Contact refusal by children following acrimonious separation: Therapeutic approaches with children and parents

Abstract

This paper aims to build on the existing literature, by presenting some thoughts based on clinical experience with nine families of children referred for intractable contact refusal with one parent following marital separation. This particular group of high-conflict divorce cases engenders an inordinate amount of frustration both within the courts and therapeutic agencies. We outline here our assessment process and therapeutic strategies, as well as consideration of the role of the wider professional system and the courts. We conclude that whether or not direct contact with the rejected parent is achieved, useful therapeutic work can be carried out to assist children in moving on with their lives.

Keywords

Alienation children contact refusal divorce therapy

Introduction

It is generally supposed that having contact with a non-resident parent is something to aim for. We share that principle. We are also aware that research findings are equivocal in that the effects on child adjustment of maintaining contact with the non-resident parent are less consistently positive than might be supposed (Lamb, Sternberg, & Thompson, 1997). This reflects the fact that each family presents with a unique set of circumstances; there are numerous variables in each child and family that need to be considered. Careful assessment needs to include all these factors before we can be sure that ongoing direct contact with the non-resident parent is in the child’s best interest. In the majority of our case sample we have concluded that it is, but have found achieving this goal to be a challenging therapeutic task. Even if direct regular contact is not the outcome, we believe that this work is worthwhile in order to reconstruct children’s outdated and distorted accounts of their fractured family history and to resolve the emotional issues that have prevented them from moving on in their lives.

Over the past three or four years our Parenting and Child Service has received increasing numbers of referrals of children refusing to see non-resident parents following their parents’ acrimonious separation. All the children expressed strong negative feelings, including contempt, fear and hatred towards the rejected parent (in most cases the father but in one case the mother) with whom some had reportedly had good and sometimes close relationships. Some children expressed fear of the parents they refused to see, sometimes referring to past experience to support this, although generally showing no fear in their presence. The referrals, which tended to come via the courts, requested assessments in order to understand better the children’s refusal or negativity regarding contact with the rejected parents and to recommend what therapy might improve the situation. In some cases there was an assumption that therapy was indicated and we were asked to provide this.

Wallerstein and Kelly (1976) first described the phenomenon of a child rejecting one parent following parental separation. They and others have recognized that, where this occurs in the absence of realistic concerns, it represents an unusual and extreme manifestation of the range of behaviours exhibited by children in high-conflict divorce cases (Johnston, 2003).

Explicit in a number of referrals to our team was a view that the negative and hostile feelings of the aligned parent towards the rejected parent had become transferred deliberately and consciously or else inadvertently into the child. The deliberate induction by one parent of negative and alienating feelings in the child towards the other parent has been called Parental Alienation Syndrome (PAS) (Gardner, 1998). Faller (1998) has assessed the theoretical and evidence base for PAS, concluding that much of the evidence for a syndrome was weak and of limited usefulness to clinicians and the courts. Kelly and Johnston (2001) have reformulated the problems of the alienated child (rather than alienating parent) as being multifactorial, related to factors in the child and in both parents. They have usefully defined the alienated child as a ‘child who freely and persistently expresses unreasonable negative feelings and beliefs (such as anger, hatred, rejection, and/or fear) toward a parent that are disproportionate to their actual experience of that parent.’

Research findings point to the deleterious effects of hostile marital conflict involving the children on their subsequent psychological adjustment (Vandewater & Lansford, 1998). What limited long-term follow-up studies exist of children alienated from a parent following marital separation show a poor psychological outcome in adulthood, although it is not clear whether this is due to chronic marital hostility rather than the specific phenomenon of alienation and contact refusal (Baker, 2005). Johnston and Roth Goldman (2010) reported preliminary findings from a longitudinal study. They found that as young adults, many suffered emotional distress and had difficulties forming attachments, although there was variability in outcome, reflecting the mixed picture of cases.

For the purposes of this paper we will refer to the aligned versus rejected parent, and will refer to the child as alienated rather than a parent as alienating (Kelly & Johnston, 2001).

Legal framework

Issues of enforcing contact are particularly challenging to the courts. The Children Act 1989 provides the legislative framework in the UK for resolving disputes about contact between resident and non-resident parents. Judicial decisions are made on the basis of the child’s welfare and section 1(3) of the Act sets out the criteria by which this is to be judged. These include the wishes and feelings of the child and consideration of their emotional needs and the two can be in conflict. The key underpinning principle enshrined in guidance and case law is that children benefit from continued relationships with both parents and there is a good evidence base to support this position, which is now part of general guidance (Royal College of Psychiatrists Factsheet, 2009).

Courts internationally have struggled to achieve effective interventions (Bala, Hunt, & McCarney, 2010) and it remains the case that close working between clinicians and the courts is important in this area of practice (Fidler & Bala, 2010).

Enforcement of Contact Orders has historically been difficult to achieve. This is essentially because the final recourse at the court’s disposal to deal with persistently non-compliant resident parents can punish children. For example, if a mother appears persistently to breach a Contact Order, she may ultimately be threatened with removal of her children or prison – a penalty which, if imposed, would deprive the children of their primary carer. It is easy to understand why the courts are reluctant to use the ultimate sanctions available to them. The Children and Adoption Act 2006 sought to deal with the difficulties by introducing new enforcement and punishment options in order to try to achieve compliance. Legislation alone seems not to have been an effective solution to these difficulties, and this has led us to explore further the possibility of therapeutic interventions.

Rationale for a ‘trial for change’

Our referrals have arisen in the context of child protection concerns, some as joint letters of instruction from all parties’ legal representatives and often because experts reporting to the court or children’s guardians had recommended a trial of therapy. Child protection concerns in these situations come under the category of emotional abuse and are most often because of the aligned parent’s apparent failure to promote and support contact with the rejected parent.

There is a widespread view that therapy in the most conflicted and intractable cases is ineffective (Weir, 2006). We have therefore embarked on this work with a view to establishing whether, within our own collective mind as a multi-disciplinary team, we agree with this view or, if not, whether we are able to develop treatability criteria. We have focused on developing an approach towards comprehensive assessment and a trial for change which is specifically goal-orientated.

Given that many of the children caught up in this situation do not manifest symptoms of a mental disorder, and outside their family may be functioning quite well, the question arises as to whether this therapeutic work is justifiably carried out by a specialist child mental health service. Cases such as these would not meet criteria for Tier 3 Child and Adolescent Mental Health Services (CAMHS), and many are seen by private professionals. Within the private law arena, however, they remain a cause of great frustration and concern.

The clinical justification for this work stems from a knowledge that children are likely to be adversely affected if they resolve intolerable psychological conflict by extruding one parent from their lives. We have undertaken this work in the best interest of children in the belief that, where possible, children benefit from ongoing relationships with both parents and from both parents continuing to be involved in their upbringing. This gives them the best chance of developing a positive and real sense of self and identity and also of knowing that they are cared about and loved by both their parents, whether or not they will have regular direct contact with both.

Also, the work is taken on in an attempt to bring closure and some kind of resolution to a situation that may have been going on for many years. The adversarial nature of the UK family law system can unintentionally intensify and exacerbate the trauma and distress for parents and, therefore, for children. It has been reported that children continue to suffer and be torn apart more by the ongoing conflict between the parents than by the original separation (Pitcher, 2010).

Difficult clinical issues

The referrals have frequently been made to us where referrers and other professionals involved have a strong suspicion (either substantiated or not) that the child’s refusal or reluctance to see a parent has emanated originally from the aligned parent’s feelings and hostile position in relation to their former partner or spouse. This suspicion is combined with the belief by professionals that, now that the child has adopted and internalized this hostile position fully, the aligned parent can present as supportive of the contact.

These situations at the time of referral to us have become very stuck, leaving the children distressed and conflicted. Difficult assessment issues include:

some of the parents’ mutual hostilities and conflict appear to have been re-routed and triangulated through the child (Minuchin, 1974);

it may be unclear what of the child’s current emotional position comes from his or her own negative feelings about the parents’ separation and the loss of one parent and what has been transferred, either consciously or not, by the aligned parent from his or her own feelings;

in some cases the child’s current negativity towards the rejected parent comes from past actual experience of that parent, for example, violence or frightening arguments;

the child may be attempting to resolve feelings of conflict by rejecting one parent;

chronic hostility between the parents may have had an impact on the child’s mental and emotional health and on general development and functioning.

An important question for us has also been to what extent children should be encouraged, coerced or even required to have contact with the parents they have rejected in the face of their strong and distressed opposition (Weir, 2006).

There are clearly a number of challenges for clinicians, not least, as expressed by Blow and Daniel (2002) that ‘Working with embattled ex-partners and their children is among the most emotionally draining of all the work we do.’

In these situations, clinicians seek to obtain a clear view of children’s true wishes and feelings, when children have frequently been brought protesting to meetings and when they are often reluctant to enter into conversation about the rejected parents at all. Children are required to engage in conversations about events that are clearly troubling and distressing to them.

A central part of the work involves eliciting a clear view of the reasons behind a parent’s hostile stance towards their ex-partner and the potential for contact, as active support from the aligned parent is vital if contact is to happen. This is done with the understanding that, particularly when the matter is before the court, the aligned parent will strive to present a positive view of contact, whatever the underlying reservations and concerns.

All our referrals have been received after fathers, and in one case a mother, have made applications for contact. However much in the course of the work we may reframe the issue as being one of relationship as much as contact, clinicians nevertheless may continue to appear to support contact between children and the rejected parent, even when children say they are fearful of this.

In order to seek to reduce parental conflict and maximize parental co-operation for the benefit of children, clinicians strive to retain a neutral and even-handed position of deliberately not taking sides in the work with parents together. This is the case even when it is recognized that one parent may have been the subject of aggressive or more unreasonable behaviour, as it is recognized that both parents may have contributed to the difficulties and current impasse (Johnston, 2003; Lebow & Rekhart, 2006). Without such neutrality, any productive work with the couple is not possible. However, in therapeutic work with parents this therapeutic positioning is prone to be misunderstood and requires clear explanation at the outset of therapy if both parents are going to be able to maintain a commitment to the work. It is important to emphasize that it is not the therapists’ responsibility to hold the child protection concerns: that is done by social care. This leaves the therapists free to adopt a non-judgemental neutral stance that is essential for any effective agent of therapeutic change (Boscolo, Cecchin, Hoffman, & Penn, 1987).

Assessment of child and family

In these complicated situations there is a need for thorough assessment based on clear information, followed by a coherent formulation and plan for follow-up in a clinical treatment setting, child protection agency (if indicated) or court arena.

It is important that the assessment reaches a conclusion on emotional harm suffered by the child, and whether or not this reaches the threshold for significant harm. In this context, professionals need to be clear that contact with the rejected parent is in the child’s best interest (Lucey, Sturge, Fellow-Smith, & Reder, 2003; Sturge & Glaser, 2000). It is also important that the assessment arrives at a view on whether it is likely that clinical and further court intervention can make a difference – or whether a continuing, protracted involvement of clinical services and the courts and legal services might further contribute to harm and distress to the child, without any probable positive compensation.

Ellis (2007) proposed a process of assessment that addresses the question of whether there is a basis in reality for the child’s extreme fear or anger; this has been referred to as ‘realistic estrangement’ (Fidler & Bala, 2010). Garber (2007) sets out in detail specific components to be included in the assessment and Freeman (2011) considers aspects of the differential diagnosis. In our experience, each case, although overtly similar in its manifestations of contact refusal, is underpinned by an individual set of psychological circumstances. It is crucial to explore the child’s developmental issues and current psychological dilemma in relation to their relationship with each parent. Separation anxiety, the nature of attachment relationships, loss and grief, possible traumatic incidents involving a parent, and experiences ranging from subtle forms of inadequate parenting to emotional abuse, are all relevant. We try to obtain a clear idea of the child’s current level of functioning, using interview assessment as well as objective data, such as the Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997), although in many instances function appears to be preserved in school and other areas outside the family.

Our assessments comprise meetings with different combinations of family members. Essential to the work is the parents’ agreement to meet together with us, without the children. We work towards a meeting of the child with the rejected parent when possible and when the child and both parents are in agreement.

First family meeting

In the initial meeting with the family living at home – usually mother and child – we are clear that any discussion with the child should be age appropriate and sensitive to the distress and conflict in the current situation. We hear the history of the present difficulty, including detail of the child’s last contact with the non-resident parent and reasons why contact has ceased. We enquire about solutions that have previously been advised and attempted in relation to the difficulty, what has been successful and the reasons for lack of success. We hear also, as appropriate, of different views on the problem. In this meeting and in subsequent individual meetings, we try to acquire information that leads to an understanding of the extent to which the current impasse around contact is rooted in the child’s mind in real actual behaviour or events in the past.

Parents individually

From each parent in separate meetings we hear their own individual accounts of their relationship and family history, of what might have begun well, of what went wrong, and what each feels they tried to do to improve the situation for the child. We assess the insight of each parent into the impact on the child of their separation and their current dispute about contact. We hear of each parent’s wishes in relation to contact and, where there is a court order in place, how the parent living with the child will work to ensure compliance with the court order when the child might be in opposition. We assess the aligned parent’s ability to do this consistently and over time; if this appears not to be possible, therapy is unlikely to succeed. We seek agreement from both parents to a firm contract of meetings with us together, when they will work to reach a shared way of addressing both their difficulties and their child’s needs. Importantly, with the parents separately, we try to obtain agreement that change and compromise are required from each of them, although in our experience parents are generally more able to focus on what the other can do differently than on what they themselves are going to change. A clear contract for therapeutic work, based on an explanation of our approach, is an essential precursor to the therapeutic intervention.

Parents together

The meetings with the parents together have a number of important functions. Firstly, it is a significant message to the child that the parents can meet together safely, which may not have happened for some time. Secondly, the parents are informed of the importance for children of having good continuing relationships with both parents after they have separated. This is important psycho-education, as some parents genuinely believe that, because of the distress expressed by children at times of contact, it may be better that contact does not happen; this needs to be carefully disentangled to identify and evaluate the causes of distress, rather than simply inferring that distress means that contact should not happen. Thirdly, the parents are supported to find a way of having a continuing co-parenting relationship in the best interest of their child, despite the ongoing difficulties for them. This is necessary so that the parents can come together to discuss and make shared decisions about their child, in relation to school, activities or holidays. Most importantly, the parents need to be able to discuss and plan the child’s contact with the non-resident parent so that it is as positive an experience as possible. The aim of this work in therapy is to de-triangulate the child from the parents’ difficulties, as the parents are supported to deal with these themselves.

Siblings together

A sibling group together can be assessed through talking or play or drawing, or by completing a Kinetic Family Drawing (Burns & Kaufman, 1972) together. The latter involves the children drawing a picture of their family with everyone doing something; this is a task designed to obtain an understanding of the child’s view of their family and family relationships in a non-direct way. Alternatively, children might together draw their own picture of their family or a family tree. In this way information may be obtained on the children’s view of family relationships generally and also on close relationships for them in their family.

Child individually

The focus is on hearing the child’s current views, worries and fears in relation to daily life, and also perceptions of family relationships and difficulties. Typically, as is well described elsewhere (Pitcher, 2010), the child presents a rigidly held negative attitude towards the parent they refuse to see, with little ambivalence or possibility of exploration. An individual mental state assessment identifies any mental health issues, such as anxiety, depression or post-traumatic symptoms, as the difficult and hostile situation between their parents may have impacted on the child’s mental and emotional health and on general development and functioning. They may also have witnessed a high level of aggression or even violence. The assessment of children aged five to eight years may use a Story Stem Assessment (Hodges, Steele, Hillman, Henderson, & Kaniuk, 2005), which allows assessment of the child’s underlying expectations and perceptions of family roles, attachments and relationships, without asking the child direct questions about their family, which might cause them conflict or anxiety. Following assessment, a recommendation may be made for individual therapy locally for the child to address individual issues and any mental health concerns or diagnoses.

Child with rejected parent

There are sometimes contra-indications to a child meeting with a rejected parent, such as the child’s traumatic memories of that parent’s violence in the past or when there are real concerns about the nature of the relationship between the child and that parent. Otherwise, and when agreed by the child and aligned parent, it is helpful to meet with the child together with the rejected parent. This is to assess any negative reactions by the child, such as fear, distress, discomfort and any inappropriate behaviour by the rejected parent, such as over-intrusiveness or emotional pressure. This observation also allows a discrepancy to be noted between a child’s protests about seeing a parent and the absence of any fear or distress when in their presence.

We have sometimes used a form of role play, where the child watches in the room while a clinician talks to and asks questions of the rejected parent on behalf of the child. In our experience, children have been interested in this ‘game’ and have found it a non-threatening way of asking some difficult and searching questions through their clinician-persona; for example: ‘why did you leave me?’ or ‘why do you prefer to live with another family?’ They have fully understood the very serious purpose of the game.

Working with the professional system

We have found that it is essential at the outset of the work to evaluate the dynamics of the professional system involved with the child, as the professional system can become dysfunctional because of the family’s level of conflict. Different parts or members of the professional system may become polarized and in dispute in a way that mirrors the disagreements and animosity of the parents. For example, one agency may side with one parent and another with the other parent.

For this reason, we find it necessary to begin the work with a meeting between our service, the referring agency and other professionals involved, including legal representatives and the children’s guardian, so that all parties are very clear from the outset about the purpose and aims of the referral. The meeting would reach an agreement on the scope and limits of the work undertaken by the therapy agency and on the location of responsibility for other aspects of the work, including clarifying the child protection responsibility held by local social care. There will need to be agreement from the local authority that no decisions will be made without communication with the professional network.

An important function of this meeting is to recognize the conflictual nature of the situation and to predict difficulties with splitting and taking sides amongst professionals in order to try to ensure that this does not happen. The meeting will establish good communication channels.

Clinicians can be expected to have different views and at times to disagree on the management and treatment of a child or family. When experienced mental health clinicians fall out and argue heatedly and unreasonably, it is important to stop and consider what might be going on. In our team, a family therapist and clinical psychologist found themselves at heated loggerheads about the management of the work with a family newly referred; they had met with the parents on two occasions, which had been characterized by non-stop and barely controlled verbal aggression and hostility between the two that had been only just tolerable and manageable by the clinicians; recognizing separately that the heated feelings between them were uncharacteristic for them both, the clinicians came together to meet and understood that their disagreement had been projected from the couple; they were then able to think about the work differently, informed by this experience.

We recommend a professionals’ meeting again at the end of a time-limited trial for change, when therapists share with the referring agency their thoughts on progress to date, with recommendations for future work. The agencies then agree together the next stage of work with the family. Unless there is reason otherwise, such as disagreement between professionals that needs to be resolved, parents can be informed of professionals’ meetings, which are recorded, so that they are clear that all agencies are working together with shared goals.

There may be very differing beliefs held by professionals about the possibility of change in one or both parents. If one agency is working to assess and work with the possibility of change, while another agency holds the view that change is not possible for one or both parents, the situation can become very stuck, confusing for the parents, unhelpful to the children and ultimately contentious. Our team took on a trial for change with a separated parental couple that was ended abruptly by the rejected parent; only after this had happened did it become clear that both the parent and the local referring social care team held a shared belief that the aligned parent could not change and that the rejected parent did not need to change; we learned that we and the local team had not been clear enough with each other that our work towards change required that all concerned believed in the possibility and need for change by both parents.

Therapy

Possibility of change

During the assessment process, account is taken of the chronicity and stuckness of the situation. It is important to assess the capability and readiness for change of each individual person, the family unit and the professional system as a whole. It is essential to assess what change, however small, will make a difference, and also the ability of individuals, relationships and networks to engage and work therapeutically with clinicians. There is assessment of therapy interventions that might be effective.

Risks to children

This work is undertaken solely for the well being of the children. The concerns for children who resolve their conflict of loyalties between estranged and warring parents by completely obliterating or denigrating the absent parent include the following:

the child is rejecting and demeaning a part of himself or herself;

the child loses the continuing protection and support of a divided, but nonetheless potentially functional, two-parent system;

mourning the loss of the absent parent is not resolved but is buried beneath the negative emotions of hatred, fear, contempt;

the child continues to resolve this and other difficult conflicts by splitting all good into one person and all bad into another, and does not move on to an important stage of emotional development of being able to integrate and manage good and bad aspects of a loved one in a dependent relationship and later in an adult, mature relationship;

a child, typically although not always the eldest, may be inducted into an age-inappropriate responsible adult role as carer and protector of the aligned parent, usually the mother, whom the child perceives as being abandoned and vulnerable and in need of support and protection; these children are at risk of mental health or relationship difficulties if this situation does not change;

all of this can interfere with the child’s usual, optimal development as school work, friendships and family relationships may suffer as the child is drawn into the family conflict.

Trial for change

Following our assessment and in agreement with the referrer, we may proceed to a ‘trial for change’. This is short, time-limited and focused therapy to test the capacity of the parents to move on. It focuses on addressing family issues that are impinging on the child’s happiness and well being. Goals may include reduced exposure of the children to expressions of hostility between parents, and better communication and co-operation over contact. There may need to be acknowledgement of previous inadequacies in parenting, or upsetting experiences for the child, which were revealed during the assessment phase.

Narrative work takes place to assist the parents to construct a shared account for the child of the fractured family history that has led to the current situation. This account seeks to correct any errors or distortions that have become fixed in the child’s mind, which may have originated from or be perpetuated by the aligned parent. Addressing the ‘frozen narrative’, as aptly described by Blow and Daniel (2002), is a core part of the work, sometimes uncovering painful beliefs or emotions in one or both parents.

Children often hold fantasies or distorted memories of what happened between their parents and why one parent left; they may attribute all of the blame to one parent or they may blame themselves. They benefit from being told an age-appropriate shared version by parents together of the reality of their separation, including that it was not the child’s fault; this will include a clear account of how they plan now to continue jointly to co-parent the child. It can also be helpful for children to learn, or be reminded, of the good relationship their parents once shared, even if that is now a long time ago.

Having met the whole family during assessment, we begin therapy usually by working with parents together without the child, in order to begin to think with them about the continuing difficulties in their relationship that are impinging on their co-parenting. The aim is to work towards relieving the child of a role as emotional conduit between the parents. Clinicians may have different perspectives on whether it is helpful at this point to include the child also in this stage of therapy, as it is clearly important to have a continuing awareness of the child’s ideas and feelings. However, we have concluded that at an early stage in the treatment it is crucial to establish a working alliance with the parents as a parenting couple, if possible, for the work to have the best chance of a positive outcome.

This stage of therapy works towards the child being relieved of any emotional and practical role in the parents’ difficulties through the parents meeting and talking together. Importantly, the parents will need to ensure that the child is clear that the parents being able to discuss issues together does not mean that they will re-unite, as this will not happen, because children often harbour long-standing hopes that their parents will get back together.

Regularly in clinical meetings we hear parents criticizing each other for their shortcomings, as they fight over their children. If parents can focus on the children and their needs and on their shared love of them, the outcome may be more hopeful.

During the work with parents together and as a way of reintroducing a reluctant or rejecting child to the reality of the rejected parent, a child may view that parent at first through a video link. This could be the rejected parent talking to a clinician asking questions on the child’s behalf. Later the child may watch a meeting of both parents via the video link, with a clinician asking questions for the child and helping the parents to give a clear account of their history and their plans for co-parenting the child now and in the future. The child watching through the video link would always be accompanied by the other involved clinician who would make clear anything that might be difficult to understand and who would support them with this process. This technique can be helpful as de-sensitization for children whose alienation has taken on a phobic character.

What is helpful to children may not necessarily be that contact is resumed, if it has become discontinued. Rather, the aim of the therapeutic work with the children could be the modification of their one-dimensional negative picture of their rejected parent into something more rounded and realistic and with some positive elements for them to take into adolescence and adulthood, when this is possible. For this to occur, children may need help to recall some past positive memories of the rejected parent. The aligned parents’ participation in this work is essential, and their ability, or not, to contribute to a revised, more positive view of the other parents will significantly determine the nature and success of the outcome.

Family vignettes

The following vignettes with fictitious names are loosely based on families we have seen but have been materially changed.

Thomas, 13, Mary, 12, and Matthew, 8, had stopped seeing their father three years before referral to our team. Their parents’ separation had reportedly been by mutual consent but precipitated partly by the father’s mental ill health, which had responded well to treatment. The mother had a fixed idea that three years earlier the father had remarried, which he denied. The referral was by solicitors for assessment of whether the mother was blocking contact and whether she had ‘poisoned’ the children against the father. The therapeutic work with the children corrected their belief that their father had abandoned them, as he told them he was fighting to see them and loved them very much. The children witnessed their parents together having conversations about them. They had some social contact with their father when they updated their memory of a scary, mentally ill man. Thomas and Mary still said they did not want to see their father or have regular contact. We recommended twice-yearly supervised contact for the three children. From this work, we confirmed that when young children have not seen a parent for a long time, a positive outcome is difficult, but that small important gains may be achieved by correcting children’s false beliefs and relieving them of overwhelming negative emotions and fears.

Freddie, 11, and Alex, 8, were removed into care following parental separation, precipitated by an allegation of physical abuse by the mother’s daughter against her step-dad, the boys’ father. The boys were actively aligned with their biological father, who employed aggressive tactics to brainwash them against their mother. The role of the court was essential; by acting decisively first to remove the boys into care, and then separate them when it became apparent that Freddie was adversely influencing Alex, they prevented the situation from becoming irredeemably entrenched. The therapeutic role involved trying to understand Alex’s relationship with both parents, including clarifying in our mind that the mother was a suitable carer and had previously had a good relationship with her son. We carried out individual work with Alex to support him emotionally, and to gently explore his dilemma, which kept these issues alive, rather than allowing them to be resolved in a dysfunctional way by repudiating his mother. The court, despite the reservations of a number of professionals, backed our recommendation for Alex to be returned to his mother, which went surprisingly smoothly given his stated hostility towards her. Freddie never shifted his position and remained in foster care. Future work with the father was recommended before any contact with his sons could be sanctioned.

Elizabeth, 10, had determinedly refused to see her father since her parents’ volatile and conflictual relationship had ended early in her life. Her father continued to apply for contact and we were asked by the lead solicitor to make an assessment of Elizabeth’s true wishes and feelings. During assessment we learned of frightening domestic violence by Elizabeth’s father towards her mother, which had been witnessed by Elizabeth. On trauma screening, Elizabeth met the threshold for post-traumatic stress disorder (PTSD), for which she was offered treatment. We did not support the father’s application for contact and recommended that Elizabeth could make her own decision about contact with her father at a future time if she wished. This vignette demonstrates that a child’s refusal of contact may be based on real, frightening experiences.

What we have learned

In our experience, the outcome is likely to be less good where there have been drawn-out legal proceedings, during which the child has had no contact with the rejected parent and has maintained a resolute and stuck negative view for more than a year or two. Prompt action is important, as any delay in referral for assessment and therapeutic work may reduce the opportunity of a favourable outcome. The financial settlement between the couple needs to have been agreed and implemented, as this can otherwise be the cause of continuing unspoken resentment and can sabotage any attempts to move forward. The outcome is likely to be less hopeful for children over about 12 years of age, where the difficulties began at an earlier stage.

A thorough assessment tailored to the situation of each family is essential, based on real and verifiable factors rather than on speculation and extrapolation. The assessment needs to include the professional network, including local social care as appropriate. If during the assessment the parents are not seen together, the outcome is much less hopeful. In addition, the level, severity and duration of conflict and animosity between parents are prognostic factors. We would agree with current literature that the most severe cases are unlikely to respond to therapeutic intervention alone (Fidler & Bala, 2010).

When, through frustration and desperation at not obtaining contact with a child, a parent makes application for a residence order, this frequently has the effect of intensifying the child’s sense of threat from the rejected parent with a fear of removal from the parent they live with. This increases the child’s wish to have no contact with the rejected parent. The rejected parent’s legal representative can helpfully advise of this potential pitfall. Courts and clinicians can also feel a sense of helplessness, anger, frustration and desperation at times, with the child caught in the middle of what often appears to be an intractable situation. Importantly, the courts and clinicians work in partnership.

We have concluded that the issues and their resolution are not straightforward in these situations. Particularly in cases where active obstruction by the aligned parent is suspected, it might sometimes appear that the answer to the problem lies in change and reconciliation to the demands of the situation by that parent alone, and that this would provide a solution. This may not always be the case, as the rejected applicant for contact may also be contributing to the intractability of the situation, perhaps through earlier failures in family relationships. In these situations, without the expectation of change by both parents, the potential remains for the rejected parent to maintain a continuing vendetta in order to discredit and potentially undermine the position of the resident parent and thus covertly sabotage the children’s residence. This is not in the best interests of children. Where both parents are assessed as contributing to the continuing acrimony and stuckness, the therapy will work towards change and improvement by both parents.

The courts, legal representatives and other involved agencies can be helpful in conveying the message that the solution to the difficulty will require the active involvement of both parents, and may require change by both, in order to move on.

Outcomes

In six of the nine families, we estimated that there was some positive outcome for the child. Almost all of the children in the improved group seemed to have made some shifts in the way they viewed the rejected parent. However, in the case of Elizabeth, 10, described in a vignette above, the positive outcome derived from clear recommendations that would bring an end to the assessment and court process and from the diagnosis of trauma and referral for treatment; these would leave Elizabeth freer to move on.

We felt that the therapeutic work had made no difference in two families – one where the mother refused to meet with the father and no progress was made, and in another where the different agencies involved did not share common aims. In one case of complicated extended family dynamics, we were not clear whether or not the work to clarify generational roles and boundaries in the family had had a positive impact for the child.

Conclusion

Clearly, there needs to be careful assessment and evaluation of capacity for change before embarking on this difficult therapeutic work. We would tentatively suggest that where parents are unable to meet together, where the child has had no contact with one parent for over 2 years, or where the child is over 12 years of age and has experienced a situation of chronic conflict, the prognosis is much more guarded. Our over-riding conclusion, however, is that given these provisos, some valuable work can be done. The achievement of direct contact with the rejected parent is not the only positive outcome of this work. Perhaps as important for the children is the picture of that parent and of their family history that they will carry into their future lives. If, through the therapeutic work, that picture can be modified even slightly to a more accurate, up-to-date version, so that the children are more comfortable with where they have come from, then we regard this as well worth doing. It is also important to emphasize that these changes may be small, require significant time and clinician effort, and be difficult to measure with traditional quantitative evidence-based research methods. We are seeking the smallest difference that makes a difference and this may be time well invested in terms of the children’s future well being, mental health and potential capabilities as parents themselves.

Footnotes

Declaration of Conflicting Interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Author biographies

Margaret DeJong, MDCM, FRCPsych (Can), FRCPsych (UK), is Consultant Child and Adolescent Psychiatrist in the Department of Child and Adolescent Mental Health at Great Ormond Street Hospital for Children and Honorary Senior Lecturer at the Institute of Child Health. She is Head of the Parenting and Child Service, an assessment and therapeutic service for children with a background of abuse, neglect and trauma.

Hilary Davies, BA (Hons), MA (Social Work) & CQSW, MSc (Family Therapy), is a Family Therapist and former Social Worker. She worked for 14 years in the Parenting and Child Service in the Department of Child and Adolescent Mental Health at Great Ormond Street Hospital for Children.

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