Standards of Practice for Court Ordered Parent-Child Therapy

The Court has the right to expect the highest standards of professional practice from psychotherapists who conduct therapy in response to Court orders.

The professional practices of therapists who provide Court-ordered psychotherapy to children and families should therefore reflect the highest standards of professional practice.

Professionally established guidelines exist that define standards of professional practice for forensic psychologists (Specialty Guidelines for Forensic Psychology, 2013) and guidelines have been proposed for professional standards of best practice regarding child custody evaluations (Patel, & Choate, 2014), yet no professional guidelines have been proposed or established for mental health therapists providing Court-ordered therapy.

I would propose that this is easily rectified: Mental health therapists should always render services at the highest professional standard of practice.

If our child had cancer, wouldn’t we want THE BEST doctors and THE BEST treatment available anywhere for the treatment of our child.  Why should we expect any less from psychotherapy?  Children’s futures, their healthy or unhealthy development, their future success, struggles, and pain, can all depend on the quality of the psychotherapy services they and their families receive.  This is an awesome professional responsibility.

Mental health therapists should provide to their clients exactly the same standard of professional care that the therapist would want for his own daughter or for her own son.  For our own children we would want the best possible treatment, whether for cancer or psychological issues. Why should we provide less professional competence to our client children and families than we would want for our own children and families?

Mental health therapists should always render services at the highest standard of professional practice.

And Courts have the right to expect the highest standard of professional practice for child and family litigants referred by the Court for therapy.

Defining the Quality of Care

For many years now I have taught clinical assessment and treatment planning to Master’s level students seeking to become psychotherapists. Prior to my entering private practice I served as a psychologist on medical staff at Children’s Hospital of Orange County where I supervised pre-doctoral and post-doctoral psychology interns and fellows in the APA accredited internship at the hospital. I later served as the Clinical Director for a children’s assessment and treatment center, where I trained and provided clinical supervision in child and family therapy for psychology interns and post-doctoral fellows treating young children who were primarily referred through the Department of Children’s Services and the foster care system.

The following framework for clinical assessment represents the professional standard of practice that I would EXPECT from any graduate student I teach or therapist I supervise if they were to provide Court-ordered family therapy to restore a fractured parent-child relationship, and the following framework would definitely be what I would expect of therapists at the professional level who provide Court-ordered psychotherapy to children and families.

The Court and our clients have the right to expect the highest standard of professional practice from psychotherapists who provide Court-ordered psychotherapy to children and families, and therapists who provide Court-ordered psychotherapy to children and families should expect to provide the highest quality of care to their clients.

Source of Clinical Information

Therapists conducting Court-ordered therapy to treat and resolve parent-child conflict should collect appropriately comprehensive clinical data necessary to develop an accurate case conceptualization which is needed for the development of an effective treatment plan.

For child and family issues, the collection of appropriately comprehensive clinical information would typically involve collecting information from the following sources:

Parental Clinical Interviews: Clinical interviews conducted with each parent individually to obtain each parent’s perspective on background history and symptom information. 

Parent-Child Assessment: Initial parent-child therapy assessment sessions with the parent and child who are the clients targeted for treatment, to observe and conduct clinical probes of individual functioning and conjoint relationship dynamics, including client responses to clinical intervention probes.

Child Assessment: Separate child clinical assessment interviews that include clinical probes and assessment of the child’s emotional and psychological functioning.

Relevant Collateral Sources: Review of relevant reports and documents and clinical interviews with relevant collateral sources of information, such as additional family members.

Written Case Conceptualization and Treatment Plan

Therapists providing Court-ordered psychotherapy to restore a fractured parent-child relationship should, within 4 to 6 weeks of the initial intake assessment, produce a written case conceptualization and treatment plan.

Content Domains of the Case Conceptualization

This written case conceptualization should document the following:

  • Presenting Problem:  A brief introduction to the issues and symptoms that necessitate therapy
  • History of the Presenting Problem:  A description of how the presenting problem emerged, its developmental course over time, and its severity
  • Family History:  A description of current family relationships, the family’s history, and relevant information about the parents’ family of origin history
  • Academic & Work History:  A description of the child’s school behavior and academic performance, and the work history of the parents
  • Additional Relevant History:  A description of additional relevant information, such as possible trauma history within the family (including in the childhood of the parents or with the grandparents), histories of alcoholism and substance abuse within the family (including in the parent’s childhood or with the grandparents), and histories of psychiatric diagnoses within the family (including the extended family). Additional relevant social, legal, and medical histories should be documented.

Jones, K. D. (2010). The unstructured clinical interview. Journal of Counseling and Development, 88, 220-226.

  • Case Conceptualization: The symptoms to be addressed by therapy should be specified and a theoretically substantiated clinical determination should be made regarding the apparent origins of these symptoms.

The theoretical framework that organizes the case conceptualization can be from any of the six primary schools of psychotherapy; psychodynamic, humanistic-existential, cognitive-behavioral, family systems, post-modern social constructionism, neuro-social developmental, or can draw from and integrate several theoretical models (the anticipated length of this case conceptualization would be 1-2 pages and would assume the reader has a professional level knowledge of the theoretical foundations).

Content Domains of the Treatment Plan

The written treatment plan should specify a set of theoretically substantiated treatment interventions that are directly linked to the clinical case conceptualization regarding the origins of the symptoms.

The written treatment plan should specify an estimated timeframe for accomplishing the resolution of the identified symptoms, with due consideration given to the variability of treatment related influences that may arise and alter this estimated timeframe. The written treatment plan should also offer an estimated prognosis for recovery of normal-range development and relationships.

If the estimated timeframe for resolving the symptoms exceeds six months, then a six month benchmark of anticipated gains should be identified and the reasons for the longer than six month estimate of therapy should be documented.

Treatment Progress Updates

At six-month intervals during the course of therapy, the therapist should provide written treatment progress updates specifying the treatment gains to date and the estimated timeframe for achieving a resolution of the symptoms.

If treatment progress has not been substantial in six months of therapy, then an explanation of the barriers to treatment should be documented, and adjusted interventions should be identified to address these barriers.

There are a variety of possible reasons for the failure to achieve substantial treatment progress in six months,

Neuro-biological limitations. These include factors such issues as autism-spectrum limitations, prenatal child exposure to drugs or alcohol that affects cognitive and behavioral development, parental psychiatric disturbances such as bipolar disorder or schizophrenia, etc. These types of issues present an inherent limitation to the treatment gains that can be expected, and realistic treatment expectations need to be established.

Therapist failure. The therapist may lack adequate knowledge and expertise to enact the therapy, or the client-therapist fit may not promote treatment success. A change in therapists may be indicated.

Inaccurate case conceptualization. The initial case conceptualization may have been in error leading to treatment interventions that were off-target to the origins of the symptoms. A revision in the case conceptualization and the treatment plan may be necessary.

Note: Research in psychotherapy efficacy finds that all theoretical orientations are effective (Wampold, 2001). According to the empirical research, the key determinative feature in psychotherapy efficacy is that the therapist has a model of psychotherapy for case conceptualization and that the client accepts this model as an explanation for the problem.

Client factors. A client within the family system may be resistant to the goals of treatment, resulting in slowed treatment progress. The nature of the client factors affecting therapeutic progress should be identified and revised treatment interventions to address and adjust to client factors should be specified.

Inadequate time. Treatment progress is being made, but the prior issues creating the symptoms are complex and deeply embedded and require a longer period of time to resolve. The underlying issues slowing treatment progress should be documented along with an estimated time frame and prognosis, and the factors affecting prognosis should be identified.

Treatment expectations:

  • In most cases of parent-child conflict, substantial treatment progress should be expected from six months of therapy.
  • Treatment should be expected to resolve the symptoms in no longer than one year of therapy.
  • Failure to meet these expectations should generate documentation as to the reasons for the failure of therapy to meet these expectations.

Note on Child Development:

The developmental phases of childhood are relatively brief and each phase is associated with important child experiences and emerging developmental capacities that build sequentially and cumulatively upon earlier developmental maturation.

Child developmental phases occur at approximately three-month intervals during the first year, six-month intervals during the second year, and then express a roughly two-year interval pattern between subsequent developmental phases:

Ages
0-1 infancy development, early emergence of foundational brain systems
1-2 toddler development, socio-language integration and exploratory locomotion
2-4 preschool socio-emotional-behavioral integration
4-6 early school entry and more elaborated socio-cognitive development
6-8 increasing stability in self-regulation and enhanced maturation in family bonding
8-10 elaborated personal and peer (social) achievement motivations
10-12 enhanced social awareness and modeling of same-gender parent, enhanced early proto-adult cognitive reasoning
12-14 increasing independence in self-identity, physio-social puberty changes
14-16 stabilization of adult-like cognitive reasoning and enhanced adult-like self-independence, gender-bonding motivations emerge
16-18 emergence of adult-level cognitive and social maturation
18-20 transition into young adult responsibilities and self-reliance

A six month time period reflects fully ¼ of the timeframe for a developmental phase. Disruptions to normal-range development lasting longer than six months will have increasingly deleterious effects on healthy child development, as the phased sequencing of later developmental experiences become increasingly desychronized with developental readiness.

When treating children, therapy should have as its goal, and should make significant efforts toward achieving, a substantial resolution of treatment-related issues within six months, and no longer than one year.

Failure to achieve this goal, important to maintaining the healthy developmental trajectory of the child, should receive examined scrutiny to identify the reasons why therapy was unable to achieve this goal, leading to appropriate treatment modifications to address and resolve the limitations to the extent possible and in the least amount of time feasible.

Therapy lasting one year is fully ½ of a developmental phase. Therapy should achieve substantial resolution of developmental child symptomatology within a year. Given the critical importance of time-related factors in child development, failure to achieve this standard should receive review and require specific documentation of the factors limiting therapeutic progress. Substantial alteration of the treatment context and organization of therapy may be indicated.

Clinical Review of Treatment

In any initial review of the case conceptualization and treatment plan, broad latitude should be granted to the therapist’s identification of the theoretical framework for case conceptualization and treatment planing. Later reviews should expect moderate to substantial treatment progress with due consideration for legitimate barriers to treatment progress identified in the update report and within the context of the therapist’s responsibilities to resolve the family conflicts.

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

References

Professional Practice Guidelines

Specialty guidelines for forensic psychology. (2013). American Psychologist, 68(1), 7-19

Patel, S.H. & Choate, L.H. (2014). Conducting child custody evaluations: Best practices for mental health counselors who are court-appointed as child custody evaluators. Journal of Mental Health Counseling, 36, 18-30

Jones, K. D. (2010). The unstructured clinical interview. Journal of Counseling and Development, 88, 220-226.

Psychotherapy Research

Wampold, Bruce E. (2001). The Great Psychotherapy Debate: Models, Methods and Findings. Routledge.

On Unicorns, the Tooth Fairy, and Reunification Therapy

The Myth of “Reunification Therapy”

The emperor has no clothes.

There is no such thing as “reunification therapy.”

There is psychoanalytic therapy (e.g., object relations therapy: Kohut, 1977; or self-psychology, Stolorow & Atwood, 1987),

There is humanistic-existential therapy (e.g., client-centered therapy, Rogers, 1961; or existential therapy, Yalom, 1980)

There is cognitive-behavioral therapy (e.g., CBT, Beck, 1976;  with general “Learning Theory” defining child behavior therapy; Patterson, 1982)

There is family systems therapy (e.g., Structural Family Systems therapy, Minuchin, 1974; or Strategic Family Systems therapy, Haley, 1963, Madanes, 1981; or Humanistic family systems therapy, Satir 1967)

There are post-modern therapies (e.g., solution focused therapy, Berg, 1994; or narrative therapy, White and Epston, 1990)

But there is NO model of therapy that has ever been proposed for what constitutes “reunification therapy,” meaning that therapists can essentially do whatever they want under the label of “reunification therapy.”

If therapists wish to describe the type of therapy they are conducting, they should use actual and established models of psychotherapy rather than vague and imprecise descriptive terms that do not increase understanding but that give the appearance of credibility without the substance of credibility.

The construct of “reunification therapy” is a haven, and a cover, for professional ignorance and incompetence.

The construct of “reunification therapy” is a mythical entity of no defined substance. Any therapist that uses the term “reunification therapy” is a charlatan. There is no defined thing as “reunification therapy” and they know it. If they are doing family therapy, then they should say, “family therapy,” in which case a follow up question could be, which model of family therapy are they employing?

I recognize that this is a strong accusation on my part. This weblog post has a comment section. I challenge any therapist to provide a reference citation for what “reunification therapy” entails… <crickets> … there is none.

Professional psychology should be ashamed of itself for knowingly perpetuating the myth of “reunification therapy” by not challenging the use of this construct.  There is NO SUCH CONSTRUCT as “reunification therapy” that has ever been defined within professional mental health.

If the therapist is doing family therapy, then the therapist should say this, which allows for the follow-up question of which model of family therapy is the therapist employing?

Establishment psychology blasts Gardner’s model of PAS as “junk science” yet allows the mythical construct of “reunification therapy” to go unchallenged. Professional psychology should be ashamed of itself.

If any therapist says that he or she does “reunification therapy” – run. That therapist is incompetent and is hiding his or her incompetence behind a mythical label. There is no such thing as “reunification therapy.”

If a therapist says that he or she does “reunification therapy,” ask for a citation reference regarding what “reunification therapy” is so that you can read up on “reunification therapy.” You will get no reference citation, because none exists. No model of “reunification therapy” has ever been proposed at any time, anywhere.

When engaging the services of a therapist to treat “parental alienation,” ask the therapist which of the five standard models of psychotherapy the therapist employs in “reunification therapy.”

Psychoanalytic – Psychodynamic
(generally “object relations”; Kohut)

Humanistic – Existential
(generally “client-centered”, Rogers, or existential therapy, Yalom, for adults; Ayers for humanistic “play therapy” with children, Oaklander for gestalt therapy with children)

Cognitive-Behavioral Therapy
(generally Beck for CBT; or “Learning Theory” involving operant and classical conditioning for child “behavior therapy”)

Family Systems Therapy
(generally Minuchin for Structural Family Systems therapy, occasionally others)

Post-Modern Therapy
(generally Berg for solution focused therapy)

Sometimes the therapist may say “eclectic” or “integrative.” This means that the therapist applies several of the above models depending on the situation and needs of the client. If the therapist responds “I’m eclectic” or “I use an integrative approach,” ask which models they tend to prefer and which models they tend to integrate.

If the therapist cannot describe which models of psychotherapy they are employing, then they are just making things up based on their whims at the moment and calling it “psychotherapy.”  Run.

If you are hiring an attorney to handle a divorce, you want a family law attorney not a corporate attorney. Ask. What area of law do you specialize in?  If you are getting cosmetic surgery, you want a plastic surgeon not a cardiac surgeon. Ask. What type of surgery do you do?  As a consumer, you may not know the technicalities of the various types of law or medicine – or psychotherapy models – but the professional should.  A professionally competent psychotherapist should be able to explain to you the treatment model being used. This is a part of the INFORMED consent process.

You have the right to consent to therapy, and in order to consent to therapy you the right to be informed about what therapy will involve. How does the therapist conceptualize the issues? How is treatment going to resolve these issues?  This is called the “treatment plan.”  Ask for a written “treatment plan.”

I am a clinical psychologist… I know what is out there passing itself off as “psychotherapy”…

“The emperor has no clothes.”

Do not trust that the psychotherapist knows what he or she is doing. Your family and your child are too important. I would recommend that you become an informed consumer by learning about the various models of psychotherapy.

But if you don’t want to personally learn about the various available models of psychotherapy, then at least ask the treating therapist to explain his or her approach, and how the therapist sees this approach to psychotherapy as solving your specific problems with your child.

If your child had cancer, the doctor would explain to you the treatment options, such as surgery, chemotherapy, radiation, or some newer form of treatment. You would be presented with the available options and recommendations, and you would be able to ask questions in order for you to make an informed treatment decision. Psychotherapy is no different.

Your child is too important, and your relationship with your child is too important.

Application of Therapy Models to Attachment-Based “Parental Alienation”

Treatment Structure:

Individual child therapy is NOT the appropriate treatment approach for attachment-based “parental alienation.” The issue in attachment-based “parental alienation” is interpersonal involving the parent-child relationship. Therapy sessions should be structured as conjoint parent-child relationship therapy. Some individual sessions with just the child or just the parent(s) may be appropriate (within a family systems model), but the focus is on treating the relationship.

Imagine a therapist conducting marital therapy but only seeing the wife individually.  Marriage therapy involves the relationship. Marriage therapy sessions involve BOTH the husband and the wife to resolve their relationship issues.  The same is true for the treatment of attachment-based “parental alienation.”  The treatment focus is on the parent-child relationship and therapy sessions should involve BOTH relationship partners.

Individual therapy with the child is NOT the appropriate model for resolving attachment-based “parental alienation.”

Treatment Models

Psychodynamic psychotherapy (generally object relations therapy) for attachment-based “parental alienation” is NOT the appropriate treatment model for attachment-based “”parental alienation.” It will be entirely ineffective for resolving the parent-child relationship, although it would be an appropriate model for treating the narcissistic/(borderline) personality dynamics of the alienating parent.

Psychodynamic psychotherapy is generally, if not always, individual therapy, and it does not have a theoretical structure for conjoint in-session relationship therapy.  Could it be adapted to conjoint in-session relationship therapy?  Perhaps, but I’ll leave that to others to propose such a model appropriate to treating the parent-child relationship issues of attachment-based “parental alienation.”

To Psychotherapists: Kohut does have some extremely important constructs related to empathic failure and narcissistic processes that are directly relevant to both the interpersonal trauma issues and the treatment of attachment-based “parental alienation” – it’s just that an individualistic object relations therapy model is not an appropriate treatment framework.

Kohutian theory, however, is directly relevant.

Humanistic-existential therapy, including all forms of non-directive client-centered and play therapy models, is CONTRA-INDICATED for the treatment of attachment-based “parental alienation.” Client-centered treatment models will collude with the psychopathology and will make things worse.

Humanistic-existential therapy assumes an authentic individual.  However, in attachment-based “parental alienation” the child is being induced/(seduced) into a role-reversal relationship in which the child is being used as a “regulating other” by the narcissistic/(borderline) parent to regulate the parent’s psychopathology.  The child’s psychological authenticity has been nullified, and continues to be nullified, by the psychopathology of the narcissistic/(borderline parent). 

Under these conditions, humanistic-existential models of therapy are NOT appropriate and will only serve to collude with the psychopathology.

To Psychotherapists:  Rogerian interpersonal conditions of empathy, unconditional positive regard, and genuineness remain vitally important components of the therapeutic relationship.  It’s just that a non-directive therapy is not an appropriate treatment model for attachment-based “parental alienation.”  The therapist needs to be an active interventionist, consistent with a Structural or Strategic Family Systems (or Humanistic, Satir) model of unbalancing family “homeostasis” to create interpersonal change within and across family relationships.

Empathy, unconditional positive regard, and genuineness remain vitally important components of the therapeutic relationship.

Humanistic-existential therapy tends to be individual therapy. The therapist will meet with the child individually and the parent will seldom be involved in therapy. Avoid humanistic-existential therapy, it will be harmful and will only make the situation worse.

Cognitive-behavioral therapy (CBT) involves altering distorted and false beliefs that are creating distorted emotional responses. With a skilled CBT therapist, this treatment model could be helpful in treating attachment based “parental alienation,” particularly to the extent that the therapist challenges the irrational beliefs of the child.

However, a comprehensive CBT model for treating the specific issues associated with the family dynamics of attachment-based “parental alienation” has yet to be proposed. Of central importance is that the CBT therapist reads the work of Arron Beck on personality disorders (Beck, et al., 2004).  The quality of the CBT work will improve substantially to the extent that the therapist understands the underlying “schemas” of personality disorders and their interpersonal manifestations.

Child behavior therapy involves delivering positive and negative “consequences” for appropriate and inappropriate child behavior. While child behavior therapy has a good intention, it will likely only make matters worse.

The targeted parent will be directed by the therapist to establish reward and punishment contingencies and to deliver these “consequences” for the child’s “problem behavior.” In attachment-based “parental alienation,” however, the child will be unresponsive to rewards and “positive attention” and will instead frequently provoke negative consequences (punishments) that will then create increasingly negative and hostile parent-child exchanges, that will be used by the child (and by the narcissistic/(borderline) parent) as “evidence” of the targeted parent’s insensitivity to the child’s needs, and as reasons and justifications for the child’s wanting to terminate the child’s relationship with the targeted parent.

To Psychotherapists: The reason for this treatment failure is that the child’s behavior is not under the “stimulus control” of the behavior of the targeted-rejected parent.  Instead, the child’s behavioral responses to the targeted-rejected parent are under the “stimulus control” of the child’s relationship with the allied and supposedly “favored parent.”  The focus of behavior change must target the correct locus of the stimulus control for the child’s behavior in the relationship cues, reinforcers, and punishments within the child’s relationship with the allied and supposedly “favored” parent.

It is possible that high quality behavior therapy combined with cognitive restructuring can be helpful, particularly if the child is separated from the ongoing distorting influence of the narcissistic/(borderline) parent during the active phase of treatment.  A key feature of effective behavior therapy will be focusing on a quality of the interaction called the “stimulus control” of the child’s behavior. 

Currently, in attachment-based “parental alienation,” the stimulus control for the child’s distorted behavior toward the targeted-rejected parent is in the child’s relationship with the allied and supposedly “favored” narcissistic/(borderline) parent.  Effective behavior therapy would need to alter the locus of this stimulus control away from the child’s relationship with the narcissistic/(borderline) parent and back onto the authentic source of stimulus control in the child’s relationship with the targeted parent.

Family systems therapy is the appropriate and indicated therapy model for treating attachment-based “parental alienation,” with Structural Family Systems theory being the primary indicated treatment framework, although a Strategic Family Systems model can also be effective. Family systems therapy involves multiple family members in the sessions (although it is highly unlikely that the involvement of the the narcissistic/(borderline) parent directly in the parent-child therapy sessions with the targeted parent will be warranted based on a variety of treatment considerations), and the family systems therapist will be an active participant in therapy. Initially, the therapist will seek to alter, disrupt, and “unbalance” the unhealthy “homeostasis” (relationship stability) within the family relationships in order to then re-structure family relationship patterns without the symptom present.

To Psychotherapists:  There may be circumstances in which conjoint sessions with the targeted parent and the allied and supposedly “favored” parent could be productive. The family therapy issue is helping the family transition from an intact family structure to a separated family structure. The locus for the family’s difficulty is in the narcissistic and borderline vulnerabilities of one of the spousal partners.  Helping the spousal relationship, and particularly this vulnerable spousal partner, effectively navigate the experience of loss and grief regarding the end of the marital bond can resolve the expression of pathology within the family.  It is skilled family systems work, but it is possible in some cases.

If a conjoint-spousal intervention is attempted, the child should NOT be present for these conjoint parental sessions (the child must be de-triangulated from the spousal conflict), although the child can be made aware that these parental sessions are occurring as part of the therapy process.  By the therapist taking over the caregiving role for the narcissistic/(borderline) parent, this may help release the child from the necessity of maintaining a role-reversal caregiving relationship for the vulnerable narcissistic/(borderline) parent.

However, a family systems approach with attachment-based “parental alienation” becomes challenging precisely because it will be effective.  As the therapy creates change in the child’s symptoms, the allied and supposedly “favored” narcissistic/(borderline) parent will apply ever increasing psychological pressure on the child to resist the influence of therapy and remain symptomatic.

The resistant pressures applied on the child by the pathological narcissistic/(borderline) parent for the child to remain symptomatic, even as family systems therapy is applying treatment-related resolutions encouraging the child’s release of symptoms and the restoration of normal-range relationships within the family, will turn the child into a psychological battleground between the forces of effective therapy that are resolving the child’s symptomatic state and the continuing and increasing psychological pressures being applied on the child by the narcissistic/(borderline) parent to remain symptomatic.

Turning the child into a psychological battleground will be psychologically harmful to the child.  The only way to resolve this dilemma is to either,

1) Terminate effective therapy and discontinue efforts to resolve the child’s psychopathology, thereby choosing to leave the child in a symptomatic state of a cut-off relationship with a normal-range and affectionally available parent that is the product of the distorted parenting practices of a narcissistic/(borderline) parent who is using the child in a role-reversal relationship to meet the needs of the pathological parent, or

2) Provide the child with a protective separation from the ongoing pathogenic influence of the narcissistic/(borderline) parent during the active phase of the child’s treatment and recovery.

Family systems therapy will be effective, but this becomes a problem because the effectiveness of family systems therapy will be met with active resistance by the pathology of the narcissistic/(borderline) parent who will place increasing psychological pressure on the child to remain symptomatic. Turning the child into a psychological battleground between the goals of therapy and the pathology of the narcissistic/(borderline) parent is not recommended. But the only alternative is to terminate effective therapy.

Ineffective Therapy

There is a third alternative, which is to conduct entirely pointless ineffective “therapy” that lasts for years and produces absolutely no change (except the further strengthening and entrenchment of the child’s hostile rejection of the parent), and unfortunately this is far too often the type of “therapy” currently being employed with attachment-based “parental alienation.” 

Usually the ineffective mode of therapy is a non-directive “wing-it” style of Humanistic-oriented therapy, typically involving “validating the child’s feelings” in an apparent hope by the therapist that this will have some sort of magical “self-actualizing” impact on the child that will somehow stop the parent-child conflict.  The “wing-it” component sometimes involves encouraging the targeted-rejected parent to apologize to the child for supposed past parental failures. That these alleged “parental failures” in the past never actually occurred or are gross distortions of the actual events doesn’t seem to be relevant to the therapist in the “wing-it” style of “therapy,” and the therapist-elicited parental apologies to the child never produce the hoped for change in child attitude or behavior.

The Required Therapeutic Context for Effective Therapy

Therapy must begin with the child’s protective separation from the psychopathology of the narcissistic/(borderline) parent during the active phase of the child’s treatment and recovery.

We cannot ask the child to change and to relinquish the symptoms if we cannot first protect the child from the psychological retaliation of the narcissistic/(borderline) parent for any change the child makes.

Professional Expertise

An additional problem with the family systems models of psychotherapy is that there are a limited number of trained and knowledgeable family systems therapists available.  Family systems therapy is sophisticated, and so requires a high level of professional knowledge and skill.  Only a limited number of therapists will seek out the post-graduate training necessary to become professionally competent in family systems therapy.

In the absence of established knowledge and formal training in family systems models of therapy, many therapists simply choose to “wing it” and do whatever they think is best under any given circumstances.  Unfortunately, this is more common than one might imagine.  Many therapists are simply not competent to be doing family-related therapy.

Another limitation is that few child therapists and family systems therapists have experience treating personality disorders.

Most therapists in general, adult therapists included, have very limited experience and exposure to treating narcissistic personality disorders because narcissistic personalities very rarely present for therapy. Narcissistic personalities do not desire self-insight and would much rather maintain their grandiose self-opinion and judge others to be inferior rather than to engage in self-reflection regarding their own possible inadequacy. Borderline personalities will present to therapy because of the chaotic drama in their lives and intense depression, but most therapists do not treat borderline patients and those that do tend to be adult-oriented therapists who work from individual models of psychotherapy. 

For child therapists, the lack of exposure to narcissistic and borderline personality processes is even more acute, since personality disorders are rarely a feature of child therapy.  Most child therapists lack professional knowledge related to recognizing and treating personality disorder dynamics.

However, narcissistic and borderline personality features are prominent components of attachment-based “parental alienation” so that family systems therapy with attachment-based “parental alienation” will be improved considerably to the extent that the therapist is knowledgeable about personality disorders, such as Beck et al. (2004) and/or Millon (2011).

Post-Modern Therapies

Post-modern therapies would represent an intriguing application of social constructionism to the pathology of attachment-based parental alienation, but it is unclear how the principles of solution-focused or narrative psychology could be applied to the distorted family processes involved in attachment-based “parental alienation.” I would invite solution focused therapists and narrative therapists to attempt the application of their theoretical frameworks to the treatment of the trans-generational transmission of attachment trauma associated with the pathology of attachment-based “parental alienation.”

I suspect that there are intriguing applications of these models to the issues in attachment-based “parental alienation,” but I’m unsure on how to actualize this application since, while I am familiar with the theoretical constructs of these models, they are not directly within my area of professional expertise.

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

References

Psychoanalytic – Psychodynamic Therapy

Kohut, H. (1977). The Restoration of the Self. New York: International Universities Press.

Stolorow, R., Brandchaft, B., and Atwood, G. (1987). Psychoanalytic Treatment: An Intersubjective Approach. Hillsdale, NJ: The Analytic Press.

Humanistic-Existential Therapy

Rogers, C.R. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston: Houghton Mifflin.

Yalom, I.D., Existential Psychotherapy. New York: Basic Books, 1980.

Cognitive-Behavioral Therapy

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: Meridian.

Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castalia.

Family Systems Therapy

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

Haley, J. (1963). Strategies of psychotherapy. New York: Grune and Stratton.

Madanes, C. (1981) Strategic Family Therapy. San Francisco: Jossey-Bass Inc., 

Satir, V. (1967). Conjoint Family Therapy: A Guide to theory and technique. Palo Alto, California: Science and Behavior Books, Inc.

Post-Modern Therapy

Berg, Insoo Kim (1994) Family Based Services: A solution-focused approach. New York: Norton.

White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: W. W. Norton.

Personality Disorder Dynamics

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

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

The Legal Context: Control the Language

Caveat: Dr. Childress is not an attorney. Nothing in this post should be construed as legal advice. For legal advice consult an attorney and follow the recommendations of the attorney.  Dr. Childress is a clinical psychologist.

Choosing the Battlefield

Language defines the conceptual battleground.  In taking control of the language we fight on a battlefield of our choosing.

The dynamic of “parental alienation” immediately acts to define the targeted parent as “abusive” thorough the child’s symptomatic display of supposed “anxiety” and by the child’s expressed hostility and rejection toward the targeted parent.

Once the distorted parenting practices of the narcissistic/(borderline) parent induce the child into adopting the “victimized child” role relative to the targeted parent, immediately the child’s symptoms accuse the targeted parent of “abusive” parenting, so that the targeted parent is immediately placed on the defensive of proving a negative, of proving that he or she is not abusive despite the symptomatic allegations from the child’s anxious, fearful, and hostile rejection, and despite the support these child symptomatic allegations receive from the verbal reports of the supposedly all-wonderful allied and seemingly “favored” parent.

The allegations from the child’s symptoms immediately place the targeted parent on the defensive of trying to prove a negative, that the targeted parent is NOT abusive. The targeted parent is being forced to fight on the battlefield chosen by the narcissistic/(borderline) parent, of trying to prove a negative.

The Battlefield of “Parental Alienation”

When the targeted parent tries to fight back by alleging that the narcissistic/(borderline) parent is “alienating” the child, the response from the narcissistic/(borderline) parent is essentially “prove it.”  The trap is set for the targeted parent who then begins chasing the narcissistic/(borderline) parent down a rabbit hole of trying to prove to others the insidious and hidden parental influence on the child of the narcissistic/(borderline) parent.

Meanwhile, the narcissistic/(borderline) parent remains hidden behind the child, and any effort to penetrate this protective shield to reach the underlying pathology of the parent is redirected by the narcissistic/(borderline) parent back onto the child,

“We should listen to the child.  We should listen to what the child wants.”

“The child should be allowed to choose whether or not to go on visitations with the other parent.”

“What can I do, I can’t make the child go on visitations with the other parent. Am I supposed to drag the child from my car?”

And in response to the targeted parent’s allegations that the narcissistic/(borderline) parent is actually the bad parent who is distorting the child’s feelings toward the targeted parent, the narcissistic/(borderline) parent presents for public display and public consumption the child’s (symptomatic) display of hyper-bonding toward the narcissistic/(borderline) parent as a means to counter the targeted parent’s accusations against the narcissistic/(borderline) parent.

“I’m the wonderful parent.  The child is well-behaved with me.  The child loves me.”

“I only want what’s best or the child” (which is to not be with the “abusive” other parent).  See how wonderful I am.  I’m just listening to what the child wants.”

Against the allegation of “parental alienation,” the response of “prove it” becomes the entrance to the rabbit hole, inviting the targeted parent to fight on the battlefield selected by the narcissistic/(borderline) parent.

And the child’s display of “victimization” draws sympathy and support from others. We have a natural inclination to protect children, and the child’s (induced) allegations that the targeted parent is abusive, allegations made through the child’s displays of supposed “anxiety” and expressions of supposed fearfulness toward the targeted parent, elicit a reflexive response from others of protection that further places the targeted parent on the defensive of having to prove a negative, of having to prove that he or she is NOT abusive, and that the child’s displays of supposed anxiety are unwarranted and false.

The targeted parent is fighting on the battlefield chosen by the narcissistic/(borderline) parent. The focus remains on the targeted parent and on the allegation that the targeted parent is “abusive,” and the focus is kept off of the psychopathology of the narcissistic/(borderline) parent, who is instead allowed to continually present in the coveted role as the all-wonderful, perfect, and ideal parent.

This is the perfect world for the narcissistic/(borderline) parent: the other parent is suffering relentlessly for having the audacity to divorce the narcissistic/(borderline) parent and the narcissistic/(borderline) parent continually has the opportunity to present to others as the all-wonderful, perfect and ideal parent.  What could be better?

Meanwhile, the targeted parent is kept on the defensive, having to prove to each new therapist, to child protection workers, to the child’s attorney, to the Court, to everyone, that the targeted parent is NOT abusive, always having to prove a negative.

And this uphill continual battle swirls through years of legal litigation that financially bankrupt the targeted parent. “Prove it” outlasts. Delay favors the pathology. With each passing month the alienation becomes more entrenched. The targeted parent’s relationship with the child continues to deteriorate. Therapy is delayed by legal tactics, by noncompliance with Court orders, by changes in therapists, and to each new therapist the targeted parent must again prove the negative.

And when therapy does take place, the therapists who are supposed to restore the parent-child relationship meet only with the child, they side with the child in the pathology, and nothing changes.  Years pass.  The alienation is effective.

The allegation of “parental alienation” is fighting on the battlefield chosen by the narcissistic/(borderline) parent.

And during this battle, whenever the targeted parent tries to fight back by trying to educate therapists, custody evaluators, and the Court about what is occurring by alleging “parental alienation,” providing them with reading material, trying to convince them that the allegation of “alienation” is authentic, this only seems to provoke skepticism and backlash from the therapists, custody evaluators, and the Court, who allege that “parental alienation” doesn’t exist and who question whether the targeted parent’s allegation of “parental alienation” against the apparently “favored” parent is simply an effort by the targeted parent to avoid responsibility for his or her own bad parenting that has resulted in the child not liking this parent.  Allies are few.

The allegation of “parental alienation” is fighting on the battlefield chosen by the narcissistic/(borderline) parent.

Step 1: Take control of the language. Choose the battlefield.

Using the term “parental alienation” is problematic.  It is the battlefield chosen by the narcissistic/(borderline) parent who will respond, “prove it.”  Instead, I would recommend using the more clinically accurate phrase of “pathogenic parenting” by the other parent.

“patho” = pathology; “genic” = genesis, creation.

The term “pathogenic parenting” refers to parenting practices that are so aberrant and deviant that they are inducing significant psychopathology in the child, which is exactly the case in attachment-based “parental alienation.”

Pathogenic parenting is an established clinical construct in psychology.  It is typically used in reference to distorted attachment bonding patterns of the child as a result of “pathogenic parenting.”  Many less-than-competent therapists may not recognize the term, but any mental health professional familiar with the attachment system will understand the meaning of the phrase.

The term “parental alienation” has an inexact meaning in clinical psychology, and it places the focus on the parenting behavior of the narcissistic/(borderline) parent who then replies, “prove it,” which is exactly the battlefield desired by the narcissistic/(borderline) parent.

The allegation of “pathogenic parenting,” on the other hand, is a defined construct in clinical psychology and it places the focus on the child’s symptoms rather than on the parenting behavior per se, and, as importantly, it makes an explicit counter-accusation THROUGH THE CHILD’S SYMPTOMS that it is the parenting of the narcissistic/(borderline) parent that is abusive because it is inducing serious child “pathology.”

With the phrase “pathogenic parenting,” the focus of “prove it” shifts to documenting the nature and severity of the child’s symptom display, symptoms that are now as accusatory of the parenting practices of the allied and “supposedly” favored parent as they are of the targeted parent.  Through the term “pathogenic parenting” we are choosing the conceptual battlefield.

With the concept of “pathogenic parenting,” the child’s symptoms become the focus, and the child’s symptoms become accusatory of BOTH parents, instead of just one parent.

With the construct of “parental alienation” the argument is whether the child’s behavior toward the targeted parent is justified and authentic or whether the child’s behavior is induced by the allied and supposedly “favored” parent.  With the construct of “pathogenic parenting,” however, the child’s behavior is identified as severely pathological, and the question is not whether the child’s symptomatic behavior is being induced, just who is inducing it; the targeted-rejected parent (in which case the child’s symptomatic behavior is an authentic response to the pathogenic parenting of the targeted parent), or the allied and supposedly “favored” parent (in which case it represents “parental alienation”).

The task for clinical psychology becomes to determine which parent is “abusive,” because the severity of the child’s pathology requires that the parenting practices of either one or the other parent is abusive of the child.  One or the other parent is inducing the child’s symptomatic pathology. 

EITHER, the parenting practices of the targeted-rejected parent can be documented as sufficiently outside of normal-range parenting practices as to represent emotionally, psychologically, or physically abusive parenting (or sexually abusive when this allegation is made), OR – the child’s symptoms are the product of pathogenic parenting by the allied and supposedly “favored” parent who is triangulating the child into the spousal conflict through the formation of a cross-generational parent-child coalition against the other parent.

Based on the documented severity of the child’s symptom display, one or the other of these alternatives must be true.

Child Protection

The allegations being made through the child’s symptom display are very serious, and they must be taken very seriously by mental health professionals. The parenting practices of the targeted parent must be fully assessed.

I would recommend that, if possible, a formal report be generated from a mental health professional documenting a professional assessment of the parenting practices of the targeted parent.  This report can then be provided to future therapists and to the Court so that the targeted parent does not have to repeatedly prove a negative, that their parenting practices are not abusive of the child.

The allegations against the targeted parent being made through the child’s symptoms are very serious, and if these allegations are found to be false, that the parenting practices of the targeted-rejected parent are not abusive of the child, then the allegations of abusive parenting made through the child’s symptoms should turn back on the parenting practices of the narcissistic/(borderline) parent as being psychologically and developmentally abusive of the child by inducing the child’s false symptom display toward the targeted parent.

Children’s behavior is the product of the parenting they receive.

If the parenting practices of the targeted parent are documented to be sufficiently outside of normal-range parenting practices, with due consideration given to the broad spectrum of normal-range parenting present in the general population and with due deference for parental prerogatives in establishing family values through culturally acceptable parental discipline and guidance practices, then we need to engage a child protection response that includes therapy to alter the identified aberrant and distorted parenting practices of the targeted-rejected parent.

If, however, the parenting practices of the targeted parent are documented to be broadly normal-range, with due consideration given to the broad spectrum of normal-range parenting practices evident in the general population and with due deference for parental prerogatives in establishing family values through culturally acceptable parental discipline and guidance practices, then the child’s symptoms become an indictment of the psychologically and developmentally abusive parenting practices of the allied and supposedly “favored” parent that requires a child protection response of separating the child from the abusive parenting practices of the narcissistic/(borderline) parent during the active phase of the child’s treatment and recovery.

Attachment-based “parental alienation” is NOT a child custody issue, it is a child protection issue.

The seriousness of the allegations made through the child’s symptomatic pathology create a high degree of clinical and development concern and lead to only two possible interpretations, either 1) the child’s pathology is the product of pathogenic parenting by the targeted-rejected parent that is inducing the child’s symptomatic behavior, or 2) the child’s pathology is the product of pathogenic parenting by the allied and supposedly “favored” parent that is inducing the child’s symptomatic behavior.

The evidence in the child’s symptom display of severe  psychopathology requires one or the other interpretation.

Step 2:  Documenting the Child’s Symptoms

Obtaining professional documentation of the child’s symptoms is necessary for a clinical determination of “pathogenic parenting,” but obtaining this professional documentation may prove difficult.

Child Custody Evaluations:  If a child custody evaluation is conducted, then the professional report generated from the custody evaluation will usually provide an adequate documentation of the child’s symptoms. The clinical interpretation of these symptoms may be flawed, but the documentation of what the symptoms are is usually adequate.

In cases of attachment-based “parental alienation” the child’s symptoms are sometimes (usually) misinterpreted as oppositional-defiant behavior or as authentic anxiety, when in actuality the child’s hostile-rejecting symptoms reflect narcissistic and borderline personality disorder traits in the child’s symptom display or, in the case of excessive anxiety symptoms, the child’s symptoms represent an absurd and unrealistic Specific Phobia, father type or mother type.

Of note in correctly recognizing the nature of the child’s symptom display are two distinctive features of a narcissistic personalty that differ from oppositional-defiant behavior, 1) the absence of empathy associated with a narcissistic personality, and 2) the splitting dynamic associated with both borderline and narcissistic personalities.

The presence in the child’s symptom display of either of these two symptoms should trigger a more complete assessment of the child’s symptoms from a personality disorder perspective. 

Within attachment-based “parental alienation” the child’s acquisition and selective display of narcissistic and borderline personality disorder traits represents the “psychological fingerprints” of the child’s influence and control by a parent who possesses narcissistic and borderline personality traits.

Once the child’s symptoms are adequately documented, obtaining an accurate clinical interpretation of the data becomes possible.

Therapist Reports:  If a professional report from a child custody evaluation is not available, then the targeted parent may be able to obtain a written report from a treating therapist documenting the child’s symptoms.  Again, the clinical interpretation of these symptoms by the treating therapist may be flawed, but as long as the child’s symptoms are professionally documented then obtaining a more accurate clinical interpretation of the symptoms becomes possible.

The three diagnostic indicators of attachment-based parental alienation are,

1. Attachment System Suppression

A suppression of the child’s attachment bonding motivations toward a normal-range and affectionally available parent. 

Due consideration should be given to the broad spectrum of normal-range parenting typically evidenced in the general population, and due consideration should be allowed for legitimate parental prerogatives in establishing family values and for the the normal-range exercise of legitimate parental authority and discipline within the family.

2. Personality Disorder Traits

The child’s symptom display evidences five specific narcissistic and borderline personality disorder traits toward the targeted parent that include grandiosity, entitlement, an absence of empathy, a haughty and arrogant attitude, and splitting.  These narcissistic and borderline personality disorder traits are displayed selectively and specifically toward the targeted parent and may not be evident with other people or relationships, such as with therapists and teachers.

3.  Delusional Belief

The child’s symptoms display an intransigently held, fixed and false belief regarding the fundamental inadequacy of the targeted parent that is characterized by the child as being “abusive” of the child.  The child’s delusional belief is offered as justification for the child’s expressed desire to terminate the child’s relationship with the targeted parent.

The presence in the child’s symptom display of this specific set of characteristic diagnostic indicators represents definitive clinical evidence for the presence of pathogenic parenting by the allied and supposedly “favored” parent as being the sole cause of the symptomatic child-initiated cut-off in the child’s relationship with a normal-range and affectionally available parent.

Anxiety Variant

In the anxiety variant, typically evident with younger children or in association with the hostile-rejecting pattern, the child’s symptoms of unwarranted extreme and excessive anxiety toward the targeted parent meet DSM-5 criteria for a Specific Phobia, but the type of phobia will be a bizarre and unrealistic “father type” or “mother type.”

The presence in the child’s symptoms of a bizarre and unrealistic “mother type” or “father type” of Specific Phobia represents definitive clinical evidence for the presence of pathogenic parenting by the allied and supposedly “favored” parent as representing the sole cause of the symptomatic child-initiated cut-off in the child’s relationship with a normal-range and affectionally available parent.

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

Three Levels of Analysis

In proposing the construct of “Parental Alienation Syndrome” (PAS), Gardner too quickly abandoned the professional rigor required by professionally established constructs and principles, and he instead proposed a “new syndrome” that was outside of established psychological constructs, and which was instead based solely on a set of anecdotal clinical indicators.  Although Gardner was correct in identifying a characteristic constellation of clinical features, his absence of professional and scientific rigor has ultimately undermined our ability to achieve a solution to the family tragedy of “parental alienation.”

We need to return to the fundamental definition of what “parental alienation” is, and employ the necessary professional rigor required to re-define the interpersonal processes associated with the construct of “parental alienation” from entirely within standard and established psychological constructs and principles.  We construct any building by first laying the foundation. The foundation provides the stability on which the rest of the structure can rely.

Gardner built the foundation for his theory of PAS on the shifting sands of anecdotal clinical indicators that were not anchored in any professionally recognized theoretical principles or constructs.  When we then try to leverage the theory of PAS to achieve a solution in the mental health and legal settings, the sands shift beneath our feet and the structure collapses.

We cannot achieve a solution until we have established a firm, accurate, and substantial theoretical foundation for defining the construct of “parental alienation” that relies entirely on standard and established psychological principles and constructs. We begin constructing any structure by laying the foundation.

An attachment-based model of “parental alienation” establishes the required theoretical foundations for the construct of “parental alienation” on a bedrock of well-established psychological principles and constructs, which then allows us to leverage the theoretical foundations to create the diagnostic, legal, and treatment solutions needed within the mental health and legal systems.

Levels of Analysis

The construct of “parental alienation” can be understood at three distinct, and yet interrelated, levels of analysis,

1) The Family Systems Level

2) The Personality Disorder Level

3) The Attachment System Level,

Each of these levels rests upon the foundational structure provided by the underlying level.  The family systems level of analysis is embedded within the deeper psychological context of the personality disorder level, which itself is embedded in the still deeper level of the attachment system.

At its core, “parental alienation” represents the trans-generational transmission of attachment trauma from the childhood of the alienating parent to the current family relationships, and involves the reenactment of relationship trauma embedded in the “internal working models” of the alienating parent’s attachment networks.

This trans-generational transmission of attachment trauma is mediated by the narcissistic and borderline personality disorder traits of the alienating parent that represent the coalesced product of the alienating parent’s insecure anxious-disorganized/anxious-preoccupied attachment patterns.

It is the influence of the narcissistic and borderline personality disorder traits of the alienating parent that create the primary driving force for the enactment of the alienation process within the family.

At the surface level, “parental alienation” represents the manifestation of a cross-generational parent-child coalition of the child with the narcissistic/(borderline) parent against the other parent, the targeted-rejected parent, in which the child is used by the narcissistic/(borderline) parent as a weapon to inflict suffering on the other parent for having failed to properly appreciate the inflated self-grandiosity of the narcissistic/(borderline) parent, and for having the temerity to leave (abandon) the narcissistic/(borderline) parent.

“If others fail to satisfy the narcissist’s “needs,” including the need to look good, or be free from inconvenience, then others “deserve to be punished”Even when punishing others out of intolerance or entitlement, the narcissist sees this as “a lesson they need, for their own good” (Beck, et al., 2004, p. 252).

Maintaining clarity in the complex dynamics of “parental alienation” requires understanding what level of analysis we are discussing; the family system processes, the personality disorder processes, or the attachment system processes, although all three are intertwined and interrelated.

Level 1: The Family Systems Level

The central construct at the family systems level is the child’s triangulation into the spousal conflict through a cross-generational parent-child coalition with one parent (the narcissistic/(borderline) against the other parent.

Haley (1977) refers to the cross-generational coalition as a “perverse triangle” and offers the following definition:

“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.” (Haley, 1977, p.37)

It is important to recognize that it is definitional of this construct that “the coalition between the two persons is denied.” It is, therefore, entirely pointless for child custody evaluators and therapists to ask the child if the allied and supposedly “favored” parent is somehow influencing or creating the child’s hostility and rejection of the other parent.

A cross-generational coalition is, BY DEFINITION, denied.

Of course the child says, “no.”  And the allied and supposedly “favored” parent supports the child in this denial by maintaining that it is entirely the child’s decision and the child’s choice. (“The child should be allowed to decide whether or not to go on visitations with the other parent. We should listen to the child.”).

“The coalition between the two persons is denied” (Haley, 1977)

That the child denies that there is a coalition is ENTIRELY CONSISTENT with there actually being a coalition.  The presence of a cross-generational parent-child coalition must be determined by collateral evidence that “indicates a coalition” rather than by any direct evidence. The nature of this collateral evidence will be described in future posts.

Level 2: Personality Disorder Level

Beneath the distortions at the family systems level is the psychopathology of narcissistic and borderline personality dynamics. The inability of the family to navigate the transition from an intact family structure to a separated family structure is the direct result of the distorting influence on family relationships of prominent narcissistic and borderline personality traits of the alienating parent.

Narcissistic and borderline personality disorder traits represent very serious psychopathology that can severely distort child development and the relationship dynamics within the family.

Based on my professional knowledge of child development, child and family therapy, and the central role of parenting in influencing healthy and unhealthy child development, I would rank order the worst possible parenting as:

  1. Sexual abuse/incest
  2. Narcissistic and borderline personality parenting
  3. Physical child abuse
  4. Domestic violence
  5. Suicidal/depressed parenting

Some professionals may argue that the psychological trauma resulting from physical child abuse is more developmentally problematic for the child than the effects of narcissistic and borderline parenting, and I certainly understand the concern regarding the impact on child development of physical child abuse.  But I would argue that the psychological trauma from the childhood experience of parental violence is treatable, whereas the effects of narcissistic and borderline parenting distort the child’s very self-structure organization, resulting in potentially severe and lifelong deformations of personality and severe distortions to interpersonal relationships.

Obviously, all of the forms of distorted parenting noted above are extraordinarily bad, and all of them are extremely detrimental to child development. My rank ordering of them is simply to give an indication of how severely bad narcissistic and borderline personality parenting is on the child’s development.

“Parental alienation” is not a child custody issue, it is a child protection issue.

The distortions to the family processes created by the psychopathology of the narcissistic/(borderline) parent are manifestations of a variety of features of the parental psychopathology.  One of the central features driving the alienation dynamic is the characterological inability of the narcissistic/(borderline) parent to experience and process sadness. According to Kernberg (1975),

“They [narcissists] 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 then 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.” (p. 229)

The divorce and loss of the intact family structure creates an experience of sadness and loss for everyone involved. For the narcissistic/(borderline) parent, the experience of sadness and grief at the loss of the intact family is translated into “anger and resentment, loaded with revengeful wishes.”

Through the pathogenic parental influence of the narcissistic/(borderline) parent, the child is then also led into a similar interpretation of the child’s own sadness and grief at the loss of the intact family as being “anger and resentment, loaded with revengeful feelings” directed toward the targeted parent instead of the authentic feeling of “real sadness for the loss of a person whom they appreciated.”

The authentic child isn’t angry and resentful.  The authentic child is sad.

At the core of the child’s experience is a misunderstood and misinterpreted grief response involving deep, deep, sadness, initially resulting from the loss of the intact family but later amplified by the loss of an affectionally bonded relationship with the beloved, but now rejected, targeted parent.

The child’s misinterpretation of an authentic experience of deep sadness (i.e., grief) surrounding the loss of the intact family and the loss of an affectionally bonded relationship with the beloved-but-rejected targeted parent, is created and fostered through the distorted pathogenic parenting practices of the narcissistic/(borderline) parent.

Level 3:  The Attachment System Level

The principle feature at the attachment system level is the reenactment in current family relationships of attachment trauma embedded in the “internal working models” of the alienating parent’s attachment system.

The attachment system mediates both the formation and the loss of close emotional relationships.

The loss experience associated with the divorce activated the alienating parent’s attachment system in order to mediate the loss experience.  The activation of the alienating parent’s attachment system activated the relationship trauma networks embedded in the “internal working models” of the alienating parent’s attachment system (it was this core trauma that led to the formation of the narcissistic and borderline personality traits).

So that, following the divorce, two sets of attachment representation networks become concurrently activated in the attachment system of the alienating parent, one set representing the current family members, and one set embedded in the internal working models of the alienating parent’s attachment system, representing patterns of attachment expectations formed in childhood.

The attachment representations in the internal working models of the alienating parent’s attachment system are in the pattern:

  • Victimized Child
  • Abusive Parent
  • Protective Parent

The concurrent simultaneous activation of two sets of representational networks, one set from the past trauma patterns and one set involving the current family members, creates a psychological fusion, or equivalency, between these two sets of activated attachment networks.

So that, in the mind of the alienating parent, the current child represents the “Victimized Child” of the internal working models of attachment, the other parent corresponds to the “Abusive Parent” representation in the internal working models of the attachment system, and the coveted and ideal “Protective Parent” role is adopted by the alienating narcissistic/(borderline) parent.

The characters are now all in place for the reenactment of the attachment trauma.  All that remains is to induce the child into initiating the reenactment drama by adopting the “Victimized Child” role.

Common thinking appears to be that the alienating parent induces the child’s rejection of the targeted parent by “bad-mouthing” and saying derogatory things about the other parent.  While this does happen, it is not the driving communication force for inducing the child’s rejection of the other parent.

The critical feature for initiating the trauma reenactment narrative is NOT to define the targeted parent as the “Abusive Parent,” it is getting the child to adopt the “Victimized Child” role.  This is critical to understand,

The key feature of enacting the alienation process is to induce the child into adopting the “Victimized Child” role relative to the other parent.

Because once the child adopts the “Victimized Child” role this immediately defines the targeted parent into the “Abusive Parent” role, and the child’s victimization role also immediately allows the alienating narcissistic/(borderline) parent to adopt (and conspicuously display to others) the coveted role as the ideal and all-wonderful “Protective Parent.”

The key defining feature in enacting the alienation process is not that the targeted parent is abusive, it is that the child is a victim.  The focus of alienation is inducing the child’s false belief that the child is the “victim” of “abusive” parenting practices by the targeted parent, which is then used to justify the child’s attitude toward the targeted parent of hostile rejection because the targeted parent “deserves” to be punished” for his or her “abusive” parenting.

This represents a key feature of the trauma reenactment narrative, that the targeted parent “deserves to be punished” for the “abusive” parenting toward the child (it is so central to the dynamic that it could almost be diagnostic).

“If others fail to satisfy the narcissist’s “needs,” including the need to look good, or be free from inconvenience, then others “deserve to be punished” (Beck, et al., 2004, p. 252).

Now, none of this reenactment narrative is true.  The targeted parent is not abusive, the child is not victimized, and the narcissistic/(borderline) parent is not the all-wonderful protective parent.  But truth is not a relevant consideration for a narcissistic/(borderline) parent in the throes of pathology. 

“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.” (Millon, 2011, p. 407)

The trauma reenactment narrative captivates the psychologicial state and functioning of the narcissistic/(borderline) parent.  In the mind of the narcissistic/(borderline) parent, the trauma reenactment is absolute truth, and there is no amount of contradictory evidence that can convince the narcissistic/(borderline) parent that the constructed storyline of the reenactment narrative isn’t true.

In the distorted psychopathology of the narcissistic/(borderline) parent, the child is being victimized by the abusive parenting of the other parent, so that the child is in desperate need of the protective parenting of the all-wonderful narcissistic/(borderline) parent who is rescuing the “victimized child” from the “abusive parent.”  In the mind of the narcissistic/(borderline) parent, this is truth.

But it is a false story, born of the psychopathology of a narcissistic/(borderline) personality, a narrative reenactment of childhood trauma with constructed characters and a constructed “truth.”

And the child can be induced into adopting the “Victimized Child” role because the child does have an authentic experience of sadness and grief that is being triggered by the presence of targeted parent, which, under the distorting influence of the narcissistic/(borderline) parent, is being misinterpreted by the child as “evidence” of the “abusive” parenting of the targeted parent. 

Something about being with the targeted parent hurts.

(i.e., the child feels an authentic sadness and grief at the loss of an affectionally bonded relationship with this parent). 

It must be something bad that the targeted parent is doing that’s making me hurt.

(no it’s not, the hurt is just normal sadness as the result of an unfulfilled attachment bonding motivation).

The alienating parent must be right, something the targeted parent is doing is “abusive,” and that’s what’s causing my hurt.

(no, the hurt is just sadness at the unfullfilled attachment bonding motivation with the beloved-but-rejected targeted parent).

When a therapist or the child’s attorney believes the constructed false story of the reenactment narrative, they become co-opted into colluding with the severe psychopathology, to the extreme detriment of the child’s healthy development and in abrogation of their professional responsibilities to the child.

I am personally appalled by the level of professional ignorance and incompetence that exists in diagnosing and treating this family process.  While complex, all the facets of this dynamic are entirely within standard and accepted domains of professional knowledge, principles, and constructs, and should be expected domains of professional competence when diagnosing and treating this “special population” of children and family processes.

  • Family systems constructs of triangulation and a cross-generational parent-child coalition are standard and established professional constructs that should represent a domain of expected clinical competence in diagnosing and treating child and family dynamics, particularly in high-conflict divorce settings. 
  • Narcissistic and borderline personality traits are established and accepted professional constructs defined within the DSM diagnostic system and as such should be within the domains of professional competence for all mental health practitioners, particularly when diagnosing or treating potential role-reversal parent-child relationships within the context of high-conflict divorce settings.
  • The nature and functioning of the attachment system is an established psychological construct with extensive empirical support in the research literature, and should be an expected domain of professional competence for all mental health practitioners who are diagnosing and treating family processes involving a disruption to the child’s attachment bonding motivations toward a parent.

In both my personal and professional view, there is absolutely no reason why a mental health professional should miss diagnosing the severity of the psychopathology involved, and the consequences of professional failure are so devastating to the child’s development as to raise for me serious professional concerns regarding the professional competence of any mental health professional who does miss the diagnosis.  If you don’t know what you’re doing, you shouldn’t be working with this “special population” of children and family processes.

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

References

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

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

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

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

Therapy: Cross-Generational Parent-Child Coalition

A Cross-Generational Coalition: The “Perverse Triangle”

The construct of “parental alienation” represents a variant of a more familiar and elaborated clinical construct of the child’s “triangulation” into the spousal conflict, in which the child is being drawn into the two-person spousal conflict to form a three-person, triangulated, conflict that includes the child.

“Anxiety within either husband or wife or both may arise, for example, as they attempt to balance their needs for closeness with their needs for individuation… One way to resolve such an anxious two-person relationship within the family, according to Bowen (1978), is to triangulate – draw in a significant family member to form a three-person interaction.” (Goldenberg & Goldenberg, 1996, p. 173; emphasis added)

“During periods when anxiety is low and external conditions are calm, the dyad or two-person system may engage in a comfortable back-and-forth exchange of feelings.  However, the stability of this situation is threatened if one or both participants gets upset or anxious, either because of internal stress or from stress external to the twosome.  When a certain moderate anxiety level is reached, one or both partners will involve a vulnerable third person.”(Goldenberg & Goldenberg, 1996, p. 173; emphasis added)

The twosome may “reach out” and pull in the other person, the emotions may “overflow” to the third person, or that person may be emotionally “programmed” to initiate involvement.” (Goldenberg & Goldenberg, 1996, p. 173; emphasis added)

Should anxiety in the triangle increase, one person in the triangle may involve another outsider, and so forth until a number of people are involved.  Sometimes such triangulation can reach beyond the family, ultimately encompassing social agencies and the courts.” (Goldenberg & Goldenberg, 1996, p. 173; emphasis added)

Triangulation is a standard family systems construct.  Nothing new.  Nothing exotic.

The specific type of “triangulation” involved in the construct of “parental alienation” is called a “cross-generational parent-child coalition” of the child with the allied and supposedly favored parent against the other parent.

One of the leading figures in family systems theory, Jay Haley (1977), defined this type of cross-generational coalition as comprised of three primary features,

  1. “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” (Haley, 1997, p. 37; emphasis added)

2. “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.” (Haley, 1997, p. 37; emphasis added)

3. “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.” (Haley, 1997, p. 37; emphasis added)

Haley refers to a cross-generational parent-child coalition as a “perverse triangle”,

“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.” (Haley, 1997, p. 37; emphasis added)

The “Perverse Triangle”

The reason that Haley refers to this particular variant of the child’s triangulation into the spousal conflict as “the perverse triangle” is that the coalition crosses generational boundaries. The crossing of generational boundaries should never occur.

The prototype exemplar of a generational boundary violation is sexual abuse/incest. Now I want to be entirely clear on this, I am NOT suggesting that the cross-generational parent-child coalition involved with “parental alienation” involves the sexual abuse of the child, I am merely highlighting the high degree of clinical concern associated with cross-generational boundary violations.  Cross-generational boundary dissolutions are highly pathological and damaging to the development of the child.  Cross-generational boundary violations, whether physical or psychological, are of a high degree of clinical concern.

In her article in the “Journal of Emotional Abuse,” Kerig (2005) describes the psychological damage to the child of a cross-generational “boundary dissolution.”

“The breakdown of appropriate generational boundaries between parents and children significantly increases the risk for emotional abuse.” (Kerig, 2005, p. 6)

“When parent-child boundaries are violated, the implications for developmental psychopathology are significant (Cicchetti & Howes, 1991). Poor boundaries interfere with the child’s capacity to progress through development which, as Anna Freud (1965) suggested, is the defining feature of childhood psychopathology. (Kerig, 2005, p. 7)

“In the throes of their own insecurity, troubled parents may rely on the child to meet the parent’s emotional needs, turning to the child to provide the parent with support, nurturance, or comforting (Zeanah & Klitzke, 1991). Ultimately, preoccupation with the parents’ needs threatens to interfere with the child’s ability to develop autonomy, initiative, self-reliance, and a secure internal working model of the self and others (Carlson & Sroufe, 1995; Leon & Rudy, this volume).(Kerig, 2005, p. 6)

“A theme that appears to be central to the conceptualization of boundary dissolution is the failure to acknowledge the psychological distinctiveness of the child… Examination of the theoretical and empirical literatures suggests that there are four distinguishable dimensions to the phenomenon of boundary dissolution: role reversal, intrusiveness, enmeshment, and spousification… Enmeshment in one parent-child relationship is often counterbalanced by disengagement between the child and the other parent (Cowan & Cowan, 1990; Jacobvitz, Riggs, & Johnson, 1999). (Kerig, 2005, pp. 8-10)

“There is evidence for the intergenerational transmission of boundary dissolution within the family. Adults who experienced boundary dissolution in their relationships with their own parents are more likely to violate boundaries with their children (Hazen, Jacobvitz, & McFarland, this volume; Shaffer & Sroufe, this volume).(Kerig, 2005, p. 22)

“Lethal” Strain of Parent-Child Conflict

What makes the perverse triangle processes of “parental alienation” different from less severe forms of parent-child coalitions is the presence of a narcissistic/(borderline) personality disordered parent who introduces significantly distorted psychopathology into the parent-child coalition.

Note: the formation of a narcissistic/(borderline) personality organization very likely involved “boundary dissolution in their relationships with their own parents,” thereby making these parents, the narcissistic/(borderline) parent, “more likely to violate the [psychological] boundaries of their children.”

The cross-generational coalition creates increased child conflicts with the other parent, the targeted parent.  However the significant degree of psychopathology introduced by a narcissistic/(borderline) parent greatly amplifies and transmutes the “ordinary” levels of increased parent-child conflict with the other parent into a “lethal” strain of parent-child conflict, in which the child seeks to completely terminate the child’s relationship with the other parent.

Essentially, the child is psychologically “killing” the other parent in the child’s heart and attachment motivations. It is the “lethal” nature of the parent-child conflict created by the severity of the psychopathology of the narcissistic/(borderline) parent that transforms the family processes of “parental alienation” into a qualitatively different level than less virulent forms of the “perverse triangle” of the child’s cross-generational coalition with one parent against the other parent.

What is classically referred to as “parental alienation” is not some form of exotic family process, but actually represents a variant of a fairly standard family dynamic involving the formation of a cross-generational parent-child coalition against the other parent (i.e., a “perverse triangle”; Haley, 1977), that includes an enmeshed relationship of the child with the allied and supposedly favored parent and a corresponding disengagement of the child from the other parent.

What makes the family processes of “parental alienation” distinctive is the addition of narcissistic/(borderline) personality disorder psychopathology that creates a particularly virulent and “lethal” strain of the family relationship dynamics in which the induced parent-child conflict toward the targeted parent results in the child’s motivation to completely terminate, or cut-off, the child’s relationship with the targeted parent.

What is traditionally described as “parental alienation” is not some strange and exotic psychological process (although the psychological processes of the narcissistic/(borderline) parent are a complex and interwoven knot of psychopathology manifesting across multiple levels).  What is classically described as “parental alienation” is simply the child’s triangulation into the spousal conflict by the distorted parenting practices of the allied and supposedly favored parent that creates a cross-generational parent-child coalition against the other parent (i.e., a “perverse triangle”).

The variation factor that elevates “parental alienation” into a qualitatively different presentation from a typical cross-generational parent-child coalition is simply the introduction of significant parental psychopathology in the form of parental narcissistic/(borderline) personality organization that distorts, elevates, and transmutes the child’s conflict with the other parent into a particularly virulent and “lethal” form of parent-child conflict in which the child seeks to completely terminate (cut-off) the child’s relationship with the other, targeted, parent.

The presence of parental narcissistic/(borderline) personality processes will be evident in the child’s symptom presentation of prominent narcissistic and borderline personality traits in the child’s relationship with the targeted parent.  Parental influence of the child by a narcissistic/(borderline) parent will leave “psychological fingerprints” in the symptom display of the child (see my blog: Legal: “Psychological Fingerprints”).

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

Supplemental Quote:

The following quote by Juni is technical and dense, but I include it for professionals because of its linkage of triangulation with narcissistic parenting.

“From the perspective of object relations, it is clear that the triangulated person is not valued as a person in his own right; rather his function is solely that of a repository of transferential affect from the dyad which cannot be affectively elaborated at its natural source. Thus, Alanen’s (1977) depiction of the double bind victim in terms of Kohut’s (1977) narcissistic object, insofar as he is depersonalized and used in the service of the perpetrator’s own needs, seems quite applicable in defining the role of the triangulated as well.” (Juni, 1995. p 93)

Juni, S. (1995). Triangulation as splitting in the service of ambivalence. Current Psychology: Research and Reviews, 14, 91-111.

References:

Family Systems Constructs:

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.

Role-Reversal and Boundary Dissolutions

Kerig, P.K. (2005). Revisiting the construct of boundary dissolution: A multidimensional perspective. Journal of Emotional Abuse, 5, 5-42.

 

Therapy: Initial Considerations (1)

I received the following question regarding therapy and I thought I’d reply through my blog.

Caveat:  Without conducting an independent assessment of family relationships, I cannot offer advice on any specific situation.  I can, however, offer general commentary regarding the issues and factors to be considered in treating an attachment-based model of “parental alienation.”

Here is the question I received:

I am currently in a position where our therapist is asking the courts to remove our children from the alienating parent and have them placed back in my custody.  Do you have any general suggestions for reunification for an alienated parent?  The expectation in our situation is that our 14 year old will be very resistant and our 12 year old will be receptive, based on what the therapist has learned in the last 90 days of sessions.”

An aside: The therapist needs to be careful in the phrasing of this recommendation because treatment providers are prohibited from offering child custody recommendations.  With regard to “parental alienation” this becomes more complex because the pathogenic parenting of the narcissistic/(borderline) parent shifts the clinical concerns from child custody to child protection.  Yet caution still needs to be exercised by treatment providers relative to child custody considerations.

As a clinical psychologist I can discuss treatment-related issues, but I cannot offer an opinion on custody.  This becomes somewhat convoluted when the treatment issue is one of child protection, and therapy requires the child’s protective separation from the pathogenic parenting of the narcissistic/(borderline) parent that is inducing the child’s symptoms, in order to protect the child from harm associated with being turned into a “psychological battleground” by the continuing pathogenic influence of the narcissistic/(borderline) parent who is pressuring the child to maintain the child’s symptomatic rejection of the other parent even as therapy is trying to restore this parent-child relationship.

In my view, my only option since I cannot offer recommendations for child custody considerations is for me to decline therapy until such time as the child’s protection during the active phase of treatment can be guaranteed by a protective separation of the child from the pathogenic influence of the narcissistic/borderline) parent whose distorted parenting practices are inducing the child’s symptomatic state.

However, there are currently many less-than-competent therapists who would be more that willing to pick up any cases that I decline, so that essentially those who are knowledgeable must decline to conduct therapy, leaving treatment to those therapists who have little to no idea what they’re doing.  This is unfortunate.

Initial Comments:

The stages, focal areas, and processes by which we treat and resolve the child’s symptoms that are created by the pathogenic parenting of the narcissistic/(borderline) parent, and by which we also restore the child’s authenticity rather than simply replacing the child’s psychological domination by the narcissistic/(borderline) parent with our own psychological domination of the child, go beyond my ability to describe in a single weblog essay.

So I will begin to describe these therapeutic processes and interventions in this response, beginning with the overall structural goals of the therapeutic process, and then I will follow up on these initial considerations in future blog essays focusing on the various specific components of the therapy process.

The Symptomatic Eldest Child

It is not unusual for the eldest child to be the initial focus of the narcissistic/(borderline) parent for distortion and alliance, while the younger children are left relatively unattended to by the distorting psychopathology of the narcissistic/(borderline) parent. Over time, however, once the eldest child has psychologically surrendered to the psychopathology of the narcissistic/(borderline) parent, the focus of both the narcissistic/(borderline) parent and the eldest child then becomes turned toward inducing the same pathology in the younger siblings, until eventually all the children are induced into cutting off their relationships with the targeted parent.

So if the eldest child is fully symptomatic but the younger child isn’t, this means that the psychopathology of the “alienation” process has not yet achieved full completion. Under these circumstances, I would estimate that the psychopathology has achieved 3/4 to 2/3 completion, which provides us with some degree of healthy to work from. My preference would be to catch the psychopathology early, at about the 1/4 to 1/3 point, no later than 1/2 completion, but that’s not always possible (seldom possible in today’s climate relative to treating “parental alienation”).

The strategy of the narcissistic/(borderline) parent is to delay therapy and buy time for the pathology to become established in the child. The longer effective therapy is delayed, the more entrenched the child’s symptomatology becomes. Time is on the side of the narcissistic/(borderline) parent and the psychopathology.

When the youngest child retains some degree of healthy, then there are ways to use the youngest child’s continued healthy as a formative seed around which to reconstitute healthy parent-child and sibling relationships throughout the family, in which the remaining healthy of the youngest child can serve as a source of “social referencing” within therapy sessions for what constitutes “normal-range” and balanced.

This is particularly true if normal-range child grievances and “breach-and-repair” sequences between the targeted parent and the youngest child can be elaborated in therapy to achieve an effective and successful resolution, then this provides a model for the eldest child of how conflict and conflict resolution is handled in a healthy and productive way.

Protective Separation

Reunification therapy requires the child’s protective separation from the pathogenic parenting practices of the narcissistic/(borderline) parent during the active phase of the child’s treatment and recovery.

From a therapeutic perspective, the protective separation is needed in order to protect the child from being turned into a “psychological battleground” by the continuing psychological pressures applied to the child by the narcissistic/(borderline) parent designed to maintain the child’s symptomatic rejection of the other parent even while therapy is trying to restore the child’s affectionally bonded relationship with the targeted parent.

The analogy is to an infectious disease process (or more accurately, to a computer virus infecting the “files” of the child’s attachment system). The first step in treating an infectious disease is to isolate the child from the source of the pathogenic agent. If, for example, we try to treat the child with antibiotics while the child is continually re-exposed to the pathogenic agent (i.e., the germs or virus in the infection analogy; and the distorted parenting practices of the narcissistic/(borderline) parent in the “alienation” process), the child will simply become continually re-infected even as we try to treat the disease process, leading to the creation of a highly treatment resistant strain of the pathogenic agent.

The first step in treating attachment-based “parental alienation” is to protectively separate the child from the source of the pathogenic parenting during the active phase of the child’s treatment and recovery. Once we have restored the child’s normal-range and balanced psychological functioning, then we can boost the child’s natural “immune response” to the pathogenic agent and reintroduce the child to the psychopathology of the narcissistic/(borderline) parent.

Children love both parents. That is simply the way the attachment system works. We want the child to have healthy and positive relationships with both parents, and we also want to protect the child from the distorting influence of “corrupt files” contained within the attachment system of the narcissistic/(borderline) parent.

The Goal of Therapy

If we can obtain the child’s protective separation from the pathogenic psychopathology of the narcissistic/(borderline) parent during the active phase of treatment, then we can initiate the restoration of healthy and balanced child authenticity. A subtle point of therapy is that the goal is not to restore the parent-child relationship, the goal of therapy is to restore a healthy and balanced authentic child. If we are able to achieve this goal, then a healthy and positive parent-child relationship with the targeted parent will also be achieved.

Children love their parents. Restore the healthy and authentic child and we will restore a healthy and balanced parent-child relationship.

Of note is that normal-range children are sometimes annoying to their parents. This is an important part of the children’s healthy development in which they are expressing their own authenticity and individuation into the parent-child relationship.  We are not seeking “perfect children,” we are seeking psychologically, emotionally, and socially healthy children. Low-level episodes of child protest behavior and minor “breach-and-repair” sequences are not only normal, they are developmentally vital to the child’s healthy development of autonomous self-structure.

In addition, parents are often annoying to their children. Parents set limits, establish and enforce household rules, and have expectations for appropriate child social behavior. All of these parenting functions are normal-range and healthy, and all of these parental functions can, at times, provoke episodes of normal-range child protest behavior. Children can sometimes be annoying to parents. Parents can sometimes be annoying to children. This is normal-range and healthy.

Correcting Child Pathology

However, in attachment-based “parental alienation,” the child is expressing pathological narcissistic and borderline personality disorder traits acquired from the pathogenic parenting of the narcissistic/(borderline) parent. One of the primary interventions toward restoring the authentic child is to eliminate this expression of psychopathology by the child.

The treatment approach toward the psychopathology is to adopt a stance of relentless kindness, gentleness, understanding, and a relaxed-pleasant emotional tone within the simultaneous context of directly and steadfastly challenging the child’s expressions of narcissistic and borderline psychopathology (i.e., entitlement, a haughty and arrogant attitude of contempt, an absence of empathy, polarized black-and-white thinking, emotional tirades of verbal abuse, etc.).

Gandhi said, “the antidote is the opposite.” Think of the child’s hostile over-angry symptoms as a muscle spasm of the emotional system. We want to relax the spasming anger system. The emotion of relaxed pleasant-happy relaxes emotional spasms in the brain.

“No worries. It’s all good. Everything is going to be okay. I love you very much.”

At the same time, we want to provide the child with clear social feedback that the psychopathology is a distorted symptom of pathology and that it is not acceptable, not because of who the targeted parent is, but because of who the child is. We are kind and compassionate because of our values, because of our character. We expect the child to display normal-range social behavior as a reflection of the child’s healthy and positive character.

We cannot force someone to be nice, we can only force them to be submissive. Kindness is a choice. Kindness is a mater of character. Using force with another person is a violation of the other person’s autonomy. The other person has a right to be who they are. We want to try to avoid discipline responses and instead shift to guidance based strategies of dialogue and communication that seek the child’s cooperation, not merely the child’s obedience (think Gandhi, who was relentlessly challenging, but who did so with gentle kindness and a willingness to dialogue).

At the same time, we have the right to reject the child’s angry, contemptuous, disrespectful attitude and behavior. That attitude and behavior is not acceptable. However, we also approach the child with an understanding that the symptomatic expressions are not emanating from the authentic child, but from the pathogen that has infected the child. The child has been held as a psychological hostage by a narcissistic/(borderline) parent (see “The Hostage Metaphor” article on my website; http://www.cachildress.org), and in that context the child has had to completely surrender psychologically to the psychopathology of the narcissistic/(borderline) parent in order to survive.

How would we respond to the child having a fever as a result of an pathogenic virus? The child has acquired a “computer virus” from the psychopathology of the narcissistic/(borderline) parent that is infecting the child’s emotional and relationship systems (primarily the attachment system, but also the empathy system). This pathogenic “computer virus” is crashing the child’s social and emotional functioning, which represents the symptom induced by the pathogen, the “fever” if you will.

We want to respond with calm and relaxed confidence in the healthy authenticity of the child, while also gently and relentlessly challenging the child’s current symptomatic pathology.

Harmonic Resonance: When we pluck the middle C string on a harp, the other two C strings an octave above and below also begin to vibrate in “harmonic resonance.” We want to do the same thing. We want to respond to the child’s authentic self, that is buried within the child, underneath the child’s symptomatic psychopathology, to reawaken the authenticity of the child through our “harmonic resonance” with it, through our fundamental confidence in the child’s inherent goodness of character.

The therapist can play an important role is this by offering the child a balanced third perspective on the child’s self-authenticity. The child has received one perspective of truth from the narcissistic/(borderline) parent, another perspective of truth from the targeted parent (which the child has been induced to reject). The therapist is in a position to offer a balancing and normal-range third perspective that calls forth and validates the child’s inherent goodness of character.

The Misattribution of Grief

This is a critical component of therapy (see “Reunification Therapy” article on my website; http://www.drcachildress.org). The child authentically feels hurt and pain as a product of the child’s relationship with the targeted parent. The origins of the child’s authentic hurt and pain is initially the result of the child’s grief response at the loss of the intact family structure that occurred with the divorce. But once the child is induced by the pathogenic parenting of the narcissistic/(borderline) parent to reject the other parent, who is actually deeply loved by the child, the child experiences a second and more profound grief response over the loss of an affectionally bonded relationship with the beloved but now rejected targeted parent.

However, under the distorting influence of the narcissistic/(borderline) parent, the child is led into a misinterpretation of this authentic experience of sadness and hurt as falsely representing an emotional signal that something the targeted-rejected parent is doing, or something about the mere personhood of the targeted parent, is so bad, so “abusive” of the child, that it is this quality of the targeted-rejected parent that is creating the child’s authentic experience of immense sadness and suffering associated with the targeted-rejected parent.

This attribution of meaning by the child, created under the distorting influence of the narcissistic/(borderline) parent, is not true, but in the absence of an accurate attribution of meaning the child comes to accept and believe the distorted meaning construction of the narcissistic/(borderline) parent for the child’s authentic experience of sadness and suffering associated with the targeted-rejected parent.

The accurate attribution of meaning is that the child actually loves the targeted parent very much, and very much wants and misses having an affectionally bonded relationship with this parent, but the child’s inability to establish this affectionally bonded relationship with the targeted-rejected parent is producing a tremendous grief response of sadness and suffering. It is as if the child’s beloved parent has died.

This is vitally important for the therapy process to understand. The child authentically experiences a deep sadness and hurt associated with the targeted-rejected parent, which the child is falsely attributing to the “abusive” parenting or personhood of the targeted-rejected parent (under the distorting pathogenic influence of the narcissistic/(borderline) parent).

Therapy needs to reorient the child to the child’s authentic grief response, and provide a balanced and accurate attribution to the child’s authentic experience. Once the child receives and recognizes an accurate attribution of meaning for the child’s sadness and pain, i.e., that the child actually loves the targeted parent and wants an affectionate bond with this parent, then the “computer virus” will be cleansed from the child’s emotional and relationship systems and the child can fulfill and complete the normal-range functioning of these brain systems.

However, while the child is in the parental care of the narcissistic/(borderline) parent, the child is in a psychological hostage situation and does not have permission from the hostage taker to form an affectionally bonded relationship with the beloved but rejected targeted parent, and the child is instead required by the hostage taker to actively reject the beloved other parent (see “The Hostage Metaphor” article on my website; http://www.cachildress.org). If the child shows any bonding motivations with the targeted parent, or even fails to adequately display overt rejection of the targeted parent, then the child faces a withering psychological retaliation from the psychopathology of the narcissistic/(borderline) parent.

Unless we can first protect the child from psychological retaliation from the psychopathology of the narcissistic/(borderline) parent for any child display of affectionate bonding or failure to display adequate rejection of the other parent, we cannot ask the child to bond with the targeted parent because to do so will only expose the child to psychological retaliation from the narcissistic/(borderline) parent.

We must first secure the child’s protection. Only then can we proceed with therapy.

(end Part I of Therapy)

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

Question: The Violent Child

I received this question and thought I’d reply through my blog because my response may have broader applicability to the experience of many targeted parents.

Please note, I cannot speak to any individual situation since I have not conducted an independent assessment of the situation and relationships.  I am only addressing the broader issues, not any specific situation.

Here is the question I was posed:


I have a question that no one seems to be able to answer yet.   What is a non-custodial targeted parent to do when a child (teenager) is encouraged to act violently towards the targeted parent, siblings, and even pets of the targeted parent.

Children’s protective services does not deal with child violence within it’s child protection parameters.  The police recommend that the targeted parent call them whenever the child acts violently for the health and safety of the other household members.  However, the children’s minor’s counsel and the Courts say that calling police endangers the child. They view the child’s violence as proof of the targeted parent’s incompetence to manage the child.

How should the targeted parent respond to the child’s (teenager’s) violence that is endangering family members? When the targeted parent follows the  advice of the police, the Court holds these actions against them, but failure to involve the police endangers the other family members.  So far the only definitive answer I’ve received about this situation is “I DON”T KNOW”.


A:  Situations such as the one described require the involvement and guidance of a competent mental heath practitioner, so the answer to the question “How should the targeted parent respond?” is that the targeted parent should engage the services of a competent mental health practitioner and follow the recommendations of this practitioner.

Caveat:  What if the situation actually does involve problematic parental responses from the targeted parent?  Perhaps the targeted parent IS responding in a problematic way to the teenager.  Without my conducting an independent assessment of the situation, there is no way I can provide a specific answer to the question posed.  The solution is to involve a competent mental health practitioner and follow the guidance offered by this mental health practitioner.

Caveat:  I acknowledge that there are far too many incompetent mental health practitioners out there, especially regarding the diagnosis and treatment of the “special population” of children and families experiencing attachment-based “parental alienation.”  Also, the narcissistic/(borderline) parent may prevent (through a variety of methods) the involvement of a competent mental health practitioner.

Caveat:  Therapy for attachment-based “parental alienation” requires the child’s protective separation from the pathogenic parenting practices of the narcissistic/(borderline) parent during the active phase of the child’s treatment and recovery.  Unless the child is protectively separated from the pathogenic parenting of the narcissistic/(borderline) parent during the active phase of the child’s treatment and recovery, there is no solution available.

That’s the core of what professional mental health needs to comprehend in order for professional mental health to begin speaking with a single voice to the Court.  When mental health speaks with a single voice, the Court will be able to act with the decisive clarity necessary to solve the  tragedy of attachment-based “parental alienation.”

Unless the child is protectively separated from the pathogenic parenting of the narcissistic/(borderline) parent during the active phase of the child’s treatment and recovery, no solution to “parental alienation” is available.


Qualifier:  In my response below, I am not addressing any specific situation.  What to do in any specific family situation will require an individualized assessment of the relationships within the family.  But from a general perspective regarding extremely hostile-violent child behavior as conceptualized within an attachment-based model of “parental alienation”…


Understanding Personality Disorders

Attachment-based “parental alienation” is driven by the narcissistic/(borderline) personality disorder of the alienating parent (that is formed from distorted “internal working models” of the parent’s attachment system).  So let me begin my response by providing a brief orientation to the construct of “personality disorders.”

It is increasingly recognized that personality disorders involve blends of distorted personality traits (Widiger & Trull, 2007; American Psychiatric Association, DSM-5 Chapter 3, 2013) rather than fixed categories. So when talking about personality disorders it is helpful to consider blends of traits rather than distinct categories.  To the extent that these blends organize around particular categories, such as narcissistic or borderline expressions of personality traits, then we can use these category names as a convenient label in our discussions.

In addition, the underlying “self-structure” organization of the narcissistic and borderline personality organization is the same (Kernberg, 1975), involving the person’s tremendous sense of core-self inadequacy and fears of abandonment. The difference between a narcissistic and borderline personality organization is simply that the borderline personality directly and continuously experiences this fundamental self-inadequacy and abandonment fear, which leads to tremendous ongoing disruptions to self-identity and problematic affect regulation, whereas the narcissistic personality has created a psychological defense of grandiose self-inflation against the experience of core-self inadequacy and abandonment fears, thereby allowing for greater superficial self-cohesion and superficial affect regulation (as long as the narcissistic defense holds).

In addition, the construct of “personality disorders” developed across the period from the 1930s to 1980s, with a more formal entry into the DSM-3 diagnostic system in 1980. Parallel to this process, however, was the work of John Bowlby in attachment theory, which was formalized in the 1970s across three seminal volumes (Bowlby, 1969, 1973, 1980). Since the 1980s, increasing research has linked the two constructs (Brennan & Shaver, 1998), particularly around the formation of borderline personality organization (Fonagy, et al., 2003; Holmes, 2004; Levy, 2005; Lyddon & Sherry, 2001).

From Brennan & Shaver (1998):
“In the clinical literature, there is increasing support for conceptualizing personality disorders as disorders of attachment (e.g., Heard & Lake, 1986; Shaver & Clark, 1994; West & Sheldon, 1988; West & Sheldon-Keller, 1994). There is growing empirical evidence connecting borderline personality disorder with patterns of insecure attachment reflected in representations of childhood relationships with parents (Patrick, Hobson, Castle, Howard, & Maughan, 1994; Sack et al., 1996; Stalker & Davies, 1995; West et al., 1994).

In attachment-based “parental alienation,” the primary personality disorder driving the distorted family process is a narcissistic/(borderline) organization, with some “alienating parents” expressing a stronger narcissistic personality organization while others display a more pronounced borderline presentation.

In addition, other personality disorder traits can be evident, which lends additional textures to the symptom presentation within the family. I have encountered blends that include antisocial personality traits, histrionic personality traits, paranoid personality traits, and obsessive-compulsive personality traits. Each of these complex blends presents a different symptomatic feel to the “parental alienation” dynamics.  These additional personality disorder traits arise from within the unique “internal working models” of each unique person’s attachment system, which then coalesce in later development into the characteristic patterns reflected in the “personality disorders” types.

The reason I describe this as prelude to addressing the general question of an excessively violent and hostile child that occurs within the context of attachment-based “parental alienation” is that I’ve seen the presentation of the excessively hostile child (teenager) clinically to be generally associated with a narcissistic/(borderline)/antisocial personality blend. From my anecdotal clinical experience, the addition of antisocial personality traits in the alienating parent appears to create a particularly aggressive variant of “parental alienation” with strong domestic violence overtones.

I have generally seen this pattern with males as the alienating parent (perhaps because of the higher prevalence for males to display narcissistic and antisocial personality traits), with mothers then being the recipient of the child’s (teenager’s) excessive violence and threats (as a vehicle in expressing the father’s narcissistic and antisocial violence toward the mother). This pattern may also be associated with a history of pre-divorce domestic violence qualities within the family involving control, dominance, and verbal/emotional abuse from the narcissistic/(borderline)/antisocial parent (husband) toward the other parent (wife).

While these gender-related factors are likely typical, they are not absolute, and there is no reason why women cannot also be the perpetrators of this hyper-aggressive variant.

The Child’s Behavior

Children are a product of the parenting they receive.

If the child is aggressive, mean, rude, and disrespectful, this is the product of the parenting the child is receiving from the allied and supposedly “favored” parent.

The child and the supposedly “favored” parent will contend that the child’s atrocious behavior is the product of the fundamental human inadequacy of the targeted parent, who “deserves” the child’s hostility and contempt because of this parent’s inherently awful nature as a human being.

First, this effort at excusing and justifying the child’s atrocious behavior and the extremely poor parenting by the allied and supposedly “favored” parent that is reflected in the child’s behavior, is absurd on its face,

Second, the effort to excuse and justify the child’s atrocious behavior is a direct and evident symptom of the narcissistic/(borderline) personality processes and attitudes of the allied and supposedly “favored” parent that are being transferred to the child through the aberrant and distorted parenting practices of the narcissistic/(borderline) parent.

1.  Absurd on its Face: The assertion that the targeted parent deserves the child’s contempt and cruelty is absurd.  We do not treat other people with kindness or cruelty based on our judgments of what they “deserve.” We treat others with kindness or cruelty based on our value systems, based on who WE ARE as a person, based on how we define ourselves. We treat others with kindness, and respect, and consideration, not because of who they are, but because of who we are.

It doesn’t matter if the child doesn’t like his or her teacher.  The child is still expected to display socially organized and cooperative behavior, and especially non-aggressive behavior.  It doesn’t matter if the child believes the store clerk was rude, the child is nevertheless expected to display socially organized and non-aggressive behavior.  The child may not agree with or like the discipline meted out by the soccer coach, but the child is NOT allowed to vent cruelty or aggression toward the soccer coach.  And if this is our expectation for the child’s responses to teachers, store clerks, and coaches, then the same applies to the child’s response to his or her parents.

The aggressive and hostile cruelty of the child is NOT because of who the targeted parent is, the child’s aggression and cruelty is the result of who the child is.  Knowing this is the bedrock foundation of good parenting.

For anyone, including the allied and supposedly “favored” parent, to in any way attempt to excuse or justify the child’s aggressively hostile attitudes and cruelty reflects distorted beliefs and parenting that support the child’s development of distorted values and character traits. Even IF the targeted parent was a bad person and parent, the child should nevertheless respond with kindness, compassion, and consideration, not because of who the parent is, but because of who the child is.

Those are the values we teach our children.

In some cases, the excusing argument may be offered that the child “only acts this way with the targeted parent.” Then this excuse becomes EVEN MORE REASON to indict the parenting of the allied and supposedly “favored” parent, because this argument offered by others (or by the behavioral evidence provided by the child), means that the child inherently possesses the ability to regulate his or her affect but is CHOOSING not to do so in a specific case because the child believes that this person, this parent, “deserves” the child’s cruel treatment.

The child’s regulated behavior in every other situation reveals the lie in the assertion that the child is being “provoked” into dsyregulated anger, because the child has clearly displayed the demonstrated capacity to regulate his or her anger in other situations. Instead, the child is CHOOSING to be cruel, hostile, and mean to this select person whom the child believes “deserves it.”

2.  A Reflection of Narcissistic/(Borderline) Parenting: The attitude that we are somehow allowed to judge others and mete out cruelty to others we judge as deserving of our contempt is a reflection of a narcissistic/(borderline) personality process.

The narcissistic personality maintains a grandiose self-perception that judges others as inferior, and with an air of haughty arrogance feels justified (entitled) in the contemptuous treatment of others who the narcissist judges to be unworthy, so that the fundamental inadequacy of the other person justifies the contempt and cruelty delivered by the narcissist. The other person “deserves” the contempt and abuse because of the other person’s inadequacy.

This highly distorted narcissistic attitude represents a fragile defense against the narcissist’s own internal experience of fundamental inadequacy (and fear of abandonment because of this inadequacy). It is the narcissist who feels immensely inadequate and completely unworthy of being loved, and who then responds to these deep and profound feelings of inadequacy and unlovability by creating a narcissistic defense of grandiose over-inflation of self importance and devaluation of others (“I’m not inadequate, you are. I’m wonderful; I’m ideal. It’s you who are inadequate. And if you don’t recognize and acknowledge my wonderfulness, then you ‘deserve’ to be punished.”).

“If others fail to satisfy the narcissist’s “needs,” including the need to look good, or be free from inconvenience, then others “deserve to be punished”… Even when punishing others out of intolerance or entitlement, the narcissist sees this as “a lesson they need, for their own good.” (Beck, et al., 2006, p. 252).

The borderline personality organization also feels entitled to vent unbridled anger on others who “deserve” the borderline’s anger because they failed to adequately love the borderline. The narcissistic and borderline personalities are simply superficial variations in the manifestations of the inner core experiences of fundamental self-inadequacy and fear of rejection and abandonment by others. The core driving experience for both types of personality organizations is the same, with variations in the the overt manifestation of these underlying core beliefs.

Extremely Poor Parenting

A child’s behavior of aggressive violence is NEVER appropriate and is NEVER justified. ANY attempt by a parent to justify IN ANY WAY a child’s aggressive violence toward anyone (including and especially the other parent) reflects highly distorted parenting practices and a narcissistic/(borderline) personality organization of the parent who believes that venting of contemptuous anger can be “justified” when the other person “deserves” it.

If the minor’s counsel for the child or the Court concur with the child’s permission to become violent and cruel, then this is absolutely and fundamentally wrong.  There is NO valid excuse or justification for a child’s display of cruelty and violence toward anyone.  NONE.

That doesn’t mean that other people aren’t problematic. They are and can be.  But we teach our children to maintain their emotional and behavioral composure, to self-regulate their emotional and behavioral responses, and to exercise appropriate values and character in their response.  This is called “parenting.”

Pathogenic Parenting

Transferring a highly distorted belief system to the child, i.e., that the child is allowed to judge others and to deliver tirades of abusive anger if the child judges that the other person “deserves” it, represents extremely bad parenting. It is the beginning formation of narcissistic entitlement and borderline emotional dysregulation in the child as a product of distorted parenting practices by a narcissistic/(borderline) personality, who holds the distorted beliefs that the child is acquiring.

Children are a reflection of the parenting they receive. The distorted attitudes and behavior expressed by the child are NOT the product of the parenting from the targeted-rejected parent, as this parent has little to no influence on the child. The child’s highly distorted belief system and behavioral license are the product of the extremely bad parenting the child is receiving from the allied and supposedly “favored” parent.

When the child’s expressed attitudes and behavior are severe, such as would appear to be the case if the police need to be called to intervene, then the degree of severely poor parenting reflected in the child’s behavior raise child protection concerns. The allied and supposedly “favored” parent is doing such an extremely poor job of parenting that strong consideration should be given to switching primary parental care to the targeted parent, who can then strive to provide the child with better parenting and guidance that can restore the child’s balanced personality formation and undo the obvious damage to the child’s character development caused by the extremely bad parenting of the allied and supposedly “favored,” narcissistic/(borderline) parent.

Conclusions of Dr. Childress

Children are a reflection of the parenting they receive.

Hostile aggressive behavior by the child is a reflection of extremely bad parenting. To propose that the child’s hostile-aggressive behavior is the product of the targeted parent is absurd on its face and should be rejected without consideration.

We will welcome consideration of the child’s grievances when these are expressed in appropriately socialized ways.  We talk, we dialogue, we discuss.  Violence, threats, and cruelty are NEVER acceptable, are NEVER excusable, and are NEVER justified.  Child grievances expressed as violence, threats, and cruelty will not be considered until such time as these are expressed in socially acceptable ways.

Even IF the parenting of the targeted parent is problematic (which it isn’t), the child should still be expected to maintain appropriate self-regulation.

An attempt by the allied and supposedly “favored” parent, to excuse the child’s atrocious behavior as somehow being understandable and justified because the targeted parent somehow “deserves” or provokes the child’s behavior is direct evidence of the narcissistic/(borderline) personality structure of the allied and supposedly “favored” parent who is supporting the child’s development of highly problematic affect regulation and attitudes of contemptuous disrespect for others.

If the child displays aggressive, threatening, or cruel behavior, then this is an indictment of the parenting practices of the allied and supposedly “favored” parent, and, if the child’s aggression, threats, and cruelty are severe, then child protection considerations may be warranted regarding the pathogenic parenting practices of the allied and supposedly “favored” parent as evidenced in the child’s attitudes and behavior, so that a change in primary parental care may be indicated.

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

References

Spectrum of Personality Disorder Traits

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

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.

Attachment and Personality Disorder Formation

Brennan, K.A. and Shaver, P.R. (1998). Attachment Styles and Personality Disorders: Their Connections to Each Other and to Parental Divorce, Parental Death, and Perceptions of Parental Caregiving. Journal of Personality 66, 835-878.

Fonagy, P., Target, M., Gergely, G., Allen, J.G., and Bateman, A. W. (2003). The developmental roots of Borderline Personality Disorder in early attachment relationships: A theory and some evidence. Psychoanalytic Inquiry, 23, 412-459.

Holmes, J. (2004). Disorganized attachment and borderline personality disorder: a clinical perspective. Attachment & Human Development, 6(2), 181-190.

Levy, K.N. (2005). The implications of attachment theory and research for understanding borderline personality disorder. Development and Psychopathology, 17, p. 959-986

Lyddon, W.J. and Sherry, A. (2001). Developmental personality styles: An attachment theory conceptualization of personality disorders. Journal of Counseling and Development, 79, 405-417

Attachment Theory

Bowlby, J. (1969). Attachment and loss. Attachment, Volume 1. NY: Basic Books.

Bowlby, J. (1973). Attachment and loss: Volume 2. Separation: Anxiety and anger. NY: Basic.

Bowlby, J. (1980). Attachment and loss: Volume 3. Loss: Sadness and depression. NY: Basic.

Association of Narcissistic and Borderline Personality

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