The VFLPN’s (Pathways) event entitled “My Wife is trying to Poison Me” and Other Manifestations of Focused Delusions in Family Law Disputes occurred on Wednesday the 18th of October 2017. The event was the second of a tripartite series presented by key note speaker Jennifer Neoh, a clinical psychologist whose private practice is focused entirely on a family law population. The theme of her talk centred on the tendency of professionals to overlook delusional content and psychosis when focused accusations have been made between separating families involved in family law matters.
Dr Neoh began her presentation by acknowledging the emotional intricacies characteristic to family law disputes and the separation process generally. She noted that high levels of conflict and stress both prior to and post separation often compound to create mental health issues, which can in turn further exacerbate the circumstances and complicate court proceedings. Individuals often experience a kind of ‘separation psychosis’ whereby their ‘separation behaviour’ is different from their normal behaviour, with individuals typically questioning their actions in disbelief when reflecting back on events months later. However she flagged that the notion of ‘separation psychosis’ can sometimes further complicate proper diagnosis, as it can detract attention away from any pre-existing mental health issues, by attributing behaviour to the experience of separation rather than any underlying condition.
Using the “Diathesis Stress Model of Mental Illness”, Dr Neoh then explained the dividing line between mental illness and ‘ordinary’ experiences of stress. The model employs a continuum which places significant mental health symptoms (i.e. schizophrenia, bipolar disorder, anxiety, depression) at one end and robust mental health at the opposite, with stress being the key element in this mental health matrix. Applied in a family law context, she highlighted that relationship stress and parental separation can contribute to mental health problems and vice versa. Genetic predispositions to mental illness further influence how an individual experiences stress and whether that experience of stress will push the individual ‘over the line’ into mental illness; where a genetic disposition is present, low levels of stress can generate mental health symptoms. Consequently, Dr Neoh stressed the importance of ascertaining an individual’s mental health history when undertaking assessments.
Dr Neoh then turned to a series of case studies to illustrate instances of delusional content and psychosis in family law disputes. The common thread throughout the case studies was the tendency of external parties (including psychiatrists, psychologists, lawyers, family members, etc.) to characterise serious mental health issues as mere ‘eccentricities’ associated with the separation process/relationship stress, and/or failing to identify the behaviour as a mental health issue at all.
The first case study, ‘The Q Family’, is an example of where mental health issues, which were initially overlooked, caused relationship stress. The case involved a father who made accusations that the mother was trying to poison him. He believed his wife was poisoning his food and removed himself from the household to test his hypothesis. When he presented for psychiatric analysis, the assessor entertained the possibility that his hypothesis was true, without assessing the wife. Upon second assessment, undertaken by Dr Neoh and also including the wife, the father was diagnosed with delusional disorder. He finally conceded that he had developed physical symptoms due to extreme levels of stress at work, and presented with “blurred” thoughts about his accusations in the aftermath of his episode of psychosis; stating “I don’t know why I said that”. This instance exemplifies how stress can push people into delusional content and create unwarranted relationship stress and accusations.
The next case study, ‘The D Family’, illustrated how eccentricities prior to separation can move into more serious mental health issues after separation. In that case the mother began making allegations to the police that the father was stalking and harassing her. The police developed concerns about the mother’s health, as did staff at the children’s school, and subsequently an investigation was launched. At the initial assessment the mother then proceeded to make accusations of child sexual abuse, triggering the involvement of Child Protection who were also concerned about her mental health. Despite these numerous concerns, the assessing psychiatrist found that the mother had no mental health problems and did not believe she had any psychotic disorder or major mood disorder. The mother was later subjected to another assessment as her solicitor held concerns about her capacity to provide instructions. The second psychiatrist also determined that the mother had no mental health problems, but was rather a victim of family violence by the father. The concurrent psychologist was also of the opinion that the mother’s symptoms were caused by family violence and diagnosed post-traumatic stress disorder. The mother’s family further held the belief that she did not have any mental health issues, “she is the same as she always is”.
Upon presenting to Dr Neoh, the mother was difficult to comprehend, underweight, exhibited disorganised behaviour, entertained grandiose themes and scored incredibly high on clinical scales for paranoia, schizophrenia, psychotic experience, etc. As part of her assessment, Dr Neoh looked deeper than the preceding psychiatrists and accessed subpoenaed documents, which revealed a much clearer picture of mental illness. The documentation exhibited several reported concerns by child protection, emergency department hospital staff and the children’s school. Pivotally, it surfaced that the mother had been involuntarily admitted to a psychiatric ward and diagnosed with acute paranoia/disorganisation during the time of assessment. This scenario highlights the importance of going beyond the presenting evidence and seeking out further documentation, such as by way of subpoena, to gain holistic knowledge about an individual’s condition in order to more accurately unpack the accusations being made. The scenario also demonstrates how numerous parties involved in a matter can fail to properly identify behaviour as delusional content, and the different thresholds employed by treating practitioners who fail to distinguish psychiatric wellness and ‘good parenting’; effectively declaring a ‘clean bill of health’ without considering the true impact of the behaviours upon any children involved.
Finally, the case study of ‘The B Family’ exhibited how mental health issues can contribute to separation stress and that failure by professionals to identify and recognise delusional content can further complicate circumstances. There, the father had a long history of conflict and was receiving psychiatric care for several years. The treating psychiatrist had diagnosed him with anxiety, and the concurrent psychologist from the same clinic believed Asperger’s. These practitioners did not consider a renewed diagnosis over the years and did not provide any treatment for his condition.
In contrast, it was Dr Neoh’s opinion that the father had Bi-Polar Disorder. Documentary evidence and his presentation at assessment depicted the father as erratic, disorganised, having had a number of psychiatric admissions to private hospitals. He scaled 99% on the mania scale and was determined to be experiencing a manic episode at the time of presenting. Unfortunately, the consequence of failing to recognise these conditions was a 10+ year-long court case and severe disturbance for the children throughout this prolonged period. These facts highlight the importance of utilising up-to-date documentation and the need for a willingness to re-evaluate diagnosis, particularly over a long period of treatment, so as not to overlook vital indicators of delusional content and to protect the best interests of any children involved.
However not all focused beliefs will amount to mental health problems. It must be recognised that fictional accusations, particularly relating to sexual abuse, are unfortunately common in family law matters. Professionals must thoroughly investigate the matrix of facts when evaluating any accusations made. Dr Neoh suggested looking at the timeline of investigations and any influences on the allegations, such as multiple physical exams and/or interviews, poor interview techniques, etc. She urged professionals to ask the key question, “When did you first develop that belief / have a problem?” An inability to answer with detail or fault in the story timeline conveyed may point to a delusional underpinning, a misunderstanding by the accusatory party or vexatious intentions. Moreover, the expectations and lay understandings of the parties involved must also be considered. Here, Dr Neoh pointed to a lack of understanding regarding the sequelae of sexual abuse. Parents are often quick to jump to conclusions if their child presents sexualised behaviour, when in fact there are many avenues from which children can develop these behaviours. For example, a child who masturbates should not be presumed to be the victim of child sexual assault. It must also be recognised that children will feed on these presumptions and provide responses to questions (i.e. “who did this to you?”) in a way they think is desirable using their limited pool of knowledge. She further warned of the dangers of confirmation bias, whereby holders of a belief take on a ‘tunnel vision’ approach and only look for data that confirms their point of view. Finally, Dr Neoh underlined the importance of asking the right questions. Asking clients why they hold a certain belief is absolutely essential to unpacking the accusations made, and in order to provide an accurate diagnosis of the individual’s mental health.
In conclusion, Dr Neoh urged professionals to consider the possibility that sometimes focused, singular beliefs may have a delusional underpinning. Mental health problems can often be overlooked because stressed parents in the midst of separation are expected to have reasons for the separation and be emotionally upset; therefore pre-existing and/or developing mental health issues are often not given enough consideration. Dr Neoh advised that professionals must seek out more information, look beyond the visible content and allow for further hypotheses instead of relying on the accusation postulated. Nonetheless, it must be acknowledged that there is a lot of grey area between misguided, determined overvalued beliefs and delusional beliefs, and that by nature this area is quite difficult to navigate.