DK: I have mentioned before that, though a General Psychiatrist and a Child and Adolescent Psychiatrist, I have worked with families during my whole career, spanning 1975 to the present. I don’t limit my practice to any age group or any particular problem set. Usually a family seeks therapy because they are troubled by a family member. That person is called the Identified Patient. I don’t use medication. But I want to make it clear, I am not anti-medication. I find that if I can get the family engaged, medications are less necessary.

My great concern is that the way that Psychiatry has embraced medication has altered the way we talk about human experience and pain. I wish more people knew how to work with whole families. That is why we started this blog, as a place to start conversation about un-medicalizing human experience. We have evolved ways of using language to help people think about their own experiences. This way of using language works to enter the labyrinth which I am characterizing as the family’s inner sanctum.
A psychiatric diagnosis is a short-hand characterization of experience. This may be obscure, but I think of the Diagnostic and Statistical manuals as catalogs of over-extended metaphors for human experience. The early Diagnostic and Statistical Manuals contained no statistics except for the word in the title. Diagnostic labels have great capacity for leading us astray. The following story illustrates this viewpoint.

In this era it is not uncommon for someone to call and tell me their child’s diagnosis and that the family doctor or school counselor wants them to see a psychiatrist for medication. If they say their doctor says he has bipolar disorder and needs to be started on medication, I say, “I don’t work that way” and then describe what I do, and what they will have to do. If they say they don’t want to bring the whole family, I say, “So maybe you should find someone else.” You see this is a different way of working. I insist that everyone who lives in the house come to the session. I do part of the first interview on the phone in order to find out who is involved.

Working with difficult situations requires the power of the whole family. It is a different way of thinking about Psychiatric disorders. And a different way of thinking leads to different behavior by the practitioner. As I have mentioned before, I believe all that we consider “psychopathology” is related to interpersonal experience, until proven otherwise.

This illustration gives a picture of how the use of a psychiatric diagnosis and treatment with medication can affect a family’s living over a long range of experience. It demonstrates the cost of characterizing behavior with a diagnosis and ignoring the broader unnamed troubles in the family. But you will also note I pay attention to the totality of family concerns or the whole stress network. Just to make it picturesque, I am calling it the Family’s Labyrinthine Inner Sanctum. The interior of a family is a sacred place and must be treated respectfully. There are secrets, there is pain, there are mysteries, there are multiple ways of seeing the same events. The family’s symbolic interior, the basis for establishing meaning is there as well. But a review of the child’s symptoms won’t get you there. There is an art to doing the first interview.

The  Case: The Maher’s were referred by their family doctor, a colleague of mine, who knows what I do. Father called because Trish, 18, a high school senior, was “completely out-of-control.” Four months earlier, she quit taking her medications, Tegretol and Prozac. She had started taking medications at age four when she was diagnosed with bipolar disorder. When they called for an appointment, I told them that I wasn’t much of a medication man and that they would need to bring the whole family. They decided to come in. Based on my phone conversation with the father, I expected a very disturbed, probably manic, young woman. In anticipation I called the inpatient unit to see if there were beds.

A different Trish arrived from what I expected. Instead of disturbed and chaotic, she was composed and for the most part thoughtful in an appealing way. She was a self-owning young woman who agreed she had been difficult of late. She was annoyed with what she viewed as her parents’ over-reactions. The pediatric neurologist who had taken care of Trish for 12 years sent the clinical records, which began with her diagnosis at age 4. The notes included the initial evaluation by a well-known child psychiatrist that ended with an indefinite conclusion, she “might” have bipolar disorder.

The uncertain diagnosis was made at a point in cultural time when child psychiatry researchers were newly interested in the possibility of bipolar disorder in children and articles were appearing in the child psychiatry journals. In keeping with the new standard of practice for the time, the child psychiatrist thought she “deserved” a trial of lithium. However, the “trial” was a one-way street, and never ended. She was later changed to Tegretol and Prozac by the neurologist. Those were the medications she had quit taking fourteen years later, in October, four months before they came to see me in. What is important to note here is that he was not certain it was bipolar disorder, but took action anyway. Lithium is not a benign agent physiologically.

I learned in the first interview that a month before Trish quit taking the medications her father, an executive in a large corporation, was “down-sized”. He was let go with a six-month severance package. He acted as if it was not a big deal. “It was only a business decision.” He felt certain he would soon find a new executive level position. The mother on the other hand, was upset by his nonchalance. She felt that the ship of the family had been torpedoed and was slowly sinking. I found the parents discouraging. They were polite suburbanites with little capacity or language for self-observation. But they were clear about Trish and what was wrong with her.

Father was conservative and repressed. Mother, who was very hesitant when she spoke about her own life, was very articulate about her daughter. There were times when she appeared sadistic, smirking as she described Trish, her messy bedroom, her coming in late last Friday night. Her smirk gave evidence of gratification from Trish’s behavior. I had the impression that since age 4 Trish was an unnaturally compliant child most of her life. At 18 she had become mildly, but appropriately rebellious. She was trying to figure out a way to be more than her mother’s little girl.

At one point, the parents felt as though I should see Trish alone. I did, for two visits. Trish was thoughtful about herself. Of her friends she said, “I like these people, I am having fun; I never knew how to have fun before. I can see my parents have never been happy. I don’t want to turn out like them.” She was concerned that her mother was trapped and didn’t have any friends. She was trying to get her mother connected to the mother of one of her girl friends who lived on a farm. This mother had a wonderful sense of humor, and seemed to enjoy her life. She thought this mother could be a good influence on her own mother. Trish was worried about her parents. She was trying to help her mother grow up a little, to become more of a person, to find satisfaction in her own life. Four months later, Trish graduated from high school then went away to college. There was never any reason to restart the medications. But, of interest, the family continued with the therapy project. I saw them into the summer, ending when Trish was preparing to leave for college.

Just one month after Trish left for college, her mother, Carol Marie, called me. I was surprised because she wanted to be a patient and come in to see what she could learn about herself. I saw her biweekly for six months, twelve visits. Father, Arthur, would not participate because he was busy hunting for another permanent job (he never found one) and working as a car salesman. Carol Marie was upset with him. He would not come to the sessions. Carol Marie was a deeply repressed woman. She felt cornered by her marriage, but she had very little language for her disappointment. She told stories of their life, which sounded pain-filled, and explained the distance between herself and her husband. In my work with them about Trish’s problems, she became enticed by the idea that she might find a way to love herself. Much to my surprise, she enjoyed being in therapy and became very enlivened. She would arrive for an interview feeling surprised about something she had done.

Occasionally the subject of Trish arose. She was away at college and sometimes her poor judgment made her a source of distress. She did have the college freshman’s way of doing dumb things. Carol Marie saw these things as symptoms of her bipolar disorder. But bad judgment in a college freshman is not yet a diagnostic category. In her case the troubles she got into were more symptomatic of naiveté and an unusually soft heart.

I am going to take a break here. In the next chapter I will describes Mother in individual Therapy. Her story will give a sense of where Trish’s behavior at age 4 came from. It came from the labyrinthine inner sanctum.