HOW CAN—AND SHOULD— PROFESSIONALS ACCURATELY DISTINGUISH BETWEEN ALIENATION AND ESTRANGEMENT?

Steven G. Miller, M.D.

PASG INTERNATIONAL CONFERENCE Stockholm, Sweden
Friday, August 24, 2018

© 2018 The Massachusetts Medical Education Group, LLC.

GOALS AND OBJECTIVES § To raise consciousness!

§ To propose a clinical model with specific criteria to distinguish between alienation and estrangement.

• This combines elements of a medical model with a family systems approach.

§ To review some basic concepts.

QUESTION
What does evidence-based practice mean? ANSWER

QUESTION
What does evidence-based practice mean? ANSWER

It means that clinicians should use the best available evidence

BEWARE SPECIOUS ARGUMENTS!

§ NONSENSE CONTROVERSIES—ABSOLUTELY FALSE!

• There’s no such thing as PA—it doesn’t exist!
• It’s just a theory!
• Experts can’t even agree on a definition!
• It is not supported by empirical evidence!
• Gardner was a [fill in false allegation]!
  § PSEUDO-CONTROVERSIES—FALSE OR NO RELEVANCE!

• It’s not a syndrome!
• It’s not in the DSM-5!
• Most cases are hybrids.
• The research is of poor or questionable quality!
• It’s not admissible in court!

Many people
who claim to go by the book have never read the book or even know which book

”Cases of severe alienation are likely to be highly counterintuitive. Clinicians who attempt to manage them without adequate skills are likely to find themselves presiding over a cascade of clinical and psychosocial disasters.”

Miller, Steven G. (Chapter 2). Clinical Reasoning and Decision-making in Cases of Child Alignment. Page 11.

Edited by
Baker and Sauber, 2013

THE HIGH CONFLICT MODEL

• §  Assumes that both parents are significantly responsible for the family dynamics.
• §  Fails to properly consider the possibility that one party is an aggressor and the other is in defense mode, trying to manage a horrific family crisis.
• §  Entails multiple severe cognitive errors, e.g., stereotyping errors.
• §  From both clinical and legal perspectives, use of the High Conflict Model in a case of parental alienation is a recipe for disaster.

HIGH CONFLICT MODEL

Edited by Lorandos, Bernet and Sauber, 2013

Sir William Osler 1849-1919

“Medicine is a science of uncertainty and an art of probability.”

”We balance probabilities and choose the most likely.”

Sherlock Holmes

The Hound of the Baskervilles 1902

PROPOSED CLINICAL CRITERIA TO DISTINGUISH ALIENATION FROM ESTRANGEMENT

BUT FIRST …

IMPORTANT NOTES

§ These criteria are for experienced mental health clinicians who have a sophisticated understanding of certain advanced clinical concepts.

§ The criteria are intended to inform clinical judgment—not to replace it.

§ They assume the clinician or forensic evaluator will employ sound clinical judgment based on the scientific method.

§ This model assumes the clinician has a sophisticated understanding of certain clinical concepts. For example:

• How to weight and combine clinical findings to rule in, or rule out, a clinical hypothesis.
• How to employ the laws of conditional probability for clinical problem-solving and decision-making.
• How to conduct a proper causation analysis.
  § This latter point has major implications with respect to the “hybrid hypothesis.”§ These criteria do not necessarily provide final or definitive answers. Rather, they help to determine the most rational conclusions given the available evidence.

THE SIMPLE ODDS FORM OF BAYES’ THEOREM

Posterior (Final) Odds =
Prior (Initial) Odds x Weight of Evidence

• §  This tells us what to believe—what is the most logical and rational conclusion—given the evidence.
• §  It permits us to continuously update our belief in a hypothesis as new evidence becomes available.
• §  It can be used in sequence for each piece of evidence (assuming that each piece of evidence has conditional independence).

ACCURACY OF A DIAGNOSTIC TEST: KEY POINTS

§ SENSITIVITY
• TRUE POSITIVE RATE =

The detection rate § SPECIFICITY

• TRUE NEGATIVE RATE =
100 minus the false positive rate

§ POSITIVE LIKELIHOOD RATIO (LR+)
• Used if test is (+) or evidence is present

§ NEGATIVE LIKELIHOOD RATIO (LR–)
• Used if test is (–) or evidence is absent

CLINICAL DECISION RULES (CDRs)

§ CDRs have become very important in medicine.

• Concept: ELEGANT SIMPLICITY!
• Examples: Ottawa Ankle Rules; Wells’ Criteria

• §  Although we do not yet have a CDR to distinguish alienation from estrangement, this model is quite similar to a CDR.
• §  Beware the Two Deadly Ds!

• Too much information (TMI) tends to:

ü Dilute the message
ü Distract the audience (reader, listener, etc.)

PROPOSED CLINICAL CRITERIA TO DISTINGUISH ALIENATION FROM ESTRANGEMENT

§ TWO CRITERIA FOR THE CHILD *

• Child Criterion 1 (CC1)
• Child Criterion 2 (CC2)§ TWO CRITERIA FOR THE FAVORED PARENT

• Favored Parent Criterion 1 (FPC1)
• Favored Parent Criterion 2 (FPC2) 

  § TWO CRITERIA FOR THE REJECTED PARENT

• Rejected Parent Criterion 1 (RPC1)
• Rejected Parent Criterion 2 (RPC2)* The child criteria must be used individually for each child.

§ CHILD CRITERIA

• Child Criterion 1 (CC1)s CC1-A, or s CC1-B, or s CC1-C
• Child Criterion 2 (CC2)
  § FAVORED PARENT CRITERIA

Three levels based on severity

• Favored Parent Criterion 1 (FPC1) s FPC1-A, or

s FPC1-B, or

Three levels based on severity

s FPC1-C
• Favored Parent Criterion 2 (FPC2)

§ REJECTED PARENT CRITERIA

• Rejected Parent Criterion 1 (RPC1)
• Rejected Parent Criterion 2 (RPC2)

THE CHILD CRITERIA

THE EIGHT MANIFESTATIONS (In Original Form)

§ A campaign of denigration.
§ Weak, frivolous or absurd reasons for the rejection. § Lack of ambivalence.
§ ”Independent thinker” phenomenon.
§ Reflexive support of the alienating parent.
§ Absence of guilt.
§ Borrowed scenarios.
§ Rejection of friends and extended family.

CHILD CRITERION 1 (CC1): The child manifests unreasonable negative beliefs, feelings and/or behaviors about the rejected parent that are significantly disproportionate to the child’s actual experience with that parent AND there is a pattern of denigration for which the child provides weak, trivial, frivolous or absurd reasons.

These are considered the ”core findings” of alienation. To make a determination of alienation, the child MUST meet CC1—in other words, CC1 is MANDATORY.

If the above core findings are present, then determine which of one the following sub-criteria best fits the child’s clinical presentation with respect to SEVERITY (select only one):

CC1-A: The child manifests the above ”core findings”; OR

CC1-B: In addition to having the core findings in CC1-A, the child expresses beliefs about the parents that suggest pathological splitting. Examples include: a marked lack of ambivalence about the parents; reflexive support for the favored parent in almost every conflict or situation; portraying one parent as ”all good” and the other as ”all bad”; or, despite evidence to the contrary, denying positive experiences with the rejected parent in the past;

OR

CC1-C: In addition to having the core findings of CC1-A, and the pathological splitting required for CC1-B, the child engages in unwarranted cruel or unkind treatment of the rejected parent AND displays little or no guilt or remorse regarding that mistreatment.

CHILD CRITERION 2 (CC2): The child’s use of language suggests that the child’s beliefs and feelings have been unduly influenced by the favored parent. This may be indicated by the content, choice of words, syntax, cadence, inflection, or other parameters.

For example, the child relates incidents, expresses opinions, or criticizes the rejected parent in a way that is not plausible, or not credible, and that closely resembles the beliefs, feelings attitudes, or experiences of the favored parent.

In addition, the child may claim that these negative views and beliefs are his or her own in a way that is not plausible or credible.

THE FAVORED PARENT CRITERIA

THE 17 STRATEGIES OR BEHAVIORS (Divided into Six Groups)

§ Badmouthing
§ Limiting contact
§ Erasing of memories

§ Undermining trust
§ Undermining authority

§ Undermining love

NOTE TRIAD RE UNDERMINING

FAVORED PARENT CRITERION 1 (FPC1): The favored parent, without a valid reason, either consciously or unconsciously, has exhibited one or more alienating behaviors, or has employed one or more alienation strategies, that are potentially damaging to the child’s relationship with the other parent.

Such behaviors include but are not limited to: badmouthing; limiting contact; disrupting communication; interrupting visits; undermining authority; withholding love; withholding information; suggesting the other parent does not love the child; suggesting the other parent is dangerous; encouraging the child to denigrate or disrespect the other parent; or enabling the child to minimize contact with the other parent.

If any of the above alienation behaviors are present, one must then categorize FPC1 based on SEVERITY as described on the following slide.

Next, grade FPC1 for SEVERITY (selected only one):

FPC1-A: There is mild alienating behavior with respect to the number and/or intensity of the behaviors;

OR

OR

FPC1-B: There is moderate alienating behavior with respect to the number and/or intensity of the behaviors;

FPC1-C: There is severe alienating behavior with respect to the number and/or intensity of the behaviors.

FAVORED PARENT CRITERION 2 (FPC2): The favored parent has intentionally provided information to a professional involved in the case that is substantially inaccurate or misleading.

Furthermore, any intentional misrepresentation must be directly relevant to the case, for example, false allegations of abuse or neglect, or false statements regarding the family’s history or present situation.

Comment From Previous Conference

Comment by a workshop participant regarding a presentation on how to assess the probability of parental alienation using criteria that focus on the ”8 manifestations,” the “17 strategies,” and the presence or absence of intentional misrepresentations by the respective parents.

THE REJECTED PARENT CRITERIA

REJECTED PARENT CRITERION 1 (RPC1): The rejected parent has NOT treated the child in a way that is genuinely abusive or significantly neglectful, and has NOT engaged in markedly deficient parenting. In other words, there is an absence of bona fide abuse or severe neglect.

That is, any negative behavior by the rejected parent must NOT be clinically-significant and must NOT be causally-connected to the child’s negative beliefs, feelings, or behaviors.

Notes:

• §  This criterion is positive if the above findings are absent!
• §  This might be confusing at first, but it is logical. If the rejected parent has not been abusive or neglectful, and has not engaged in markedly deficient parenting, that supports a determination of alienation, rather than estrangement!

REJECTED PARENT CRITERION 2 (RPC2): The rejected parent has NOT intentionally provided relevant information to a professional involved in the case that is substantially inaccurate or misleading.

If the parent has engaged in any intentional misrepresentation, it must NOT be directly relevant to the case. In particular, there must be NO false allegations of abuse or neglect, and NO substantially inaccurate or misleading statements regarding the family’s history or present situation.

Notes:

§ This criterion is positive if the above findings are absent!

§ As with RPC1, this is logical. If the rejected parent has not lied—but, rather, has been truthful—that supports a determination of alienation, not estrangement!

”In solving a problem of this sort,
the grand thing is to be able to reason backward. That is a very useful accomplishment,
and a very easy one,
but people do not practise it much.”

Sherlock Holmes
A Study in Scarlet, 1887

”My dear Watson, you as a medical man are continually gaining light as to the tendencies of a child by the study of the parents. Don’t you see that the converse is equally valid? I have frequently gained my first real insight into the character of parents by studying their children.”

Sherlock Holmes The Adventure of the Copper Beeches 1892

JUDGES UNDERSTAND THIS! SO DO SCIENTISTS!

DISCOVERY OF NEPTUNE 1846

ASSUMPTIONS

1. There is conditional independence between criteria.

• Note that conditional independence (CI) is not the same as absolute or unconditional independence.
• Loosely speaking, CI means the evidence is independent except for the effects of alienation.
• 2. The estimated sensitivities and specificities are reasonably accurate.

• They reflect an expert consensus opinion.
• Although carefully-considered, these assumptionshave not been validated in a clinical trial.
• HOWEVER, regarding sensitivity and specificity, great precision is NOT required.

Table 1. Estimated Sensitivities, Specificities and Likelihood Ratios

EXAMPLE OF A SENSITIVITY ANALYSIS Calculations for 6 pieces of evidence each of which

has a sensitivity and a specificity of 75% (so positive LR = 3)

(All calculations were done to 5 decimal places and then rounded.)

What clinical insights does this provide?

Clinical Insights:
§ An LR(+) of 3 is generally considered weak evidence. § But 3 x 3 x 3 x 3 x 3 x 3 = 729, so the total LR(+) = 729. § So six pieces of weak evidence = very strong evidence! § But only if there is conditional independence!

RECALL THAT THIS MODEL EMPLOYS SIX (6) CRITERIA, EACH OF WHICH HAS CONDITIONAL INDEPENDENCE.

§ Two criteria for the child

• Child Criterion 1 (CC1)
• Child Criterion 2 (CC2)§ Two criteria for the favored parent

• Favored Parent Criterion 1 (FPC1)
• Favored Parent Criterion 2 (FPC2)§ Two criteria for the rejected parent

• Rejected Parent Criterion 1 (RPC1)
• Rejected Parent Criterion 2 (RPC2)

OTHER USEFUL INDICATORS

§ There was a previously-good or normal baseline relationship between the child and the parent.

• Under this model, that is a PRE-REQUISITE.

• §  The child denies or downplays positive memories of therejected parent (”erasing of positive memories”).
• §  The person’s affect (either parent’s or child’s) is inconsistent or incongruous with the verbal content.
• §  Signs of pathological enmeshment: • Infantilization.
  • Adultification.
  • Parentification.

§ Over-empowerment

• Especially if extreme or severe.
• Ask: Who is doing the over-empowering?§ Boundary violations

• Especially if extreme or severe.
• Ask: Who is violating whose boundaries?§ Extreme or bizarre behavior

• Look for ”extreme extremism.”
• Ask: Is this normal—not just common—behavior?ü The above triad—sometimes called THE BIG THREE— should be applied to each member of the family.

  ü These three variables can be used for both children and parents.

Figure 1. Master Algorithm for the Alienation Criteria

1. The alienation criteria apply only to cases in which a child is strongly aligned with one parent and has rejected the other.

2. To determine the post-test (or, more generally, the posterior) probability of alienation, one must first determine or estimate the pre- test (or, more generally, the prior) probably of alienation. One can never use any diagnostic test or clinical finding to determine a post- test probably unless one knows or estimates the pre-test probability.

3. These criteria do not necessarily provide the actual post-test probability of alienation; rather, they update the pre-test probability to a post-test probability given the evidence under consideration!

So this is not a “cookbook” !!!

USE YOUR INSTRUMENTS! TRUST YOUR INSTRUMENTS!

PROTOTYPE CASES WITH BAYESIAN ANALYSES

FAMILY 1
Meets all 6 criteria using CC1-A and FPC1-A

Table 2.1. Calculations for a family that meets all 6 criteria with CC1-A and FPC1-A

Table 2.2. Calculations for the same family using very low priors

FAMILY 2
Meets all 6 criteria using CC1-C and FPC1-C

Table 3.1. Calculations for a family that meets all 6 criteria with CC1-C and FPC1-C

Table 3.2. Calculations for the same family using very low priors.

HYBRID ALGORITHM

Figure 2. Algorithm for Mixed Alienation and Estrangement

1. To be clinically-significant, any component of estrangement must involve genuine abuse, neglect or markedly deficient parenting—not merely suboptimal parenting—and be severe enough to have caused the rejection in the absence of an alienating parent or other alienator.

2. To be causally-connected, any estrangement component must be temporally-connected to the child’s rejection of the parent.

3. Estrangement behavior by a parent will not necessarily cause a child to reject that parent.

4. If alienation and estrangement are both present, it is important to determine the respective severity and relative contribution of each.

1. To be clinically-significant, any component of estrangement must involve genuine abuse, neglect or markedly deficient parenting—not merely suboptimal parenting—and be severe enough to have caused the rejection in the absence of an alienating parent or other alienator.

2. To be causally-connected, any estrangement component must be temporally-connected to the child’s rejection of the parent.

3. Estrangement behavior by a parent will not necessarily cause a child to reject that parent.

4. If alienation and estrangement are both present, it is important to determine the respective severity and relative contribution of each.

”I never guess.
It is a shocking habit— destructive to the logical faculty.”

Sherlock Holmes
The Sign of the Four, 1890

Thank You! QUESTIONS?

For a copy of this slide set write to Dr. Steve Miller at: smillermd@aol.com