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\begin{document}

\title{Current Treatment Protocols for Adult Survivors of Severe Parental
Alienation A Scoping Review Alyse Price Tobler August 17 2022 final}



\author[1]{Dyann Ross}%
\author[1]{Peter Innes}%
\author[1]{Mandy Matthewson}%
\author[2]{Alyse Price-Tobler}%
\affil[1]{Affiliation not available}%
\affil[2]{University of the Sunshine Coast}%


\vspace{-1em}



  
  \date{May 22, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
This study aimed to review the academic peer-reviewed and grey
literature pertaining to current treatment protocols for mental health
practitioners working therapeutically with adult survivors of severe
parental alienation. The academic databases searched were Medline (Web
of Science), PsycNET (APA), and Psychiatry Online. Grey literature
searches were conducted through Google, professional websites, published
books and Facebook. No peer-reviewed articles matching the inclusion
criteria were located. However, four pertinent grey literature resources
were discovered. It was found that there is a dearth of ethical
standards and professional practice guidelines that include a
comprehensive treatment protocol for mental health practitioners who
work with adult survivors of severe parental alienation and more
research needs to be undertaken. Also, to\\
understand the degree, acuity, complexity, and severity of the
developmental and ongoing acute trauma of severe parental alienation, a
treatment protocol must be developed as well as a gold standard for
competence, training, and ongoing professional development for mental
health practitioners working with adult survivors.%
\end{abstract}%



\sloppy


Current Treatment Protocols for Adult Survivors of Severe Parental
Alienation: A Scoping Review.

Alyse Price-Tobler, 11Clinical Psychotherapist, School of Social
Sciences, University of the Sunshine Coast, Australia. Email
Alyse.price-tobler@research.usc.edu.au. Dyann Ross,22Senior Lecturer in
Social Work and Mental Health, School of Social Sciences, University of
the Sunshine Coast. Peter Innes33Senior Lecturer in Research and Data
Analysis in Sociology and Psychology, School of Social Sciences,
University of the Sunshine Coast. and Mandy Matthewson44Senior Clinical
Psychologist School of Psychological Sciences, University of Tasmania.

Abstract

This study aimed to review the academic peer-reviewed and grey
literature pertaining to current treatment protocols for mental health
practitioners working therapeutically with adult survivors of severe
parental alienation. The academic databases searched were Medline (Web
of Science), PsycNET (APA), and Psychiatry Online. Grey literature
searches were conducted through Google, professional websites, published
books and Facebook. No peer-reviewed articles matching the inclusion
criteria were located. However, four pertinent grey literature resources
were discovered.

It was found that ethical standards and professional practice guidelines
that include a comprehensive treatment protocol for mental health
practitioners who work with adult survivors of severe parental
alienation do not exist and need to be developed. Also, to understand
the degree, acuity, complexity, and severity of the developmental and
ongoing acute trauma of severe parental alienation, gold standards for
competence, training, and ongoing professional development for mental
health practitioners working with adult survivors must be determined.

\emph{Keywords for academic peer-reviewed article and grey literature
search\textbf{:} parental alienation* parental conflict* adult* adult
children* child abuse* depression* anxiety* mental health practitioners*
therapists* and adverse childhood experiences*.}

\emph{Keywords for the grey literature review were parental alienation*
child* treatment program* and reunification program*. However, these
keywords evolved and changed as the review developed. Differing keyword
clusters that produced results generated in searches 2, 3 and 4 are
listed in appendix 1, page 28.}

Current Treatment Protocols for Adult Survivors of Severe Parental
Alienation: A Scoping Review

\subsection*{Background}

{\label{background}}

The term parental alienation (PA) is used to explain the outcome of a
process involving one parent (the alienating parent) teaching their
child to reject the other parent (the targeted parent); to experience
fear in the absence of real threat when they are near the targeted
parent; and to avoid contact with them (Templer, Matthewson, Haines, \&
Cox, 2016). For example, PA can occur during post-divorce custody
arrangements when the alienating parent successfully manipulates the
child to turn against the targeted parent (Baker, 2007; Gardner, 1998).
In cases of severe parental alienation (SPA), children report that they
are frightened of and despise their targeted parent, steadfastly
refusing to have any relationship with them. This review will focus on
adult survivors exposed to the most extreme form of PA as children, SPA,
and the mental health practitioners who work with them therapeutically.

To understand SPA properly, it is important to appreciate the nature of
parental alienating behaviours (PABs) that cause SPA. PABs are
considered a form of family violence and child abuse because coercive
control is at their heart (Haines et al., 2020; . A comprehensive review
of these behaviours can be seen in Harman and Matthewson (2020). The
adverse psychological effects of being exposed to PABs in childhood
include posttraumatic stress disorder, anxiety disorders, depression,
low self-esteem, guilt, lack of trust, increased suicide risk and
substance abuse (Baker, 2007; Verhaar, Matthewson, \& Bentley, 2022).

The detrimental effects PABs have on the child, and adult survivors of
SPA can present as extensive academic, physical, psychological,
emotional, and social difficulties . For example, adults exposed to
abuse, maltreatment and family dysfunction in childhood have lived
without secure attachment, nurturance, guidance, and encouragement.
(Ellis, Gold, Courtois, Araujo, \& Quinones, 2019). The impact on adult
survivors of SPA is incredibly profound because they have experienced a
cascade of losses that other childhood abuse survivors have not been
exposed to. These include loss of identity, loss of a `good enough'
parent they cannot grieve, loss of community and all that was once
familiar . The trauma and loss history of adult survivors of SPA poses
particular challenges for mental health practitioners working with them.
These challenges include building trusting rapport with survivors who
have difficulty trusting others; and treating a poorly understood form
of trauma .

During a therapeutic session, mental health practitioners need to be
aware of the wide range of co-occurring trauma experiences the adult
survivors may present with. For example, memories as a child of feeling
rejected, unloved, criticised, threatened, subordinate, and alone may
follow the child into adulthood. These memories, feelings and
experiences can result in internalised models of uncertainty about the
world and themselves combined with various defensive and submissive
behaviours (Verrocchio, Marchetti, Carrozzino, Compare, \& Fulcheri,
2019).

To date, research has focused on children and adolescents of divorce and
related custody issues, not adult survivors of divorce. Until now, there
has been little written about outcomes or treatment protocols for mental
health practitioners who work with adult survivors of divorce, adult
survivors of PA, and adult survivors of SPA. Lack of knowledge and an
absence of best practice guidelines to treat this complex presentation
are the reasons for below standard management, recognition, and
identification of SPA symptoms in mental health care . Practitioners who
work with families and children of SPA can often feel daunted,
overwhelmed, and helpless due to a lack of clear published guidelines
(Haines, et al., 2020). This may also be the case for practitioners
working with adult survivors of SPA.

Morgan and colleagues (2020) highlight the lack of evidence present in
academic reports, commentary papers and publications regarding
interventions for PA (Morgan et al., 2020). Further, previous research
focuses on interventions for children and families. Given the lack of
research and understanding of SPA and the experiences of adult survivors
of SPA, this study has reviewed the academic peer-reviewed and grey
literature to identify evidence-based best practices used by mental
health practitioners working with adult survivors of SPA. This scoping
review aims to offer recommendations for best practices in this field
and highlight areas for future research.

\subsection*{Method}

{\label{method}}

\subsubsection*{Design}

{\label{design}}

This study employed the preferred reporting items for systematic reviews
and meta-analyses protocol (PRISMA-P; Moher et al., 2015; Page et al.,
2021) for searching peer-reviewed academic literature. A broad scoping
review of the grey literature was undertaken. A decision to include data
on both children and adults involved in intervention or treatment
programs for mild to severe parental alienation was chosen to present a
complete picture of current data. The Arksey and O'Malley (2003)
framework was applied to the review. The grey literature component of
the scoping review was guided by the question, 'what interventions and
treatment protocols are currently used with children and adult survivors
of mild to severe parental alienation?' The grey literature review was
conducted on January 11, 2022, and built upon the framework outlined by
Pham et al. (2014). The databases selected were chosen because they were
comprehensive and covered a range of disciplines pertaining to PA.

The scoping review was approached in four multiple, objective steps: (1)
Identify the research question, (2) Conduct a relevant search from the
grey literature for interventions and treatment protocols available for
child and adult survivors of mild to severe PA within the books,
databases, websites, blogs and Facebook, (3) Map out the characteristics
and range of interventions and treatment protocols, (4) Report
challenges and limitations of the interventions and treatment protocols
(Pham et al., 2014).

\subsubsection*{Procedure and Search
Strategy}

{\label{procedure-and-search-strategy}}

The peer-reviewed academic literature searches were conducted using
Medline (Web of Science), PsycNET (APA), and Psychiatry Online
electronic databases. Keyword searches (see page 2) within each database
were conducted on March 23, 2022. In addition, the grey literature
scoping review examined which current interventions, treatment
protocols, and reunification hotels/camps are available for child and
adult survivors of SPA. Also, the Researcher recorded information
available about SPA course curriculums, the cost associated with the
therapy or treatment program for survivors, the qualifications of the
person/people administering the therapy and what training, case
consultation, and associated costs are available for practitioners.

The grey literature search was designed to integrate four differing
search strategies: (1) grey literature books on PA and SPA available in
Australia, (2) grey literature databases, (3) Grey literature Google
searches, and (4) targeted websites, blogs and Facebook. In contrast to
the peer-reviewed search on adult survivors of SPA, the strategies
presented in the grey literature search are distinctly different and
described in detail, allowing them to be replicated for future research.
Given that search engines and databases use unique algorithms to produce
their relevant rating schemes, it was decided that using a combination
of these sources was likely to lead to a broader reach of articles
(Godin, et al., 2015). As with any review, documentation of each part of
the grey literature search procedure is essential to demonstrate
comprehensiveness and transparency . Therefore, all decisions,
assumptions, and challenges throughout the grey literature scoping
review were recorded (see Appendix 2, page 29).

The first grey literature database keyword search was developed from the
Australian Government website, The Australian Institute of Family
Studies . The first keywords entered for the database search were:
parental alienation* child* treatment program* and reunification
program*. This search produced thirteen results; however, none were on
parental alienation or listed keywords.

The second grey literature database search was developed from the
Australian Government website, The Australian Institute of Health and
Welfare . This database keyword search repeated the keywords in the
first search. This search did not return any results. The following
message was displayed on the screen- Sorry, we could not find any
results matching~''parental alienation* child* treatment program* and
reunification program* .

The third grey literature database search was developed from the
University of the Sunshine Coast Library, named `Emerald Insight'. This
database keyword search repeated the exact keywords as the first and
second database searches. This search returned five results, none of
which pertained to the keywords. The five articles were about child
maltreatment and neglect, child protection cases, US Immigration Policy,
employment and crime, and diversity management .

The fourth grey literature database search was developed from the
University of the Sunshine Coast Library from the `All Newspapers'
option, which then directed the Researcher to the ProQuest database.
This database keyword search was repeated. This search returned two
results. One article was written in the Toronto Star Newspaper and
contained the keywords parental alienation, child, treatment (not
program), reunification (not program) and another on Movies about the
North Sports final.

\subsubsection*{Study Inclusion Criteria for Academic Peer-Reviewed
Articles}

{\label{study-inclusion-criteria-for-academic-peer-reviewed-articles}}

\begin{enumerate}
\tightlist
\item
  Peer-reviewed in English from 2010 to 2022. This extended number of
  years (as opposed to the usual five) was chosen due to a dearth in the
  literature on PA and SPA.
\item
  Articles mentioning adult survivors of severe parental alienation
  (SPA).
\item
  Articles that included treatment protocols currently being used by
  mental health practitioners working with adult survivors of SPA.
\end{enumerate}

\subsubsection*{Exclusion Criteria}

{\label{exclusion-criteria}}

Articles that focused on children who have experienced PA.

Articles that did not mention adults, parental conflict, divorce, PA, or
SPA.

\subsubsection*{Study Inclusion Criteria for Grey
Literature}

{\label{study-inclusion-criteria-for-grey-literature}}

Grey literature articles from books available in Australia, databases,
websites, blogs, and Facebook (only about adults) printed/written in
English relating to psychological interventions for mild to severe
parental alienation (no dates applied).

Grey literature articles or information about program interventions and
treatment protocols for children and adult survivors of mild to severe
PA.

\subsubsection*{Exclusion Criteria}

{\label{exclusion-criteria-1}}

\begin{enumerate}
\tightlist
\item
  Articles that are academic and/or peer-reviewed.
\item
  Articles that did not mention parental alienation or parental
  conflict, SPA, child, adult, treatment, therapy, intervention,
  custody, or divorce.
\item
  Articles describing hypothetical examples or directly related to
  divorce with no reference to children or adults who have experienced
  mild to severe PA.
\item
  Articles that mention treatment for children experiencing PA and child
  sexual abuse sent to Deprogramming Camps, Boarding Schools, Boot
  Camps, Wilderness Camps, or Residential Treatment Centres.
\end{enumerate}

\subsection*{Peer-Reviewed Literature
Results}

{\label{peer-reviewed-literature-results}}

The peer-reviewed academic literature search was conducted within
Medline (Web of Science), Psychiatry Online, and PsycNET (APA) databases
resulting in 3922 articles. All articles published earlier than 2010
were then excluded, resulting in 597 articles. The articles within each
database search were reviewed, and all duplicates were further excluded.
These duplicates occurred when additional search terms were added to the
original ''Parental Alienation'' search term. For example, ''Parental
Alienation'' and ''Adult Children''. After removing duplicated results,
154 articles remained. The articles duplicated across the three
databases were removed based on the database with the least complete
information. Of the 154 articles, only four were duplicated across the
three databases, leaving a total of 150 articles screened for inclusion.
One hundred fifty full-text articles were excluded. Therefore, no
articles were included in the peer-reviewed academic articles literature
review. The breakdown of the database searches is recorded as follows.

The first search in the Medline (Web of Science) database using Medical
Subject Headings (MeSH) terms showed 78 results under the keyword
`parental alienation' and `parental alienation,' and subsequent keyword
combinations (refer to page 2). However, within those 78 results, none
of the articles pertained to adult survivors of severe parental
alienation or the mental health practitioners who work with them.

The second search in Psychiatry Online showed 58 results under the
keywords `parental alienation' and `parental alienation' and consequent
keyword combinations. However, within those 58 results, none of the
articles pertained to adult survivors of severe parental alienation or
the mental health practitioners who work with them.

Results from the third search in PsycNET (APA) showed 14 results under
the keywords `parental alienation' and `parental alienation,' and
subsequent keyword combinations (refer to page 2). However, within those
14 results, none of the articles pertained to adult survivors of severe
parental alienation or the mental health practitioners who work with
them.

A second search of PsycNET (APA), including APA PsycInfo, APA
PsycArticles, APA PsycBooks, APA PsycTests, APA, and PsycExtra, showed
three results. However, none of the articles pertained to adult
survivors of severe parental alienation or the mental health
practitioners who work with them. Due to the Researcher not achieving
any results at the upper levels within the three original databases and
the additional databases within PsycNET (APA), the study concluded that
more searching would not create more relevant data, so the data
collection was finalised.

In conclusion, the scoping review of the peer-reviewed literature has
analysed the currently available research data on the thesis topic,
``Working with Adult Survivors of Severe Parental Alienation: Survivors
and Mental Health Practitioners Perspectives - A Qualitative Study.''
The Researcher has determined that there are no articles on treatment
protocols for mental health practitioners who work with adult survivors
of severe parental alienation from the chosen keywords within the
peer-reviewed academic databases available.

Results Figure 1 PRISMA Flowchart of Peer-Reviewed Academic Articles .

\subsection*{Grey Literature Results}

{\label{grey-literature-results}}

The combined first keyword search of the grey literature on Google,
namely websites, and website blogs, identified 19,787,999 records on the
`Google page results'. Only the articles that specifically mentioned the
study keywords were included in these results. A reduced total of 49
records that included the relevant keywords were identified within the
first three Google pages and screened for inclusion, leaving a total of
not relevant results of (n=19,787,950).

Following the Google search, two `recommended to researcher' websites
and one `recommended to researcher' Facebook page and 24 books that
mentioned `children, adults, PA and SPA' were also located and screened
for inclusion (a total of 27). Twenty-three full electronic articles
were assessed for final eligibility, plus two books, one `recommended to
researcher' website and a `recommended to researcher' Facebook page.
Four final results were found from within the combined grey literature
sources. The first grey literature book result was `Restoring Family
Connections' by Baker et al. (2020). The second result was a book called
`An Attachment-Based Model of Parental Alienation - Foundations' by
Childress (2015). The third resource was a website by Childress (2020),
offering free treatment protocol resources, ethical standards and
professional practice guidelines for mental health professionals. Also,
a six-monthly program (service fee) for clinical consultations for
mental health practitioners who work with the child and adult survivors
of mild to severe PA or in Childress' language, `Attachment-based PA'
(ABPA) internationally, was offered. Finally, therapeutic consultations
offered explicitly for adult children of ABPA were also advertised
monthly on Dr Childress' Facebook page (Childress, 2022).

Results Figure 2

PRISMA Flowchart of Grey Literature Scoping Review .

\subsection*{Peer-Reviewed Articles Reporting on Family Therapy
Programmes}

{\label{peer-reviewed-articles-reporting-on-family-therapy-programmes}}

No peer-reviewed articles reporting on treatments available to mental
health practitioners who work with adult survivors of SPA were
identified in this review.

\subsection*{Grey Literature Books}

{\label{grey-literature-books}}

The first search included grey literature books currently available to
purchase in Australia. The grey literature book search produced two
results out of twenty-four written for mental health practitioners. The
book by Baker, Fine and Lacheen-Baker (2020) offers a how-to guide
manual recommended for licensed mental health professionals who work
with targeted parents and their adult children of PA. Baker is a
developmental psychologist and researcher, Fine is a licensed clinical
social worker, and Lacheen-Baker is a licensed practical nurse.

Baker et al. (2020) also explain that treatments are available elsewhere
for families affected by PA but are not readily available. However,
these references did not explain the treatments or where they could be
found. The program described by Baker et al. (2020) includes
``theoretical principles of PA'', ``Restoring Family Connections
Pre-program Sessions'', and `In and Out of Session Activities'' .
Testimonials were sourced from professionals with a specialist
understanding of PA. The essence of these professional testimonials is
to recommend this book to therapists who may need support and guidance
when working with alienated adult children. There were no testimonials
recorded from older children or targeted parents who had been through
the programme, and no costs were mentioned for programmes that
practitioners might design for themselves from the book.

The second book was written by Childress (2015). Childress is a licensed
clinical psychologist in California, America. In his book called ``An
Attachment-Based Model of Parental Alienation (ABPA): Foundations'',
Childress presents a model of PA using existing frameworks such as
family systems, attachment systems and personality. In addition,
Childress discusses issues faced by mental health professionals,
including diagnosis, treatment, and professional competence required
when working with SPA clients. The cost of training for mental health
practitioners is not mentioned in this book.

\subsection*{Grey Literature Database
Search}

{\label{grey-literature-database-search}}

In the second grey literature database search, no results were produced.

\subsection*{Google Search}

{\label{google-search}}

The grey literature Google search found articles on interventions for
children experiencing PA and SPA but not about adult survivors of PA or
SPA. Therefore, the below table has ranked programs according to their
position within the Google directory.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Google website search results.\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Synopsis of websites.\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Turning Points for Families (Texas, USA) is Run by Loretta Maase (MA,
LPC-S) and associates .\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Advertises an intensive four-day treatment for families experiencing
SPA. No examples of the curriculum, protocol, or interventions were
available to read, nor were any costs mentioned.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Friedlander and Walters' Multimodal Family Intervention\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
A reunification therapy with varying interventions for parental
alignment, enmeshment, alienation, and estrangement. No costs were
mentioned.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Sullivan's Overcoming Barriers Family Camp (Sullivan et al.,
2010).\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
The Overcoming Barriers article advertised a ``combination of
psycho-educational and clinical intervention within an environment of
milieu therapy'' .\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
The Family Forward Reunification Therapy and Counselling Program is a
reunification therapy and counselling program.\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
This website is run by Jones (a child and family therapist) and
Associates (2022). This program advertises that they offer a unique
program that is given referrals by the Court system to establish
``appropriate, healthy child-parent relationships''\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
The Stable Paths program.\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
This program uses the treatment model created by Transitioning Families
and is advertised as an outpatient approach to therapy for moderate to
severely alienated children in California . No costs were
mentioned.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\subsection*{Websites and Blogs Recommended to
Researcher}

{\label{websites-and-blogs-recommended-to-researcher}}

The search of websites and blogs recommended to the Researcher is listed
in the order in which they were undertaken.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Recommended websites and blogs.\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Synopsis of recommended websites and blogs.\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
PASG is an international, not-for-profit corporation .\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
No treatment protocols for adult survivors of SPA were found on the PASG
website or blogs.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
The Family Separation Clinic advertises that they specialise in working
with children who may potentially reject a relationship with their
loving parent .\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Training of PA Practitioners who work with children and their families
is offered. However, no training for practitioners who work with adults
who have experienced mild to severe PA was mentioned. No examples of the
curriculum, protocol, or interventions were available to read, nor were
any costs mentioned. No treatment protocols for adult survivors of SPA
were found.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Resetting The Family website .\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
This website advertises that they ``help your family~\emph{create a new
family model}~by using both a series of intensive educational programs.
Programs are not offered to train mental health practitioners. No
treatment protocols for adult survivors of SPA were found. No costs were
mentioned.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
The Conscious Co-Parenting Institute advertises the `High Road to
Reunification Program' run by Pruter (CCPI CEO/Founder).\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
The blog states that the method used in this program is known as the
`Custody Resolution Method'. . Adult survivors of SPA were not
mentioned. Costs were not mentioned.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Dr Craig Childress advertises working with mental health practitioners
who work with PA and SPA. Dr Childress also works with adult children of
ABPA.\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Childress also offers a Clinical Case Consultation Group for mental
health professionals for a six-month block for 90-minutes once per
month.~ The cost is \$450 (USD) for six months . Treatment-related
essays for children were included . Childress also works therapeutically
with adult survivors of mild to severe parental alienation (Childress,
2022).\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\subsection*{Discussion}

{\label{discussion}}

This study aimed to review the academic peer-reviewed and grey
literature to identify current evidence-based best practices used by
mental health practitioners working therapeutically with adult survivors
of SPA. Based on the first aim, the second aim was to offer
recommendations for therapeutic skills required to achieve effective
intervention strategies and effectual outcomes on how mental health
practitioners can assist adult survivors of SPA. The third aim (see page
19) is based on the first and second aim results and highlights areas
for future research.

The study revealed that the essential ingredients for interventions for
adult survivors of SPA include building trust and rapport with adult
survivors who have difficulty trusting others . Mental health
practitioners need to consider that these clients may have childhood
memories of feeling unloved, rejected, threatened, criticised, alone,
and subordinate well into adulthood . Mental health practitioners also
need to be aware that they treat a poorly understood form of trauma .

The scoping review has revealed substantial gaps supporting
empirically-based and researched interventions and treatment protocols
for adult survivors of SPA. In addition, the review has identified that
ethical standards and professional practice guidelines that include a
comprehensive treatment protocol for mental health practitioners who
work with adult survivors of severe parental alienation do not exist and
need to be developed. Also, to understand the degree, acuity,
complexity, and severity of the developmental and ongoing acute trauma
of severe parental alienation, gold standards for competence, training,
and ongoing professional development for mental health practitioners
working with adult survivors must be determined.

Currently, finding this level of support and training has been very
difficult for practitioners working with adult survivors of SPA.

The third aim of the study identifies that trauma-informed training and
education for mental health practitioners who work with child and adult
survivors of SPA is where future research and training needs to focus.
For example, it is imperative that mental health professionals
understand a ``disorder that centrally involves the child's attachment
system and must possess professional expertise in the nature and
functioning of the attachment system, both foundationally and as
expressed at differing developmental periods, including adulthood, as
well as trans generationally'' .

\subsection*{Challenges and Limitations of the Interventions and
Treatment
Protocols}

{\label{challenges-and-limitations-of-the-interventions-and-treatment-protocols}}

The grey literature search found a range of programs and interventions
related to family reunifications and therapies designed for children. Of
note was the paper by Templer et al. (2017), where several therapeutic
programmes, each specialising in forms of systemic family therapy, were
identified. These programmes aimed to protect children experiencing
parental alienation from further harm; improve the child's psychological
well being; strengthen the child's critical thinking skills; challenge
the child's distorted thinking; prepare the alienating parent for
improvements within the condition of the targeted parent, and child
relationship; promote healthy boundaries; and strengthen communication
within the family . Psychoeducation for all family members regarding the
effect and treatment of parental alienation was also recommended . With
regard to the general public, awareness campaigns on parental alienation
and the promotion of engagement in support networks for targeted parents
may be advantageous . The study addresses the importance of mental
health practitioners being trained and cognisant of the underlying
attachment and systems theories when working with adult survivors.
Understanding the probable mechanisms that explain the link between
intergenerational cycles of family and domestic violence and SPA within
this unique population is vital. However, the gap in the literature
regarding interventions and treatment protocols for adult survivors of
SPA available to assist mental health practitioners was profound. Adult
survivors of SPA also face challenges finding practitioners who offer
professional help for SPA. Also, developing best practices in response
to SPA is required to ensure that practitioners are adequately trained
and equipped to respond to the needs of adult survivors of SPA upon
presentation.

Conc\textbf{lu} sion

In conclusion, this scoping review offers new insights leading to
behavioural and relational interventions for researchers and
practitioners who work with trauma and violence. The adverse effects of
PA and SPA have been continually noted regarding children of prolonged,
high conflict custody and visitation disputes. For example, ``much is
known about how exposure to PABs harms children. Now is the time to
apply that knowledge to protect children from experiencing this
pernicious form of childhood maltreatment''\emph{.}

The insidious impact of PABs on adult survivors of PA in childhood
demonstrates the need for valid, research-informed interventions for
adults exposed to PABs . Also, the adverse effects and accompanying
treatment protocols that address the complex cross-sectionality of
distressing events that adult survivors of SPA may have been exposed to
as children have been neglected. This emerging area needs an urgent
light shone upon it to break the cycle of intergenerational trauma,
support the adult survivors, and train mental health practitioners to
achieve the confidence and professional competence needed to work with
this vulnerable population.

Appendix 1 Grey Literature Review Keyword Search List

Search 2- parental alienation* parental conflict* children* adult* and
treatment*.

Search 3- parental alienation* child* treatment program* and
reunification program*.

Search 4- reunification camp*.

Appendix 2 Grey Literature Database Keyword Search Strategy

The first grey literature database keyword search was developed from the
Australian Government website, The Australian Institute of Family
Studies . The first keywords entered for the database search were:
parental alienation* child* treatment program* and reunification
program*. This search produced thirteen results; however, none were on
parental alienation or listed keywords.

The second grey literature database search was developed from the
Australian Government website, The Australian Institute of Health and
Welfare . This database keyword search repeated the keywords in the
first search. This search did not return any results. The following
message was displayed on the screen- Sorry, we could not find any
results matching~''parental alienation* child* treatment program* and
reunification program* .

The third grey literature database search was developed from the
University of the Sunshine Coast Library, named `Emerald Insight'. This
database keyword search repeated the exact keywords as the first and
second database searches. This search returned five results, none of
which pertained to the keywords. The five articles were about child
maltreatment and neglect, child protection cases, US Immigration Policy,
employment and crime, and diversity management .

The fourth grey literature database search was developed from the
University of the Sunshine Coast Library from the `All Newspapers'
option, which then directed the Researcher to the ProQuest database.
This database keyword search was repeated. This search returned two
results. One article was written in the Toronto Star Newspaper. It
contained the keywords parental alienation, child, treatment (not
program), reunification (not program) and another on Movies about the
North Sports final.

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