
No other pathology in all of mental health will produce this specific set of symptoms in the child’s symptom display other than AB-PA as described in Foundations.
In addition, a professional-level diagnosis involves a full and complete professional-level understanding for the causal source of the symptom features (Foundations) that allows the mental health professional to assemble the entire picture created by the pathology – it’s the pathology of Cats in the Garden because the assembled puzzle pieces (symptom features) create a picture of three cats playing in the garden.
Special Population: Professional Expertise
AB-PA is a complex pathology. It is also a consistent pathology. When the mental health professional knows what signs, symptoms, and features to look for, the pathology jumps out into clear view. But for mental health professionals who lack the necessary training, knowledge, and expertise, the pathology can remain hidden behind the exceptionally manipulative psychological control and influence on the child by the narcissistic/(borderline) parent.
“Parental psychological control is defined as verbal and nonverbal behaviors that intrude on youth’s emotional and psychological autonomy.” (Stone, Buehler, & Barber, 2002, p. 57)
“Psychological control refers to parental behaviors that are intrusive and manipulative of children’s thoughts, feelings, and attachment to parents.” (Barber & Harmon, 2002, p. 15)
“Psychological control has historically been defined as psychologically and emotionally manipulative techniques or parental behaviors that are not responsive to children’s psychological and emotional needs. Psychologically controlling parents create a coercive, unpredictable, or negative emotional climate in the family.” (Cui, Morris, Criss, Houltberg, & Silk, 2014, p. 48)
“The central elements of psychological control are intrusion into the child’s psychological world and self-definition and parental attempts to manipulate the child’s thoughts and feelings through invoking guilt, shame, and anxiety. Psychological control is distinguished from behavioral control in that the parent attempts to control, through the use of criticism, dominance, and anxiety or guilt induction, the youth’s thoughts and feelings rather than the youth’s behavior.” (Stone, Buehler, and Barber, 2002, p. 57)
“Unresolved tension in the marital relationship might spill over to the parent-child relationship through parents’ use of psychological control as a way of securing and maintaining a strong emotional alliance and level of support from the child. As a consequence, the triangulated youth might feel pressured or obliged to listen to or agree with one parent’s complaints against the other. The resulting enmeshment and cross-generational coalition would exemplify parents’ use of psychological control to coerce and maintain a parent-youth emotional alliance against the other parent (Haley, 1976; Minuchin, 1974).” (Stone, Buehler, and Barber, 2002, p. 86-87)
The attachment-related pathology of AB-PA is sufficiently complex that it warrants this group of children and families receiving the professional designation as a “special population” who require specialized professional knowledge, training, and expertise to competently assess, diagnose, and treat.
All mental health professionals who are assessing, diagnosing, and treating this complex attachment-related, personality disorder, family systems pathology should possess professional-level knowledge in the following domains of professional practice needed for professional competence:
1.) The Attachment System: The nature, functioning, and characteristic dysfunctioning of the attachment system;
2.) Personality Disorder Pathology: The nature, development, and expression of personality disorder pathology in family relationships, particularly surrounding divorce and loss;
3.) Family Systems Therapy: The characteristic processes of family systems involved in their healthy adaptation and functioning in response to transitions and change, and in their development of maladaptive and dysfunctional patterns of relating;
4.) Complex Trauma: the authentic (and inauthentic) features of complex trauma exposure, including trauma reenactment processes.
Failure to possess the necessary professional expertise in the domains of professional competence required to conduct an appropriate assessment that leads to an accurate diagnosis and effective treatment for this attachment-related family pathology surrounding divorce would likely represent practice beyond the boundaries of professional competence in violation of professional standards of practice.
Craig Childress, Psy.D.
Clinical Psychologist, PSY 18857
Barber, B. K. and Harmon, E. L. (2002). Violating the self: Parenting psychological control of children and adolescents. In B. K. Barber (Ed.), Intrusive parenting: How psychological control affects children and adolescents. Washington, DC.: American Psychological Association.
Cui, L., Morris, A.S., Criss, M.M., Houltberg, B.J., and Jennifer S. Silk, J.S. (2014). Parental Psychological Control and Adolescent Adjustment: The Role of Adolescent Emotion Regulation. Parenting: Science and Practice, 14, 47–67.
Stone, G., Buehler, C., & Barber, B. K.. (2002) Interparental conflict, parental psychological control, and youth problem behaviors. In B. K. Barber (Ed.), Intrusive parenting: How psychological control affects children and adolescents. Washington, DC.: American Psychological Association.