Families in Psychiatry: Parental alienation and shared delusional disorders

Disturbances in family emotional involvement are best understood at the extremes. At one end, there is extreme cutoff in the controversial diagnosis of parental alienation. At the other end is the extreme enmeshment in shared delusional disorders. What are the mechanisms that allow these conditions to develop? Helping families understand these mechanisms can help them change the trajectory of the family, by moving toward the middle, toward appropriate family emotional involvement.

How does enmeshment begin?

Good parents want to instill good morals, values, and behaviors in their children. Good parents want to teach their children to be good citizens, have good manners, and to treat others with respect. However, sometimes parents desire something more from their children; they want their children to continue a family business, be part of their religious organization, or to be “just like us.” Parental influence is easier when communities are isolated. When shared family beliefs are pervasive and impede the individuation of thoughts, feelings, and behaviors, these families are considered enmeshed and undifferentiated. Enmeshed families are more susceptible to indoctrination. Indoctrination is easier when there is a high level of emotional involvement, meaning that children are kept close, and differentiation and individuation are discouraged.
Using a child for one’s own needs is exploitative; however, many parents might not understand how their own unconscious psychological needs affect their children. This is seen clearly when children are rejected because they are “different.” For example, some parents have stated that a lesbian, gay, bisexual, and transgender sexual orientation is “against their religion,” and demand that their child conform to the family beliefs and norms. In these cases, the adolescent or young adult has to decide whether to leave the family, conform to its beliefs, or hide his or her identity.


Emotional overinvolvement in undifferentiated enmeshed families is central to the diagnosis of shared delusional disorder. One example of a shared delusion is delusional parasitosis. This is a rare delusional disorder where the patient is convinced of being infested with worms, insects, parasites, or bacteria while no objective evidence exists to support this belief. Somatic delusions are shared with one or more members of a family in 5%-15% of cases (J. Behav. Health 2014;3:200-2 ).
Salvador Minuchin , Ph.D., and his colleagues outlined the impact of enmeshment in families where a child has an eating disorder. They described children so overprotected that there was a virtual moat around the family system, blocking out the world.
    Interpersonal differentiation in an enmeshed family system was poor, with identity fusion between parent and child. In this dynamic, the child is unable to establish a clear identity apart from the parent. Orthorexia , a term coined in 1997 by Dr. Steven Bratman, is defined as an obsession with “healthy or righteous eating.” The obsession with healthy foods can be structured within family habits. When enmeshment and family isolation are present, orthorexia can show up as a folie à famille (Heru, personal experience).
More exotic examples are known by the French terms folie à deux and folie à famille. Dr. Ernest-Charles Lasegue (Ann. Med. Psychol. 1877;18:321) was the first person to describe folie à deux . He stated that the inducer created the delusions from his/her psychosis and imposed them upon a “passive” individual; the induced subject was not truly psychotic but instead “absurdly credulous.” Several varieties are described. Folie imposée is the one we typically think of, where the naive individual has a resolution of symptoms when removed from the dominant person. Folie simultanée is where simultaneous and identical psychoses occur in two predisposed people who have had a long and intimate association with each other. There is usually no dominant partner, and separation does not alleviate the symptomatology. Folie communiquée involves the transfer of psychotic delusions after a long period of resistance by the passive partner. The recipient of the delusions subsequently develops his own delusions, independent of the primary subject’s, and these persist following separation.
Folie induite , a variant of folie communiquée, is diagnosed when new delusions are added to old ones under the influence of another deluded patient. The secondary person enriches the newly acquired delusions. Another method of classification is based on the number of individuals involved: folie à trois (three), folie à quatre (four), folie à cinq (five), and, as mentioned earlier, folie àfamille.
What is the mechanism for enmeshment? Several predisposing factors can occur: social isolation, the presence of a naive or “absurdly credulous” person, and in the case of relatives, a shared genetic predisposition. It is most common for the dominant person to drive the belief that is then accepted by dependent family members. In the case of children, there is also identification with a parent and a lack of drive for separation.

Role of alienation

At the opposite end of the spectrum is alienation, most publicly described in the disputed diagnosis of parental alienation syndrome ( PAS ) (The Parental Alienation Syndrome, 2nd ed., Cresskill, N.J.:Creative Therapeutics Inc., 1998). PAS sometimes arises in the context of child-custody disputes. The primary manifestation is the child’s unjustified denigration of one parent. According to Dr. William Bernet and Amy J.L. Baker, Ph.D., PAS features “abnormal, maladaptive behavior (refusal to have a relationship with a loving parent) that is driven by an abnormal mental state (the false belief that the rejected parent is evil, dangerous, or unworthy of love)” (J. Am. Acad. Psychiatry Law 2013;41:98-104 ). There is considered to be brainwashing of the child by one parent against the other parent in order to gain leverage in a court of law.
What is the mechanism in alienation? Enmeshment and overidentification of the child with the favored custodial parent is common. The child depends on this adult for his survival. The process of divorce can increase enmeshment with the custodial parent. The parent might reinforce the enmeshment by instilling fear of the “other” parent. The belief that the “other parent” is “bad” is transmitted through conscious and unconscious mechanisms.
The conscious mechanism is direct expression of anger toward the alienated parent. The anger might be motivated by rejection or as revenge for rejection with a desire to punish. The unconscious mechanisms include projective identification. In this situation, anger is seen as being embodied within the “other.” The projecting parent who continues to “hate” keeps the children tied to her out of projected fear of the “other.” The parent who uses projection is likely to have a primitive character structure. The child of the narcissistic custodial parent then acts out the shame and rage at the failure of the marriage.
These domestic tragedies have been around since the beginning of time. In Greek mythology, Medea, having been abandoned by Jason, took her revenge by murdering her two children. “Hell hath no fury like a woman scorned” is a paraphrase from William Congreve’s The Mourning Bride (1697).

What does the DSM-5 say?

Are these disorders and syndromes “real” psychiatric illnesses? The DSM-5 no longer separates delusional disorder from shared delusional disorder. If criteria are met for delusional disorder, that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used.
Those who advocated for inclusion of PAS cited the benefits that follow from a legitimate diagnosis such as legitimatizing problems that family therapists and psychotherapists encounter, allowing insurance coverage, and stimulating research. However, PAS was rejected as not having a good enough scientific basis.

Managing affective involvement

How does the psychiatrist manage families where emotional involvement is extreme? Psychiatrists first need to decide whether the family is capable of making changes and is willing to work on structural change within the family. If not, we can help patients remove themselves from destructive family situations. If the patient in your office wants to leave the family system or minimize the impact of the family system, individual psychotherapy that identifies the impact of family dysfunction, such as cognitive-behavioral therapy, can be used as a type of deprogramming. Exit strategies also can be discussed.
Al-Anon , for example, clarifies the influence of the family system on family members’ well-being by asking several questions, including:
Do you tell lies to cover up for someone else’s drinking?
Do you feel that if they cared about you, they would stop drinking to please you? Do you make threats, such as, “If you don’t stop drinking, I’ll leave you?”
Are you afraid to upset someone for fear it will set off a drinking bout?
Have you considered calling the police for help in fear of abuse?
Do you feel like a failure because you can’t control the drinking?
Do you think that if they stopped drinking, your other problems would be solved? If you think there is capacity for family change, the following strategies are helpful: 1. Education about appropriate differentiation
According to Dr. Murray Bowen , one of the main tasks of individuation is finding the right level of differentiation from parents. At one end of the differentiation spectrum is emotional fusion, and at the other end is emotional cutoff (disconnection between family members or refusal to engage with certain family members) (see “Family Evaluation ,” New York: W.W. Norton & Co., 1988).
When family enmeshment is present, we can educate the family about individuation. In this way, the family develops a greater intellectual understanding of how they function, compared to their cultural norm. The family may benefit from creating a genogram that clarifies patterns of emotional involvement in their family of origin. Look for intergenerational patterns, and discuss how emotional differentiation occurred in prior generations. Teach the family about the emotional tasks of differentiation.

2. If there is alienation, parse out the reasons

Clarify conscious mechanisms that force the child to reject the other parent. Help the parent understand the consequences for the child in having no access to the other parent. Again, using a genogram helps identify intergenerational patterns, such as emotional cutoffs. Explore the reason for prior family emotional cutoffs. Identify typical patterns in the family for managing anger and conflicts.
In cases of divorce of the custodial parent, look at how anger is managed and stages of grief. Look for the presence of narcissistic injury. Discuss what a good divorce is and the healthiest way for the child to grow up. Help the parent manage and process her own affect without contaminating the child. It is not the role of the child to be the parental caregiver.
Help the child see that there was a loving relationship in the past and that new family goals can be created. The child also might experience anger and grief, and it is important to educate the child about how to manage those feelings appropriately rather than using blame and alienation. Help the child be empowered by positive ideals rather than negative emotions.
Psychiatrists often avoid working with these families, and perceive them as stuck and unable to change. This might be true for some families but certainly not all. Many families find themselves in situations that they do not understand and with problems they need help resolving. Educating and working with families who are stuck and who ask for and want change can change the life trajectory of many people.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013).