Standard of Practice in Assessment, Diagnosis, and Treatment

I just wrote the following email to an attorney who was seeking consultation.  I thought the information I provide might be more broadly of interest

To an attorney:

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Attachment-Related Pathology

A child rejecting a parent is an attachment-related pathology.  The attachment system is the brain system governing all aspects of love and bonding throughout the lifespan. A child rejecting a parent is a problem in the love and bonding system of the brain; in the attachment system.

The attachment system NEVER spontaneously dysfunctions.  It ONLY becomes dysfunctional in response to pathogenic parenting (patho=pathology; genic=genesis, creation).  Pathogenic parenting is the creation of significant pathology in the child through aberrant and distorted parenting practices.

Attachment-related pathology is always caused by pathogenic parenting, either from the mother or from the father.  The diagnostic question is which parent is the source of the pathogenic parenting creating the child’s attachment-related pathology (the rejection of a parent).  In this case, is it the mother’s parenting (child abuse), or is it the father’s parenting (a “cross-generational coalition” with the child against the targeted parent)?

Pathogenic parenting is an established construct in both clinical psychology and developmental psychology and it is used most commonly in reference to attachment-related pathology because the attachment system never spontaneously dysfunctions, but ONLY becomes dysfunctional in response to pathogenic parenting.

A “cross-generational coalition” is also a defined, standard, and established construct in family systems therapy.

The process of diagnosis regarding the source of pathogenic parenting is to evaluate the parenting practices of both parents.

1.  Targeted-Rejected Parent

We start with the parenting practices of the targeted-rejected parent. We assess the parenting practices of the targeted-rejected parent using:

The Parenting Practices Rating Scale

The Parenting Practices Rating Scale documents the findings from the assessment of the targeted parent’s parenting practices.

First, identify the category of parenting,

Abusive (level 1)
Severely Problematic (level 2)
Problematic (level 3)
Healthy (level 4)

Levels 1 and 2 parenting by the targeted-rejected parent would represent pathogenic parenting by this parent.  Treatment for Levels 1 and 2 parenting should focus on changing the parenting behavior of the targeted-rejected parent.

Levels 3 and 4 parenting represent broadly normal-range parenting and could not account for a suppression in the child’s attachment bonding motivations toward a parent.

Next, rate the parenting of the targeted-rejected parent on a continuum from 0 to 100, from neglectful-uninvolved parenting (0) to hostile over-controlling parenting (100).

Normal range parenting is anything in the 25-75 range.  Our preference in professional psychology is in the range of 40-60, but respect should be given to parents to define family values within their families and with their children, consistent with their personal, cultural, and religious values.  Some parents will tend to be more permissive and lax, but still within normal-range expectations (ratings in the 30s), some parents will tend to be more firm, structured, and rule-oriented, but still normal-range (ratings in the 60s).

If a clinical assessment by the involved mental health professional identifies that the parenting practices of the targeted-rejected parent are in the normal range (documented as Category 3 or 4; and between 25-75 on the Permissive-to-Structured continuum), then the parenting practices of this parent are broadly normal-range and cannot account for the attachment-related pathology being evidenced by the child (a rejection of a normal-range attachment bond to the parent).

2.  The Allied Parent

The next step is to assess the possibility of pathogenic parenting by the allied and supposedly “favored” parent. This becomes a little more challenging because the allied parent is hiding their negative-controlling influence on the child behind the child:

Allied Parent: “It’s not me, it’s the child who is refusing.  I tell the child to go, but what can I do?  I can’t force the child to go.”

The way to assess the pathogenic parenting of the allied parent is to lift the evidence of parental psychological control of the child from off of the child’s symptom features (the “psychological fingerprints” of parental control of the child).

We cannot psychologically control a child without leaving “psychological fingerprint” evidence of the control in the child’s symptom display.

Three symptoms in the child’s symptom display represent definitive diagnostic indicators of psychological control of the child by an allied narcissistic/(borderline) personality parent:

1.  Attachment System Suppression:  The suppression of the child’s attachment bonding motivations toward a normal-range parent.

2.  Personality Disorder Traits:  Five specific narcissistic personality traits in the child’s symptom display (grandiose judging of the targeted parent; absence of empathy toward the targeted parent; entitled expectations relative to the targeted parent; haughty and arrogant attitude toward the targeted parent; splitting/polarization of perception).

3.  Persecutory Delusion:  The child displays a fixed and false belief (a delusion) in the child’s supposed “victimization” by the normal-range parenting of the targeted parent (an encapsulated persecutory delusion).

When all three of these symptom indicators are present in the child’s symptom presentation – no other pathology in all of mental health will create this specific set of symptoms other than a cross-generational coalition of the child with a narcissistic/(borderline) parent against the targeted parent.

The presence of these three symptoms are documented using:

The Diagnostic Checklist for Pathogenic Parenting

Current Providers:

If the involved mental health professional completes these two assessment documentation instruments, then I can absolutely tell you what the origins are for the attachment-related pathology in the family based on the symptom features displayed.

Normal-range parenting by the targeted parent and the three diagnostic indicators of pathogenic parenting by the allied parent are evident in the child’s symptom display… the pathogenic parenting creating the child’s attachment-related pathology is emanating from the allied and supposedly “favored” parent (a cross-generational coalition with the child against the other parent).

Treatment-Focused Assessment

These two domains (potential pathogenic parenting by the targeted-rejected parent, and potential pathogenic parenting by the allied parent) can be assessed in six to eight treatment-focused assessment sessions.

I describe this six-session assessment protocol in the booklet:

The Assessment of Attachment-Related Pathology Surrounding Divorce

DSM-5 V995.51 Child Psychological Abuse

Pathogenic parenting that is creating significant developmental pathology in the child (diagnostic indicator 1), personality disorder pathology in the child (diagnostic indicator 2), and delusional-psychiatric pathology in the child (diagnostic indicator 3) represents a DSM-5 diagnosis of V995.51 Child Psychological Abuse, Confirmed.

Assessment leads to diagnosis, and diagnosis guides treatment:

In all cases of child abuse, physical child abuse, sexual child abuse, and psychological child abuse, the standard of practice and “duty to protect” requires the child’s protective separation from the abusive parent.

The child is then treated for the consequences of the child abuse, and the child’s healthy and normal-range development is recovered and restored.

Once the child’s healthy development is restored, the child’s relationship with the formerly abusive parent is then reestablished with sufficient safeguards to ensure that the child abuse does not resume once contact with the formerly abusive parent is reestablished.  Typically, the abusive parent is required to obtain collateral individual therapy to gain and demonstrate insight into the prior abusive behavior (in this case, the psychological abuse of the child), and the level of safeguards for the child are typically based on the degree of cooperation and insight shown by the formerly abusive parent.

It is the confirmed DSM-5 diagnosis of V995.51 Child Psychological Abuse (based on the treatment-focused assessment using the Parenting Practices Rating Scale and the Diagnostic Checklist for Pathogenic Parenting) that serves as the professional and legal rationale for the protective separation period.

My typical recommendation is for a 9-month protective separation period.

Remedy: Contingent Visitation Schedule

An alternative to a protective separation period is available from a Strategic family systems intervention of a Contingent Visitation Schedule

Strategic family systems therapy (principle theorist: Jay Haley) is one of the two primary models for family therapy, the other being Structural family therapy (principle theorist: Salvador Minuchin).  Strategic family systems therapy alters how the symptom confers power within the family.

A Contingent Visitation Schedule makes time with the allied pathogenic parent contingent upon the child remaining symptom free.

Custody is ordered as 50-50%.  If the child develops symptoms (as determined by daily rating scales, monitored by the family therapist), then time with the allied pathogenic parent is reduced (to reduce the negative pathogenic influence of this parent who is creating the child’s symptoms), and time with the targeted parent is increased (to increase the time needed to repair the relationship being damaged by the pathogenic parenting of the other parent).

This increase-decrease time in visitation is defined within the structure of the Contingent Visitation Schedule.  Once the child returns to non-symptomatic, custody visitation is returned to the shared 50-50% order.

The Contingent Visitation Schedule can be used prior to a protective separation, to give the allied parent one last chance to release the child from the coalition and allow the child to love both parents, or it can be used following the protective separation to ensure that the child psychological abuse does not resume once the distorted parenting of the allied pathogenic parent is reintroduced.

Summary

Parenting Practices Rating Scale

Diagnostic Checklist for Pathogenic Parenting

Assessment of Attachment-Related Pathology Surrounding Divorce

Contingent Visitation Schedule

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

Definition of Cross-Generational Coalition

Jay Haley (1977)

“The people responding to each other in the triangle are not peers, but one of them is of a different generation from the other two… In the process of their interaction together, the person of one generation forms a coalition with the person of the other generation against his peer. By ‘coalition’ is meant a process of joint action which is against the third person… The coalition between the two persons is denied. That is, there is certain behavior which indicates a coalition which, when it is queried, will be denied as a coalition… In essence, the perverse triangle is one in which the separation of generations is breached in a covert way. When this occurs as a repetitive pattern, the system will be pathological.” (p. 37)

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