The Spectrum Of Parental Alienation Syndrome (Part I)
Forensic Psychologist, Deirdre Conway Rand, PhD
AMERICAN JOURNAL OF FORENSIC PSYCHOLOGY, VOLUME 15, NUMBER 3, 1997
The Parental Alienation Syndrome, so named by Dr. Richard Gardner, is a distinctive family response to divorce in which the child becomes aligned with one parent and preoccupied with unjustified and/or exaggerated denigration of the other target parent. In severe cases, the child's once love-bonded relationship with relected/target parent is destroyed. Testimony on Parental Alienation Syndrome (PAS) in legal proceedings has sparked debate. This two-part article seeks to shed light on the debate by reviewing Gardner's work and that of others on PAS, integrating the concept of PAS with research on high conflict divorce and other related literature. The material is organized under topic headings such as parents who induce alienation, the child in PAS, the target/alienated parent. attorneys on PAS, and evaluation and intervention. Part II begins with the child in PAS. Case vignettes of moderate to severe PAS are presented in both parts, some of which illustrate the consequences for children and families when the system is successfully manipulated by the alienating parent, as well as some difficult but effective interventions implemented by the author, her husband Randy Rand, Ed.D., and other colleagues.
Dr. Richard Gardner was an experienced child and forensic psychiatrist conducting evaluations when, in 1985, he introduced the concept of Parental Alienation Syndrome (PAS) in an article entitled "Recent Trends in Divorce and Custody Litigation" (1). His work with children and families during the 1970s led him to write such books as Boys and Girls Book of Divorce, The Parents Book About Divorce and Psychotherapy with Children of Divorce. He knew from experience that the norm for children of divorce was to continue to love and long for both parents, in spite of the divorce and the passage of years, a finding replicated by one of the first large scale studies of divorce (2). With this background, Gardner became concerned in the early 1980s about the increasing number of divorce children he was seeing who, especially in the course of custody evaluations, presented as preoccupied with denigrating one parent, sometimes to the point of expressing hatred toward a once loved parent. He used the term Parental Alienation Syndrome to refer to the child's symptoms of denigrating and rejecting a previously loved parent in the context of divorce.
Gardner's focus on PAS as a disturbance of children in divorce is unique, although from the mid-1980s on there has been a proliferation of professional literature on disturbing trends in divorce/custody disputes, including false allegations of abuse to influence the outcome. At least three other divorce syndromes have been identified. In 1986, two psychologists in Michigan, who were as yet unaware of Gardner's work, published the first of several papers on the SAID syndrome, Blush and Ross's acronym for sex abuse allegations in divorce (3). Drawing on their experience doing evaluations for the family court, and the experience of their colleagues at the clinic there, these authors delineated typologies for the falsely accusing parent, the child involved and the accused parent. Two of the divorce syndromes named in the literature focus on the rage and pathology of the alienating or falsely accusing parent. Jacobs in New York and Wallerstein in California published case reports of what they called Medea Syndrome (4, 5). Jacobs discussed Gardner's work on PAS in his 1988 study of a Medea Syndrome mother, as did Turkat when he described Divorce Related Malicious Mother Syndrome in 1994 (6). Fathers, too, can be found with this disorder, as one of the case vignettes below indicates, but for some reason Turkat has not encountered any.
In addition to articles specifically on PAS and literature which refers to it, there is a body of divorce research and clinical writings which, without a name, describe the phenomenon. The literature reviewed here comes from a number of sources including: practitioners who like Gardner are seeking to improve the diagnostic skills and intervention strategies of the courts and other professionals who deal with high conflict divorce; attorneys and judges who come in contact with PAS cases; researchers like Clawar and Rivlin who reference Gardner's work on PAS in their large scale study of parental programming in divorce (7) and Johnston whose work on high conflict divorce (8) led her to study the problem of children who refuse visitation, including a discussion of PAS (9). When PAS is viewed from the standpoint of parts and subprocesses which create the whole, the literature which pertains increases exponentially, for example: psychological characteristics of parents who falsely accuse in divorce/custody disputes; cults who help divorcing parents alienate their children from the other parent; and psychological abuse of children in severe PAS including Munchausen Syndrome by Proxy type abuse.
The trends identified by Gardner and others are the result of important social changes which began to take root and flower around the mid 1970s. The legal treatment of divorce and child custody shifted from the preference for mothers to have sole custody and the "tender years presumption" to the preference for joint custody and "best interests of the child." This gave divorce fathers more legal options for parenting their children and increased the quantity and intensity of divorce disputes as parents vehemently disagreed over the numerous custodial arrangements now possible. By the late 1970s, rising concern about parental programming of children to influence the outcome of disputes led the American Bar Association Section of Family Law to commission a large scale study of the problem. The results of this 12 year study were published in 1991 in a book called Children Held Hostage (7). Clawar and Rivlin found that parental programming was practiced to varying degrees by 80 percent of divorcing parents, with 20 percent of engaging in such behaviors with their children at least once a day. Further discussion of this book appears below.
At the same time as new divorce trends have been emerging, sweeping social changes have been occurring in society's treatment of child abuse. Mandated reporting became the law of the land in the 1970s and the procedures for making reports were simplified such that anonymous reports are now accepted and acted upon in some states. As the number of suspected abuse reports practically doubled, so did the number of false and unsubstantiated reports, according to statistics compiled by the National Center for Child Abuse and Neglect in 1988 which showed that non-valid reports outnumbered cases of bona fide abuse by a ratio of two to one (10).
According to some observers, false allegations of abuse in contested divorce/custody cases have become the ultimate weapon. Judge Stewart wrote that "Family Courts nationwide are feeling the effects of a new fad being used by parties to a custody dispute-the charge that the other parent is molesting the child...The impact of such an allegation on the custody litigation is swift and major...The Family Court judge is apt to cut off the accused's access to the child pending completion of the investigation" (11, p. 329). In response to concerns such as these, the Research Unit of the Association of Family and Conciliation Courts obtained funding for a study on sex abuse accusations in divorce/custody disputes (12). Data for 1985-1986 were gathered from family court sites across the country. At that time, the incidence of sex abuse allegations in divorce was found to average two percent, but varied from one percent to eight percent depending on the court site. Results of this study suggest that sex abuse allegations in divorce may be valid only about 50 percent of the time. Many of the court counselors and administrators interviewed believed they were seeing a greater proportion of such cases than in previous decades.
Ten years later in 1996, Congress amended the Child Abuse Prevention and Treatment Act to eliminate blanket immunity for persons who knowingly make false reports, based on information that 2,000,000 children were involved that year in non-valid reports, as opposed to 1,000,000 children who were genuinely abused (13). In addition, many states have already enacted laws against willfully making a false child abuse report. In California where the author and her husband practice, the Office of Child Abuse Prevention revised their manual for mandated reporters several years ago to include a section on false allegations in which the coaching of children during custody disputes is described as a major problem and Gardner's work on PAS is referenced (14).
In the meantime, the 1980s saw a massive campaign to train social workers, police, judges and mental health professionals in such concepts as "children don't lie about abuse." To make up for society's blind eye to child abuse in the past, professionals are encouraged to unquestioningly " believe the child " and to reflexively accept all allegations of child abuse as true. Widespread media attention and a proliferation of popular books and movies on child abuse continues to suggest that the problem is widespread and insidious. Parents and professionals alike are enjoined to be vigilant for what are touted as "behavioral indicators" of sex abuse. These include the common but vague symptom of poor self esteem, conflicting "indicators" such as aggressive behavior and social withdrawal, and child behaviors which may be developmentally normal such as sexual curiosity and nightmares. Little attention is paid to the fact that children may develop the same symptoms in response to other stressors, including divorce and father absence.
Children, too, are being sensitized to abuse, taught about "good touch/bad touch." At the end of such a lesson in school, they may be asked to report anyone who they think may have touched them in a bad way. Although some instances of legitimate abuse are detected in this manner, children sometimes misunderstand the lesson such that a kindly grandfather going to scoop up his young grandson in his arms, as he had done many times before, may find the child pulling back from him in horror and accusing him of "bad touch." Adults conducting these classes are sometimes so eager to find abuse that in one Southern state, the parents of over half the class were arrested.
The foregoing outline of recent social changes is not meant to imply that Parental Alienation Syndrome and false allegations of sex abuse in divorce are synonymous. PAS can occur with or without such abuse accusations. Although false allegations of sex abuse are a common spin-off of severe PAS, other derivative false allegations may include physical abuse, neglect, emotional abuse, or a fabricated history of spousal abuse. In addition, there seems to be an increase in PAS type cases of accusations by the alienating parent that it is the alienated parent who is practicing PAS, a tactic which tends to confuse and neutralize interveners.
PARENTAL ALIENATION SYNDROME
According to Gardner, PAS is a disturbance in the child who, in the context of divorce, becomes preoccupied with deprecation and criticism of one parent, which denigration is either unjustified and/or exaggerated. Gardner sees PAS as arising primarily from a combination of parental influence and the child's active contributions to the campaign of denigration, factors which may mutually reinforce one another. Gardner distinguishes between Parental Alienation Syndrome and the term "parental alienation." There are a wide variety of causes for parental alienation, including bonafide parental abuse and/or neglect, as well as significant deficits in a rejected parent's functioning which may not rise to the level of abuse. From Gardner's perspective, a diagnosis of PAS only applies where abuse, neglect and other conduct by the alienated parent which would reasonably justify the alienation are relatively minimal. Thus Gardner conceives of PAS as a specialized subcategory of generic parental alienation. Since introducing the concept of PAS in 1985, Gardner has written two books on the subject (15, 16), and included a chapter on it in his book entitled Family Evaluation, in Child Custody Mediation, Arbitration and Litigation(17).
Depending on the severity of the PAS, a child may exhibit all or only some of the following behaviors. It is the cluster of these symptoms which prompted Gardner to consider them as a syndrome.
1) The child is aligned with the alienating parent in a campaign of denigration against the target parent, with the child making active contributions;
2) Rationalizations for deprecating the target parent are often weak, frivolous or absurd;
3) Animosity toward the rejected parent lacks the ambivalence normal to human relationships;
4) The child asserts that the decision to reject the target parent is his or her own, what Gardner calls the "independent thinker" phenomenon; 5) The child reflexively supports the parent with whom he or she is aligned;
6) The child expresses guiltless disregard for the feelings of the target or hated parent;
7) Borrowed scenarios are present, i.e., the child's statements reflect themes and terminology of the alienating parent;
8) Animosity is spread to the extended family and others associated with the hated parent.
In Gardner's experience, born out by the clinical and research literature reviewed below, mothers are more frequently found to engage in PAS, which is likened by Clawar and Rivlin to psychological kidnapping (7). Where PAS with physical child abduction occurs, however, Huntington reports that fathers are in the majority (18). Gardner recognizes that fathers, too, may engage in PAS and gives examples in his books. For consistency and simplicity, though, he refers to the alienating parent as "mother" and target parent as "father."
According to Gardner, the brainwashing component in PAS can be more or less conscious on the part of the programming parent and may be systematic or subtle. The child's active contributions to the campaign of denigration may help to create and maintain a mutually reinforcing feedback loop between the child and the programming parent. The child's contributions notwithstanding, Gardner views the alienating parent as the responsible adult who elicits or transmits a negative set of beliefs about the target parent. The child's loving experiences with the target parent in the past are replaced with a new reality, the negative scenario shared by the programming parent and child which justifies their rejection of the alienated parent. In light of these observations, Gardner warned that children's statements in divorce/custody about rejecting one parent should not be taken at face value and should be evaluated for PAS dynamics. According to psychologist Mary Lund, this insight is one of Gardner's most important contributions because it alerted the legal system, parents and mental health professionals dealing with divorce to an important possibility which can have disastrous effects if unrecognized (19).
Gardner emphasizes the importance of differentiating between mild, moderate and severe PAS in determining what court orders and therapeutic interventions to apply. In mild cases, there is some parental programming but visitation is not seriously effected and the child manages to negotiate the transitions without too much difficulty. The child has a reasonably healthy relationship with the programming parent and is usually participating in the campaign of denigration to maintain the primary emotional bond with the preferred parent, usually the mother. PAS in this category can usually be alleviated by the court's affirming that the preferred or primary parent will retain primary custody.
In moderate PAS, there is a significant degree of parental programming, along with significant struggles around visitation. The child often displays difficulties around the transition between homes but is eventually able to settle down and become benevolently involved with the parent he or she is visiting. The bond between the aligned parent and child is still reasonably healthy, despite their shared conviction that the target parent is somehow despicable. At this level, stronger legal interventions are required and a court ordered PAS therapist is recommended who can monitor visits, make their office available as a visit exchange site, and report to the court regarding failures to implement visitation. The threat of sanctions against the alienating parent may be needed to gain compliance. Failure of the system to apply the appropriate level of court orders and therapeutic interventions in moderate PAS may put the child at risk for developing severe PAS. In some moderate cases, after court-ordered special therapy and sanctions have failed, Gardner states that it may be necessary to seriously consider transferring custody to the allegedly hated parent, assuming that parent is fit. In some situations, this is the only hope of protecting the child from progression to the severe category.
The child in severe PAS is fanatic in his or her hatred of the target parent. The child may refuse to visit, personally make false allegations of abuse, and threaten to run away, commit suicide or homicide if forced to see the father. Mother and child have a pathological bond, often based on shared paranoid fantasies about the father, sometimes to the point of folie a deux. In severe PAS, Gardner has found that if the child is allowed to stay with the mother the relationship with the father is doomed and the child develops long-standing psychopathology and even paranoia. Assuming the target parent is fit, Gardner believes that the only effective remedy in severe PAS is to give custody to the alienated parent. In 1992 he suggested that courts might be more receptive to the change of custody option if the child was provided with a therapeutic transitional placement such as hospitalization, an intervention employed with success by the author and her husband ( see case vignette in Part II ).
Gardner's original conception of PAS was based on the child's preoccupation with denigration of the target parent. It was not until two years later when he published his first book on PAS that he addressed the problem of PAS with false allegations of abuse. Gardner prefers to view such allegations as derivative of the PAS, observing that they often emerge after other efforts to exclude the target parent have failed. Some of the literature reviewed below, however, indicates that false allegations of abuse may also surface prior to the marital separation, symptomatic of a pre-existing psychiatric disorder of the alienating parent which may not be diagnosed until there is further mental deterioration after the divorce. Gardner was among the first to recognize that involving a child in false allegations of abuse is a form of abuse in itself and indicative of serious problems somewhere in the divorce family system. Insofar as PAS with false allegations of abuse can result in permanent destruction of the child's relationship with the alienated parent, it can be more harmful to the child than if the alleged abuse had actually occurred.
Gardner supports joint custody for those parents who can sincerely agree on it and have the ability to fulfill this ideal. Research by Maccoby and Mnookin suggests that about 29 percent of divorced parents are successfully co-parenting three to four years after filing (20). Gardner opposes imposing joint custody on parents in dispute and between whom there is significant animosity. For these families, Gardner recommends that a thorough evaluation be conducted to develop a case specific plan with the right combination of court orders, mediation, therapeutic interventions, and arbitration.
HIGH CONFLICT DIVORCE AND PAS
High conflict divorce is characterized by intense and/or protracted post separation conflict and hostility between the parents which may be expressed overtly or covertly through ongoing litigation, verbal and physical aggression, and tactics of sabotage and deception. Clinical and research literature suggest that Parental Alienation Syndrome is a distinctive type of high conflict divorce which may require PAS specific interventions, just as the problems of divorced families have been found to respond to divorce specific interventions rather than to traditional therapies. In their book on children caught in the middle of high conflict divorce, Garrity and Baris treat PAS as a distinctive divorce family dynamic, devoting two chapters to PAS, one on understanding it and the other on a comprehensive intervention model (21).
In high conflict divorce without significant PAS, the parents do most of the fighting while the children manage to go back and forth between homes, maintain their own views and preserve their affection for both parents. They cope by developing active skills for maneuvering the situation or by adopting a survival strategy of treating both parents with equal fairness and distance (8). Periodically, children may exacerbate parental conflicts by embellishing age appropriate separation anxieties, telling each parent things the parent wants to hear and shifting their allegiance back and forth between the parents. Nevertheless, they avoid consistent alignment with one parent against the other and are able to enjoy their time with each parent once the often difficult transition between homes has been accomplished.
In high conflict divorce with significant PAS, the children are personally involved in the parental conflict. Unable to manage the situation so as to preserve an affectionate relationship with both parents, the child takes the side of one parent against the other and participates in the battle as an ally of the alienating parent who is defined as good against the other parent who is viewed as despicable. In a study of 175 children from high conflict families, Johnston found that chronic hostility and protracted litigation between the parents contributed to the development of PAS among older children (9). In other words, where the system is unable to settle and contain parental divorce conflicts, the children may be at increasing risk for developing PAS as they get older. Johnston acknowledges that her findings support Gardner's contention that as many as 90 percent of children involved in protracted custody show symptoms of PAS.
A large scale study of patterns of legal conflict between divorce parents three to four years after filing contained them significant finding that the most hostile divorce couples were not necessarily those engaged in the most contentious legal battles (20). This suggests that PAS may occur not only in the context of litigation but may develop after litigation has ceased, or proceed a new round of litigation after many years, supporting what Dunne and Hedrick found in their clinical study of severe PAS families (22).
According to Johnston, high conflict divorce is the product of a multilayered divorce impasse between the parents (8). Often, the impasse has its roots in one or both parents' extreme vulnerability to issues of narcissistic injury, loss, anger and control. These vulnerabilities prevent a satisfactory divorce adjustment and feed an endless, sometimes escalating cycle of action and reaction which promotes and maintains parental conflict. The parents are frozen in transition, psychologically neither married, separated or divorced, a pattern which may pertain even when only one parent is significantly disturbed. Using Johnston's model, PAS can be viewed as an effort by one parent, with the help of the children, to "resolve" the divorce impasse with a clear-cut understanding of who is good, who is to blame and how the parent to blame should be punished. The following vignette illustrates this. Like the other case examples interspersed throughout this article, it is a composite scenario synthesized from real cases encountered by the author and her colleagues.
Mr. L had adopted his wife's child from her previous marriage and he and Mrs. L. had a child of their own, a girl who was six years old when Mr. L. moved out of the family home. During the six months leading up to this precipitous event, Mrs. L. was living in one part of the house with the older child while Mr. L. and his daughter had rooms together in a separate part of the house. The parents hardly spoke to one another but the children visited back and forth freely with each other and with both parents. Under the circumstances, Mr. L. did not think his wife would object to his leaving, but just in case there was a scene he decided to move out first and then work out the practical issues with Mrs. L. He left a letter for her and another one for the children, explaining his decision and affirming his desire to make arrangements for visitation and child support. Mrs. L. was furious. She immediately had the locks changed and successfully blocked her husband's efforts to contact the children by phone or to see them. Both children probably felt betrayed by father and Mrs. L. amplified such feelings by telling the children their father had abandoned them and did not- care about them at all. She also alleged that he had had numerous affairs during the marriage although Mr. L. always denied that. These allegations may have sprung from the fact that Mrs. L. found out six weeks after her husband left that he was dating someone. Outraged, she told Mr. L. that he would never see the children again. She and the children began calling Mr. L. and his girl- friend at all hours, screaming accusations and obscenities over the phone until a restraining order was obtained. When efforts by father's attorney to arrange for mediation between Mr. and Mrs. L. were stonewalled, Mr. L. got a court order for visitation. Three months had passed when his first opportunity to see his children since moving out was scheduled. On the eve of this visit, Mrs. L. called child protective services and accused Mr. L. of sexually molesting their daughter. According to the social worker's notes which were obtained during subsequent litigation, Mrs. L. told the social worker that she "knew" while she and her husband were still living together that he was molesting their daughter.
The family law judge ordered a custody evaluation which was very thorough and took months to complete. The evaluator documented a number of instances in which the girl's statements about abuse and hat mg. her father seemed to be strongly influenced by mother's overwhelming anger and that of the older half sibling, who was strongly aligned with the mother. Mrs. L. was diagnosed with a severe narcissistic personality disorder with antisocial features, while Mr. L. was seen by the evaluator as rather passive by comparison and as ambivalent and conflict avoidant. The evaluator was able to hold one meeting with father and daughter together, during which their loving attachment to one another was apparent. This was the little girl's first opportunity to talk to her father about the feelings engendered by his leaving. As it turned out, it was also her last opportunity. The PAS intensified such that efforts to convene further father/daughter sessions failed when the child threw tantrums in the waiting room and ran screaming into the parking lot where her mother was waiting.
Seven months after the marital separation, the custody evaluator's report was released. It stated that the alleged abuse had in all probability not occurred but failed to diagnose severe PAS with false allegations of abuse. The evaluator recommended that the mother retain primary custody and that the girl and her parents each become involved in individual therapy to facilitate father/daughter reunification. Not surprisingly, Mrs. L. arranged for the child to see a therapist/intern who never saw the custody evaluator's report. Based on input from the mother alone, the therapist treated the girl for abuse by her father instead of providing divorce specific therapy aimed at helping the little girl to adjust to her parent's divorce and to establish a post divorce relationship with her father. The girl's anger at her father became more extreme with each passing month and defeated the visitations planned by the family mediation center. Finally, a year after the separation, the custody evaluator was prepared to testify as to the PAS and to make the strong recommendations needed to remedy the situation. By that time, the father was convinced that nobody could do anything about his daughter's continued expressions of hatred toward him. He also felt daunted by the prospect of further litigation and an even greater financial drain. He decided to let go, hoping that one day when his daughter was older she would understand and seek him out.
CHILDREN HELD HOSTAGE: DEALING WITH PROGRAMMED AND BRAINWASHED CHILDREN
By the late 1970s, judges, parents, and mental health professionals involved with divorce were so concerned about parental programming that the American Bar Association Section on Family Law commissioned this 12 year study of 700 divorce families (7). Clawar and Rivlin found that the problem of parental programming was indeed widespread and that even at low levels it had significant impact on children. Data from multiple sources was analyzed including: written records such as court transcripts, forensic reports, therapy notes and children's diaries; audio and video tapes of interactions between children, their parents and others related to the case; direct observations, such as children with parents and clients with attorneys; and interviews with children, relatives, family friends, mental health professionals, school personnel, judges and conciliators.
Gardner's work on PAS is referenced at the beginning of Clawar and Rivlin's book (7), but the authors take issue with what they represent as his position, that less severe cases need not be a cause of great concern. They found that PAS can result from a variety of complex processes, whether or not one parent engages in a systematic programming campaign and whether or not alienation is the programming parent's goal. Parental alienation is only one of a number of detrimental effects. According to this study, even well meaning parents often at tempt to influence what their children say in the custody and visitation proceedings.
Mild levels of parental programming and brainwashing seem to have significant effects.
Clawar and Rivlin anchor their work in 30 years of literature on social psychology and the processes of social influence, variously referred to in the literature as thought reform, brainwashing, indoctrination, modeling, mimicking, mind control, re-education, and coercive persuasion. These terms describe a variety of psychological methods for ridding people of ideas which authorities do not want them to have and for replacing old ways of thinking and behavior with new ones. For the purposes of research, Clawar and Rivlin ascertained the need for more precisely defined terminology. They selected the words "programming" and "brainwashing." They defined "program" as the content, themes, and beliefs transmitted by the programming parent to the child regarding the other parent.
"Brainwashing" was defined as the interactional process by which the child was persuaded to accept and elaborate on the program. Brainwashing occurs over time and involves repetition of the program, or code words referring to the program, until the subject responds with attitudinal and behavioral compliance.
According to Clawar and Rivlin, the influence of a programming parent can be conscious and willful or unconscious and unintentional. It can be obvious or subtle, with rewards for compliance that were material, social or psychological. Noncompliance may be met with subtle psychological punishment such as withdrawal of love or direct corporal punishment, as illustrated in the case vignette of S in Part II. The author encountered another case in which the alienating mother handcuffed her son to the bedpost when he was 12 years old and the boy asserted he was not willing tocontinue saying his father had physically abused him. The Clawar and Rivlin study found that children may be active or passive participants in the alienation process. As the case of the 12- year-old boy suggests, the nature and degree of the child's involvement in the PAS may change over time.
This study identifies the influential role of other people in the child's life, such as relatives and professionals aligned with the alienating parent, whose endorsement of the program advances the brainwashing process. In a general way, these findings appear to replicate Johnston's research on high conflict divorce which identified the importance of third party participants in parental conflicts (8). Rand noted the influence of so-called "professional participants in Munchausen Syndrome by Proxy type abuse which in divorce can overlap with PAS "(23).
Clawar and Rivlin identify eight stages of the programming/brainwashing process which culminates in severe Parental Alienation Syndrome (7). Recognizing the power imbalance between parent and child, they view the process as driven by the alienating parent who induces the child's compliance on step by step basis:
1 ) A thematic focus to be shared by the programming parent and child emerges or is chosen. This may be tied to a more or less formal ideology relating to the family, religion, or ethnicity;
2) A sense of support and connection to the programming parent is created;
3) Feeling of sympathy for the programming parent is induced;
4) The child begins to show signs of compliance, such as expressing fear of visiting the target parent or refusing to talk to that parent on the phone;
5) The programming parent tests the child's compliance, for example, asking the child questions after a visit and rewarding the child for " correct " answers;
6) The programming parent tests the child's loyalty by having the child express views and attitudes which suggest a preference for one parent over the other;
7) Escalation/intensification/generalization occurs, for example, broadening the program with embellished or new allegations; the child rejects the target parent in a global, unambivalent fashion;
8) The program is maintained along with the child's compliance, which may range from minor reminders and suggestions to intense pressure, depending on court activity and the child's frame of mind.
CLINICAL STUDIES OF PAS
According to Gardner and seconded by Cartwright, Parental Alienation Syndrome is a developing concept which clinical and forensic practitioners will refine and redefine as new cases with different features become better understood (24). This section reviews the work of practitioners who, like Cartwright, seek to elaborate on Gardner's work by contributing their own knowledge and experience from work with moderate to severe PAS cases.
Dunne and Hedrick
Practicing in Seattle, Washington, Dunne and Hedrick analyzed sixteen families who met Gardner's criteria for severe PAS (22). Although the cases show a wide diversity of characteristics, the authors found Gardner's criteria useful in differentiating these cases from other post-divorce difficulties, lending support for the idea that PAS has distinctive features which differentiate it from other forms of high conflict divorce. Among the severe PAS cases examined, some involved false allegations of abuse and some did not. Children in the same family sometimes responded to the divorce with opposing adjustments. For example, the oldest child in one family, a 16-year-old girl, aligned with her alienating mother while her 12-year-old brother's desire for a relationship with his father led to the mother finally rejecting the boy.