Families in Psychiatry: Parental alienation and shared delusional disorders

Role of alienation

At the opposite end of the spectrum is alienation, most publicly described in the disputed diagnosis of parental alienation syndrome (PAS) (The Parental Alienation Syndrome, 2nd ed., Cresskill, N.J.:Creative Therapeutics Inc., 1998). PAS sometimes arises in the context of child-custody disputes. The primary manifestation is the child’s unjustified denigration of one parent. According to Dr. William Bernet and Amy J.L. Baker, Ph.D., PAS features “abnormal, maladaptive behavior (refusal to have a relationship with a loving parent) that is driven by an abnormal mental state (the false belief that the rejected parent is evil, dangerous, or unworthy of love)” (J. Am. Acad. Psychiatry Law 2013;41:98-104). There is considered to be brainwashing of the child by one parent against the other parent in order to gain leverage in a court of law.

What is the mechanism in alienation? Enmeshment and overidentification of the child with the favored custodial parent is common. The child depends on this adult for his survival. The process of divorce can increase enmeshment with the custodial parent. The parent might reinforce the enmeshment by instilling fear of the “other” parent. The belief that the “other parent” is “bad” is transmitted through conscious and unconscious mechanisms.

The conscious mechanism is direct expression of anger toward the alienated parent. The anger might be motivated by rejection or as revenge for rejection with a desire to punish. The unconscious mechanisms include projective identification. In this situation, anger is seen as being embodied within the “other.” The projecting parent who continues to “hate” keeps the children tied to her out of projected fear of the “other.” The parent who uses projection is likely to have a primitive character structure. The child of the narcissistic custodial parent then acts out the shame and rage at the failure of the marriage.

These domestic tragedies have been around since the beginning of time. In Greek mythology, Medea, having been abandoned by Jason, took her revenge by murdering her two children. “Hell hath no fury like a woman scorned” is a paraphrase from William Congreve’s The Mourning Bride (1697).

What does the DSM-5 say?

Are these disorders and syndromes “real” psychiatric illnesses? The DSM-5 no longer separates delusional disorder from shared delusional disorder. If criteria are met for delusional disorder, that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used.

Those who advocated for inclusion of PAS cited the benefits that follow from a legitimate diagnosis such as legitimatizing problems that family therapists and psychotherapists encounter, allowing insurance coverage, and stimulating research. However, PAS was rejected as not having a good enough scientific basis.

Managing affective involvement

How does the psychiatrist manage families where emotional involvement is extreme? Psychiatrists first need to decide whether the family is capable of making changes and is willing to work on structural change within the family. If not, we can help patients remove themselves from destructive family situations. If the patient in your office wants to leave the family system or minimize the impact of the family system, individual psychotherapy that identifies the impact of family dysfunction, such as cognitive-behavioral therapy, can be used as a type of deprogramming. Exit strategies also can be discussed.

Al-Anon, for example, clarifies the influence of the family system on family members’ well-being by asking several questions, including:

Do you tell lies to cover up for someone else’s drinking?

Do you feel that if they cared about you, they would stop drinking to please you?

Do you make threats, such as, “If you don’t stop drinking, I’ll leave you?”

Are you afraid to upset someone for fear it will set off a drinking bout?

Have you considered calling the police for help in fear of abuse?

Do you feel like a failure because you can’t control the drinking?

Do you think that if they stopped drinking, your other problems would be solved?

If you think there is capacity for family change, the following strategies are helpful:

1. Education about appropriate differentiation

According to Dr. Murray Bowen, one of the main tasks of individuation is finding the right level of differentiation from parents. At one end of the differentiation spectrum is emotional fusion, and at the other end is emotional cutoff (disconnection between family members or refusal to engage with certain family members) (see “Family Evaluation,” New York: W.W. Norton & Co., 1988).

When family enmeshment is present, we can educate the family about individuation. In this way, the family develops a greater intellectual understanding of how they function, compared to their cultural norm. The family may benefit from creating a genogram that clarifies patterns of emotional involvement in their family of origin. Look for intergenerational patterns, and discuss how emotional differentiation occurred in prior generations. Teach the family about the emotional tasks of differentiation.