Most people know of a pattern that happens when families separate. That pattern is when one parent turns a child against the other parent without good reason. But, for decades, giving that pattern a short name has caused endless trouble even though labels are meant to help!
This hassle has taken up a heck of a lot of the energies of those trying to get the pattern described, recognised, researched and helped. Now the slightest mention of the label instantly enrages some people.
Let’s unpack why this has happened. If you can be bothered to read it all, you’ll see that, one way and the other, unpacking labels has been the story of my life.
Pretty well everyone has tackled this topic in many different ways – e.g. Bill Bernet, Sue Whitcombe’s comprehensive and prize-winning account, Craig Childress, Kelly and Johnston, and Joan Kloth-Zanard (see her list of other names for PA in the comments here). This attempt of mine may need a bit of taming, so please comment below.
I am not here proposing that we need any more or different names for Parental Alienation. My aim is to explore the history and why we have been through the several names we use and still argue about them.
Labels are front-loaded
As a British child psychiatrist, I had for decades been one of those who rejected ‘Parental Alienation Syndrome’ out of hand. I think most NHS-based helping professions in the UK are still the same – happily rejecting what was taken to be typical trans-Atlantic nonsense. 😦
I was also similarly critical of the uses of labels for Personality Disorders. Mostly they seemed to be used to class the people negatively, as not worthy of understanding or treatment. Mostly the Personality Disorder label was an excuse to get rid of them from mental health settings and services. The labels were used as reasons to not help them. Worse, the labels underlined that the people labelled were not worthy of treatment. Indeed this label means they were untreatable. Nowadays there is more help available and, one hopes, a more helpful attitude.
The personality labels were a key cover-up of an unethical rationale that pretty much validated rejection and punitive treatment by everyone. Talk about repeating patterns! Attention-seeking people were labelled as if they needed attention. But the labels were part of a package of refusing to attend to them, a reason to reject them in fact. Treatment as usual.
Of course no one would openly admit this implicit rationale that I rebelled against. And you can see why I didn’t like using these labels! That kind of plainly nasty social control by supposedly ‘helping professions’ meant I became an anti-psychiatrist (see below) with humane and constructive intentions to improve the profession and services. I preferred to think in terms of ‘problems of living’.
Fair enough, but it meant I was prejudiced and wrongly dismissed the validity there is in labels like ‘PAS’ and ‘Personality Disorder’. If a parent’s Personality Disorder is held to be the prime cause of PAS, who will try to engage them and help them change? My former rejection of these labels in favour of ‘problems of living’ isn’t going to help. Nor will a mental health system help that uses those labels to reject the people who need help.
So I have been personally interested, since I saw the light on Alienation, in how on earth this ignorance happened when I had always thought I was quite an intelligent and open-minded type of person! We have a list of nearly 70 presumptions or stereotypes or counter-intuitive or cognitively dissonant hurdles that we have to set aside to think clearly in this field of family conflict. Labels are like that – they immediately trigger a whole set of assumptions.
I like Anna Raccoon’s clear description of how it happens. She gives it a great name too: ‘Determinative Labelism‘. That refers to the way she – even she! – found herself constructing complete pictures and stories quite differently when she read the word ‘defendant’ as opposed to when she read the word ‘victim’. Even a more neutral term like ‘complainant’ doesn’t stop …
our ability to conjure up a mental picture of a person and ascribe qualities to them based purely on words [and] labels. Try it yourself – ‘Mohammed Emwazi and Barnaby Carruthers-Smythe’. Got a picture of them both? I’ll bet you have. I’m prepared to bet that you might at a pinch ascribe characteristics to each of them. Absolutely no logical reason why; but it is almost impossible not to do.
The trouble with psychiatric labels
Back to the story of our label here … Others had described that parent-turning-child-against-parent pattern beforehand. But the label that started up the storm was psychiatrist Gardner’s 1985: ‘Parental Alienation Syndrome’ (PAS). His eight features of PAS are actually still a very useful descriptive list (see Footnote 1.). O’Sullivan’s clear overview (2013) for family lawyers includes Andre’s (2004) even more useful checklist of questions to ask. For details on references, see final section of my overview here.
Gardner presented his PA Syndrome in the style of a medico-psychiatric diagnosis for the child. It was intentionally not meant to describe a family pattern. The Alienated child often does fit other official labels of Disorder too. And the child can seem quite ‘mad’ in their complete belief in hateful things about a safe, caring and once-loved parent. The label’s use of ‘Parental’ is meant to refer to the rejected parent. The 8-features description just about steers clear of pointing to the causation, the influence around the child.
Why is it so important to keep to the child’s behaviour? Because otherwise the label won’t get into the medical-scientific rationale of the American Diagnostic and Statistical Manual of Mental Disorders, the DSM, now in its 5th version. Yet despite these efforts, Gardner – and many others since – have failed to get ‘PAS’ or ‘PA Disorder’ into the DSM. Sue Whitcombe describes well how ‘PAD’ has been shaped up for several sections of the DSM but never been accepted. A parallel process has happened more quietly with the International Classification of Diseases (ICD). But it would take even longer to include that story here.
Why has this label for a pattern of rejection itself been so rejected?
The PAS label is too transparent
I think the rejection is because the underlying cause lurks so closely beneath the surface description. This label describes the surface but in a way that is too transparent about what’s beneath. It is not surprising that people take the word ‘Parental’ to mean to blame the parent doing the Alienation, not to the parent who is the target of the Alienation. We imagine we can see the cause and the family relationship as well. And no wonder.
Those of us who use the term Parental Alienation / Syndrome most firmly DO want to show the relationship that is the main cause: the resident parent who shapes the child’s rejection of the other parent. We ARE wanting to tell the world that a parent can turn the child against the other parent and that it harms the child too. So, when people make the mistake about which parent ‘Parental’ refers to, we cannot honestly say “No, no! How on earth did you think that?! It’s just a neutral description of the child’s behaviour. We don’t know what on earth might be causing it. We’ll look at what’s causing it all later.”
So this label of the child’s behaviour, and this attempt to keep blame out of it, fails at the first hurdle. The problem is that, however disturbed the child, we are very much implying that it is a family relationship thing. PAS is a description of a family pattern … even when it tries to keep the family out and describes only the child’s behaviour. PAS is serious. We want it in the DSM. But the DSM rules say “Sorry we don’t allow your type in”.
In fact there can often be other factors – than the key family relationship – that play their part in what happens. So Kelly and Johnston (2001) renamed PAS ‘the alienated child” and set out how each individual case needs a unique assessment of all the many factors involved. Later they did accept that there are cases where the main cause is the Alienating parent. Fidler, Bala and Saini (2013) found an even more neutral description: Children Who Resist Post-separation Contact. That does separate off the key assessment of what causes children to resist contact.
In physical medicine, good clinical practice and science follow a careful step-by-step logic of describing what the patient presents before examining and investigating for signs of what may be causing the trouble. Only then does a differential diagnosis (that takes in the likely causes) allow a final diagnosis to be decided. And only after that can suitable treatment be chosen. So doctors and scientists are used to separating out the description, the cause and the label.
Mental health trouble sometimes fits that disease logic. But most mental health disorders are not quite so physical-disease-shaped. Note that the DSM lists Disorders, not Diseases. The attempt to scientifically separate description from cause for mental health Disorders can get a bit strained.
For example, we know that many who are diagnosed with Depressive Disorders have relationship causes. They are helped more by psychological or relationship therapies than pills. Similarly, DSM has had to work hard to know how to deal with that ordinary relational ’cause’ of what may well present as severe depression: that is, bereavement – normal or pathological grieving.
The pattern, and the label given to that pattern, the pattern we call ‘Parental Alienation’, can’t help but tie up together the inseparable child and their behaviour with their family relationships around them. But other labels do let us describe the pattern neutrally, and separately look at the possible causes, the differential diagnosis. In particular, the question of whether there is a good reason for a child to resist seeing their other parent, or whether there isn’t.
The value of psychiatric labels
In the USA and elsewhere, unless PAS is officially categorised in DSM as a ‘Disorder’, it will not be taught to mental health and other helping professions, cases are weakened in courts, and health insurance won’t pay for therapy. Given the insurance-DSM-based services, only the rich will be able to pay for help. And PA will continue to be dismissed as insignificant or invalid, especially in family courts. (The main health service in the US is based on health insurance, not in free-at-the-point-of-delivery NHS. But in the UK very few services indeed recognise that PA exists let alone merits their help … and if you’re ignorant of PA, your help may be unhelpful anyway!)
Even if a child can be given other Disorder labels in DSM, that may not ensure that people will learn about or think of Parental Alienation as a cause – although Alienation is mentioned in all but name under several other factors that help cause Disorders. General courses will not include any non-DSM topic, so professionals may well remain unaware of Alienation. Within the new PAS-less DSM-5, two leading voices have developed two good solutions that overlap a bit.
Bill Bernet and two DSM-colleagues have had published a powerful expansion of the new DSM5 category of Children are Affected by Parental Relationship Distress. They describe four common scenarios where children react “to parental intimate partner distress; to parental intimate partner violence; to acrimonious divorce; and to unfair disparagement of one parent by another.” Reactions of the child may include “the onset or exacerbation of psychological symptoms, somatic complaints, an internal loyalty conflict, and, in the extreme, parental alienation, leading to loss of a parent–child relationship.”
Craig Childress focuses more on the child abuse category. Best demonstrated in this campaign statement, he strongly challenges those professionals who should know about the other non-Disorder DSM categories like child abuse. He demands that they DO know about these, and that they ARE competent to assess them. In effect he is forcing them to own their professed standards and to read and know about all the sections of DSM down to p 715 and beyond!
Most detractors are ideological feminists. They have been very persuasive in demolishing the idea of PAS. They equate the missing DSM label with it being unscientific. So they say study of PAS is ‘junk science’. Some early things Gardner said didn’t help with the feminist critics. But later clarification – and repeating forever that it is not PAS when there is actual abuse behind the rejection of a parent – has not stopped the critics’ dismissive belief that PAS is always used as a cover-up for (male) abusers to access their ex-partner or children to continue. They remain equally blind to PA happening with all gender patterns, not just resident mother and non-resident fathers. Even same-sex separated parents can get full-blown PA.
Harman and Biringen (2016) review Parental Alienation’s status as science and rate it as equivalent to, and following in the tracks of, the longer established sister science of domestic violence. They mean that complex relationally-based patterns like DV and PA can never expect to be calmly objective sciences. And also, where domestic violence was not believed at first, so PA is now struggling to be believed. They show that to make the medically-shaped DSM the epitome of what is good science is itself not a rational idea.
Feminists have been among the strongest critics of the psychiatric establishment’s ways. Many more famous others – and me too (see above)! – have powerfully criticised this DSM / ICD kind of medical model being used for mental health problems. Psychiatrists who have challenged psychiatry include Jacques Lacan, Thomas Szasz, Giorgio Antonucci, R. D. Laing, Franco Basaglia, Theodore Lidz, Silvano Arieti, and David Cooper. Others are Michel Foucault and Erving Goffman. Thomas Szasz argued that mental illness is logically a myth in his book The Myth of Mental Illness (1961). Most of these critics imply that societal or family relationships are the right context to understand and help.
So it is curious that ideological feminists collectively both espouse and attack the psychiatric model.
A pattern not a syndrome
‘Parental Alienation’ is more commonly used now without the provocative ‘Syndrome’ added on. PA on its own as a ‘pattern’ is better accepted, less likely to trigger the DSM-based ‘junk science’ criticism. Because it has been used commonly for so long, the term Parental Alienation is hard to change now even if we wanted to. It’s what you Google.
If it didn’t have that DSM connection, the word ‘syndrome’ is actually quite appropriate for what can, in characteristic cases, be such a predictable set of features (see Footnote 1). Calling any pattern a ‘syndrome’ – as in ‘baby battering syndrome’ – is often just a way to say: “Seriously folks, we’re not making this up – this pattern is important and it really does keep happening.” Once it’s taken seriously, the label is less important. Unfortunately, Gardner’s use of syndrome didn’t work so well in this respect.
Professionals and family courts (in the UK at least) prefer more nuanced thinking about each case in its own right and in terms of the child’s welfare. Rather than argue DSM labels, a focus on the child and on the one specific context of family separation means other terms like ‘the alienated child’ (Kelly & Johnston 2001) have developed. As we’ve said, neutral terms like Children Who Resist Post-separation Parental Contact (Fidler et al 2013) more explicitly leave it to further assessment to determine the disputed underlying reasons. But neutral terms then cannot convey the main point about cases where a parent turns their child against the other parent.
Any label may be more of a door or chapter-heading or Google search we go through to complicated situations, and much less a specific individual diagnosis. If each child and family should be uniquely assessed in all its particular complexity and nuance, the labels used are better thought of as indicative or descriptive than as definitive diagnoses of particular children or families.
Relationships and other causes of Disorders
In a family pattern like Parental Alienation, the close relationship is disturbing to someone else involved, especially the child. Another relationship disorder pattern is what used to be called ‘folie à deux‘. Now that one IS in the DSM (as ‘shared psychotic disorder’) as well as the International Classification of Diseases (ICD) (as ‘induced delusional disorder’).
In PA, if the alienating parent’s mental state had the features of the more severe mental health Disorder, psychosis in its own right (and some say it sometimes does), then Parental Alienation Syndrome could well fit those ‘folie à deux’ categories. A close relationship causes the (other) individual’s Disorder too.
Like the name ‘folie à deux’, PAS pretty much declares the relationship causation up front in the label and the description of the features. In PAS, if the cause was more clearly a really mad parent, it would count as a ‘folie à deux’. The resident family’s delusional hatred for the Alienated parent doesn’t quite have the features of a true psychosis, otherwise PAS would indeed be an ‘induced delusional disorder’ or a ‘shared psychotic disorder’ in the child.
As well as ‘folie à deux’ or shared psychotic disorder and like the NATP campaign does, Prof Bill Bernet lists the DSM headings that describe other relationship factors that are in Parental Alienation even if that is not named: parent-child relational problem, child psychological abuse, child affected by parental relationship distress, and factitious disorder imposed on another (aka Munchausen syndrome by proxy).
A disorder that looks so well
Two of these – ‘folie à deux’ and ‘factitious disorder imposed on another’ – are a bit different to the others. The child’s Disorder is more specifically and directly shaped or caused by the imposing relationship. The Disorder is induced by the imposition. It may be less ‘real’ because of that, the child showing the symptoms required by the imposer and losing them when the imposition is removed. You can be sure the child is disturbed but they may be unaware, even profess that they are content, to play their part. The other categories are relationship factors that are known to play a part in a range of children’s Disorders. They are less specific.
One feature is hard to get round: the Alienated child may present to all intents and purposes as a thrivingly healthy child. Amy Baker (2007) has famously shown how cults are a model for PA. Jon Atack writes about how when people are taken in by cults, the experience has a beginning and an end but no middle. He means that if you meet people who are so under the influence of others, they may claim to be very happy indeed. There may be nothing about the individual on their own that shows any known Disorder (given that PA is not an option!). It is only in the wider relationship context and long-term outcome that the trouble becomes clear. But that wider context doesn’t compute with DSM.
Under the DSM general heading ‘Other conditions that may be a focus of clinical attention’ there are more categories that could apply in Parental Alienation. For example, Other Problems Related to the Social Environment, includes: Phase of Life Problem (… problem adjusting to a life-cycle transition … leaving parental control …).
You’d also think a rejected parent could claim V62.4 Social Exclusion or Rejection “… when there is an imbalance of social power such that there is recurrent social exclusion or rejection by others … bullying, teasing, and intimidation by others; being targeted by others for verbal abuse and humiliation; and being purposefully excluded …”. But unfortunately this one refers to ‘peers, workmates, or others in one’s social environment’. I don’t think there’s a similar category for the – much more important – undue exclusion and rejection by one’s children or ex-family.
Anyway, Parental Alienation / Syndrome / Disorder is not in DSM 5 by name. Elsewhere these terms are accepted as legitimate, but the American Psychiatric Association and the DSM 5 consider that “more research is needed” before it merits the category of a or Disorder of an individual child or relevant other condition. The APA / DSM does not dispute that the pattern exists and causes harm (they are not saying that it is ‘junk science’). They just say it cannot be classed as the mental health Disorder of an individual child.
Reasoning is needed not more research
I don’t think more research will solve this impasse with DSM. The nature of the family pattern of PA means it just does not fit the rules of DSM. The pattern cannot be dismantled – description from cause – to meet the DSM requirement. Even though there are some very similar looking categories that DSM does include – shared psychotic disorder, and imposed factitious disorder – PA cannot persuade the doorman to let it in the club. There are some rather knife-edge reasons for this rejection.
But there is really no logical reason the words ‘alienation’ or ‘parental alienation’ or even ‘undue inefluence on the child’ couldn’t be included in the descriptive text. ‘Estrangement’ is used with its implication that the distant relationship has a good reason. And that is perhaps the clue to the enormous ideological pressure that has kept the words ‘parental alienation’ out of the DSM. So if ‘research’ means that we have to keep talking and persuading the world that the ideological resistance to PA is not valid, then ‘more research’ is needed.
Otherwise, Child abuse is inherently a relationship, and it is a relationship that causes harm to the child. So child abuse can be a cause or factor of a child’s Disorder (or not). Various child abuses – ‘confirmed’ or ‘suspected’ – are listed in DSM and ICD but only under ‘Other conditions that may be a focus of clinical attention’ not as Disorders (see DSM p 715). The person doing the abuse may, in their own right, also fit a DSM category of Personality Disorder.
As with Child abuse, PA cannot wriggle out of being a relationship pattern that similarly causes harm. If you use that label for that pattern, then you cannot escape the meanings the words convey.
Take a different example: Murder. Murder combines a dead body – which is definitely in a medical condition – and the cause of the death: a murderer. A murderer is plainly a serious cause of a medical condition – maybe it is included as a causal factor in the DSM! Sometimes you don’t know the dead body is the result of murder. Sometimes you don’t know who the murderer is. But ‘murder’ is a really good word for the picture we want to name.
But because it includes the relational cause, ‘murder’ is not a medical diagnosis itself.
Like Fidler et al (2013) since, Gardner could have called the PA Syndrome: Children Resisting Contact after Separation (CRCS), and then suggested subcategories relating to causes: 1. CRCS Undue influence / Alienation. 2. CRCS Justified / Estrangement. 3. CRCS Hybrid (i.e. mixture of 1. and 2.). But these would still not be labels for a child’s Disorder. A child may resist contact with or without having a mental health Disorder.
As well as others who have suggested new labels, Craig Childress has provided the basis for a campaign in the USA to challenge the American Psychological Association and their position on PA. (NB this APA is not the same as the psychiatric APA). Craig proposes an Attachment-based approach that distances itself from ‘Gardnerian PAS’. He uses the DSM categories that are already in DSM in relation to emotional abuse categories. Seen as a child with Disorders resulting from emotional abuse there is no need for new DSM categories.
He and the campaign argue reasonably and persuasively that professionals are not competent in terms of their own published professional standards if they deny that this kind of pattern happens and that children are harmed by it, and if they do not know how to assess professionally-well-recognised emotional abuse and Attachment patterns properly. This powerful argument would be even stronger if it was based on a broader spectrum of types of PA, including the more mixed, less straight-forward kinds of PA. That would make it even more important that professionals knew how to assess all the nuances. But the less clear-cut PA might be harder to demonstrate – for the purposes of the campaign – the emotional abuse effects on children in DSM terms.
My own preferred labels
Hard thinking leads me to confirm that Alienation is the best name for it. Parental Alienation, as we’ve said, is what you Google. This blogpost is to explore why people have come up with the other names. I am not seriously proposing any new names here. My personal preferences are to illustrate some of the points I’ve been exploring.
As many others do, my own approach has been to recast PA as unsurprising when you look at bigger maps and wider spectrums of life’s relationships and strife. In a very different way (than Craig’s approach), Attachment is a very useful map on which to find Parental Alienation as a pattern and to understand both the harm being caused and the parent/s causing that harm. Read more on all that in my overview. This blogpost draws on the exploration of labels in that overview. See the overview itself for details on the references used here.
My own preference for a short label is: Child Alienation. This reminds us that the chief concern should be for the child in the middle.
My preferred longer term is: Parental Child Abduction and Alienation. You can bracket these together because the two can be almost exactly the same thing … in extreme cases, one is a quick, the other a slow route to the same outcome. That label instantly ensures our minds are framed right. Alienation like Abduction is wrong and abusive – a situation needing urgent intervention, not by-standing for months and years. That combo-label includes the term PA while it reduces the huge hassles that PA on its own has caused for decades.
The trouble with bringing Abduction into it is that family courts – who deal with private law cases – just cannot cope with a concept from another realm. And of course there are lots of families where Alienation has not reached a stage of clear-cut assessable abuse of the child and is a long way short of the completely cut off stage that is like Abduction.
Using labels: a summary
We can’t do without words and labels. They have diverse functions and meanings. Shared meanings result in good communication. Different or mistaken meanings mean misunderstanding or sometimes instant conflict.
My antipathy to psychiatric labels for ‘problems of living’ meant that I dismissed for decades the important field now usually labelled: Parental Alienation. For different reasons, the American DSM has rejected it as a Syndrome or Disorder because it is an un-disguisable family and abusive relationship pattern, not a child Disorder. This doesn’t mean it does not exist or cause harm. Many real things in the world exist but are not included in the DSM.
After thinking through again the medical model of labels for mental health, I am aware of both its strengths and weaknesses when it comes to relationship troubles.
Efforts should continue to get the DSM and ICD to include the words ‘parental alienation’ or the like – probably best under ‘Parent child relational problem’. Meanwhile, if the DSM and ICD are – for good or bad reasons – determined to keep PA out of their club, I know of a club that welcomes it … That’s the club headed “Undue Influence” along with dozens of stronger names for it. See Learning about a common enemy on this blog, and also the Open Minds Foundation for more.
Using constructive words in practical situations helps constructive outcomes. So loaded labels or words like Alienation or Personality Disorder terminology may well not help possible collaboration happen. But where hope for collaboration has gone and harm is happening, that negative reality needs words that point to what is happening. Unattractive things attract unattractive labels.
There are many reasons why we need good words for a concerning pattern. Common and ancient usage – e.g. social alienation (see footnote 2.) – means that Alienation is a good label for this pattern. The same considerations apply to using labels like Narcissistic or Sociopathic Personality Disorder to label, understand and work with a parent. These too may usefully point to a valid recurring and concerning pattern of personal behaviour.
Where we need to take things seriously, heavy labels may shape the best interventions. But the negative label merits careful use remembering that, like the professional helpers, the child also has to ‘work with’ the same negatively labelled parent even more closely in pursuit of the ideal of having a relationship with both parents.
Attachment theory of the right kind (Crittenden 2008) has much to offer, going beyond the blaming labels to a more useful understanding of ongoing disturbance and how to help.
Nick Child, Edinburgh
Gardner’s (1985) ‘Parental Alienation Syndrome’ describes eight characteristic behaviors of the child.
- A campaign of denigration and hatred against the targeted parent;
- Weak, absurd, or frivolous rationalizations for this deprecation and hatred;
- Lack of the usual ambivalence about the targeted parent;
- Strong assertions that the decision to reject the parent is theirs alone (the ‘independent-thinker phenomenon’);
- Reflex support of the favored parent in the conflict;
- Lack of guilt over the treatment of the alienated parent;
- Use of borrowed scenarios and phrases from the alienating parent; and
- Denigration not just of the targeted parent but also to that parent’s extended family and friends.
‘Social alienation’ – individuals alienated from society – has been widely studied for centuries. In families, our focus is on patterns that are more interpersonal and more recently named. But for old and new, the meanings contained in the concept are the same. People with more power are not sensitive to others with less power in relationships that could be or actually had been more satisfactory. They do something that distances the less powerful person from their due sense of social connection. The alienated person is left at a loss – a loss of power, of connection, meaning, and norms (Seeman 1959).