Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Friday, March 24, 2017

Critical Thinking About Child Custody, Especially Parental Alienation Claims

I recently received a document relevant to decisions about a girl who prefers Parent A but has been sent to live with Parent B. She had been ordered to receive treatment for the “parental alienation” by Parent A  that is argued to be the reason for her preference for A over B. The girl, whom I will call Sophie, is 14; the parents have been apart and in high conflict since she was 11. Parent B has asked the court’s permission to move Sophie, along with Parent B and B’s romantic partner, to a neighboring state, where they are now living and where Sophie is attending school.

B has asked a proponent of a treatment for parental alienation  (let’s refer to him as Mr. P. Pat) to comment on Sophie’s present status and to support the argument that B, the partner, and Sophie should all remain together in the new state, and Parent A should be prohibited from all contact with Sophie. Mr. P. Pat argues that Sophie is doing much better now than she was at age 11, when the parental separation began. She is doing well at her school, studying music, and roller-skating This shows, Mr. P. Pat says, that Sophie has benefited greatly from 1. Separation from Parent A, and 2. Her experience of the Pat method of therapy for parental alienation effects. What’s more, Sophie’s improvement is evidence that the problem was indeed parental alienation. Mr. P. Pat also argues that Sophie must not have contact with Parent A because even the slightest contact will undo all the benefits she has received.

Let’s examine these arguments a bit (it won’t take much). Mr. P. Pat is taking advantage of the tendency most of us have to fall for the argument that post hoc  means propter hoc—that if one event follows another, the second one must be caused by the first. For example, if I eat a mango for the first time and I shortly develop a skin rash, post hoc reasoning suggests that the mango caused the rash—maybe I’m allergic, maybe it was contaminated by some agricultural chemical. But, of course, I could have a rash because I’ve contracted rubella, or because I’m allergic to something else I ate in the same meal with the mango, or because I put my arm on a table that had been polished with a furniture polish I’m sensitive to. All those things could have happened before the rash, but post hoc reasoning often chooses just one of the previous events and firmly assigns causation to the chosen possibility.

How does post hoc reasoning apply to Mr. P. Pat’s claims about Sophie? He states that she has received his treatment and that she is doing well (a claim made without any independent evaluation of Sophie, by the way) and that, therefore, the treatment must have caused her to do well (post hoc, ergo propter hoc). Let’s suppose, for the sake of argument, that Sophie is indeed doing well. What alternative hoc factors can we consider to be possible causes of Sophie’s status?

First, we need to think about maturational changes—changes in personality and behavior that normally accompany advances in chronological and developmental age, no matter what experiences the individual is having. The effect of maturation is one that is largely ignored by proponents of fringe beliefs about child development issues, and regrettably is also ignored by laws that classify humans from birth to age 18 as children, without further definition. Between age 11 and age 14, Sophie has passed through some important steps in development. Physically, this would have entailed puberty, with rapid physical growth and changes in appearance as well as reproductive maturation. Cognitively, Sophie would experience advances in executive function and in formal operational thinking, the capacity to think hypothetically and to separate variables from each other. Emotionally, she has moved through a phase of mercurial, “temperamental” responses, including unpredictable crying and anger, to a calmer responsiveness; she has also moved from a period of life in which family relationships are paramount to one in which peer relationships and school events take precedence emotionally. All of these make Sophie a different person than she was at age 11 and make her in many ways easier to deal with than she was a year or two ago.

Other changes have also taken place in Sophie’s life. One is that she and her parents and siblings have moved toward resolving their feelings about the parents’ divorce. To do this, Sophie had to disengage from the parents’ conflict and focus on her own life, a task that would be made much more difficult by insistence on the idea of parental alienation.

In Sophie’s case, her forced separation from Parent A has included separation from a sibling. She now lives alone with B and B’s romantic partner. This change has removed her from all the possible influences of her sibling for good or ill—the sibling may have encouraged or have discouraged Sophie from her positions about A and about B, may have provided comfort when Sophie was distressed about the family situation or may have acted to distress her further, and may or may not have provided a role model for a constructive response to both parents’ wishes.

Sophie has also moved away from a neighborhood and a school where most adults and many classmates were likely to have known about the parental conflict and to have weighed in on one side or the other. She is beginning high school and has much to get used to in a new school setting, distracting her from the family focus she probably had earlier.

This is enough of a laundry list to demonstrate my point that Sophie’s situation is post more than one hoc, yet Mr. P. Pat points to a single factor as the cause of any changes to be seen in Sophie. He has apparently failed to look for evidence for alternative rival hypotheses, either about the initial diagnosis of parental alienation or about the effects of the treatment.

An article by Dr. Madelyn Milchman discusses a better way to handle the task of understanding child or family problems in the context of child custody evaluations. (Milchman, M.S. (2015). The complementary roles of scientific and clinical thinking in child custody evaluations. Journal of Child Custody, 12, 97-128.) Dr. Milchman pointed out that scientific hypotheses are well-formulated only if they are falsifiable – only if it is possible for observable evidence to be used to reject the hypothesis. A hypothesis that appears to be supported by any possible observation is one that cannot be rejected and therefore is not useful for understanding events. In clinical work like child custody evaluation, practitioners are not doing scientific hypothesis testing in the usual sense, but they need to avoid their own biases and presumptions by testing their own preferred hypotheses and possible conclusions about a family. They do this by looking for consistency of evidence and pursuing issues of inconsistencies, and they also do it by formulating alternative hypotheses to see whether the evidence supports one or more alternatives better than it supports their preferred hypothesis.

Like scientists, clinicians cannot “prove” a hypothesis beyond the shadow of a doubt. The job is to try to disconfirm a hypothesis and to accept it only when the evidence does not disconfirm it.  For the clinician, this involves thinking about other causes that can explain evidence that is consistent with the preferred hypothesis. In Sophie’s case, the preferred hypothesis, that treatment has changed her behavior toward her parents, is weakened by the existence of a list of other factors that may have worked individually or together to alter her attitude. Clinicians also need to think about evidence that is inconsistent with a preferred hypothesis. In Sophie’s case, such evidence might be revealed by an assessment by a psychologist who has not been involved in her treatment (and ideally, one who is not committed to the idea of parental alienation). According to the documents I have seen, this possibility has been refused by Parent

Tuesday, March 14, 2017

I'll Get to Scotland Before Ye: "Parental Alienation" Again

I recently received several documents related to an accusation of “parental alienation” (defined by its advocates as the intentional persuasion of children by one, perhaps mentally ill, parent, that they should avoid and reject the other parent). Proponents of this idea assume that unless there has been demonstrated abusive treatment by the rejected parent, such rejection is prima facie evidence that the preferred parent has emotionally manipulated the children. Such manipulation, they claim, is in itself prima facie evidence that child abuse has occurred and that the children’s mental health is threatened, so they must be rescued from the preferred parent and given treatment that will restore their mental health and with it their affection for the currently rejected parent.

There’s a lot of prima-facie-ness here, it seems, and the implausibility of these claims extends to the documents I received.

Much as I hate to do this, I am not going to reveal the source of the documents, the name of the family they allude to, or the treatment program involved. I am afraid that the identification of the source of the documents would cause trouble for someone. I am not going to discuss family details, but will focus on some of the claims made by people who assessed the family and then proposed and carried out a treatment that closely resembles other “parental alienation” treatments. It abruptly removes children from their home, places them in close contact with the rejected parent, and uses videos, games, and some threats to try to change the children’s attitudes. How is such a serious proceeding initiated ? A court order is obtained, upon the recommendation of the treatment proponents, who have been hired by the rejected parent.

There is much to be said about this situation, and I have already said various things to the effect that I am sure it is possible for “parental alienation” (as defined above) to occur, but that I see no evidence that it occurs often even among high-conflict divorcing families. I have also noted that proponents of treatments for the supposed problem have given no real evidence that their methods are effective ways to change children’s attitudes—although I have no doubt that the inclusion of threats will change children’s behavior.

In this post, I want to touch on the issue of evidence for effectiveness of treatments. To the best of my knowledge, there have never been either randomized controlled trials of the treatments, or well-designed nonrandomized studies. Instead, one proponent of a treatment claims that he has evidence for the effectiveness of his treatment in the form of a single-subject ABA design. This research method looks at behavior during one set of circumstances, usually just everyday life with no treatment given (A); then creates a new condition, generally involving an intervention of some kind (B) and looks at behavior during that period; finally, the A situation is returned and behavior is again observed. Graphs or other displays show whether the change from A to B, and back again, is accompanied by a change in the behavior of interest (in the parental alienation case, of course, this would be rejection of one parent).

That proponent notes, in one of the documents I have, that this method is “one of only two research designs that can definitively determine causality, the other design being a randomize control experimental design”. There are several problems with this statement. One is that no research design “definitively” determines causality, as the results of psychological research are reported in terms of the probability that a given outcome has occurred by chance alone, and this probability may be close to 5 % in cases where a significant difference between groups is found. In addition, a textbook on research in education points out that ABA designs are weak in terms of external validity and require many replications followed by a randomized study before the conclusion that a treatment has a given effect can be drawn.

The proponent of the treatment runs into an additional problem when claiming that the treatment causes a change in the child’s behavior. ABA studies are normally careful to identify a single variable whose effect is to be tested and to hold constant other factors that could affect child behavior. The treatment in this case changes multiple factors between A and B, and between B and a return to A. A, the original situation, has the child in his or her own home, with normal opportunities for play and other preferred behaviors, and in the company of the preferred parent. The B situation abruptly removes the child from the familiar setting and places him in an unfamiliar place, in the company of the rejected parent and of a therapist who demands attention to videos and may make threats about the child’s uncomfortable placement elsewhere if he or she does not cooperate, or about continuing separation from the preferred parent. The return to A  returns the child to a familiar, unpressured social and physical environment. Are we surprised that behavior would be different in A and in B, particularly in the light of threats made in the B situation? The failure to isolate an independent variable makes this use of ABA ineffective as a research design.

There is a further important point about material in the document that makes claims about the conclusions drawn from a variant on the ABA design. The document states that “A single-case ABAB reversal design quickly and efficiently identifies the cause of the issues and restores the child’s healthy development as quickly as possible.” The results of either ABA or ABAB studies are irrelevant to this claim. If well done, such studies could show that a treatment was effective in changing a behavioral symptom. This, however, would not identify the cause of a problem; causes of problems are not being studied by this method. (As an example, let me point to applied behavior analysis as a treatment for autism, where the fact that an operant conditioning technique is helpful to the child does not mean that he was autistic because the parents used different methods in their child care routines.)  

It seems that the “parental alienation” proponents involved in these documents are inclined to fancy footwork rather than logical analysis as they put forward claims for their methods of assessment and treatment. Unfortunately, it would appear that judges and attorneys have in some cases fallen for this line of chat, and challenges have been few.

(Could it possibly be that people who have heard once or twice of applied behavior analysis—also called ABA—recognize that abbreviation and think “oh yeah, that’s a thing, I heard of it”? I hope not, but stranger things have occurred.  )

Sunday, March 5, 2017

Are You a Good Enough Parent? How Can You Tell?

A friend was telling me yesterday about some conversations she’s had with her niece, who is the mother of a one-year-old. The young mother seems to be in a sort of “mother’s arms” race with her friends, who vie to find the latest thing that absolutely must be done for the baby, the toy that must be bought, and the classes mother and child must be involved in. My friend’s niece is getting pretty exhausted but fears the consequences of giving up the competition. So, my friend, quoting me quoting Donald Winnicott, said, “all you have to do is be a Good Enough parent.” (Actually Winnicott talked about a Good Enough Mother, because this was before fathers became parents.)  

But the niece cut through all these fine words by asking, “How do I know whether I’m a Good Enough parent?” Friend and I were both stymied by this one, and I resolved to try to give it some thought.

The idea that you just have to be “good enough”, not perfect, in parenting is really derived from what we know about young children’s physical growth. If a child has a normal, “good enough” diet, he or she will grow to the height dictated by genetic characteristics. Giving the child an even better diet, with extra vitamins, protein, and so on, will not make the child grow taller than the limits set by heredity. On the other hand, a less than “good enough” diet will result in less adequate growth and diminished stature relative to genetic possibilities, in childhood and adulthood. This gives us a pretty good idea about what is a “good enough” diet, because we can see direct effects of diet on growth in height (and even more importantly, growth in head size).

All right—now we have a useful metaphor to guide us in thinking about being a “good enough” parent. You know a diet is “good enough” when the child grows as is typical, or that it isn’t “good enough” when growth is slowed. What can we look at in the child that will tell us whether the parenting is “good enough”? 

This is an answerable question, but like many points about development it depends: it depends on age. This may be chronological age for typically-developing children or developmental age for children with challenges, but it’s critical to understand that indicators of good development will be different for different ages. We would not expect a two-week-old to make eye contact with a parent, but we do expect that from a two-year-old. We would expect a two-week-old to show a strong startle reflex, but we would have reason to worry if a two-year-old still showed that reflex. It’s different strokes for different folks… of different ages.

Let’s look at what might be some good indicators of “good enough” parenting and resulting development for a one-year-old. These aren’t all the possibilities, but they are ones that come to mind as important and pretty easy to observe.

  • ·         Has the child’s growth, including growth in head size, been typical since birth, according to the growth chart kept by the pediatrician?( It is not important that everything be at the 99th percentile, but it is important that the child stay at or above the percentile that was indicated in the early months.)
  • ·         Is the child working on motor achievements like pulling to stand, bearing weight on the legs, or even independent walking? (It does not matter if the child has never crawled or if other motor achievements like rolling over have been delayed relative to “the book”; if the baby has been sleeping supine, they probably have been a bit delayed )
  • ·         Is the baby interested in familiar people? Does he or she explore your face, put a finger up your nose or in your mouth, grab for your glasses or earrings?
  • ·         Is the baby starting to feed himself, with finger foods or spoon, with bottle or cup?
  • ·         Does the baby play peek-a-boo, either by watching breathlessly as you hide your face or by covering her own face and then popping out joyously?
  • ·         Do the baby and a parent have at least ten minutes in a row of fun together at least once every day? (You can count games at feeding or bath time provided you both enjoy them.)
  • ·         Does the baby communicate by pointing, by facial expression or moving the head away from something, by vocalizing?
  • ·         Does the baby look where you look or pay attention to words you use by looking for an object?
  • ·         Does the baby look for an object you’ve hidden while she watched?
  • ·         Does the baby throw or drop things and watch what happens to them? (This includes food, full sippy cups, etc.)
  • ·         Is the baby very rarely apathetic, uninterested, disengaged, lethargic?
  • ·         Can you usually comfort the baby when he cries?
  • ·         Does the baby look or move to you when something scary happens?

If the answers to most or all of these questions are “yes”, you can figure that what you have been doing is Good Enough. Your baby’s development is showing you that you are providing the needed environment, so just keep on with what you’re doing.

 But please keep three things in mind. One is that you may have been doing an excellent parenting job, but if your baby is chronically sick, injured, or developmentally challenged in some way, the results of your good parenting may not be as obvious as you’d like. The second is that, once again, these questions are age related. A six-month-old will not do the same things as a one-year-old no matter how good the parenting is, and a two-year-old will have moved along in many ways. The third is that—just like what we saw about extra protein—extra toys, CDs, videos, classes, and toys will not make the baby’s development extra good; in fact, concentrating on those extras may rob a baby of the pleasant daily routines and fun that are the foundation of cognitive and emotional development.

Dr. Spock once said that bathing a feverish baby in cool water worked just as well as an alcohol rub, but it “didn’t smell so important”. Being a parent whose everyday caregiving is really “good enough” may not smell as important as chasing the latest toys and classes, but it may work even better than the fads do.

Thursday, March 2, 2017

Reactive Detachment Disorder is Fake News

Are you worried that your adopted, foster, or even biological child could have Reactive Detachment Disorder? Well, don’t be. There is no such thing.

Of course, that simple fact has not stopped various people from using the term Reactive Detachment Disorder. My first encounter with the expression was in about 2003, when I saw this expression used on a quite respectable Internet medical information site. I emailed them about it and they quickly admitted their mistake, apologized, and made the correction. Nevertheless, Reactive Detachment Disorder has remained a notional diagnosis, from the earliest example I can find, a 2002 discussion of the Hansen child starvation case in Utah, to the present day. A 2007 book by P.A. Potter, “Jekyll and Hyde: Arrested development and personality disorders”, refers to Reactive Detachment Disorder in adult criminals. Current websites like and come up in response to a Google search for Reactive Detachment Disorder (although some of these sites actually talk about Reactive Attachment Disorder). Reactive Detachment Disorder is referenced as associated with crime at (“Defendant’s mental health scrutinized on first day of trial”) and given as a reason for judicial leniency at

 In many of these cases, Reactive Detachment Disorder is said to be connected with antisocial behavior in adolescence or adulthood. This suggests that what the speakers/writers are really talking about is the equally notional “Attachment Disorder”, another faux diagnosis perpetrated by proponents of a belief system that attributes violent, aggressive behavior to past difficulties with emotional attachment. This is a view created by such luminaries as Foster Cline and Nancy Thomas. Recent information about the Institute for Attachment and Child Development in Colorado, to the effect that the Randolph Attachment Disorder Questionnaire (RADQ) is still used there, suggests that the IACD staff is committed to the same belief system, although they do not use the term Reactive Detachment Disorder.

What does it mean to say that there is no such thing as Reactive Detachment Disorder? This is not to deny that there is antisocial, disturbing behavior shown by both children and adults. It is, however, a denial, first, that this term is ever used among knowledgeable mental health professionals; second, that assumptions associated with the term (as in its connection with “Attachment Disorder”) are correct; and finally, that the term is among those listed in either of the two professionally-developed sets of mental health diagnoses, the International International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The term Reactive ATTACHMENT Disorder does appear in both ICD and DSM.  It is not applicable to older children ,adults or adolescents. It does not involve aggressive behavior. Here are its symptoms:
 A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
      The child rarely or minimally seeks comfort when distressed.
      The child rarely or minimally responds to comfort when distressed.
B. A persistent social or emotional disturbance characterized by the following:
      Minimal social and emotional responsiveness to others
      Limited positive affect

Of course, this description of symptoms does not deny that some children show aggressive, disturbing, antisocial behavior, of the kind that the term Reactive Detachment Disorder seems to include. Such behavior is associated with the idea of callous-unemotional traits, with conduct disorder, and with oppositional defiant disorder—all legitimate diagnostic categories. I’ve discussed this before, at

As I pointed out in that post, there is much confusion about Reactive Attachment Disorder, which is widely assumed by journalists and poorly-trained therapists to involve antisocial behavior and to be present in adolescents and adults as well as young children. The “RAD defense”, claiming that an attachment disorder caused a crime, has been around for a while—and disturbingly, this defense includes not only the idea that a person with RAD is likely to be a criminal, but the claim that a child with RAD may be so evil that an adult caregiver is forced to kill the child. Isn’t this enough confusion? Why bring the notional Reactive Detachment Disorder into the picture?

The use of the “detachment” term probably began as a simple mistake, but I would speculate that it would be a tempting thought for the Cline-Thomas mindset. A child is detached—how wrong! Children are supposed to be attached, and in the belief system in question that means that they are obedient, compliant, attentive and affectionate and grateful to parents. They are “respectful, responsible, and fun to be around”. They respond enthusiastically to parents’ offers of affection (“on the parents’ terms”) but they do not demand attention or affection on their own terms. In other words, they allow their parents to be detached, to be unresponsive and inattentive to the relationship except when in the mood; the ideal child in this mindset is always available and interested in emotional contact with the parent, is never angry or disappointed when ignored or rejected, and asks for nothing but what the parent wants to give. A child who doesn’t meet these standards must be mentally ill, or simply willful, and draconian methods are needed to make the child “attached” while still allowing the adults to be detached. However, the pathology here seems to be not so much in the child as in the parents or practitioners who promote these beliefs and practices.

In sum, there are a lot of really bad ideas implied by the term Reactive Detachment Disorder, and it does not provide any meaningful information for the use of parents, mental health practitioners, or the courts. It would be a step forward if journalists and others would stop using Reactive Detachment Disorder and seek a real—and appropriate—diagnostic category.

Wednesday, March 1, 2017

If You Have Queries About Infant Eye Contact

A number of people have brought up questions about infant eye contact on pages that are so full that no more comments can be published. It's really difficult for me to move those comments to other pages and to be sure you can see them!

If you have recently asked a question on this subject and have had no answer, please put your comment HERE on this page.