Alan D. Blotcky, PhD

About half of marriages end in divorce, and approximately 6 out of 10 divorces involve children. Even when amicable, a divorce is a difficult situation. However, divorces can be tumultuous, and children often pay the price. One way this is manifested is in false allegations of abuse in child custody cases. Typically, one parent accuses the other parent of physical and/or sexual abuse of their child to gain leverage in their court proceeding. This tactic can be particularly impactful because judges tend to award primary physical custody to the parent who made the allegation, even if the accused parent’s actions are not substantiated. Thus, false allegations can be a powerful weapon to limit or deny custody and/or visitation in a vindictive manner.

Although a strong visceral reaction to an abuse allegation is expected, it can be counterproductive. Similarly, a rushed response can make the situation worse. In contrast, a wait-and-see attitude leaves the door open for a thorough evaluation before a disposition is decided upon.

To be clear: False allegations of abuse are a form of parental alienation. Alienation involves the concerted effort of one parent to undermine the other parent’s relationship with their child. Nothing could be worse than a custody decision that is based on a false allegation. To make matters worse, once a custody decision has been issued, modification of it is burdensome and an uphill challenge.

The clinical evaluation is an important part of proceedings in which allegations have been made. A successful case requires coordinated efforts among the judge, attorneys, and a court-appointed evaluator, who is often a psychiatrist or clinical psychologist.

The approach outlined in this article is based on years of experience with hundreds of cases of abuse allegations, and it consists of sequential steps. The evaluation process is aimed at determining if an allegation of abuse has occurred or not—in other words, whether the allegation has been fabricated by a parent with the intent of sabotaging and harming the other parent.

For obvious reasons, the evaluation must include both parents and the child to understand the entire narrative. All 3 individuals—the accused parent, the accusing parent, and the child—must be a part of the evaluation process. After all, we want our conclusions and recommendations to be based on full and accurate information.

The accused parent is often advised by their attorney not to participate in the evaluation process. This is ill-conceived advice. By doing so, the mental health professional evaluator will be deprived of critical information that can shine a light on the falsity of the claim. Otherwise, all the information will be coming from the accusing parent, whose allegation will hold greater weight if it is not disputed.

It is always a good idea for the child in such a case to be seen for an independent forensic evaluation. This would be in addition to the child’s involvement with the court-appointed evaluator.

If this is the first allegation of abuse, and it occurs during a child custody case, its validity must be questioned. In fact, there is a significant probability that the allegation is false, as it is unlikely that a parent’s first abuse of the child occurs after the child custody case has been initiated. Thus, if a parent does not have a history of abusing the child, it is not likely that the first abuse is occurring during the legal proceeding.

A series of allegations against a parent during a child custody proceeding is also a major red flag. An accusing parent often believes that multiple allegations against the other parent are more convincing to a judge than a single allegation. However, repeated abuse of a child during a circumscribed time period—during a child custody case, for example—is quite improbable.

Detecting a false allegation is easier with the use of a timeline. Marking the major occurrences in a child custody case can show the specific sequence of events. A false allegation of abuse may occur during the custody case, and not before. It may also occur in response to legal action taken by the other parent. For example, if a mother files for full custody of her child, this sets the stage for the father to report a false allegation of abuse against the mother with the hopes that the allegation will derail the mother’s quest. The motive of the false allegation can be detected by examining its place on the timeline of events.

False allegations of abuse often include unwitting help from the children. Children aged between 3 and 7 years can be easily coached by a parent to testify against the other. Because most children want to please their primary parent, they are easily swayed, cajoled, convinced, and brainwashed. It is difficult for children to know the truth once a parent has coached them extensively. False allegations can involve older children and teenagers as well, but their coaching is more easily transparent and adolescents may even admit to it.

5 Beliefs That Motivate False Accusations of Child Abuse

There are 5 common beliefs that motivate a parent to lodge a false allegation of abuse against the other parent (

). If any of these beliefs are discovered, the allegation of abuse is likely false. Detecting these beliefs in a parent requires careful interviews over several sessions. A parent will never admit to fabricating a false allegation. The clinician must be skilled to see through the defensiveness, deceitfulness, and/or distractions of an offending parent.

Harmful and false beliefs by the accusing parent can also be detected through interviews with the child and the accused parent. Usually, the child or the accused parent will provide critical clues as to the accusing parent’s belief system. Bits and pieces of information will fit together into a detailed narrative that exposes the falseness of the allegation at hand. Remember, the accusing parent generally does not recant nor apologize for their attempts at relationship interference.

Once an allegation of abuse has been declared by a parent, there is a process that should ensue.

First, the judge should appoint a psychiatrist or clinical psychologist to evaluate the child and both parents. This evaluation must include interviews, psychological testing, and a review of collateral data (eg, emails, texts, recordings, pictures, etc). The evaluator should have access to other independent assessments of the allegation, such as Department of Human Resources investigations or a forensic evaluation of the child.

The psychiatrist or clinical psychologist must be experienced in child custody evaluations. Similarly, there should be a wait-and-see attitude about the allegation until the evaluation process has been fully completed. In other words, no assumptions or decisions should be considered until all the facts and information have been collected and assessed. The evaluation by the mental health professional should be aimed at determining the validity of the stated allegation of abuse.

During this time, attorneys should not respond to an allegation of abuse by filing motions for dramatic or extreme action, such as obtaining full custody of the child. However, granting a parent temporary custody until the matter is settled may make sense, especially if the child’s physical safety is of acute concern. Similarly, the attorneys must not try to sabotage the evaluator in order to win their case. The evaluator’s conclusions and recommendations should be given strong weight in the judge’s final decision.

A false allegation of abuse by a parent should be met with firm consequences, such as a fine, supervised parenting time, court-ordered counseling, and/or loss of primary custody. Swift and decisive consequences will dissuade future false allegations of abuse.

The accusing parent may not be appropriate for primary custody. Even shared custody may not be appropriate. A parent’s willingness to fabricate an allegation of abuse against the other parent is a poor prognostic indicator. It is not simply an accident or a mistake. A false allegation is an intentional and purposeful attempt to undermine the child custody proceeding.

Similarly, the false allegation has implications for the future well-being of the child, and a false allegation should be considered a form of parental alienation. This experience, especially if they are asked to take an active role in the allegation, teaches the child to be dishonest, deceitful, manipulative, conflictual, and blaming. Furthermore, the love the child should have for both parents is compromised and potentially destroyed.

A false allegation of abuse is serious, and it must not be tolerated in the court system. Based on the consequences, a false allegation represents a psychiatric emergency. As such, it must be handled and dealt with in a direct and timely manner. A child’s mental health and well-being depend upon it.

is a licensed clinical psychologist in private practice in Birmingham, Alabama. His forensic practice focuses on child custody and alienation cases. He is also a clinical associate professor in the Department of Psychology at the University of Alabama at Birmingham.

Articles

False allegations of abuse during a custody battle can seriously harm children. Here's how psychiatrists can separate fact from fiction. 

Child Abuse Allegations: Sorting Out Lies Versus Truths

 the highest 1-day total in new COIVD-19 cases—21,683—since the start of the pandemic, largely due to the Delta variant.

remain effective against the Delta variant,

 particularly against hospitalization and death.

 In fact, roughly 97% of those recently hospitalized were unvaccinated.

only 65% of all Americans 12 years old and above

 This figure is both alarming and tragic; alarming because the low number of vaccinations has allowed the Delta variant to take hold, and tragic because the painful and sorrowful consequences of this pandemic will not be stamped out at this rate.

The defeat of this pandemic falls under the purview of all mental health professionals. We have a major role to play in being proactive and vocal in our support of vaccinations for all Americans.

Safely and Effectively Defeating the Pandemic

The stark reality is that the worst pandemic in more than a century has not been defeated. More than 639,000 Americans have died from coronavirus. The anguish it has caused is undeniable. Yet, even after 19 months of hardship and sacrifice, we are still debating the need and efficacy of our medical miracle: the vaccines. Vaccines are the 

safest and most effective way to finally defeat the pandemic.

 That is not a political or ethical or personal statement. It is a medical, scientific fact. It is a certainty.

This pandemic can be eradicated, just like diphtheria, smallpox, polio, measles, and mumps. How did we eradicate those illnesses? The American public overwhelmingly accepted vaccines for these diseases.

An important characteristic of vaccines is that they provide both individual and community protection. When a sufficiently large proportion of individuals in a community is immunized, those individuals serve as a protective barrier against the transmission of the disease in the community, thus indirectly protecting those who are not immunized. The proportion of the population that must be immune to provide this herd immunity varies according to the specific disease. For measles, that proportion was 90%. The proportion for COVID-19 

From the very beginning, the COVID-19 pandemic became a litmus test for political devotion. Americans took political sides as to whether mask wearing, social distancing, and handwashing were necessary mitigation measures. Public health experts were ridiculed. Science and medicine were ignored. The exact same political jockeying has been evident with the vaccines. Millions of unimmunized Americans hold the belief that the vaccines are untested, unsafe, and/or ineffective. 

 is prevalent on certain internet sites. Republican leaders—both national and statewide—have discouraged the use of vaccines, until they realized that their constituents were dying in higher numbers because of their reluctance to get vaccinated. Better late than never, 

Republican leaders and right-wing news outlets are changing

 their message about the necessity for vaccines.

In our time of political divisiveness and misinformation, vaccination mandates are necessary. It is not about losing individual rights and freedoms. It is about saving lives and doing what is best for the country at this time of profound existential crisis.

Vaccination mandates have an important history in the United States.

 In 1855, Massachusetts became the first state in the country to enact a school vaccination requirement. In 1905, the US Supreme Court issued its landmark ruling in Jacobson v. Massachusetts, upholding the right of states to compel vaccinations. Challenges to mandatory vaccination laws based on religious and philosophical belief have led various courts to hold that no constitutional right exists to either religious or philosophical exemptions. In 1990, the US Supreme Court again acknowledged that courts will not recognize a privacy right to refuse state-mandated vaccinations.

Now is the time for vaccination mandates. We cannot allow misinformation and misplaced political leanings to cloud our judgment about the necessity for widespread immunization. Until we reach the 70% to 90% mark, COVID-19 will continue to wreak havoc in our country. And more dangerous variants could emerge—including vaccine-resistant ones—if herd immunity is not reached as fast as possible.

 that all employees must be vaccinated. Google and Facebook have issued similar mandates.

 Saks Fifth Avenue is requiring all their employees to be vaccinated. All employees of the 

 must provide proof of full vaccination. All employees of Lyft are required to be vaccinated. President Joe Biden announced a requirement that all federal employees be 

Vaccination mandates are the way for us to finally defeat this pandemic. The US government will not mandate vaccines, but states, cities, schools, colleges, and businesses can. We must not wait another day. Each passing day leads to more illness, more angst, and more death.

Our country’s mental health depends on our success in defeating this pandemic. Achieving herd immunity is the key to success. Mental health professionals at every level must be at the forefront of our efforts in this direction.

is a clinical psychologist and freelance writer in Birmingham, Alabama.

is a financier and former Director of Communications in the White House. He lives in New York City.

1. Bella T, Kornfield M. Florida breaks record for new coronavirus cases as surge of infections rip through state. 

 August 1, 2021. Accessed August 5, 2021. 

https://www.washingtonpost.com/nation/2021/08/01/florida-highest-coronavirus-cases-record/

2. Katella K. 5 things to know about the delta variant. Yale Medicine. August 3, 2021. Accessed August 5, 2021. 

https://www.yalemedicine.org/news/5-things-to-know-delta-variant-covid

3. Smith-Schoenwalder C. CDC data: Coronavirus coverage lowest among 12-15-year-olds. US News and World Report. July 14, 2021. Accessed August 5, 2021. 

https://www.usnews.com/news/health-news/articles/2021-07-14/cdc-data-coronavirus-vaccine-coverage-lowest-among-12-15-year-olds

4. COVID-19 vaccines: get the facts. Mayo Clinic. Accessed August 5, 2021. 

https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-vaccine/art-20484859

5. Choi I. Dr. Fauci said up to 90% of population needs to get vaccinated for herd immunity against virus. 

. December 27, 2020. Accessed August 5, 2021. 

https://www.businessinsider.com/fauci-up-to-90-population-needs-vaccine-for-herd-immunity-2020-12

6. Miller R, Rand DG. More Republican politicians are endorsing vaccination. It just might work. 

. August 3, 2021. Accessed August 5, 2021. 

https://www.washingtonpost.com/outlook/2021/08/02/republicans-endorse-vaccines-effective/

7. Malone KM, Himan AR. Vaccination mandates: the public health imperative and individual rights. Centers for Disease Control and Prevention. Accessed August 5, 2021. 

https://www.cdc.gov/vaccines/imz-managers/guides-pubs/downloads/vacc_mandates_chptr13.pdf

8. Bella T. Disney and Walmart mandate that employees be vaccinated as COVID-19 cases spike nationwide. 

. July 31, 2021. Accessed August 5, 2021. 

https://www.washingtonpost.com/business/2021/07/31/disney-walmart-vaccine-mandate-delta/

9. Whitten S. Netflix will require Covid vaccinations for actors and some crew on U.S. productions. 

. July 28, 2021. Accessed August 5, 2021. 

https://www.cnbc.com/2021/07/28/netflix-to-require-covid-vaccinations-for-actors-some-crew-on-us-sets.html

10. Benveniste A. More companies are requiring vaccinations for employees. Here’s the latest list. 

 Updated August 1, 2021. Accessed August 5, 2021. 

https://www.wbaltv.com/article/more-companies-are-requiring-vaccinations-for-employees-heres-the-latest-list/37192324#

Our country’s mental health depends on defeating this pandemic. The key to victory? Vaccine mandates. 

Defeating the Pandemic: The Necessity of Vaccination Mandates 

False allegations of abuse in child custody cases are an all-too-common phenomenon. Typically, one parent accuses the other parent of physical and/or sexual abuse of their child to gain leverage in their court proceeding. Nothing can befuddle or sidetrack a custody case more than an allegation of abuse. This is particularly important because judges tend to award primary physical custody to the parent who made the allegation, even if the accused parent’s actions are not substantiated. Thus, false allegations can be a powerful weapon to limit or deny custody and/or visitation in a vindictive manner.

Handling an allegation of abuse is a sensitive and thorny problem for attorneys and judges. All allegations of abuse must be taken seriously. While a strong visceral reaction to an abuse allegation is expected, it can be counterproductive. A rushed response can make the situation worse. In contrast, a wait-and-see attitude leaves the door open for a thorough evaluation before a disposition is decided upon. In essence, evaluation needs to occur before disposition.

Let us be clear: false allegations of abuse are a form of parental alienation. Alienation involves the concerted effort of one parent to undermine the other parent’s relationship with their child. Nothing could be worse than a custody decision that is based on a false allegation. And once a custody decision has been issued, modification of it is burdensome and an uphill challenge.

Clinical psychologists, psychiatrists, and other mental health professionals are often turned to in cases of abuse allegations. The court appoints them to evaluate the parties involved and to make recommendations. Allegations of abuse call for a coordinated effort between the judge, the attorneys, and the court-appointed evaluator.

A clinical approach to evaluating allegations of abuse presented here is based on years of experience with hundreds of cases of abuse allegations. This approach consists of sequential steps that should be taken. The evaluation process is aimed at determining whether an allegation of abuse has occurred or not—in other words, whether the allegation has been fabricated by a parent with the intent of sabotaging and harming the other parent.

The evaluation of possible abuse must include both parents and the child. Seeing just the child, just the accused parent, or just the accusing parent is not sufficient to understanding the entire narrative. All 3 individuals must be a part of the evaluation process. After all, we want our conclusions and recommendations to be based on full and accurate information. This can only be accomplished with the participation of all 3 individuals

The accused parent is often advised by his/her attorney not to participate in the evaluation process with the psychologist or psychiatrist. This is ill-conceived advice. By doing so, the mental health professional will be deprived of critical information that can shine a light on the falsity of the claim. Otherwise, all the information will be coming from the accusing parent, whose allegation will gain weight if it is not disputed.

If this is the first allegation of abuse, and it is occurring during a child custody case, its validity must be questioned. In fact, there is a significant probability that the allegation is false. It is unlikely that a parent’s first abuse of a child will occur after a child custody case has been opened. Thus, if a parent does not have a history of abusing the child, it is not likely that the first abuse is occurring during the legal proceeding.

A series of allegations against a parent during a child custody proceeding is also a major red flag. An accusing parent often believes that multiple allegations against the other parent are more convincing to a judge than a single allegation. But repeated abuse of a child during a circumscribed time period—during a child custody case, for example—is quite improbable.

Detecting a false allegation is easier with the use of a timeline. Marking the major occurrences in a child custody case can show the specific sequence of events. A false allegation of abuse may occur during the custody case and not before. It may also occur in response to legal action taken by the other parent. For example, if a mother files for full custody of her child, this sets the stage for the father to report a false allegation of abuse against the mother, with the hopes that the allegation will derail the mother’s quest for custody. The motive of the false allegation can be detected by examining its place on the timeline of events.

Children between the ages of 3 and 7 years are easily coached by one parent against the other. False allegations of abuse often include unwitting help from the children. Children want to please their primary parent. They are easily swayed, cajoled, convinced, and brainwashed. It is difficult for them to know the truth once a parent has coached them extensively. False allegations can involve older children and teenagers as well, but their coaching is more easily transparent and even admitted to by the adolescent in question.

There are 5 common reasons why a parent will lodge a false allegation of abuse against the other parent. There are certain powerful beliefs that an accusing parent will have that lead to the promulgation of false allegations (

Five Beliefs That Motivate False Accusations of Child Abuse

If any of these beliefs are discovered, the allegation of abuse is likely to be false. Detecting these beliefs in a parent requires careful interviews over several sessions. A parent will never admit to fabricating a false allegation. The clinician must be skilled enough to see through the typical defensiveness, deceitfulness, and/or distractions of an offending parent.

Harmful and false beliefs by the accusing parent can also be detected through interviews with the child and the accused parent. Usually, the child or the accused parent will provide critical clues as to the accusing parent’s belief system. These clues can be pieced together to provide a full understanding of the destructive dynamics at play. Bits and pieces of information will fit together into a detailed narrative that exposes the falseness of the allegation at hand. But, again, the accusing parent will never recant and will never apologize for his/her underhanded attempt at relationship interference.

Critical Points to Keep in Mind During the Evaluation

Once an allegation of abuse has been declared by a parent, the following process should ensue:

1. The Judge should appoint a clinical psychologist or a psychiatrist to evaluate the child and both parents. This evaluation must include interviews, psychological testing, and a review of collateral data (emails, texts, recordings, pictures, and others). The evaluator should have access to other independent assessments of the allegation, such as DHR investigations or a forensic evaluation of the child.

2. The clinical psychologist or psychiatrist must be experienced in child custody evaluations.

3. There should be a wait-and-see attitude about the allegation until the evaluation process has been fully completed.

4. Attorneys should not respond to an allegation of abuse by filing motions for dramatic or extreme action, such as obtaining full custody of the child.

5. Giving a parent temporary custody until the matter is settled may make sense, especially if the child’s physical safety is of acute concern.

6. The evaluation by the mental health professional should be aimed at determining the validity of the stated allegation of abuse.

7. The attorneys must not try to sabotage the evaluator in order to win their case. The evaluator’s conclusions and recommendations should be given strong weight.

A false allegation of abuse by a parent should be met with firm consequences, such as a fine, supervised parenting time, court-ordered counseling, and/or loss of primary custody. Swift and decisive consequences will stop future false allegations of abuse.

A false allegation must be considered a form of parental alienation. By being involved in one way or another, the child learns to be dishonest, deceitful, manipulative, conflictual, and blaming. The love the child should have for both parents is compromised and even destroyed by the process of a false allegation. False allegations of abuse must not be tolerated in the court system.

The accusing parent may not be appropriate for primary custody. Even shared custody may not be a good idea. A parent’s willingness to fabricate an allegation of abuse against the other parent is a poor prognostic indicator. It is not simply an accident or a mistake. A false allegation is an intentional and purposeful attempt to undermine the child custody proceeding.

A false allegation of abuse is serious business. It represents a psychiatric emergency. As such, it must be handled and dealt with in a direct and timely manner. A child’s mental health and well-being depend upon it.

A clinical approach to detecting false allegations of abuse in child custody cases.

Finding the Difficult Truth 

My brother and I had not seen each other in over 25 years. We had not been together since 1994, when we gathered to bury our father. Those days are chiseled in my mind because it was the time when OJ Simpson had his infamous Bronco chase live on national television. Watching that drama unfold helped to distract us from the sadness of the moment.

But my separation from my brother ended in January 2020, when I traveled back to Dallas to see him for a weekend. Forty-eight hours is a small amount of time compared to the loss of 25 years. But for me, it was intimate and validating. It was relaxing and fun as well.

My brother and I were extremely close as kids. He is 7 years older than me, but we spent huge amounts of time together until he got his real first girlfriend, who turned out to be his future wife. Because of the age difference, my brother was a mixture of older brother and second father. We had great fun together, but he also helped to guide me and teach me. He taught me how to play tennis and how to play the baritone ukulele. I looked up to him; he was smart and driven and self-assured. He was funny, sarcastic, unflappable, and destined to be successful. In contrast, I was a tall, lanky, sensitive, shy kid who was not very confident.

My brother was uniquely important to me because my parents had an unhappy marriage. I relied on him to shield me from their ongoing arguments. He did that very well. And he did it despite receiving much of the brunt of our mother’s unhappiness and anger. My brother was always loving and caring with me, so I could never understand why she was so critical of him. It was unfair and it was hurtful—to both of us.

Our family strife ended with my mother’s death from cancer. We did not talk much about her illness and imminent death in our family, and I had a difficult time grappling with it. I was a 13-year-old kid who was sad and confused, and, in a real way, I was losing my brother at the same time. He was in medical school by then and was about to be married. Hanging out with his kid brother was not a priority for him anymore. He was about to embark on adulthood; I was still a kid in junior high school under my father’s roof. I felt alone. It took me several years to get my grounding back.  

My brother and I grew apart after I left for college, then graduate school, and then adult life. To be frank, our disconnection was much more my fault than his. I felt the need to distance myself from my family. My homelife had created intense feelings of anxiety and self-doubt in me. I wanted to get away and focus on new beginnings, but I was also wrestling with my weaknesses and mistakes. I judged myself harshly and felt like I was a big disappointment. I was my own worst enemy—a cliché that was true.

Twenty-five years passed, an inexplicably long time. I got lost in making life work for me. Being a husband—twice—and being a father to a son and 2 stepsons occupied my time and energy. I put reconnecting with my brother on the back burner, with the idea that I would tackle it sooner rather than later. Decades passed instead.

I finally decided that I was going to reach out and see him, as my wife and my son had been urging me to do for years. It was time for us to be together. Not only did I know I needed to do it, I wanted to. Time was running out. What a terrible thought—time running out on our relationship. That was simply unacceptable.

I emailed my brother to let him know that I wanted to come visit. I was excited; I was going home to Dallas to see my brother. It was right. I was ready to see him.

Weirdly, I was not at all nervous about seeing him again after all these years. I knew it would be like old times, and I was right. We both just dived back into our shared history. It seemed natural and comfortable.

Our visit together was memorable. We talked about individuals, places, and us. We shared memories and feelings, both sad and happy. We drove around our old neighborhood and hang outs. We reminisced. We talked about our parents and the trials we faced in our growing-up years. We talked about our close relationship as kids. We talked about our mother’s dysfunctional behavior and how it affected him and me alike and differently. We talked about our frustrated father and how he was our anchor.

My brother and I are both mental health professionals and so we also talked shop. We talked about our similar professional interests and our forensic work. Both of our professional lives are devoted to helping others. But this weekend, we were focused on helping each other as we reconnected.

My brother and I had lost those 25 years. Much had happened, too much for us to talk about in just a short weekend. But we ended up talking about the most important stuff: our early years and how our shared experiences have shaped us. No matter what our separate journeys have been, we are brothers and each other’s witness. Twenty-five years apart could not destroy our core connection.

Our weekend together was life-altering for me. Leaving our visit, I felt less like a confused kid brother and more like an accomplished man. I no longer felt like I had been a big disappointment.

What is the moral of this story? It is simple: it is never too late to reconnect with an important family member or a past close friend. It can be done, and it is often easier than you think. For me, it was intimate, the opening of a renewed relationship with my lost brother, and an opportunity to understand parts of myself that I had buried away.

I am more than a little embarrassed that it took 25 years for me to reconnect with my brother. After all, I am a clinical psychologist who has spent a whole career trying to help people accept themselves and nurture important relationships. But sometimes the time just has to be right. Sometimes you must find the courage to conquer a difficult roadblock, especially when it is self-imposed. All it takes is a phone call, or an email, or a text message to climb over a wall that you thought was insurmountable.

This is the first anniversary of our reconnection. During the past year, we have been texting each other because the coronavirus pandemic has prevented us from seeing each other in person. We are back in each other’s lives, and that will not change.

is a clinical psychologist in private practice in Birmingham, Alabama. He is also Clinical Associate Professor of Psychology at the University of Alabama at Birmingham.

25 years have gone and past, but is reconnecting with a distant loved one still possible?

Reconnecting With My Brother: A Lesson Learned

Delusional disorder is a major psychotic illness that is enigmatic and poorly understood. It is often difficult to treat because of the individual’s denial of a problem, difficulties in establishing a therapeutic alliance, and interpersonal and social conflicts. Unfortunately, many individuals with this disorder refuse treatment altogether. Available research suggests that 50% of patients who are adequately treated achieve a symptom-free recovery, while 90% of patients demonstrate at least some improvement.

 It has been found that persecutory delusions respond least well to treatment, with 50% improvement rates and 

 Only a handful of studies have used objective outcome measures to evaluate patient improvement during treatment for delusional disorder.

 The best objective measure of adult psychopathology in the world is the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). There have been hundreds of 

 on the MMPI-2 and the treatment of psychiatric disorders.

 Up until now, there has been nothing in the literature that addresses the utility of the MMPI-2 in tracking or documenting treatment effects in delusional disorder.

This case illustrates the effectiveness of the MMPI-2 in documenting patient recovery during treatment for delusional disorder. Practical implications for psychiatrists and other mental health professionals are discussed.

“Mary,” a 42-year-old white female, temporarily lost custody of her 3 children to her ex-husband 18 months ago due to apparent psychotic-level functioning. I was appointed by the court to arrive at a definitive diagnosis and to provide appropriate guidance about her parenting abilities and custody status. (Mary, a pseudonym, has given written informed consent for her case to be included in this presentation. Identifying information about her has been altered to protect her privacy.)

Mary’s primary symptoms included both persecutory delusions and somatic delusions. Her delusions had been present for about 2 years. She believed that her colleagues at work were concocting a scheme to have her fired. She believed that her mother was not her biological parent. Mary also believed that drones were hovering over her home and that someone had installed a camera in her car to follow her. She reported unrelenting somatic symptoms that she attributed to an alien virus that had been planted in her water at home. Because of her delusional thinking, Mary had recently quit her job and was residing with her parents.

Prior to the onset of her delusions, Mary had obtained 2 master’s degrees and had a full-time position. She had a boyfriend, many friends, and her family relationships were intact. She was described as a smart and sweet person. She had been given primary custody of her 3 children at the time of her divorce 4 years earlier; it was not a highly adversarial divorce proceeding. She had no medical problems. She had no family history of psychosis or other psychiatric disorder.

Mary had been seeing a psychiatrist for several months prior to my involvement in the case; I obtained her records from him. Mary was described as having depression and anxiety. Psychosis was not noted. She was being treated with fluoxetine 20 mg and bupropion hydrochloride extended-release tablets 150 mg, but she was not improving. Mary had not divulged any delusional material to her psychiatrist.

Clinically, Mary was appropriately attired and well-groomed for her sessions with me. She wore make-up and jewelry. She was pleasant with me and made good eye contact. Mary’s cognitive abilities were intact. Her affect was slightly dysphoric but within normal limits. She was not manic or hypomanic. Mary’s delusions were prominent, and she had little or no insight into their nature and severity. She was also suspicious of me; she thought I might be involved in the conspiracy with her colleagues at work.

I asked Mary to provide a urine screen to rule out substance abuse. Her urine screen the same day was negative for illicit drugs.

Mary completed the MMPI-2, answering all 567 questions in 90 minutes. Her responses were scored on 3 validity scales, 10 basic clinical scales, and the PSY-5 supplementary scales.

Mary showed considerable distress but in the context of normal validity scales. She approached the test in an open and honest fashion. She did not exaggerate her symptoms. She was not defensive or guarded. Her responses were considered valid. She was to be believed.

Ten basic clinical scales were developed to assess different psychiatric conditions and symptoms. See 

 below for a description of the 10 scales. Mary’s 10 basic clinical scales showed significant elevations on scales 6-8-1-3. Scales 6 and 8 were considerably higher than scales 1 and 3.While this profile often indicates schizophrenia, Mary’s history and clinical presentation were not consistent with that illness. In my view, Mary’s MMPI-2 profile was reflective of her persecutory delusions (scales 6 and 8) and her somatic delusions (scales 1 and 3), both components in her psychotic illness.

Supplementary scales are available on the MMPI-2 as well. Mary’s PSY-5 scales showed a significant elevation on the scale having to do with psychosis. This was corroborative data to Mary’s 10 basic clinical scales.

Based on her history, clinical observations, and MMPI-2 test data, I diagnosed Mary with delusional disorder. Her delusional disorder was primary. She did not have a comorbid condition, such as bipolar disorder or schizophrenia. Mary did not have major depressive disorder or an anxiety disorder nor was she abusing alcohol or drugs.

No specific stressors were identified that contributed to the onset of Mary’s delusional disorder. However, she was feeling “pressure” from juggling a full-time job with raising 3 children.

Interestingly, Mary’s psychiatrist and I independently but simultaneously came to the conclusion that she had delusional disorder. Mary was started on ziprasidone 20 mg. Fluoxetine 20 mg was continued. A brain MRI at that time was negative. Bupropion was stopped because it enhances dopamine levels and can 

I re-evaluated Mary 4 months later in preparation for her upcoming court appearance. The court would want to hear about my findings and conclusions as well as any progress in her condition since her last court hearing. I interviewed Mary on 2 occasions. She completed the MMPI-2 again, and I obtained updated records from her psychiatrist.

After 4 months on ziprasidone, Mary was remarkably improved. She was tolerating it well, and her delusions had remitted. She had developed important insight about her resolved delusions. They now seemed foreign and distant to her; they did not make sense to her. She could not even recall her suspiciousness about me. Mary’s affect was bright. She was talkative and expressive. She was appreciative of everyone’s concerns. Mary was looking for a full-time job and planned to get her own apartment.

Mary’s MMPI-2 after 4 months of treatment was remarkable as well. It was completely normal. Her validity scales were normal. All 10 basic clinical scales were normal; there were no significant elevations. In fact, there were no near-significant elevations. Her PSY-5 scales were normal as well. All signs of psychosis had dissipated.

Mary will be maintained on ziprasidone for the foreseeable future. She will have monthly to quarterly visits with her psychiatrist. Cognitive behavior therapy has been added to her treatment regimen, since it is regarded as a 

 Mary’s legal case is close to resolution. With her regained parenting abilities, the parties are approaching a compromised settlement.

This case study illustrates many important clinical and practical points.

Mary’s persecutory delusions and somatic delusions both abated with treatment. This result is consistent with the literature that reports that 50% of patients treated adequately achieve a symptom-free recovery.

 Delusional disorder in this case was treated successfully with antipsychotic medication (ziprasidone 20 mg). This finding is contrary to the data that suggest that persecutory delusions are recalcitrant.

condition, and the absence of comorbid conditions may make successful treatment of delusional disorder more attainable.

Overall, Mary’s recovery was likely due to a combination of the relatively short duration of her delusions (about 2 years), the lack of a comorbid condition, the use of an antipsychotic medication, the discontinuance of bupropion, and her high level of premorbid functioning.

The MMPI-2 proved to be a sensitive outcome measure in evaluating this patient’s improvement. Using the MMPI-2 at the time of diagnosis and later during treatment is an objective, data-driven way to assess a patient’s response to treatment. The MMPI-2 can be administered easily and is not overly intrusive.

Lessons learned from this case study are clinically interesting, but only suggestive. Well-designed research is needed to study the proposition that the MMPI-2 is a highly effective instrument for evaluating treatment outcome in delusional disorder.

Mary’s psychiatrist and I worked independently but in a cooperative fashion. This was quite helpful in facilitating Mary’s evaluation and treatment with minimal delays and roadblocks. The sharing of findings and conclusions between us led to an excellent result after much initial confusion.

Mary was fully adherent with her evaluation and treatment, whereas many patients with delusional disorder refuse treatment. Mary’s successful treatment was largely attributable to her therapeutic alliance with her psychiatrist and me. Her motivation to get well superseded any desire to resist intervention. 

 is a critical building block in adequate treatment.

Whether Mary will have a recurrence in her delusional disorder is unclear. Longitudinal research is needed to address the question of incidence recurrence in this specific illness. With other types of psychotic disorders, 

 As such, maintenance treatment in delusional disorder becomes extremely important. Treatment should include a combination of psychiatric medication and individual therapy.

The impact of psychotic disorders on child custody cases is a delicate matter. It should be recognized by all parties that a parent’s recovery from a psychotic disorder may be less than permanent. Child custody decisions need to be made with that psychiatric reality in mind. Maintenance treatment for the parent with a psychotic disorder is the vehicle by which parenting abilities can be regained and sustained.

is a clinical psychologist in private practice in Birmingham, Alabama. He is clinical associate professor, department of psychology, University of Alabama at Birmingham. Much of his clinical practice is devoted to forensic cases, including child custody, personal injury, and criminal cases.

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