Posted by (This is a continuation of the story of the “bipolar” child and her family)
DK: In the biometaphorical family systems model (this model exists mostly in my head), the family includes at least three generations. All Trish’s grandparents were deceased. Mr. Maher came from a family where his father was successful in a small-town auto parts business. His 
mother was portrayed as domineering, harsh and emotionally unpredictable, the Queen of Hearts incarnate (“Off with their heads!”). As a byproduct, Mr. Maher hated emotion and acted to quell emotion in himself, his spouse and his children. His demeanor and behavior were repressive, but his hidden motive was fear. Emotion made him feel like an overwhelmed little boy. Mr. Maher didn’t take the severance from his job personally. However, he took nothing personally. He was emotionally distant, humorless. His personal style is what I refer to as “culturally invisible pathology”.
“Culturally invisible pathology” is a behavior pattern that appears normal in cultural context. Mr. Maher was simply acting like a businessman. He suffered with a serious inability to question himself, and further, no capacity to be amused by himself. Let’s see where do we find these disorders in the DSM? Whoops! Somebody forgot to include them. Those culturally invisible patterns of behavior put pressure on intimate others. And the others become symptomatic. In this case his irritability and allergy to intimacy put pressure on his spouse.
Carol Marie was emotionally isolated with a new baby and a four year old. She had no emotional partner. This kind of isolation leads to feeling crazy. Feeling crazy results in anxiety, irritability, feeling incompetent. Young children pick up on emotional upset in adults. I think of this as the child’s “worry” about their parents. But they don’t worry inside their heads, with thoughts, they worry with their whole self. The kid’s upset is expressed in “naughtiness”. The naughtiness pushes the mother to take action, often with anger.
Anger is a great antidote for depression. Both mother and father agree that their little girl is acting crazy, and they cannot see the reason for it. The reason is grounded in a pattern of behavior, which is grounded in the shadowy ground where they learned to be humans. So they take the four-year-old girl who had a little curl right in the middle of her forehead and when she was good she was very very good and she was bad she was horrible to a child psychiatrist who sees no reason for this irregular behavior. The child is a mystery. Let’s call it bipolar disorder. Now the parents feel unfortunate but innocent. Now we need to find the right medication.
Carol Marie came from a timid, frightened family. Her father seemed invisible in her memory. Her mother protected the father but was herself fearful and depended on religion and her daughter for emotional sustenance. In the first 10 years of the Maher’s marriage there were infertility problems. Carol Marie resigned herself to having no children. Then, a miracle happened, Trish appeared. Carol Marie discovered an intimacy with her baby she had never known before. The experience was a deep comfort and soothed much of her pain.
But babies are unfaithful. They inevitably disappoint us and grow up, they individuate, say “no”, become defiant, even at age two. Then there was another baby, born when Trish was three. So the family naturally became emotionally chaotic. The husband Arthur became more distant, more repressive and more demanding. “You keep quiet. You know I hate it when you get so emotional. And keep those kids quiet. Dammit! Can’t you see that Billy needs changing? You didn’t iron my shirt. I told you I needed that shirt this morning.” Carol Marie felt overwhelmed. If only her four-year-old (Trish) was not so difficult, things would be better.
Thus, they went to see a child psychiatrist. The point here, easily lost, is that the problem did not belong to one person; it belonged to the family. When the diagnosis was made, it offered an explanation for why Carol Marie felt so overwhelmed: her daughter had a mental illness. Their anxiety now had an explanation that they were hesitant to disrupt.
When they entered therapy as a family the experience stimulated Mother’s curiosity about herself. She decided to become a patient on her own. I am being a bit hard on Mr. Maher. Despite his reservations he came to almost all of the family therapy sessions. He did make changes. He made a few meals and learned how to do the laundry. When Carol Marie dropped ‘Marie’ a surprising lustiness emerged. He had a difficult time with this new version of her. His apprehension was a great disappointment to her.
Ou
r culture gives boundless freedom to talk about children. Thus it was easy for Trish to be defined as the problem. However, there is little freedom to talk about parents or marriage, and the language for talking about parents is very limited, partly because any discussion of their participation in family problems has come to be (incorrectly) understood as blame. In my clinical work, I assume that if a person has a problem it is a manifestation of a family relational problem. This example shows how the diagnosis and medical treatment of a family problem as an individual problem organizes a family.
My not encouraging the medication to be restarted had a profound effect on the reality organization of the family. It frightened and exasperated them, but simultaneously in the mother’s case, it stimulated her curiosity about herself. In me she found a (male) symbolic mother. The point of this case summary is that when Trish was four, both parents were distressed, but in ways that were easy to leave out of discussion of the problem. When parents are worried about or troubled by children, the children are worried about or troubled by the parents the same amount, usually more. The parents were not moral failures, but exploring where they came from helped to understand ways in which they were programmed for adulthood.
In my way of thinking and practicing the family can replace the medication. In this case therapy for the family and for the mother, helped them be less apprehensive about Trish. I heard from the mother intermittently and once Trish recognized me at a restaurant. She had married a local big shot who was abusive and the marriage ended. She was working for an insurance company.
This clinical illustration is not written to stimulate defiance in practitioners or in patients but as a way to nudge the biomedical thinking a little, or to contaminate what has become conventional thinking about psychopathology. The overt goodwill, the good intentions and optimism of biomedicine produces iatrogenic illness by removing initiative from the hands of patients and their families with the result that a dependency develops on medical science and awaits their methods for problem solution.
I realize I am being over-simple and sound cavalier at times. I am doing it in the interest of disrupting consciousness, in the interest of increasing possibility for how to think about humans in their world. The biomedical model for thought and practice is different from what I am calling the biometaphorical model for thought and practice. They are not competitive models. There can be no competition for ignorance out on the vast ocean of human experience.