Health-related experiences of family court and domestic abuse in England: A looming public health crisis

Domestic abuse is known to be harmful to victim-survivor mothers’ well-being, and women are disadvantaged by gender-biased systems in England. Less is known, however, about victims’ experiences with family court specifically in relation to their mental and physical health. Interviews with 45 mothers were conducted to explore these experiences. Two main themes are presented here: (1) physical and mental health experiences associated with family court proceedings and (2) parental alienation allegations as a weapon to trap, silence, and pathologise mothers. From these themes, a conceptual framework was developed: Court and Perpetrator Induced Trauma (CPIT). These findings may have global significance for services and practitioners who work with mothers exposed to family court.


Private law proceedings and parental alienation
In 2022, 54,429 PLP applications were made in England and Wales (Ministry of Justice, 2022).Research suggests allegations or findings of DA are found in 49% to 62% of PLP applications (Barnett, 2020a).The Children and Family Court Advisory and Support Service (Cafcass, 2022) reports working with 102,500 children in PLP between April 2021 and March 2022.Reports such as the Ministry of Justice (MoJ) Harm Panel Report (Hunter et al. 2020) revealed entrenched systemic issues around recognizing and responding to harm.This and global evidence cite inherent biases in favor of fathers' testimonies and that courts are proliferating a "pro-contact approach" (Barnett, 2020b, p. 41) between children and abusers, placing children in harmful contact situations (Barnett, 2014(Barnett, , 2020a(Barnett, , 2020b;;Hunter et al., 2020;Khaw et al., 2021;Meier, 2020;Spearman et al., 2022).Allegations of parental alienation (PA) were described in the report as being used systematically to silence and diminish abuse allegations, placing victim-survivors at risk (Hunter et al., 2020).PA or more recently "alienating behaviours" is described by Cafcass (2022, p. 1) as: "circumstances where there is an ongoing pattern of negative attitudes, beliefs and behaviours of one parent (or carer) that have the potential or expressed intent to undermine or obstruct the child's relationship with the other parent." PA allegations are a litigation strategy and when used, courts disproportionately label predominantly mothers as "alienators."This highlights a highly gendered application and impact of these allegations (Haselschwerdt et al., 2011;Lapierre & Côté, 2016;Meier, 2010Meier, , 2020;;Meier & Dickson, 2017;Milchman, 2017;Prigent & Sueur, 2020;Walker & Shapiro, 2010).The world's largest study on custody outcomes found allegations of alienation "trump" any allegations of violence, leading to many mothers losing residency of their child (particularly concerning child sexual abuse) to the abusive father (Meier, 2020).In England and Wales, the government has twice rejected PA and "alienating behaviours" in the DA Act (2021) Statutory Guidance (Home Office, 2022aOffice, , 2022b) ) and Controlling or Coercive Behavior Statutory Guidance (Home Office, 2023).However, Cafcass continues to use a framework of "alienating behaviours." Concerns regarding these contradictory and siloed approaches to the issue of PA and how this impacts the safety, health, and well-being of mothers and children remain prevalent (Hunter et al., 2020;UNSRVAWG, 2023).Importantly, there is no official or agreed-upon definition of PA or alienating behaviors (Doughty et al., 2018).PA proponents acknowledge it is not possible to adequately differentiate between cases of unjustified alienation and those where a child is justifiably estranged from a parent due to abuse or other circumstances (Saini et al., 2016).

Parental alienation and healthcare systems
Global criticism has highlighted empirical inability to demonstrate markers of a mental health "syndrome" and so rejection of Parental Alienation Syndrome (PAS) and PA followed.Both terms have been denounced by many including: the European Association for Psychotherapy (2018), the United Nations (UN) Commission on the Status of Women (CSW, 2022) and Special Rapporteur for Violence Against Women and Girls (UNSRVAWG, 2023), Council of Europe (GREVIO, 2022), the World Health Organization (2020), and the American Psychiatric Association (2013).In England, concerns have been raised recently by the Association of Clinical Psychologists "that the evidence-base on parental alienation is not sufficiently robust to be making decisions about child-contact arrangements" (Observer, 2022).However, the use of PA's broader terminology and synonymous terms (i.e., "alienating behaviours" and "implacable hostility") has grown (Mercer & Drew, 2022).
Additionally, studies on PA along with associated "interventions" and "treatments" are increasing yet would not be considered sufficiently robust if measured by the National Institution of Clinical Excellence (NICE) guidance for the clinical practice of health professionals' criteria (Doughty et al., 2018(Doughty et al., , 2020)).There is no evidence that health professionals understand the complex arena that underpins PA as a litigation tactic to deny and perpetuate abuse within family courts.Furthermore, professionals report feeling ill-equipped to even identify DA (YouGov, 2019) and 85% of victims encounter health services five times before being referred for specialist DA support (SafeLives, 2017).Consequently, it appears application of consistent health, DA, and PLP frameworks is lacking and opportunities for identifying need may be missed.It is vital that professionals can identify any impacts of DA and PLP, to support victims effectively.As such, this study was conducted to explore the mental health experiences of PLP mothers in England who have been previously subjected to DA perpetrator behaviors.

Method
A qualitative study was conducted.The study was co-designed with an advisory group of multi-disciplinary professionals and female DA victim-survivors engaged in PLP in the last 10 years.The study benefited from ongoing input from conception through to study closure from these groups.Exploring lived experiences qualitatively allows for the investigation of phenomena from the perspective of how individuals interpret and attribute meaning to their existence, as well as informing larger epidemiological quantitative studies (Frechette et al., 2020;McGlinchey et al., 2021).

Recruitment
Female DA victim-survivors were purposively sampled and recruited nationally in England using email advertisement via groups supporting survivors through family court: #THECOURTSAID and The Survivor Family Network.The invite stipulated an offer to "explore the mental health and support needs of DA mothers who have been engaged in family court (FC)" with no references to PA or physical health.

Procedure
Forty-five in-depth semi-structured interviews were conducted and digitally recorded with mothers (aged 26-59 years) of 77 children (see Tables 1 and  2 for demographics), by two researchers (ED and DB) using Zoom.The semi-structured approach allowed participants to influence what was discussed while enabling data collection on specific research questions (Esterberg, 2002).Interviews lasted between 1 and 2 h.
Interviews were transcribed (verbatim).Analysis of data was undertaken using thematic analysis.Three researchers (ED, DB, and SA-K) individually conducted an initial thematic analysis of several transcripts using familiarization with the data, free coding, and identifying themes as described by Braun and Clarke (2006).NVivo 12 was used to support initial coding and organization.An initial coding framework was produced by all researchers to organize the data into meaningful groups.Weekly analysis meetings were held to discuss and refine coding.Codes were then refined  conjointly to form themes and subthemes until no new refinements were made.Two researchers analyzed all transcripts, with independent assessment by the third author.Ethical approval was granted by the University Research Ethics Committee, University of Manchester, ethics no: 2022-13743.Informed consent was obtained, and anonymity and confidentiality were maintained carefully by providing mothers with pseudonyms, with only one researcher having access to the pseudonymisation key.Participants were able to withdraw from the study up to one year after data collection.Following this, the pseudonymisation key was destroyed and data was no longer identifiable.

An overview of outcomes from proceedings
All participants reported alleged child abuse by the child's other parent.PA was presented as a counter-allegation to child abuse in most cases by fathers, social workers, Cafcass officers, the father's legal team, and/or magistrates/judges, with all allegations occurring sometime after family court proceedings had commenced and child abuse had been alleged.Two mothers believed they and their children were victims of PA by a perpetrator father, and the court refused to investigate.PA was investigated by the courts in all cases when raised against mother participants (39/45).While qualitative research does not aim to provide quantifiable results, it is notable that almost all mothers reported PA allegations.Of these cases, only a minority concluded with a rejection of PA allegations and/or found no facts supporting alienation.Investigation of DA in these cases was diminished or ignored due to the PA allegations.Almost all mothers expressed wanting only safe contact for their children and some had maintained/supported unsupervised contact.Psychology, health, social work, or medical experts were appointed in just under half of the cases to assess for PA.The mothers who were not directly accused of PA had all been threatened or warned that they would be accused of PA/synonymous terms if they did not support/maintain contact between the child and other parent.They were also pathologized in other ways such as being labeled as "bipolar." All but two cases resulted in an order for some form of contact with the reported perpetrator parent when proceedings had concluded.All cases where children and mothers reported incest/child sexual abuse or rape (and in some cases related criminal convictions) resulted in contact with the perpetrator parent, with four of these cases resulting in the child being transferred to the father's residency.The two cases not resulting in contact included one case where the child had been abducted by the perpetrator father and another in which the child had reached an age where the judge allowed the child to choose to cease contact.
Two main themes and a conceptual framework that emerged from the interviews are presented below.The main themes highlight the detrimental health experiences reported by mothers, which they attributed to PLP and PA allegations.The conceptual framework encompasses the reported health and trauma experiences of mothers and denotes the Actions, Behaviors, and Circumstances (ABCs) that mothers believed were associated with these trauma responses.Miles and Huberman (1994) defined a conceptual framework as a visual or written product, one that "explains, either graphically or in narrative form…the key factors, concepts, or variables and the presumed relationships among them" (p.18).

Physical and mental health experiences associated with family court proceedings
A summary of the physical, mental health, and other experiences as reported by mothers is provided in Table 3, with supplementary quotations in Table A1 (see Appendix A).The mothers reported wide-ranging mental and physical health experiences, where they perceived their physiological conditions to indicate the somatization of stress either immediately associated with or exacerbated by PLP.Questions on physical health experiences were not asked, yet these issues were commonly raised by participants.Mothers consistently reported physical harm to health as associated with PLP, with several citing multimorbidity.This was repeatedly noted by mothers as somatised stress and trauma responses.A minority of mothers reported existing health problems as due to the DA behaviors they had experienced prior to PLP.However, all those mothers felt that the proceedings had severely intensified these conditions.Those without preexisting health problems reported an almost complete loss of their former health and well-being, which they felt was due to PLP, and often impacted their work and home life: …health-wise I was super, super fit, always have been for years… my body's just kind of fallen apart, so I've rapidly gained three stone, which is un-shiftable, and it's not even triggered by eating, it's just come on through huge levels of cortisol… I now have interstitial cystitis, so it's stress-induced, so that's just all the time….(Margaret) Participants rarely reported health professionals viewing health problems as stress and trauma responses to proceedings.One mother (Catherine) described feeling "lucky" her consultant had linked the proceedings to her physical health conditions, suggesting that observation and action such as this from health professionals was perceived as unusual.Medicalization (where conditions and problems come to be defined and treated as medical conditions) and pathologisation (to imply there is something psychologically abnormal with an individual) of mothers' stress responses to proceedings by health/medical professionals were common.Pharmaceutical treatment including beta-blockers, anti-psychotic, anti-depressant, and other anti-anxiety medications such as lithium and citalopram was reported.For some, this then resulted in further physiological harm (see Appendix A, Janine).
Some mothers reported severe harms to their loved ones as well, with one mother attributing the death of her father to the stress of the proceedings and another describing her mother having a cardiac arrest in the middle of a court hearing (see Appendix A, Paula).
There were a minority of cases where mothers attributed their cancer to the wider experiences of the stress of continual legal proceedings (see Appendix A, Tamara).Many mothers also discussed the invisible labor of managing court-related activities, which they felt brought added pressures and trauma to their lives:

It's vaginal cancer… because that has been created because my immune systems was really low and has created a fluid that was going to my internal parts. And that fluid was generating the beginning of the cancer… Because we talk about… it's 11 years in court. (Gloria)
Whilst the mothers frequently cited the duality of mental and physical experiences, mental health experiences such as grief, suicidal ideation, depression, PTSD, and anxiety were at times raised independently and consistently linked to proceedings and the fear of or actual child removal from the mothers' residency.One participant, Charlotte, stated, "I've been suicidal because of this.I've been under Crisis Point because of the court process…" At times mothers discussed hearing of other mothers who had died by suicide, attributing this as due to court proceedings and identifying with this experience (see Appendix A, Halina).
Discourses of "fear" and being "traumatised" were most drawn upon to describe mothers' experiences of court and at times linked to the unjust nature of proceedings.Some expressed this injustice as breaches of their and their children's human rights, citing the proceedings and the behaviors of perpetrator fathers and court actors as making mothers feel they were being "tortured" and in a war-like situation (see Appendix A, Kimberley).The reported mental health experiences were often prevalent long after proceedings had ended with mothers describing "flashbacks" and "triggers" related to court.Many mothers provided comparative harrowing events to highlight how deeply traumatic court experiences were for them.Charlotte explained, "I've had a child with cancer… and this has been worse than going through that." Mothers in the study who represented minoritised ethnicities felt keenly that institutional racism created an additional impact on their mental health and heightened trauma response.This was again tied to a violation of their rights: I'm not just a woman, I'm a brown woman… when you're assertive, especially if you're Asian or Black, you get labelled as aggressive… I go into fight or flight and I can't even think straight…they don't listen, they don't understand and they sit there in judgment and they've already decided before you walk in… it's just like a play.(Halina) Metaphors related to unfathomable, disjointed, and destabilizing worlds were also consistently referred to, where mothers often described feeling as though they were on a "topsy turvy alien planet," "in Alice and Wonderland," and "discombobulated."Some equated the family court, its actors' behaviors, and the impact on their mental health as being "Kafkaesque" (see Appendix A, Jemima).

Parental alienation allegations as a weapon to trap, silence, and pathologise and as harmful to mothers' health
Mothers reported consistently that PA was raised as a counter-allegation to abuse reports after child abuse had been alleged, with only a minority of cases not concluding there was PA.Mothers described how PA not only shifted the focus of proceedings once raised but also diminished and often completely side-lined the investigation of DA and child abuse.This was again linked by mothers to fear following threats of child removal, which manifested as traumatization and suicidal ideation (see Appendix A, Rose).
Participants described PA as frequently drawn on by perpetrator parents and court actors as a mechanism of coercive control to silence abuse allegations and to pathologise mothers and children reporting abuse.At times they referred to this as "DARVO" (Deny, Attack, and Reverse Victim and Offender), that is, raising PA was used to divert the court's attention away from the perpetrator's abusive behaviors and conversely to position mothers as lying and emotionally abusing the children via PA (see Appendix A, Rose).
Mothers described that the more they resisted the PA allegations and advocated for their child, the more harshly they were treated by professionals and the more they were pathologized with PA and threatened with transfer of residency or reduced contact until they or their children were silenced (see Appendix A, Janice and Amelia).This was cited as particularly damaging to their health in terms of the fear and trauma this invoked: PA was a mechanism of its own social preproduction-any behavior, event, or situation could be described as an indicator of alienation.Living in this alienation self-fulfilling prophecy was reported by mothers as harming their mental health leading to symptoms of depression and PTSD.Mothers astutely commented on this "catch 22" situation.This also hindered mothers' ability to access support for their health experiences, which they felt were attributable to the proceedings and PA allegations (see Appendix A, Bridget):

…this is a ploy, I think, because she [daughter] doesn't want to see him [father] a lot, she just wants to see him a bit. So, she writes a letter and says, "actually, I just want to see you like this;" he can just go… "This is what mother has done"… I don't talk to my doctor about my mental health ever… he' d [father] just get a copy of my medical records and go, "look… she can't cope. " (Doreen)
Mothers often reported feeling that they were deliberately trapped in legal proceedings and related health/medical interventions as allegations of PA at times led to some being forced to attend PA "therapy" while also hindering them from accessing support from other non-PA medical professionals.They described perceptions that courts "pushed" them into an inescapable PA trap, where professionals were seen as pursuing an "alienation agenda" and then construing mothers' trauma responses and help-seeking as indicators of PA (see Appendix A, Kimberley and Bridget).
Figure 1 highlights the intersecting and cyclical health, medical, and legal trap mothers experienced when PA allegations were raised.Mothers reported health implications, which they perceived as attributable to the stress and trauma they felt due to their child reporting abuse, PLP, and PA allegations.They felt any expression or reporting of these experiences was attributed by professionals to being an indicator of PA, representing a circular trap (see figure 1).
Mothers consistently reported that the Actions and Behaviors of the perpetrators and other court actors working in and around proceedings as well as the court-related Circumstances (ABCs) were experienced as harmful to their health and well-being.They felt these ABCs induced trauma, devalued their experiences, and were a hindrance in achieving their and their children's safety and ability to heal from the abuse.We have conceptually framed mothers' experiences as Court and Perpetrator Induced Trauma (CPIT), denoting a dual representation of these ABCs and trauma responses (see Appendix A, Bridget).
Mothers discussed perceived collusion between court actors to work against mothers who report abuse and provided examples to substantiate these perceptions.They highlighted an imbalance of power dynamics, where mothers felt they were trying to advocate for the children against a collective of powerful professionals.Mothers described particularly abusive interactions in detail, which they reported created heightened stress and trauma responses.An expert witness psychologist reportedly explained to a mother in her home that he was in a powerful position over her and her child's destiny and emphasized his ability to wield this power by describing a previous occasion where he had achieved this: …one of the first things he [psychologist] started off with was saying how he' d had a 15-year-old child removed from her parents and put into care on the basis that he felt they [parents] were useless… The judge hadn't wanted to but he and the Cafcass officer had really worked on the judge to get them to agree that she should be put into care and he was really proud of that… (Deborah) The mother implies that this interaction made her feel unsafe, describing an instantaneous stress and trauma response where her heart "flipped."She stated, "When he said that my heart just sort of flipped… he told me how he thinks he can manipulate judges and the power he's got over judges." The expert is then described as using his physical stature and verbal aggression to re-emphasize his position of power over her, which mirrored the abuse she had been subjected to by her ex-partner.Additionally, he devalued her description of herself as a victim-survivor who had received support following her ex-partner's abuse (by devaluing the DA support she received), which cumulatively resulted in her physically "cowering" in her home.She felt that this not only hindered her healing but created an abusive interaction in and of itself, which she described as inducing a trauma response.She believed the language used also had misogynistic undertones (see Appendix A, Deborah).
Several mothers directly described the behavior of some court professionals as "dehumanising," "abuse," and "torture," and similarly felt that proceedings subjected them to secondary victimization, mirroring the abuse of perpetrators and making them feel unsafe.However, these actors were perceived as much more powerful than the perpetrators, having the ability to remove mothers' legal rights and that of their children, which was framed by many as "shocking," "destabilizing," and "psychological abuse" (see Appendix A, Catherine).
Medical records were accessed at times without consent and leveraged to victim-blame and pathologise mothers.These records were also treated as evidence of the mother being "unstable" or "disordered" in some way.This further inhibited healing and acted as a barrier for many mothers in seeking support.Thus, being continuously suspended in ongoing court-related circumstances was a barrier to healing (see Appendix A, Janine and Gemma).
There were some, but fewer, examples surrounding supportive behaviors from court actors.One judge acknowledged the mother's "appropriate reaction" (trauma response) to abuse, indicating heightened understanding of DA/coercive control.This brought "relief " and validation to the mother, Abigail, who said, "Part of his judgment acknowledged how significant the impact of the coercive control was on my mental health…which I thought was a relief to have that acknowledged."

Health-related experiences
The research has illuminated the overall health and well-being experiences of female victim-survivors and offers insights for those working with these groups.Mothers described the negative consequences to their health, which they believed were attributable in some way to their engagement in PLP.We frame these as trauma-inducing Actions, Behaviors, and Circumstances and associated responses, or as we have conceptually coined this as Court and Perpetrator Induced Trauma (CPIT).
CPIT goes beyond a framework of legal abuse or harassment (see Clemente et al., 2019;Coy et al., 2015;Douglas, 2018aDouglas, , 2018b;;Elizabeth, 2020;Gutowski & Goodman, 2023;Kaye et al., 2020;Rivera et al., 2018;Vollans, 2010).These authors define legal abuse broadly as DA perpetrator use of litigation and judicial systems to continue abuse and control of victims which can lead to subsequent mental health experiences.Our findings echo this work and extends it by defining CPIT which includes: (1) the Actions, Behaviors and Circumstances (ABCs) that are deemed by the mothers as trauma-inducing (which may include actions and behaviors of abusive fathers and other court actors and the broader circumstances (Home Office, 2022a), (2) the trauma responses of these mothers to these events, and (3) within the latter, potentially linked physical and mental health trauma experiences.No previous studies have identified perceived physical health impacts (although Douglas (2018b) briefly mentions weight loss) or explicated possible links between trauma and physical health experiences in this context.Additionally, no previous studies have highlighted court and court-related professionals being perceived by mothers as perpetrators of abuse within the definition of legal abuse.We argue CPIT illuminates these important experiences and makes visible those actors who may be utilizing abusive behaviors, which may help define and communicate accountability.Further, these findings may have global significance for family courts, health and social care services, and practitioners working with these women.This supports the need for a trauma-informed approach to victim-survivors (Taylor, 2022).This framework now requires further refinement, independent testing, and corroboration.

Health, trauma, and private law proceedings
The most common chronic conditions in the UK include high blood pressure, low back disorder, and depression (ONS, 2020), and so it is notable that mothers here frequently reported a wide range of mental and physical chronic conditions including and beyond these.Interestingly, the most common conditions reported here are not regularly found in the general population such as autoimmune conditions (13% of UK women; Conrad et al., 2023) and gastrointestinal conditions (1.1% of British women; Ehlin et al., 2003), which mothers reported were associated with PLP.
Our findings support the broader evidence base linking the impact of stress to trauma responses, suicide and self-harm, autoimmune deficiencies, gastrointestinal conditions, myocardial and maternal health implications, and cancer (Eckerling et al., 2021;Friedman et al., 2007;Herman, 2015;Lambert, 2009;Maercker et al., 2022;Quenby et al., 2021;Song et al., 2018;Vaccarino et al., 2021;Van der Kolk, 2014).Recent research reports women who experience DA are three times more likely than other women to attempt suicide (Agenda Alliance, 2023;McManus et al., 2022).Our participants frequently associated suicidal ideation and suicide of mothers known to them with PLP suggesting links between DA, PLP, and suicidal ideation require further investigation.Additionally, the WHO (2020) recommends surveillance of multiple risk factors concerning cancer and other non-communicable diseases (NCDs) etiology.This now includes mental health, suicidal ideation, and violence perpetrated by an intimate partner and legal or official authorities.However, the WHO does not recognize the potential interconnected links between stress, suicidal ideation, violence from others, and cancer.Yet studies are now pointing to physiological stress and insomnia as potentially linked to the onset of vaginal and cervical cancer (Rai et al., 2022).Further exploration of potential causal links is now required.In the UK, it is known that social determinants of health trigger stress pathways affecting mental health and other NCDs.Thus, targeted identification of preventable risk factors can help reduce this (Marmot & Bell, 2019).Developing and testing CPIT may improve risk-factor identification and prevention of NCDs.
We have expanded upon insights from numerous others concerning the health and well-being impacts of DA and post-separation abuse (Chandan et al., 2021;Crosse & Millar, 2017;DA commissioner report, 2022;Estefan et al., 2016;Ford-Gilboe et al., 2011;2015;Katz, 2022;SafeLives, 2017;Spearman et al., 2022;Stark & Hester, 2019;Trevillion et al., 2013;Women's Aid, 2022).We echo the call from Clemente et al. (2019) for further ethical (and trauma-informed) guidelines in legal arenas and we add for medical and health professionals, who may be called as expert witnesses and who may not understand the severe mental health consequences that such traumatic circumstances can produce.Many mothers, already disadvantaged by social determinants of violence and health, discussed medicalization and felt their mental health may be used against them (Home  Office, 2022c;Women's Aid, 2022).Diagnosing and treating women for psychiatric symptoms often prevents health and social care professionals from recognizing abuse, which diminishes victim's experiences and perpetuates victim-blaming.Consequently, increasing DA knowledge and expertise among professionals is urgently required (Thiara & Harrison, 2016).
Participants described the "relentless" nature of proceedings as entrapping them and as an omnipresent influence on their health, well-being, work, mothering, and lives broadly.It hindered their ability to negotiate safety and psychological healing for themselves and their children, echoing research reported in the UK and globally (Barnett, 2020a(Barnett, , 2020b;;Birchall & Choudhry, 2018;Katz, 2022;Spearman et al., 2022;Stark & Hester, 2019).In a minority of cases women felt supported by those who understood DA and coercive control, emphasizing the importance of this knowledge in court professionals.

Human rights of women in PLP
The secondary victimization mothers felt within PLP has been reported elsewhere and strongly condemned as an unacceptable form of gender-based violence perpetuated by societal inequity between men and women (UNSRVAWG, 2023).Globally, close to 9 out of 10 men and women hold fundamental biases against women (UN Development Programme Gender Social Norms Index, 2023).Participants frequently reported experiencing expert witnesses as dismissive, biased and judgmental (UNSRVAWG, 2023).Mothers also perceived this secondary victimization as "worse" than perpetrator behaviors and as "dehumanising."Such descriptions have been echoed by mothers in previous studies (Birchall & Choudhry, 2018, 2022;Choudhry, 2019).This was also perceived as having much more powerful and harmful consequences for victim-survivors than the original abuse.It represented, in their views, a collective of professionals acting against them.It is imperative that victim-survivors feel supported and not further harmed in PLP.
These professional behaviors may be seen as abusive or even criminal and as breaches of human rights.The former UN Special Rapporteur on Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment (UNSROT, 2019, p. 8) has noted private actors and state officials can be "direct perpetrators of domestic violence" via "endorsement of harmful practices" (such as coercive control) and failing to safeguard victims.We add, urgent investigation is now required to ensure the courts and related actors do not engage directly in conduct themselves that may be considered as torture or cruel and inhumane treatment.Mothers' and children's rights to be free from such treatment are an absolute right under Article 3 of the European Convention on Human Rights (ECHR).Professionals should instead "pivot to the perpetrator," making them accountable for their abuse rather than victim-blaming (De-Simone & Heward-Belle, 2020).
Mothers also reported the silencing of themselves and their children in relation to a range of abuses including child sexual abuse.Under Section 1 of the Children Act (1989) in England, courts are guided by the principle that the welfare of the child is paramount.Our study suggests that the best interests of the child and their rights under Articles 3 and 12 of the UNCRC are downgraded in PLPs in favor of the best interests/rights of the abuser (Choudhry, 2019;MacDonald, 2017;UNSRVAWG, 2023).DA and child abuse are crimes and should be investigated as such.It is highly concerning that these alleged crimes are being investigated within the family courts, which are intended to oversee and resolve disputes and child living arrangements, not to make findings on whether criminal abuse has occurred (Judiciary UK, 2023).Upholding children's best interests will protect them and protect the safety and human rights of victim/survivor mothers including their rights under the Istanbul Convention, which opposes DA and violence against women.
Specific attention should now be paid to minoritised women and those who were under-represented in this study such as Black women and women with disabilities.This will allow exploration of the additional impacts of intersectionality, implicit and explicit biases, institutional racism, and sex/ other protected characteristic discrimination on victim-survivors (Barnett, 2020b;Equality Act, 2010;Thiara & Gill, 2012).It may also be prudent to examine further geographical characteristics of court experiences in more depth to enable targeted support interventions for victim-survivors and professionals who work with them.Mothers in the Southeast of England appeared to represent a notable hot spot of negative experiences within our study, based on the higher rate of self-selection of mothers from this area.This may also indicate socio-demographic variables in participation.It appears that three years after the Harm Panel report, the harmful pro-contact approach remains, along with the systemic minimization of abuse in family courts and harms experienced by mothers and children (Barnett, 2014(Barnett, , 2020a(Barnett, , 2020b;;Birchall & Choudhry, 2018, 2021;Coy et al., 2015;Holt, 2018;Hunter et al., 2020;Hunt & Macleod, 2008;Macdonald, 2017;Thiara & Harrison, 2016;Women's Aid, 2022).We must urgently address why the recommendations and calls to action from others have not been heeded.

Parental alienation, PLP, and health
There remains no reliable UK data on the prevalence of the use of PA allegations.However, our findings echo evidence from research globally that these allegations are utilized to portray mothers as unfit parents, gendered in their deployment and effect, and that courts are disinclined to explore allegations of PA when raised by mothers (see Gutowski & Goodman, 2020, 2023;Meier, 2020;Meier & Dickson, 2017;Mercer & Drew, 2022;Sheehy & Boyd, 2020;Spearman et al., 2022;Women's Aid, 2022).PA allegations were raised as a counter-allegation after child abuse had been raised and this phenomenon requires further attention.Our findings replicate studies that report negative outcomes for mothers and children in cases where abusive fathers claim PA, particularly where child sexual abuse, rape, or incest disclosures are made (Barnett, 2020a;Birchall & Choudhry, 2022;Elizabeth, 2020;Feresin, 2020;Hunter et al., 2020;Laing, 2017;Lapierre et al., 2020;Meier, 2020;Mercer & Drew, 2022;Milchman, 2021;Rathus, 2020;Sheehy & Boyd, 2020;Zaccour, 2020).
PA allegations were used against our participants as a weapon to minimize, deny, and rebut DA (Barnett, 2020a(Barnett, , 2020b;;Birchall & Choudhry, 2022;Katz, 2022).This shifted blame and controlled and discredited victim-survivors' reports of abuse (DARVO; Harsey & Freyd, 2020).Additionally, a PA allegation in and of itself may be linked to specific harm to the health of mothers.Mothers reported the PA allegations triggered a set of associated events that trap, silence, and control them and their children, mirroring abusive acts of perpetrators and exposing them to harm.Our findings support studies that found mothers' mental health and accessing support were weaponised against them, (Gutowski & Goodman, 2020;Watson & Ancis, 2013) and was deceptively interpreted as an indicator of PA (Dallam & Silberg, 2016).Subsequent trauma responses to PA accusations were also at times pathologized as indicating PA.This contributed further to "assuming causation from observation" (Dallam & Silberg, 2016, p. 136.) and entrapment of mothers (Figure 1).The lens of PA is therefore evidenced as one which reinforces a bastille of oppression to mothers.
DA represents an economic burden of £74 billion annually (Home Office, 2021).Most of these costs relate to physical and mental harm.There are currently no UK studies linking these health outcomes and child arrangement outcomes, nor data describing the frequency of PA counter allegations.So, it is not possible to estimate how far-reaching these potential health impacts are.This study provides starting points for large-scale epidemiological and economic research, which is now required to establish whether there are causal links between health outcomes and PLP.Urgent intervention is now required to stop this harm to victim-survivors.
PA remains a highly controversial pseudoscientific belief system (Mercer & Drew, 2022) and highly dangerous weapon of choice which therefore should not be unopposed (UNSRVAWG, 2023).In cases where children are weaponised by a parent to exert control over the protective parent, this may be explored within a coercive control and in-depth examination of the wider pattern of behavior of the perpetrator parent within the context of the parent-child and parent-parent relationships, the history of abuse/relationship, and broader contextual factors (De-Simone & Heward-Belle, 2020;Home Office, 2022c, 2023).

Strengths and limitations
The study is limited in that it represents qualitative, self-reported data.The reported health links, conceptual frameworks, and outcomes have not been tested and experiences are not evidence of causality.The findings are, however, equally valid and important as reflecting these mothers' lived experiences.Additionally, participants are not considered a representative sample and thus work with a more representative sample is needed.Regarding strengths, the findings highlighted structural disadvantages and intrinsic societal misogyny which are acknowledged in DA legislation (DA Act, 2021) and therefore may provide transferable insights into the wider population of mothers.Further, the term PA was not used in advertising the study, therefore, the finding that participants frequently reported PA counter-allegations improves the validity of the findings.Similarly, physical health experiences were not explicitly asked about, making these descriptions of such experiences even more important.

Recommendations and conclusion
We recommend the following: 1. Immediate intervention and an urgent review into the practices of all professionals working in and around family courts is required to improve safety for victim-survivors and to understand the scale of harm being experienced in PLP in England.

Mandatory training and practice guidance for all professionals
working in and around family courts to improve system responses to DA, coercive control, and patterns of behavior, as well as build trauma-informed skills to enable practitioners to map behaviors, identify perpetrators, and support victim-survivor children and adults effectively.3. The use of "parental alienation" or "alienating behaviors" terminology and frameworks in family courts in England and associated treatments and therapies should be prohibited.The extant statutes on coercive control and DA are adequate to assess child manipulation.This should be coupled with an evaluation of the potential harms to health caused by PA allegations on mothers and families, and further testing and development of a trauma-informed framework for CPIT that may be used by health/medical professionals.
Mothers in this study experienced PA allegations and perpetrator and professional behaviors in the family courts as harmful to them and their children's health and safety.CPIT may account for a currently unknown extent of life-altering health conditions in victims and may indicate a looming public health crisis.Epidemiological, causal-comparative research is now needed.The findings have important implications for health, social, and legal professionals' practices and may help inform interventions to ensure victim-survivors are supported in a trauma-informed way in FC globally.The health and well-being of families cannot be given monetary value.It is essential that the institutions, services, and professionals aiming to protect victim-survivors, function to protect those they serve, rather than to harm.Additionally, exploration of the experiences of minoritised women and geographical patterns of court experiences require urgent attention.

Table 3 . physical, mental health, and other experiences as reported by mothers.
She[Cafcass officer] told me actually, in the garden, that if I didn't agree to contact, the judge would make a decision that I wouldn't like, and that was her threat to me on a change of residency… I was constantly accused of parental alienation, my hostilities towards father were highlighted… I used to go back and say, "let's refer back to source, what triggered my anxiety?"… and it just infuriated Cafcass more… It makes you think irrational thoughts… You become clinical… I wasn't sleeping…(Stephanie)

Table 1 .
Sciences, Faculty of Biology, Medicine and Health at the University of Manchester, Manchester, UK.Dr.Bramwell is a core founder member of SHERA RG.Ph.D., is a reader in Law at Brunel University, London Kingston Lane Uxbridge, Middlesex, UK.She is a core founder member of SHERA RG. https://twitter.com/BarnettAdrienne.Ph.D., MFPH, is a clinical professor of Public Health and Epidemiology, Director of Manchester Urban Collaboration on Health (MUCH) a World Health Organization (WHO) Collaborating Center, and honorary consultant in Public Health at Public Health England (PHE).She is based in the Department of Public Health, School of Health Sciences, Faculty of Biology, Medicine and Health at the University of Manchester, Manchester, UK. https://twitter.com/manchestermph.aware of my risks… that the court have pushed to… we would turn up to these sessions and they were just horrendous.I couldn't speak.Whatever I said… I felt literally it was just choosing not to understand… it felt deliberate.At the end of every session… she would give us an article to read about parental alienation… she made a shedload of diagnoses about me… it was just mother bash for 60 pages and concluded that the children should have a change of residence.(Adele) In my experience, the narrative is "there's no abuse, it's parental alienation, anyone else who disagrees is being influenced by the mum," by me … I was too afraid to say anything, and I learnt very quickly that if I tried to get help then that would be used against me too… "this is all you being manipulative and vindictive."(Bridget) It [DA] was just swept under the carpet… there must have been over 30 [child abuse] allegations… They were locked in a room.My eldest, she alleged that she'd had pins put into her.They came home with bruises that I saw… I was accused of parental alienation because my girls didn't want to see their dad, and I was threatened with my children being removed on numerous occasions by professionals.The fear that I felt every time I walked into that courtroom, was that I wouldn't be seeing my girls again that night.So yeah, their understanding of how that impacted on me, I don't think they put any consideration into the mental well-being of somebody that's going to lose their children, and the impact that has on the children, you know… I even said that if my children were taken away from me… I would kill myself, and I really would have done because I knew that's not what they wanted.(amelia) So, there's no impartiality.They were pursuing a parental alienation agenda.I feel like you feel very alone and small… I think the bullying, the kind of relentless pursuit, felt… it did deepen the posttraumatic… it was a deliberate move to prove mental health issues by pressuring… creating difficulty and pressure to manifest those issues.(Kimberley) I remember sitting… in this really big office and being questioned about the domestic abuse for over two hours by a junior solicitor.It was really traumatizing.I found it really difficult and then afterwards they said, "oh we're not going to use any of that…" They were constantly minimising… there was no understanding of domestic abuse at all.Or importantly the impact of domestic abuse on a child.Nothing…the health impacts are huge and it's relentless.(Bridget) I was trying to tell him I'd done the freedom programme and I had help from Women's Aid… he did my ex, basically.He went bright red in the face.He's a big bloke, brought himself up in the chair and he was just like [presses face to camera and shouts], "Women's Aid, Women's Aid, you see them on their tables, they're all men haters, they're all men haters!"Like that, right.So, when he left, I was cowering… I started off like a normal civilized human being on the settee with a cushion and I'd curled up with this cushion… (deborah) So, part of the psychological abuse is that rights that you have within the English law, under civil rights and under criminal law, were all removed.So, I knew then that this was a torture chamber, not a court of law… there was a psychological deception going on, which was very similar to what abusers use, which is that what you can see happening in front of your eyes is not what they record coming out of their mouths… You don't expect to be gaslit by a judge or a magistrate… I was sitting there thinking if you've got magistrates trying to abuse your rights you're not in a good, safe place… so I've now suddenly turned into a non-human being, I have no right to speak.(Catherine) When you report a rape, they say, "oh, you've got to go and speak to our counselors."So, I was talking to this counselor and then in the… family court case… and I don't know how they did this, but they got my counseling notes, and his female barrister were reading them out in court laughing.So, I didn't access any counseling after that, I was too scared.(Janine) I feel like I try and block out loads of stuff because it's too painful… I feel like there's a lot there that I've just not processed in any way, and I'm really worried about when I do process it.(Gemma) Continued.