A clinical psychologist is like a detective. Both systematically collect evidence to reconstruct what occurred in a particular situation.
In the case of the detective, the goal is to rely on the evidence to identify the cause of a crime, while for the psychologist the goal is to rely on the evidence to determine the cause of the symptoms.
Type of Crime = Presenting Problem
The first important information for the detective is the type of crime being investigated. Is the crime a murder, a burglary, kidnapping, embezzlement? Each type of crime will have a typical set of important information associated with it, yet the detective also avoids limiting the initial investigation based solely on the type of crime. Murders can occur as part of a burglary or to cover up embezzlement.
The detective uses the type of crime to initially structure the collection of relevant evidence, yet the detective remains open to following the evidence as it emerges and to altering initial impressions based on where the evidence leads.
For the clinical child psychologist, the “presenting problem” represents the “type of crime” in the analogy to the detective. The presenting problem defines the broad domain of initial information that is relevant to collect. Is the issue child defiance of parental directives, angry parent-child conflicts, school failure and classroom behavior problems, ADHD, child substance abuse? Each of these presenting problems will have a different set of important information associated with them.
However, the clinical child psychologist also remains open to following the clinical evidence into other domains that are not necessarily part of the presenting problem. For example, school behavior problems can result from ADHD or undiagnosed learning disabilities, and parent-child conflicts could be the product of unidentified child substance abuse, or even problems in the marital relationship. The psychologist uses the presenting problem to initially structure the collection of relevant clinical evidence, yet the psychologist remains open to following the evidence as it emerges from systematic clinical interviewing, and to altering initial clinical impressions when the evidence suggests alternative or additional issues.
Suspects = Differential Diagnoses
Based on the initial analysis of the evidence, the detective develops a tentative hypothesis of what occurred at the crime scene and begins formulating a set of possible suspects.
Additional evidence is then sought to confirm or dis-confirm these initial tentative hypotheses about the crime and possible suspects. While forming initial “leads” regarding possible causes and suspects in the crime, the detective avoids a rush to judgment that too quickly shuts down consideration of alternative possibilities.
The detective considers all possibilities and seeks evidence that may support some leads and that may dis-confirm other possibilities and suspects. For example, in investigating a possible suspect, it may turn out that this suspect has an alibi and so it becomes less likely that this person committed the crime, while following up another lead may result in additional evidence pointing to an alternative suspect as possibly committing the crime.
The detective considers all possibilities, forms tentative hypotheses, and follows up by collecting additional relevant evidence to support or dis-confirm these tentative hypotheses.
The clinical psychologist similarly considers all possibilities and then systematically collects information (clinical evidence) that dis-confirms some hypotheses and that supports other hypotheses. This process is called “differential diagnosis.” Gradually, as the clinical evidence is systematically collected, the evidence begins to constellate around some causal possibilities and begins to rule out other possibilities.
When a preponderance of clinical evidence constellates around one clinical diagnosis and rules out alternative possibilities, so that this diagnosis can be established beyond a reasonable level of clinical doubt, then this becomes the clinical diagnosis regarding the causal origins of the child’s symptoms that is then used to organize the development of a treatment plan.
The more the detective understands about how crimes occur and the more the science regarding crime scene investigation advances, the more the detective is able to collect relevant evidence that leads to an accurate conclusion regarding the causal origins of the crime.
Rarely is eye witness testimony or a confession available. Instead, the detective must rely on secondary evidence that leads to a particular suspect. In addition to circumstantial evidence such as history, motive, and opportunity, more sophisticated evidence, such as ballistics evidence, fingerprints, and DNA evidence, can all provide additional indirect evidence regarding possible suspects.
However, if a detective doesn’t understand the value or role of this advanced secondary evidence, such as ballistics, fingerprint, or DNA evidence, then the detective might not collect this evidence at the crime scene or might not correctly interpret and integrate this secondary more sophisticated evidence with other more basic information about the crime.
In analyzing and interpreting sophisticated evidence, the detective has an advantage over the clinical psychologist, since the detective can simply collect the sophisticated evidence and then send it out to a crime lab for analysis and interpretation. Clinical psychologists do not have that luxury with advanced clinical information.
The clinical child psychologist must understand the nature, role, and interpretation of advanced clinical information so that the clinical psychologist knows both to collect this clinical evidence and also how to interpret the advanced clinical evidence. The more knowledgeable and experienced the clinical child psychologist is in understanding advanced psychological principles and constructs, the more evidence becomes available to the psychologist and the more accurately the clinical psychologist can determine the causal origins of the child’s symptoms.
If the clinical child psychologist believes that child symptoms are caused by demon possession, then this severely restricts the collection and interpretation of clinical evidence regarding the cause of the child’s symptoms. If, on the other hand, the clinical child psychologist has a professional understanding for advanced principles of child development and family relationships, such as:
- the nature and role of the attachment system (Ainsworth, 1989; Bowlby, 1969, 1973, 1980; Bretherton, 1990; 1992; Bretherton & Munholland, 2008; Lyons-Ruth, Bronfman, & Parsons, 1999; van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999),
- the construct of intersubjectivity in relationships (Cozolino, 2006; Fonagy, Luyten, & Strathearn, 2011; Kaplan & Iacoboni, 2006; Shore; 1994; 1996; 1997; Stern, 2004; Tronick, 2003; Tronick, et al., 1998; Trevathan, 2001),
- the impact of parental narcissistic and borderline personality disorders on family relationships (Beck, et al., 2004; Kernberg, 1975; Kohut, 1972; Millon, 2011; Linehan 1993)
- and family systems constructs such as triangulation, boundaries, and coalitions (Goldenberg & Goldenberg, 1996; Haley, 1977; Minuchin, 1974)
then this advanced knowledge allows the clinical psychologist to collect valuable secondary evidence that provides a more accurate diagnosis, that then is used to guide the development of an effective treatment plan.
If, however, a detective does not understand the value and role of ballistics, fingerprint, and DNA evidence, then the detective does not look for and collect this evidence and so does not have this advanced level evidence available in solving the crime.
Similarly, if the clinical child psychologist is not knowledgeable about the characteristic “goal-corrected” functioning and dysfunctioning of the attachment system, about intersubjectivity in relationships and the socially mediated neurodevelopment of the brain during childhood, about the characteristic features and influence of parental narcissistic and borderline parenting processes on family relationships, and regarding family systems constructs of triangulation, boundary disturbances, and coalitions, then the clinical psychologist does not look for or collect clinical evidence in these domains and then does not have this advanced level information available in developing a clinical diagnosis.
We would be appalled at a detective who failed to collect, use, and interpret ballistics evidence, fingerprint evidence, or DNA evidence in solving a crime.
Why then do we accept a such a level of professional ignorance and professional incompetence from mental health professionals?
It seems we hold mental health professionals to a lesser standard of professional practice than detectives. I don’t know why. The failure of the mental health professional to accurately diagnose the child’s symptoms will lead to ineffective treatment that leaves the child symptomatic. This can have both short-term and long-range negative impacts on the child’s emotional, psychological, and social development that can influence both the child’s latter marital relationship as well as the child’s own parenting with his or her children in the future, thereby transmitting the psychological dysfunction to later generations.
The developmental and psychological costs on the child for the failure of mental health to accurately diagnose the child’s symptoms can be extremely destructive. So it is beyond me why we should accept and tolerate professional ignorance and incompetence in the diagnosis and treatment of children.
This blog post has a “Comment” section, perhaps child custody evaluators and mental health therapists who lack an advanced level of understanding for the attachment system, for intersubjectivity and the socially mediated neurodevelopment of the brain during childhood, for the characteristic features and display of parental narcissistic and borderline personality dynamics in family relationships (including the child’s incorporation into a role-reversal relationship with the narcissistic/(borderline) parent and the child’s display of co-narcissistic over-developed social sensitivity and precocious maturity), and for family systems constructs of triangulation, boundary disturbances, and coalitions… perhaps child custody evaluators and mental health therapists who lack a knowledge and understanding for these advanced level domains of psychology can explain to me why they don’t need to know this information, why it is acceptable for them to be ignorant.
In my view, this would be like a detective arguing that he or she doesn’t need to collect and interpret ballistics evidence, or fingerprint evidence, or DNA evidence. “It’s okay, I don’t need that information.”
That’s a very interesting position. But one with which I completely disagree. Our children and families should receive the highest standard of care possible. Anything less is unacceptable.
Imagine a detective who came to investigate a crime scene and found an unsigned typewritten note saying, “My name is Bob Jones and I committed this crime.”
It would be a pretty horrible detective who then said, “Well, I guess this case is solved. We have a confession from Bob Jones.” Particularly if the detective subsequently interviewed Bob Jones who denied ever committing the crime and ever having written the note.
“Well, even though you deny the crime and deny writing the note, I have the note saying you committed the crime, so that’s the evidence I’m going to rely on. Therefore, you committed the crime.”
What a horrible detective.
Any even marginally competent detective would consider the possibility that the unsigned typewritten note was PLANTED evidence trying to frame Bob Jones for the crime. So in addition to investigating whether Bob Jones did indeed commit the crime (i.e., Bob may remain a suspect), the detective would also entertain the possibility that this supposed “confession note” was planted evidence designed to frame Bob Jones and distract the investigation from the true source of the crime.
The detective would then collect evidence, including ballistics, fingerprint, and DNA evidence, and follow wherever the evidence led.
The child’s symptoms of rejection for the targeted parent in cases of attachment-based “parental alienation” represent PLANTED “evidence” designed to frame the targeted parent as being a bad parent.
The key to recognizing the child’s symptoms as PLANTED evidence are the “psychological fingerprints” all over the child’s symptoms of psychological influence and control by a narcissistic/(borderline) parent. Chief among this “psychological fingerprint” evidence is a specific set of five narcissistic and borderline personality traits evidenced in the child’s symptom display toward the targeted parent.
We cannot psychologically control and induce symptoms in a child without leaving “psychological fingerprints” of our control and influence of the child in the symptom display of the child.
The three diagnostic indicators of attachment-based “parental alienation” (see Diagnosis of Attachment-Based Parental Alienation), and particularly the presence of a specific set of a-priori predicted narcissistic and borderline personality disorder traits in the child’s symptom display, represent the definitive “psychological fingerprint” evidence that the child’s symptomatic rejection of a relationship with the normal-range and affectionally available targeted parent is the result of pathogenic parenting by the allied and supposedly “favored” narcissistic/(borderline) parent.
There is no other possible explanation for this specific set of child symptoms other than the pathogenic influence on the child by an allied and supposedly favored narcissistic/(borderline) parent.
The presence in the child’s symptom display of the three characteristic diagnostic indicators of attachment-based “parental alienation” (see Diagnosis of Attachment-Based Parental Alienation) represents definitive clinical evidence beyond a reasonable doubt that pathogenic parenting by the allied and supposedly “favored” parent represents the sole causative agent for the child’s symptomatic rejection of a relationship with the other, normal-range and affectionally available targeted parent.
Preponderance of Evidence
There are also additional clinical signs evidenced in the child’s symptom display toward the targeted parent that offer additional clinical evidence that the child’s symptomatic rejection of the targeted parent is being induced by the distorted pathogenic parenting practices of the allied and supposedly “favored” parent.
Taken together with the three definitive diagnostic indicators, the presence of additional clinical indicators results in a preponderance of clinical evidence constellating around the interpretation of the child’s symptom display toward the targeted parent as representing PLANTED evidence designed to frame the targeted parent as a bad parent, while the actual cause of the child’s symptoms lay in the severely distorted pathogenic parenting practices of the allied and supposedly “favored” narcissistic/(borderline) parent.
Only an atrocious psychological detective would miss collecting and interpreting this definitive clinical evidence.
Craig Childress, Psy.D.
Clinical Psychologist, PSY 18857
Ainsworth, M.D.S. (1989). Attachments beyond infancy. American Psychologist, 44, 709-716.
Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment, . NY: Basic Books.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation: Anxiety and anger. NY: Basic Books
Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. NY: Basic Books.
Bretherton, I. (1990). Communication patterns, internal working models, and the intergenerational transmission of attachment relationships. Infant Mental Health Journal, 11, 237-252.
Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 1992, 28, 759-775.
Bretherton, I., & Munholland, K. (2008). Internal working models in attachment relationships: Elaborating a central construct in attachment theory. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment (pp. 102-130). New York: Guilford Press.
Lyons-Ruth, K., Bronfman, E. & Parsons, E. (1999). Maternal frightened, frightening, or atypical behavior and disorganized infant attachment patterns. In J. Vondra & D. Barnett (Eds.) Atypical patterns of infant attachment: Theory, research, and current directions. Monographs of the Society for Research in Child Development, 64, (3, Serial No. 258).
van IJzendoorn, M.H., Schuengel, C., & Bakermans-Kranenburg, M.J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and Psychopathology, 11, 225–249.
Cozolino, L. (2006): The Neuroscience of Human Relationships: Attachment and the Developing Social Brain. WW Norton & Company, New York.
Fonagy, P., Luyten, P., and Strathearn, L. (2011). Borderline personality disorder, mentalization, and the neurobiology of attachment. Infant Mental Health Journal, 32, 47-69.
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.
Shore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale, NJ: Earlbaum.
Shore, A.N. (1996). The experience-dependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Development and Psychopathology, 8, 59-87.
Shore, A.N. (1997). Early organization of the nonlinear right brain and development of a predisposition to psychiatric disorders. Development and Psychopathology, 9, 595-631.
Stern, D. (2004). The Present Moment in Psychotherapy and Everyday Life. New York:
Tronick E.Z., Brushweller-Stern N., Harrison A.M., Lyons-Ruth K., Morgan A.C., Nahum J.P., Sander L., Stern D.N. (1998). Dyadically expanded states of consciousness and the process of therapeutic change. Infant Mental Health Journal, 19, 290-299.
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.
Trevarthen, C. (2001). The neurobiology of early communication: Intersubjective regulations in human brain development. In Kalverboer, A.F. and Gramsbergen, A. (Eds) Handbook of Brain and Behaviour in Human Development. London: Kluwer Academic Publishers
Narcissistic & Borderline Personality Disorders
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.
Kohut, H: Thoughts on narcissism and narcissistic rage. Psychoanalytic Study of the Child 1972; 27:560-400.
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.
Goldenberg, I. and Goldenberg, H. (1996). Family therapy: An overview. 4th Ed. Pacific Grove, CA: Brooks-Cole Publishing Company
Haley, J. (1977). Toward a theory of pathological systems. In P. Watzlawick & J. Weakland (Eds.), The interactional view (pp. 31-48). New York: Norton.
Minuchin, S. (1974). Families and Family Therapy. Harvard University Press.