Tuesday, March 17, 2020
"Promising" Parental Alienation Treatments and Confusing Terminology
I recently mentioned discussions about “parental alienation” (PA) on the World Health Organization website, where there is ongoing discussion of the 11th edition of the International Classification of Diseases (ICD-11). PA advocates would like to include PA as an index term—a term that can be found in the index, but in this case that leads the reader to a much more general classification. People concerned about the potential harm of PA “diagnoses” and treatments have opposed this.
If you are interested in this discussion you can go to the WHO website and set up an account that lets you read and comment on proposals.
I have just commented on one statement there, and I want to elaborate here on what I said. On the WHO website, a PA advocate cited a paper I published in Journal of Child Custody, in which I said that the outcome research on PA treatments was at no better than a “promising” level. The advocate used this statement to assert that I had said PA treatments were promising and therefore ICD-11 should include PA.
Unfortunately, this PA advocate apparently does not understand that a “promising” treatment is not in fact particularly promising, in the everyday sense of that term. The “promising” category is one that has real meaning for people who do and use outcome research in psychology, but its name is deceptive for others. This is a nuisance but I am not sure what we can do about it now—except to educate people.
Research on the effectiveness of psychotherapies can be evaluated as being at one of five levels of evidence. These levels are essentially measures of the quality of the research and the extent to which confidence can be placed in its results. The two highest levels of evidence, randomized controlled trials and clinical controlled trials, are not identical but share some important features. The crucial feature is that each method builds in standards of comparison, so that the results of a treatment are compared to the results shown in other circumstances, which may be no treatment at all, established treatments, sham treatments (placebo conditions), etc. Because treatments may—indeed are supposed to—have long-term effects, and for other reasons as well, these two high-quality methods compare people receiving the treatment to other, similar people who receive the control/comparison condition. Using such comparisons is especially important in work with children and adolescents, who are developing rapidly and whose natural changes may easily be mistaken for the effects of a treatment.
When research at those two high levels of evidence shows positive effects of a treatment, and when those effects are confirmed by independent researchers, the treatment can properly be called evidence-based. “Promising” research is work that has been designed and carried out at a lower level of evidence, for example a simple before and after comparison of a group of people, prior to and following their treatment. The “promising” nature of a treatment that shows positive results under those circumstances is that it is worth doing more complex research on the treatment, although there are no guarantees that the treatment will be shown to be effective with more challenging designs.
PA treatments are “promising” because positive effects have been reported when parents’ views of children’s attitudes after a treatment have been compared to their views before a treatment. As there is no standardized way to evaluate a child’s PA as present or absent, much less to quantify it, there have been no comparisons of the children’s attitudes themselves before and after treatment. And there certainly are no published studies reporting randomized controlled trials or clinical controlled trials of PA treatments, using controls which are essential for work on treatments for quickly-changing children and adolescents. These facts are among the many reasons why ICD-11 will not contain PA as a disorder.
When you see that a treatment is “promising”, be sure to consider exactly what is being promised!