Two of These Things Belong Together: Evidence Based Treatment, Evidence Based Practice, Evidence Informed Intervention

 

Yes, although all these things in my title have the word “evidence” in their names, one is different from the others. The differences hinge on what people mean by evidence and its implications, and this is a real question, not a version of asking what “is” is.

Under different circumstances, “evidence” can be what my neighbor tells me happened on our street, or some material that a judge decided to accept in court over the protests of one party to a suit. It can also be information that has been collected according to the rules set by a group of scientists whose work is relevant to the topic.

Since the 1990s, medical specialists and psychologists have focused a good deal of energy on creating evidence based medicine and evidence based psychological treatments. They have used the term evidence based treatments (EBTs; sometimes called empirically-supported treatments, ESTs) to describe medical or psychological interventions that have been shown to be safe and effective through information collected according to established research rules. EBTs are treatments that have been shown to be effective in treating particular conditions by at least two studies that use randomized controlled trials or clinical controlled trials. At least one study needs to be done by independent researchers, not people involved in the method itself. There are a number of other requirements for these studies, for example that the people evaluating the outcome of a treatment should be “blind” to (unaware of) which clients received the treatment and which did not. Readers can find further descriptions of the rules of research at www.effectivechildtherapy.org , a website sponsored by Division 53 (Clinical Child Psychology) of the American Psychological Association.

Although this point is not always made clear, it is also generally considered that EBTs will not be potentially harmful treatments (PHTs). It’s well understood in medicine that a powerfully effective treatment may have unwanted adverse side effects, and such treatments have to  be chosen with the understanding that there is a risk/benefit ratio to be considered. Psychologists have only fairly recently begun to consider that a psychological treatment can have adverse effects as well as—or even instead of—beneficial ones. There is still too little known about adverse events of psychotherapies to make it easy to calculate risks and benefits of treatments, but a treatment with a known potential for harm would presumably not be considered an EBT at this point.

EBTs are the ones that “just don’t belong here” out of the.group of three in my title. How are evidence based practice (EBP) and evidence informed intervention (EEI) different from EBTs? Why is it important to consider the differences?

To answer the last question first: although psychologists and other mental health professionals have been encouraged to strive to use EBTs by their national professional organizations, they do not always do so. One very practical reason is that the research has not been done to provide a clear evidence basis for all psychosocial treatments. In fact, if people did not use treatments that are currently without a clear evidence basis, no data could be collected to show whether or not those treatments are demonstrably safe and effective. (However, when such treatments are used, it should be made clear that they are experimental treatments whose effectiveness has not been decided.)

A second practical reason for failure to use EBTs is that such treatments require very specific training. They are “manualized”—that is, there are prescribed ways of handling the events and timing of treatment. People trained to carry out EBTs must go through an extensive program that makes sure that their use of the treatment method is very close to the intervention whose outcome was tested empirically. Such training can be expensive in terms of time and other resources and is not available to every mental health practitioner.

But there are other reasons for failure to use EBTs, as well as the practical points. Mental health professionals may in many cases be people who feel that they know how to help others psychologically, that their personalities and compassion are as or more important than the precise methods they use. Like physicians who may prescribe a medication “off-label”, mental health professionals may feel that they have the authority and the responsibility to alter the way therapy is done, to personalize it in ways that they feel work for themselves and for their clients.

EBPs and EEIs are the results of this last reason, as well as of the scarcity of EBT resources. In both of these approaches (EBP or EEI), the idea is that a practitioner looks to the best available empirical research on therapies and chooses treatment from those, while also considering a client’s preferences and the therapist’s own experience, or “practice wisdom”.  There are, however, some flaws in  this approach. The first is that the best available research may not be at EBT level.   For example, none of the various parental alienation treatments have evidence at the EBT level, though there is published outcome research with weaker designs and implementation. To use the EBP language, this is the best available evidence—yet it is not at the level psychologists are encouraged to use, nor are these interventions apparently presented as experimental in nature. (On the contrary, PA advocates insist that they are supported by evidence adequate for admissibility in family courts, rather than acknowledging the level of evidence available.)

It is quite understandable that practitioners choose the EBP approach when there are no EBTs available for use. But—when there are EBTs, as there are in many situations involving children’s mood or behavior, there are fewer reasons to bring in “practice wisdom” and client preferences.

Evidence informed interventions (EEIs) use the same preference and wisdom factors as EBP. But they also argue that the quantitative studies used in EBT work cannot give information from the patient’s perspective, for which they consider qualitative and mixed methods research to be most important. These types of research are expensive in time and resources and thus often use small numbers of participants, making it difficult to be sure about results and also making it hard for other researchers to replicate. A recent book on custody and parenting coordination, “Evidence-informed interventions for court-involved families” (edited by Lyn Greenberg, Barbara Fidler, and Michael Saini), presses the EEI approach rather than encouraging more stringent research designs.

According to an Australian source (facs.nsw.gov.au) an EEI approach means using research evidence (level not stated), lived experience and client voice, and professional expertise in mking treatment decisions. The nature of the research evidence is not mentioned (and I have to wonder whether there can be experience that is not “lived”?), nor is there any discussion of the proportions of these sources practitioners should use in their decision-making. EEI proponents, in my opinion, see psychotherapy as an art rather than a science and believe that family events in particular are too complex to be approached effectively on the basis of EBT-level outcome research. I cannot say that they are necessarily quite mistaken in this view, but I would say that art should not be presented as ”evidence” in the scientific sense.

Advocates of EBP and EEI have on their side the practical facts I mentioned earlier—that EBTs are not always available , and that if only currently-known EBTs are used, we can never have any more EBTs identified. Given that these issues are important, however, there would appear to be no reason to withhold from courts and clients the fact that EBP/EEIs should be identified as “experimental” for the simple reason that they are not EBTs. The failure of proponents of these non-evidence-based treatments to identify their methods appropriately leads me to question their reasons for stressing preferences and experience over evidence. An attendee at a conference recently posed for me the question: isn’t it important to provide some treatment when there is a problem? I think it is not—unless it has been demonstrated that the treatment is safe and effective. Otherwise, is the practitioner simply deciding to use a treatment because he or she can do so and wants to do something, perhaps has even told the client or a court that he or she can help?

These are tangled webs, I am afraid, and I do not claim to know why people choose EBP/EEI and fail to say this is what they are doing. What I do know is that the word “evidence” in EBT, EBP, and EEI should not be taken to have the same meaning at all times.

 

 

 

 

Challenging Parental Alienation: A New Book for Professionals and Parents

 

There is a good deal of published material about “parental alienation” (PA). Unfortunately, when parents are confronted with allegations that they have made a child reject the other parent, it can be very hard for them to find the professional journals that publish this kind of material. The books that parents could find in the library or buy are almost all by PA proponents who try to support allegations that a parent has caused a child’s reluctance for contact with the other parent.

Well, TA-DA! The first book arguing against PA principles and practices is to come out on Dec. 3, 2021! Here is the reference info:

Mercer, J., & Drew, M. (Eds.) (2022). Challenging Parental Alienation. Milton Park, UK: Routledge.

I wish I could tell you the price, but I don’t know what it is; it’s the publishers that set this, not authors or editors. But, if it turns out to be too pricey for you, you could ask your public library to buy it.

Pre-publication orders can be placed at https://www.routledge.com/Challenging-Parental-Alienation-New-Directions-Professionals-and-Parents/Mercer-Drew/p/book/9780367559762

This edited book has chapters by a number of lawyers and of psychologists and others involved in the family courts. Especially notable is that chapters deal not only with PA in the United States, but with family court and domestic violence issues in Canada, Australia, and the United Kingdom. And, we are proud that the book includes material written by a young woman who went through a PA treatment and by a mother who experienced psychotherapy based on PA assumptions.

Here is the Table of Contents, with authors’ names for each chapter:

 

Table of Contents

Chapter 1  Introduction to Parental Alienation Concepts and Practices

                       Jean Mercer and Margaret Drew

Section One  

When a Child Avoids a Parent: Understanding the Problem

Chapter 2   History of the Parental Alienation Belief System  

                       Julie Doughty and Margaret Drew

Chapter 3   The International Expansion of the Parental Alienation Belief System Through the

UK and Australian Experiences  

                       Julie  Doughty  and Zoe Rathus

Chapter 4   Experiences of Parental Alienation Interventions 

                       Adrienne Barnett, Arianna Riley, and “Katherine”

Section Two

When a Child Avoids a Parent: Identifying and Treating Problems

Chapter 5   Evaluations for the Courts in Child Custody Cases:   An Attorney’s Perspective

                        Nancy Erickson

Chapter 6   Distinguishing Alienation from Child Abuse and Adverse Parenting  

                        Madelyn  Milchman

Chapter 7    Comparison of Parental  Alienation Treatments and Evidence-Based Treatments for 

                    Children

                        Sarah Trane, Kelly Champion, and Steven Hupp

Chapter 8 Gender Credibility and Culture: The Impact on Women Accused of Alienation  

                         Margaret Drew

Chapter 9     Developmental Changes in Children and Adolescents: Relevance for Parental

                     Alienation Discussions

                         Jean Mercer

Section Three

When a Child Avoids a Parent: Scientific and Legal Analyses

Chapter 10    Parental Alienation Concepts and the Law: An International Perspective   

                             Suzanne Zaccour

Chapter 11    Questioning the Scientific Validity of the Parental Alienation Labels in Abuse

Cases                     

                             Joan Meier

Chapter 12     Parental Alienation, Science, and Pseudoscience  

                            Jean Mercer

 

Chapter 13     Conclusion: Current Issues About Parental Alienation 

                           Jean Mercer and Margaret Drew

 

 

 

Parental Alienation Science Stumbles Along

 

Over the last few years, a major goal of proponents of the parental alienation belief system seems to have been to amass a series of weakly-designed and implemented “scientific investigations” to allow the proponents to argue that there is scientific support for their views. This preference for quantity over quality is understandable, as serious empirical investigations are time-consuming and costly in planning and resources, and family courts are more impressed by hearing about dozens of studies than interested in understanding how meaningful those studies are.

Amy Baker and William Bernet have for some years been the PA principal investigators of note. Their work has featured absent or questionable control groups, retrospective self-report information in many cases, and an insistence on forcing ordinal data into Procrustean parametric analyses.

Now the Colorado psychologist Jennifer Harman is taking the lead in weak studies, whose publication allows her to assert repeatedly that children involved in ambiguously-defined parental alienation cases are victims of family violence. She has recently added to her assertions by declaring that rejected parents are the objects of coercive control by the ex-spouse.

I will briefly describe and comment on two recent Harman publications.

Harman, J., Saunders, L., & Afifi, T. (2021). Evaluation of the Turning Points for Families (TPFF) program for severely alienated children. Journal of Family Therapy, DOI: 10.1111/1467-6427.123666. (Please note, this publication is not the same as American Journal of Family Therapy, which also publishes pro-PA material.)

Harman et al. collected data about TPFF, an intensive program run by the LCSW Linda Gottlieb. Like other PA interventions, TPFF requires that children be court-ordered into the program or that an agreement between the parents be approved by the court. Like other PA treatments, TPFF lasts about 4 days, involves prohibition of contact between child and preferred parent, for at least 90 days, and requires “aftercare” for both parents and child or children, performed by a a PA-approved therapist. TPFF also requires the preferred parent to write a letter to the child acknowledging his or her attempts at alienation. Gottlieb videotapes therapy sessions, and the videotaped material was made available to Harman et al. Gottlieb, incidentally, claims almost 100% success in creating positive relationships between children and previously rejected parents; as this rate of success has been questioned, it was desirable from Gottlieb’s viewpoint to have a positive report from Harman..

Harman was interested in evidence that TPFF was safe for children, as I and other authors have questioned whether this is so. On the grounds that none of the observed 32 children from 15 families ran away or carried out any self-harm during the program, and that Gottlieb states that none of the previously-treated children with whom she keeps in touch have done so, Harman concluded that TPFF was safe for children. She did not report on other possible aspects of harm, for example the PTSD diagnosed in a child following another PA intervention. Harman stated her belief that children who have reported distress and harm from PA interventions were simply still alienated, and would not have made such reports if their alienation had been repaired.

Harman also sought to know whether TPFF was an effective treatment for PA cases. To do so appropriately, of course, she would have needed to compare a group of TPFF-treated children with a matched control group who received no treatment or some other form of treatment. To compare behavior before and after treatment (as of course has also been done by Richard Warshak and other PA proponents) is to beg for confounding of variables so that it is impossible to know whether any changes were actually caused by the intervention.  Reports following Family Bridges experience point to threats from therapists as reasons for behavior change, but it is unknown whether such threats occur during TPFF.

Like some other PA proponents, Harman asked her staff to evaluate child behaviors on a Likert scale, rating behaviors from 1 to 5. Again like other PA proponents, Harman took these evaluative data and performed a statistical analysis which would only have been acceptable if the measurement method met certain criteria which were not met. The conclusion that TPFF is an effective treatment thus remains open to question.

There are many concerns about the basic data as well as about the data analysis. The videotapes evaluated by Harman’s students were made by Gottlieb and certainly in her presence (it is not clear whether other people than parent and child were in the room at the time). This is far from an independent set of data, as Gottlieb’s presence signaled to both parents and children what behaviors were desired, and indeed necessary to bring the program to an end. The correct method would have been to have the recording done by a person who was not aware of the purpose of TPFF and who observed  parent and child without Gottlieb being present. Without wishing to stress that videorecordings can be cherry-picked, I would also note that the recordings should have stayed in the possession of the neutral recorder until handed over for analysis.

The research report by Harman, Saunders, and Afifi thus adds to the collection of weak studies of PA interventions, but in fact does not allow any clear conclusions about the safety or effectiveness of TPFF.

A second recent publication by Harman is this:

Harman, J., Maniotes, C, & Grubb, C. (2021). Power dynamics in families affected by parental alienation. Personal Relationship. (this journal is unfamiliar to me and the pdf I downloaded did not contain any DOI information.)

In this study, Harman and her colleagues approached special interest social media groups like Facebook divorce or parental alienation groups. They provided a survey and asked for emails from people who would be willing to be interviewed, and interviewed 50 fathers and 29 mothers about their experiences with their ex-spouses and children following divorce. The point of the study was to examine how these experiences fit the concept of coercive control and how power dynamics were related to parental alienation—interestingly, the very features that protective parents have been attributing to parents now rejected by their children. Harman et al. appear to have collected information closely related to parental alienation concepts, for example, that “in some cases the adultification [of children] took the form of allowing the children to decide whether they wanted to have their parenting time with the targeted [sic] parent or by sharing inappropriate information with the children”, statements frequently found in discussions by PA proponents.

It would seem that reviewers or others must have queried Harman’s personal commitment to PA ideas and her ability to be objective on the topic. Harman stated that “the first author contends that her experience as an alienated step-parent provides a unique perspective to the study and has helped to gain the trust and confidence of the parents that were interviewed, as many were afraid or concerned about their experiences not being believed.” She noted also that the second and third authors were included because they did not  have PA experience and could provide “more objective interpretation of the data”.

There are a number of concerning issues here. The first is that interviewees were sought from organized groups who were likely already to share certain views of post-divorce events, particularly views of parental alienation as they felt it had negatively affected their lives”.  This is a matter not so much of preaching to the choir but of being preached to by a choir that has memorized the hymns for the season. Members of social media groups are likely to share beliefs both before they join (this is why they join), and afterwards, when they have thoroughly informed each other of their opinions and experiences. One would imagine that anyone who planned to use regression methods would want to include a number of “nonbelievers” to show a comparison to a different power dynamic among them, but this did not happen.

That Harman thought her personal experiences would set interviewees at ease is worrisome, as it suggest that she told the interviewees about her own life, thus introducing various types of bias in the forms of the wish to please her,  social conformity to the standards she supplied about views of post-divorce relationships, and increased memory and reporting of events that could be interpreted as PA. Harman’s statement that the second and third authors would be more objective in interpretation of data seems to be an acknowledgment that she herself would not be objective—although it is difficult to know how one can be subjective in reporting statistical results.

Once again, Harman and her colleagues have added yet another questionable study to the trove already provided in courts of law as “evidence” to support PA concepts regarding identification and treatment of a posited disorder.

 

 

Talkin' Pseudoscience/Parental Alienation (Blues)

 

In recent months, I have come across the use of the term “pseudoscience” several times in advocacy for and against the parental alienation belief system. One blog post declared (but did not provide a rationale for the view) that parental alienation (PA) beliefs are pseudoscience. A little earlier, William Bernet, a well-known proponent of PA, declared in a journal article that critics of PA are pseudoscientists. The PA proponents Linda Gottlieb and Steven Miller have taken Bernet’s position in print and in testimony.

This conflict has quickly descended to the mutual finger-pointing, tit-for-tat, “I know you are but what am I?” level. “Pseudoscience” is not just an insulting term; it has a real meaning, which I will talk about here.

I would suggest, as a definition of pseudoscience, the following: pseudoscience is the claim that certain ideas have been supported by empirical data collected and analyzed by methods approved by members of the most closely related scientific discipline—when no such data collection and analysis have actually occurred. Please note that I do not say there has been no data collection at all (though that can happen), but simply that the methods used are not the ones agreed upon by members of the appropriate discipline.

To elaborate on this definition, I am going to discuss some hallmarks of pseudoscience as considered in the 2019 Cambridge University Press book Pseudoscience in Child and Adolescent Psychotherapy, edited by Stephen Hupp. The introductory chapter of this book (by Hupp, Mercer, Thyer, and Pignotti) notes a few common characteristics of pseudoscience:

1.   1   It involves exploited expertise, where someone who is a genuine expert in one field provides testimony in an area where he or she lacks training. For example, Steven Miller, a prominent figure in parental alienation discussion, is in fact an emergency medicine physician. Warren Farrell, who has testified about his observations of children in PA cases, is a political scientist who has written about fathers’ rights.

2.   2    There is no research support (as in the claims made by Craig Childress and Dorcy Pruter) , but the promoters of the treatment have financial interests in the treatment.

3.    3   There is inflated research support; “exaggerated claims are made on the basis of poorly designed or conducted research or research published in journals with very low scientific standards”. This is the case with the well-known research reports of Richard Warshak or of Amy Baker, reports which present weakly-designed and implemented research as if it met high standards.

4.    4   An important mechanism of the treatment is implausible based on current scientific knowledge, as is the case with PA claims about brainwashing.

5     Pseudoscience often includes references to established biological or physical concepts that are irrelevant to claims made and appear to have no purpose but obfuscation and a “veneer” of science. Reports about PA methods supposedly associated with polyvagal theory would be included here, although polyvagal theory itself is very much open to similar criticism.

 

Proponents of the PA belief system claim, pseudoscientifically, that they have empirical research evidence for their concepts, even though they have in no case complied with the evidence base standards set in medicine and in psychology over at least 20 years now. In addition, as I have just shown, their claims share hallmarks of pseudoscience. It is for them to correct these failings if they do not wish to be called pseudoscientists. Incidentally, addressing a topic other than PA, the developmental psychologist Lawrence Steinberg recently discussed the pitfalls of claims of cause and effect in outcome studies with nonrandomized or other correlational designs – highly relevant to PA issues (nytimes.com/2021/10/10/opinion/Instagram-facebook-mental-health-study.html).

 

What, then, about the statement that opponents of PA are pseudoscientists? This is absurd on the face of it, because opponents have done only a very few empirical investigations of matters associated with PA, and none of PA itself or of  the proprietary PA interventions. PA opponents on the whole do not offer claims of scientific evidence, so what they do offer is not pseudoscience. Instead, PA opponents have offered commentaries and critiques of PA claims that are designed to show weaknesses of PA concepts and of PA outcome research. If PA proponents paid  attention to these critiques and made serious efforts to develop acceptable empirical work on this topic, there would be benefits for children and parents. Such benefits, however, do not seem to be a major goal of PA advocates.

 

Gottlieb Addresses FAF on Interesting Subject of Cognitive Errors about PA

 

The organization www.familyaccessfightingforchildrensrights.com has been putting on a series of webinars by proponents of the parental alienation (PA) belief system. On Oct. 3, 2021, the speaker was Linda Gottlieb, creator of the Turning Points for Families (TPFF) intensive intervention for children who reject or resist contact with a divorced parent following posited manipulation by the other parent. Gottlieb addressed herself to the subject of “nonspecialists” and “pseudoscientists” and advised parents whose children are resisting contact with them to use her statements to have professionals who disagree with her positions dismissed from the case they bring.

There is, of course, a certain flavor of the schoolyard taunt “I’m rubber, you’re glue” here, as Gottlieb and other PA supporters have been correctly termed pseudoscientists, and the idea of a specialty in this area has been severely questioned as tending to focus on one issue when many should be considered.

Here are some concerning ideas put forward by Gottlieb in the webinar:

1.     1. Gottlieb continues to speak of diagnosis of PA, when it is clear that there is no such diagnostic category in DSM-5 or ICD-11. She does not speak of identification of child or parental behavior, as would be appropriate if there is no established diagnosis of the family situation in question.

2.     2.  Gottlieb fails to note that there is no established protocol for identifying PA and discriminating PA cases from cases where resistance results from experiences with the rejected parent.

3.    3.   Gottlieb continues to insist that when a child is identified as showing PA, and when the preferred parent is known to have shown parental alienating behaviors, this situation is equivalent to an adverse childhood experience (ACE). ACEs have been shown to correlate with a number of undesirable physical and mental health outcomes, and Gottlieb claims that similar outcomes would result from PA. This is, however, simply proof by assertion, as no empirical work has ever shown any particular outcome, positive or negative, of the child’s experience when PA is claimed to be a factor.

4.      4. Gottlieb’s argument that PA is an ACE leads her to state categorically that where there is PA, the preferred parent’s actions are equivalent to child abuse (CA). The PA=CA equation is repeated throughout the presentations.

5.     5.  Having defined PA as equal to CA, Gottlieb proceeds to state the position that PA is even worse than CA. In order to make this argument, she refers to her own experience with foster children who had been abused and neglected and who nevertheless wanted to visit their parents. Children in PA cases do not want this, by definition, which leads Gottlieb to say that their experiences of manipulation have been so severe as to interfere with the “instinctive” wish for contact with parents, as displayed by the foster children. Gottlieb and other PA proponents have frequently made this argument, and it is time to rebut it.

Let’s consider the differences in the current living situations of these two groups. Children in PA cases are living comfortably in familiar homes, with adults they trust and care for, with access to friends, siblings, supportive school situations, and sports or hobbies they have chosen. Foster children are in unfamiliar settings that may or may not be comfortable, they are supervised by unfamiliar adults who do not necessarily care for them, they may share the foster home with the carer’s children and a number of other foster children and therefore feel a lack of either privacy or friendly intimacy, they may suffer abuse from other children or from the foster parents themselves, they may be mocked at school as foster children or seen as potential problems by teachers, and they may not be able to visit other children in their homes or have any contact with their “home” friends. The food they are given and the religious practices of the foster home may be quire unfamiliar to the children.

Should we be surprised, then, that foster children long for their familiar home setting and even for contact with a parent who may at times have been abusive (but is not being abusive at the time)? And should we be surprised that a child in a PA case does not wish to exchange a familiar, comfortable setting, with pleasant social contacts and familiar activities, for a less familiar, even unknown, situation with a parent who has been rejected for various weaker or stringer reasons? I don’t think we need to enter into ill-informed discussions of instinct to answer these questions.

6.     6.  Gottlieb’s argument that PA=CA is intended to justify prohibition of contact between the child and the preferred parent for 90 days, often increased in further 90 day increments. Defining the preferred parent as a child abuser is the foundation for making these cases equivalent to child protection cases and removing the child from the home.

 

Gottlieb’s lengthy presentation failed to support her claims about PA or the implication that her TPFF intervention is a successful one.

By the way, another PA proponent, Jennifer Harman, who makes claims about PA and CA exactly like Gottlieb’s, has recently published what purports to be an evaluation of TPFF (see Harman, J., Saunders, L., & Afifi, T.[2021]. Evaluation of the Turning Points For Families (TPFF) program for severely alienated children. Journal of Family Therapy.) Regrettably but unsurprisingly, Harman et al report positive outcomes for TPFF while continuing to make the usual design errors of PA supporters. They use a Likert scale but apply parametric statistics, they have no comparison group, and they base their conclusions on videorecordings made by Gottlieb rather than on any independent data source. I might also point out that they define harm to children as limited to self-harm and running away—curiously different from the mental health disorders they attribute to untreated PA experiences.