Barry Bricklin, Ph.D.

Gail Elliot, Ph.D.


Outpatient Versus Inpatient Approaches

Formal and continuously operating settings for an inpatient approach are few and far-between.  An inpatient setting offers certain advantages over outpatient settings.  Longer therapeutic exposure times can be arranged among estranged family members within inpatient settings than is possible in typical outpatient settings.  There are extended opportunities to re-educate both the children and the parents.  Neutral settings in which Mental Health Professionals have more time to teach the critical interpersonal skills needed for healthy family life are easier to provide in inpatient settings.  There are prolonged opportunities to teach estranged parents how to deal, both emotionally and behaviorally, with the angry bitterness and condemnatory attitudes of alienated children.  It is difficult for any parent to learn how to respond to alienated children, who typically spew forth hateful and demeaning allegations.

However, inpatient approaches are sometimes clinically unfeasible, and few courts are willing to order them, at least as a “starting position” toward therapeutic reunification.

Over the years, we have searched for ways to incorporate into an outpatient approach the elements of an inpatient approach that give the latter its greater compellingness.

We share some of the results of this endeavor in this article.  Please note that this paper is essentially an outline for a more extensive piece we are preparing for a future Custody Newsletter (published by PACE).  Many detailed procedures need to be in place in addition to those listed here.  Note also that some are case-specific.  There is no one-size-fits-all formula in this field.


The Use of Traditional Therapeutic Procedures

By “traditional,” we mean when a Mental Health Professional (hereafter abbreviated MHP) employs “regular” individual therapy, family therapy, couples therapy and so forth.

In our experience, these traditional approaches are usually not only ineffective in alienation cases, but more frequently make things worse.  Most traditional therapists accept what their patients tell them as unvarnished truth, and end up as advocates.  From this position (advocates for their patients), they cannot carry out the functions required that can lead to family reunification.  (For more on this, see our article in The Custody Newsletter, 2002, Issue 22, pp. 82-85.  It is published by The Professional Academy of Custody Evaluators or PACE.  Also see our article in The University of Arkansas at Little Rock Law Review, 2000, Vol. 22, pp. 501-528.  It is called “Qualifications of and Techniques to Be Used by Judges, Attorneys and Mental Health Professionals Who Deal With Children in High Conflict Divorce Cases.)

MHP Involvement in PAS-type Cases

Any MHP who wants to be effectively involved assisting in parent-child estrangement cases must know much more than how to adequately diagnose and treat the family members involved, although it should be noted that diagnosis and treatment in alienation cases are quite complex and time-consuming endeavors.  (See the above-referenced articles for information on the complexity of the diagnostic process necessary to pinpoint what is going on in estrangement cases.  Interested MHPs might also consider attending one of the two-and-a-half day workshops we provide for PACE.  The MHP must establish the causal factors at work, and how each of the family members is behaving in ways that not only sustain the estrangement but more typically keep making it worse.)  The MHP must also know the many therapeutic tools unique and specific to alienation cases.

In addition to diagnostic and treatment skills, the MHP must have a fairly comprehensive view of how members of the legal system typically approach estrangement cases.

The list of what the MHP needs to know about the court system is a long one.  There are many essential “Do’s” and “Don’ts.”  Some of the most important are listed below.

1.            The MHP must know how to specifically respond to the many different legal and clinical situations that may exist when he or she is called upon to enter the case.  Each situation will require a different response.   For example, the MHP response would be very different if a court has already established the existence of alienation as opposed to a case where only one parent believes it to be in the picture.

2.            The MHP must know how to respond to all the many “facts” the court has already found to be “true” at the time he or she enters the case.  The nature of this list, the list of what the court assumes to be established fact, will impact how the MHP approaches the case.

3.            He or she must know how to respond to a case where no legal process has already occurred.

4.            He or she must know how to differentially respond depending upon who is asking for help.

5.            The MHP must know how to determine who are the people in the case that may become opponents, and how to discover what “facts” they will try to put in evidence.

6.            Unless the court has already established that alienation does in fact exist, and the MHP is called in as a neutral expert to provide guidance, he or she must be skilled in forming strong partnerships or alliances with attorneys who have only vague understandings of what alienation is and what its treatment involves.  Without such an alliance, it is unlikely the MHP will be able to attain the kind of court order needed in these cases.

The list goes on.  There is one other area in which it is greatly important that the involved MHP be knowledgeable, especially if he or she is to serve as a nonlocal expert.  This is where the MHP may be called upon to present written or spoken evidence to a court where he or she is not already well established as a credible and perhaps even ‘favorite” witness.  The MHP must appreciate the “politics” of how to approach members of the court.  This goes far beyond trying to find out how a particular court views estrangement cases.  Many of the consultations we perform nowadays for attorneys around the country, involve how to approach a specific case, for example, what points to make and which points to avoid trying to make.  We may be called upon to help the attorney determine which witness can best make some certain point or who, on the opposing side, to challenge and who to avoid challenging.  This “must-know” list is also a long one.

Therapeutic Involvement in PAS-Type Cases

We will cover two main points that involve what is required for a MHP to be effective in PAS-type cases on an outpatient basis.  The first spells out what we see as a necessary but not sufficient condition for involvement.  Necessary-but-not sufficient means that if this condition is not achieved, there is little chance the therapeutic endeavor will be successful, but yet by itself the condition is not sufficient to lead to success.  This condition is the proper involvement of the court.  The second point we will cover involves acquiring knowledge about therapeutic techniques that are unique to estrangement cases. 

Therapeutic involvement of the court has two steps.  One is to gain a court’s willingness to be involved in the first place.  The second is for the MHP to know what to ask of the court, once the willingness is there.  Please note that if all the steps already mentioned are not followed, there is a much decreased chance that the procedures to be described about approaching the court and what to ask of it will be effective.


Gaining a Court’s Cooperation

Assuming that the steps already mentioned have been followed, at some point both the attorneys and the judge may need some brief overview of the special complexities involved in achieving reunification in estrangement cases.  Following, is a sample letter we write for the attorneys, and eventually the judges.

Dear Attorneys:

The purpose of this letter is to detail what we have learned over the years in working with families such as the one involved in this matter.  In providing this background material, we hope to demonstrate why we require a very special and “strong” order from the relevant Court.  Briefly, we have learned that absent such an order, there is little chance that reunification therapy, conducted in an out-patient setting, in cases such as this, has much chance of succeeding.  We will start by explaining some of the complexities involved in dealing with alienation/estrangement cases.

In alienation cases where we ourselves have not already conducted a comprehensive custody evaluation (and often even in cases where we have), it is not possible to establish a completely clear diagnostic picture within the typically constricted time-periods afforded by such evaluations.  Even comprehensive evaluations that span several months may not yield a clear diagnostic picture of “who is doing what to whom,” especially when the ongoing dispute involves “who threw the first stone” that is, who is usually the “wicked initiator” and who is the (often misguidedly responding) victim.  In typical psychological treatment cases, it is often possible to formulate a diagnostic impression prior to beginning the treatment.  This is almost impossible to do in cases that involve alienation of affection or estrangement between a parent and child, especially where there has been a history of conflict between the parents.  When a mental health professional (MHP) formulates a diagnostic picture, he or she must assume that interview information and observational data are at least mostly true and accurate.  In alienation cases, children typically make false or greatly exaggerated negative allegations based not on their actual interactions with the so called “target parent” (the estranged or alienated parent) but rather based on what they have been told, on what they have misunderstood or on actual bribery or intimidation by the other parent.  Allegations are frequently based on a child’s desire to protect, or to seek vengeance for, a parent the child believes has been mistreated.

Further, in cases similar to this one, the child usually presents the MHP with a long list of “outrages” and other very negative allegations about the target parent.  Although most of these allegations are usually trivial, some are not—some could be serious.  The problem is that it is often impossible to confirm or rule them out.

Further still, even if the MHP can confirm that at least some of the allegations are likely true, there is no way for the MHP to gauge the psychological impact any such event really had (or is having) on the child.  The child’s verbal claims, (e.g., I’m scared of him; He disgusts me; etc.)  are usually impossible to verify.  There is no easy way (absent polygraphs and other equipment that measure nonverbal responses) to gauge if a child is actually experiencing any of these internal, non-observable states.  (Frequently, the nonverbal signs of such negative emotions, some of which are hard to simulate or fake, are totally absent.  That is, there is a total “disconnect” between the violently abusive situations the child is supposedly re-experiencing as they are verbalized, and any signs of emotional distress in the child.)  Further, some of the typical allegations made present the MHP with diagnostic conundrums e.g., “He doesn’t deserve to be in my life,” “He walked out on us,” etc.  A MHP has no way to deal with a child’s “moral” or philosophical utterances, or even to determine if they are really believed by the child.

What all this means is that there are few truly scientific procedures a MHP can use in an individual case (as opposed to using data derived from group-based statistical studies) to ascertain the degree to which a particular child could profit from ongoing contact with a particular parent.  (We have developed several data-based tests which can assist the MHP in formulating a diagnostic picture of a given child’s relationship with each parent.  The data yielded by the tests can help a MHP estimate statistical probabilities about whether what a child is verbally reporting about a parent is based on actual interactions with that parent, or rather on other “suspect” influences.  The latest statistical data on these tests are summarized in the following journal articles.  One is titled Can Child Custody Data be Generated Scientifically?  The other is titled Perception-of-Relationships Test and Bricklin Peceptual Scales: Validity and Reliability Issues.  They appear in two successive editions of the American Journal of Family Therapy, 2004, Vol. 24.  The first is in Issue 2 (pp. 119-138) and the second in Issue 3 (pp. 189-203).  Note however, that such work has to do with probabilities.  Tests are not silver-bullets.)

If one relies on research data and clinical experience, a strong case for the value of a child’s having a continuing relationship with each parent can be made.  Joan Kelly and Michael Lamb have separately and together published research that strongly suggests that children profit from having relations with both parents.  Note also that clinical experience informs of the so-called “law” of requisite variety.  This states that the more the different parenting styles a child deals with (once past infancy), the better.  (This is provided the child is receiving therapeutic guidance.)  Even if a parent has a (mildly) “negative” style, a child who interacts with this parent has the opportunity to learn how to deal with it, increasing that child’s available coping and resource-styles throughout life. 

What all this means is that there is presumptive research evidence suggesting that children in general profit from the ability to have an ongoing relation with both parents.  But note also that it is scientifically impossible, especially in alienation cases, to state with certainty, on an a priori basis, whether a particular child could profit from a relation with a specific parent.  Not only must a MHP deal with all of the diagnostic complexities already mentioned, but also with the fact that psychological life is transformational: it is a “work in continual progress.”  A parent who was previously a poor psychological match for a particular child can therapeutically upgrade and transform his or her styles and become a good match for the child.  A maturing child may come to see aspects of value in a given parent’s behavior that were initially not perceived by the child, or were perhaps not even in existence prior to the child’s changing his or her own patterns which then could induce change in the parent.  All relationships are continuously interactive and potentially transformative for each member of any given family system.

Hence the best (and probably only) way to ascertain if an alienated or estranged child could profit from an ongoing relation with a “target” parent is to set up the special kind of therapeutic program that has a chance of being successful in such cases and observing what happens.  Once the program is in place one can carefully monitor the therapeutic process for positive and negative prognostic signs.  We rarely mention these emergent signs (signs that usually do not yet exist at the outset of treatment) because some can be “faked” (while others cannot be faked).  In other words, we rarely, at the outset, tell the main therapeutic participants all of the things we are paying attention to.

A therapeutic plan that can be successful in these cases is very different than traditional plans.  For one thing, the Court must be actively involved in the process (specific details are listed later).  For another, the child must rapidly see that he or she is NOT going to be the major (or even minor) decision-maker of importance as to who attends the therapeutic sessions or for how long.  This “tail-wagging-the-dog” phenomenon in which a child gets to exercise control over parents will ultimately not only ensure that an out-patient reunification process fails, but is also ultimately harmful to the child as he or she grows up.

One other complication needs to be mentioned in reference to the successful treatment of alienation cases.  During the long periods of time these cases usually run, either the involved courts appoint, or the disputants themselves hire, traditional therapists.  These traditional therapeutic endeavors usually fail.  Finally, the case may end up with a MHP who understands the unique therapies that are required for success.  Real-life fact number one: by the time the case ends up with someone who might truly provide effective reunification therapy, many therapeutic attempts—perhaps dozens—have already failed to help.  Real-life fact number two: with each therapeutic failure, the alienated child has been further empowered and emboldened to continue his of her defiance, to continue being the tail that wags the dog.  And why not?  The child learns over and over that if he or she “holds out,” “victory” can be reached.  Each and every past therapeutic failure paradoxically makes the current reunification task more difficult to attain. 

After offering the court and the attorneys some rationale for the rather nontraditional powers we are about to request (as explained in the above-mentioned sample letter), we list them in as clear a manner as we can.  We rarely proceed in such cases without these requirements being cast in the form of a court order.  We also usually insist that much of our exact wording be used in the order, since they were developed over several years of involvement in such cases, cases in which we hopefully learned what worked and what didn’t.  Current comments (for this article) are in parentheses.

What to Ask of the Court

Here, then, are some points to be made in the needed Court Order.

1.            It is the intention of the Court that the involved child therapeutically learn how to sustain interactions with the estranged parent.  (Note that we do not say “come to love” or “get along perfectly with.”  For us, the ability for a child to sustain interactions with a parent without any credible signs of harm, is a more realistic match with what is attainable even in intact families.)

2.            Dr. Barry Bricklin and Dr. Gail Elliot are designated to be the Reconciliation Experts in this case.  Since successful reconciliation usually requires an intensive, residential (child and alienated parent together) approach, the above-named experts must be given, via the Court Order, broad power, the most important of which are here listed.

3.            Traditional therapy most usually not only does not work in alienation cases but actually makes things worse (one ends up with “advocates,” not reunification therapists).  Hence if other therapists should enter this case, Drs. Bricklin and Elliot are designated as the unequivocal team leaders in planning, integrating and evaluating therapeutic strategies.  They shall have the right to communicate directly with any such party.

4.            Drs. Bricklin and Elliot are given the power of binding arbitration with the parents on any emergent best-interest-of-the-child issue that may arise during the course of treatment.  This is essential in order to eliminate or at least mitigate situations that might increase interparental hostility, a main sustaining cause of estrangement.

5.            They shall have the power to modify any existing time-share plan that is currently in place if this is seen as needed to maintain the integrity of the reunification process, and they shall have the right to ex-parte communications with the Court.

6.            They will determine when therapeutic sessions are to occur (of course, taking into account the reasonable needs of the participants) and who should attend them.

7.            If after a reasonable interval of time (to be specified within the first few months of treatment) Drs. Bricklin and Elliot believe that reconciliation cannot be achieved on an out-patient basis they have “the right and responsibility to suggest an in-patient facility to the Court.”  (Please use that exact phrase.)  The Court can then read the documentation that provides the foundation for this suggestion, and go on to vet the recommended facility.  The ultimate decision to use an in-patient facility will be made solely by the Court.

8.            Since it is typically impossible at the outset or on an a-priori basis to know the actual amount of “upset” a rejecting child may actually be experiencing in a therapeutic process such as this—it is usually impossible to verify the verbal utterances made by alienating children in high conflict post-divorce cases—Drs. Bricklin and Elliot may call in an individual therapist for the child.  As stated, Drs. Bricklin and Elliot remain the team leaders.

9.            The parents agree not to launch any legal actions against each other while the therapy is in progress.

10.        While Drs. Bricklin and Elliot will be understanding of a child’s scheduling needs (school, sports, work, etc.) and parental commitments, it will generally be their position that attendance at the sessions should be given the highest priority by the involved parties.

11.        It is of critical importance that everyone involved in this matter, including the Court, the attorneys, the parents and the child(ren), realize that success in a reconciliation process cannot be accurately stated, or sometimes even estimated, in calendar or “normal” linear time.  Success is measured by the attainment and the maintenance of specified goals.  These will be made known to the participants by Drs. Bricklin and Elliot.

12.        There may come a time when Drs. Bricklin and Elliot suggest that the Court issue a temporary order (which can later be reviewed) that the alienated parent be designated the sole legal and physical custodian.  How this is actually operationalized can be determined at the appropriate time.  This step is essential if an in-patient facility is ordered by the Court.

13.        The fee for Dr. Bricklin and/or Dr. Elliot is _____________________.  This applies whether one of both Doctors are present (it will usually be both).  An advance payment of ___________________ is required, since the length of any specific session cannot be known in advance.  Some may run several hours.