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Concerned About Unconventional Mental Health Interventions?

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

Monday, October 28, 2019

Why Parental Alienation Should Not Be Indexed in ICD-11: Caveat Woozles

As many readers already know, the term “parental alienation” (PA) refers to a parent-child situation and to the explanation of that situation by proponents of the PA belief system. PA describes a situation in which the child of a divorced couple rejects one of the parents and resists or refuses contact with that parent but there appears to be no serious reason (like experiences of abuse) for the child to take that position. The explanation put forward by PA proponents for this scenario is that the child’s preferred parent has worked in various ways to manipulate the child’s feelings and to make him or her afraid of or angry at the nonpreferred parent.

Human beings do some very peculiar things, so this could certainly happen. However, to know that it had happened—to “diagnose” PA—you would need to have clear assurance that the child had no serious reason for rejection, AND evidence that the preferred parent had acted in ways that persuaded the child that the other parent should be avoided. You would also need to have good evidence that the child had once liked and associated with the now nonpreferred parent.

Unfortunately, courts around the world have fallen for the argument that PA is present in a child’s reluctance for contact with a parent—and they have fallen for the claim without demanding the evidence described in the previous paragraph. The consequences that follow such decisions are serious ones for children and families. Family court judges are asked by PA proponents to order a complete change of custody from the preferred to the nonpreferred parent, prohibition of contact with the preferred parent, and child attendance at non-evidence-based treatment programs that are to be paid for by the preferred parent. Young adults who earlier went through these programs have reported their own distress and the potential for harm to be done by the programs.

Because of these and other problems, in spite of lobbying by PA advocates, PA was not accepted for inclusion as a diagnosis in DSM-5 in 2013. Now, efforts are being made to include a reference to PA in a volume that may be less familiar to some readers in the U.S., the International Classification of Diseases (ICD), issued at intervals by the World Health Organization. ICD lists both physical and mental disorders, and there is currently discussion about what will be included in the next volume, ICD-11.

There is no question of including PA as a diagnosis in ICD-11. However, PA advocates are pressing to have it included as an index term; this means that if a person were to look for PA in the index it would appear but would be linked to a legitimate diagnosis. People who are concerned about the potential harmfulness of PA concepts and practices object strongly to this, feeling that indexing the term would lend PA spurious respectability and allow PA advocates to claim that PA is “in ICD-11” when this will not be true in any real sense, Linking PA to a real diagnosis may also suggest to some ICD users that the two terms actually mean the same thing, when they do not.

Here are some reasons why PA should not be included as an index term in ICD-11:

1.    1.  PA has never been operationally defined. That is, no one has outlined the measures or observations needed in order to identify PA. There is neither a way to identify the quality of behavior that would indicate PA nor a way to quantify PA (and thus to be able to see whether treatments are beneficial). One author who has looked at the effects of a treatment program, Richard Warshak, identified the children participating in the program as having been found to have PA by a family court judge—certainly a new approach to diagnosis of mental disorders.

2.    2.  PA advocates label preferred parents as abusers and claim that the child’s rejection of one parent is a sign of mental illness that has been caused by the preferred parent, who is therefore abusive and should not have contact with the child. In spite of this claim, PA advocates rarely if ever report this notional abuse to child protective services even though they may be mandatory reporters of abuse.

3.    3.  PA principles and practices are pseudoscientific. The mechanism PA advocates propose for persuasion of the child by the preferred parent, “brainwashing”, is a legal concept and not a psychological one. The language proponents choose for discussion of PA is obfuscatory, using the same terminology to refer to a child’s feelings and to efforts a parent might have made to change those feelings. Irrelevant information is often brought in to discussion of PA, as when problems of critical thinking are claimed without evidence to be responsible for a child’s resistance to contact with a parent. Claims of an evidence basis for PA treatments are based on research designs that are too weak to indicate the actual outcomes of the treatment. As Washburn et al. commented in a 2019 article in Professional Psychology: Research and Practice, “Entire fields can be regarded as pseudoscientific when there is a seemingly wholesale absence of systematic safeguards against confirmation bias (e.g., randomized controlled trials, blinding of observers…” (p. 80). Although this comment was not directed at PA in particular, it is an excellent description of PA and the reasons it can be described as pseudoscientific despite claims to the contrary
4.    4.   PA has the potential for harming children and their families both directly and indirectly. Children have reported being taken under duress, even in handcuffs, to PA treatment sites, having their money and phones taken away, and being prohibited from contacting people they trusted. This would be frightening and distressing for all children but is especially so for any who have special vulnerabilities like autism or like previous experiences of abuse. As for indirect harm, preferred parents who have to pay large sums for these treatments will find themselves without the funds to pay for needed services or even to maintain their home. Parents who work with children as teachers, pediatricians, day care providers, and so on, may lose their jobs if labelled child abusers in the course of PA claims.

Now, what about the woozle part? That's the reason for being particularly concerned about what seems to be a trivial matter of indexing. It is understandable that PA advocates want to get a toehold in ICD-11, even if only having PA as an index term. Although in the past few psychologists had ever heard of PA, more and more now recognize the term and understand the reasons for rejecting it. Unfortunately, however, for those who come across PA only in passing or are never exposed to any of the related issues, the term PA has the makings of a “woozle”—an idea that seems to refer to something real only because it has become familiar as it is mentioned repeatedly. Including PA as an index term would help push forward the “woozle” process which adds to the obfuscation and muddled thinking already associated with PA ideas. Rampant woozles make it easier for alternative psychotherapists to persuade people that they are legitimate-- and in the case of PA, being persuaded can lead to very disturbing consequences.  

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