Clinical Decision Making Errors

Dr. Steven J. Miller, MD, who has previously taught clinical decision making at Harvard Medical School, has stated that :

1. In January 2014, Steven Miller, MD, an expert in clinical reasoning and a specialist in alienation and estrangement, testified in front of a legislative task force that was investigating the family court system. Among other things, he pointed out that "this field is highly counter-intuitive to anyone who does not have extensive training and experience dealing with it . . . most people will usually get it wrong."

   1. severe parental alienation cases are the most profoundly counter intuitive diagnosis in clinical science , even surpassing borderline personality disorders cases (which is ironic because BPD/NPD is just one of the pathologies involved in pathogenic parenting ). [Talk given on 2/21/2015 at Family Access]

   2. "non-experts almost always get it exactly backwards". [Talk given on 2/21/2015 at Family Access]

2. severe cases tend to be clinical in the medical sense of the word - the underlying psychopathology is often associated with severe cognitive distortions including shared delusions and other psychotic or quasi-psychotic thinking, profound emotional dysregulation, and extreme or bizarre behavior

3. "cases of severe alienation are likely to be highly counterintuitive"

4. "studies show that many mental health practitioners lack adequate training to properly apply scientific principles (Baker, McFall, & Shoham, 2009; Begley, 2009;"

5. "Clinicians who attempt to manage them without adequate skills are likely to find themselves presiding over a cascade of clinical and psychosocial disasters."

• 1. In how PA Cases Go Wrong, why Most Peopled get it exactly backward: "Most professionals and other people get PA wrong and say the alienating parent is a great parent" or see a shortened version below.

See also: How To Choose An Alienation Expert , in press for a peer reviewed publication, lead authors Amy Baker, Dr. Miller.

Dr Miller, who has taught clinical decision making at Harvard Medical School, lists common clinical decision making errors frequently made when mis-diagnosing parental alienation, as noted in Working with Alienated Families and Children : A Clinical Guide Book :

The availability heuristic, the representative heuristic, the affect heuristic, the anchoring effect, confirmation bias, premature closure, framing errors, the fundamental attribution error, base rate neglect, the ecological fallacy

Unofficial transcription by Howie Dennison 2/27/2016 (The full length video is here and should be consulted to obtain fuller and more accurate context and to check the accuracy of the transcription):

What you need is a sub specialist in alienation and estrangement who sees it all the time, not the best psychologist in the world who rarely sees it. And, so very briefly, the short answer to this question "how does this happen", is this field is highly counter intuitive to anyone who doesn't have extensive training and experience dealing with it. They - most people will usually get it wrong. When I say people, I mean attorneys, psychologist, other mental health experts. The majority of the time they will not only get the case and the evaluations and the recommendations wrong they will get it exactly backwards.

First of all, and think how counter intuitive this is, in an alienation setting, most children will align with the abusive parent. It's like these kids that you find who have been living with their abductors for years and then they resist capture, or Stockholm Syndrome. Very counter intuitive. Number two, what we would call pathological enmeshment, an I will define that briefly, it means that the alienation parent has an unhealthy enmeshment with the child, to the point where the child has lost his or her individuality. A severe erosion of critical reasoning skills, boundary violations, sleeping with the other parent, or at least doing the bidding of the other parent, inappropriate sharing of information, which all the lawyers have heard of, pathological enmeshment is a very serious psychiatric problem, and to a non expert it looks exactly like a warm close loving healthy relationship. The non-expert comes in with perhaps Phd or an MD in Psychology or Psychiatry, and what they see is - let's just say the mother and father for simplicity ... it is about about a 50/50 spread of who does what these days. The two little girls are tightly bound to the mother "Oh I love you, I love you, I love you" and they look at Dad and say "I don't want to see him, he's are a bad man, she's perfect, he's rotten". The non-expert says "wow look at that great relationship". They don't really know how to probe to see if we have ... there are three types of of pathological enmeshment: infantalizaiton, adultification (making them adults .. "why don't you decide if you want to see dad") ... right there that's adultification right there, that's pathological enmeshment ... so I repeat pathological enmeshment, to a non-subspecialist, to an experienced forensic psychiatrist, looks just like a warm health relationship.

The fundamental attribution error means, you look at behavior ... if you see an angry man, you say "see he is an angry man, you think it is his character. In general, he is an angry man. Never mind that the reason he is angry is that someone just stole his car or his wallet". We are hardwired to say "oh, I am going to stay away from that guy, he is displaying anger". So, if the anger is situational, then it is an error. Now the relevance to us is that when an interviewer sees a sever case of alienation, the alienator is cool, calm, and collected. He or she has probably a borderline, a sociopath, or a narcissist, or all 3, and is a master manipulator, has learned to convincingly mimic normal behavior, and presents very well. "Oh yes, I encourage the child's relationship with his father, or his mother". By contrast, the targeted parent has PTSD, has not seen the child in god knows how long, maybe years, has been told that he is the one who is the problem, or she is the problem, and comes

in all intense, all angry, and all stressed out. Now I personally sat through a whole course at an AFCC meeting where the person teaching the

course, said to the people in the group "go by what you see. If the parent presents anxious and intense, you can be sure that is how they parent." No that is an elementary error in clinical reasoning and decision making. Not if it is a fundamental attribution error.

The severe cases are fundamentally different than moderate cases. In a moderate case, it is very reasonable to try to educate the parent to be cooperative. But in a severe case, where you have what one expert calls an obsessed alienator, that person with almost 100% certainty, has a severe personality disorder. Normal people just don't do that to their children and one clue is that they block access for years on end for trivial, frivolous reasons that you would never block access to your children for. Another indication or indicator would be the repeated breaching of court orders, which a normal person would never do. Just to give you a glimpse of the pattern, when you see excuses like "They don't like him, and they don't want to see him, and I am not going to force them", you should sit bolt upright in your chair.

Normal psychotherapy makes these cases [or severe parental alienation] worse. So if it is a skilled psychotherapist who thinks you can come in and do dyadic therapy of "why don't you find something to apologize for" or "Johnny how did that make you feel", that is a disaster. Don't try that, even with a medium case. They will almost always get catastrophically worse. So you have to match the therapist with the kid. That's my answer.

There are two places, one in Canada run by Kathleen Ray and another in Texas run by Richard Warshak. Give them day days with the kid, and the kid returns to the rejected parent happy as a clam to be reunited. But they require a change in custody and no contact with the alienating parent for 90 days. Other than that, there is no hope for a severe case, don't even think of doing it with office therapy.