The Problem With Simple Formulas in Mental Health

Dave: I’ve been reflecting lately on my experience of being a hard-core family therapist disguised as a child psychiatrist, working in a cultural climate that sees no reason to question the limits of “biological psychiatry”.  This includes its promotion of the concept of “chemical imbalance” as a way to explain human emotion and its behavioral concomitants.

At this point in cultural time family therapists who work with families and children can feel vulnerable from several angles. They run the risk of being dismissed both by other mental health practitioners and by families. But additionally– and this was true before biological psychiatry– working with children inevitably touches strong emotional (transference) currents in the self of the therapist.

Family therapy with children and families induces deep self-reflection in the therapist. When the psychotherapeutic work goes well, the experience is profoundly gratifying; we learn about love and healing. But when anxiety or ambiguity or both are high, especially at the beginning of treatment, or if the treatment does not go well, we find ourselves in touch with disturbing feelings of self-doubt, more specifically, impotence, naiveté, confusion, despair, isolation, and frustration. My impression is that in the last 15 years, fewer and fewer family therapists feel capable of working with children in the sense of being therapeutic to a whole family.

These feelings, of course, are transference feelings (nonrational relationship responses), fantasies about what will happen to the family, to the child, to us, if we don’t get it right. These feelings and fantasies are not trivial. Transference, whatever it is, runs the world. Transference feelings are intensified in any therapeutic situation, but the voltage increases when working with marriage, increases again when we add children, and goes into the red zone when combining marriage, children and more severe disturbances (depression, OCD, ADHD, eating disorders, bipolar disorders).
The Disconnect Between Family Therapy and Modern Psychiatry:

“Chemical imbalance” is a persuasive metaphor freely used by modern psychiatry to support the use of psychotropic medications in all sorts of clinical situations where children are being disturbing or creating anxiety. This metaphor is also used to shore up the perpetually unsteady image of psychiatry in medicine. The logic of “chemical imbalance” persuades both patients and practitioners that context and subjective experience are not important. But that logic interferes with the task of deciphering the not-enunciated pain behind the pain.

Biological psychiatry’s simplified formulation of human problems is derived from a particular set of knowledge and belief system that underlies medical bioscience. Family therapy thinking represents an alternative system of knowledge and beliefs, with a different view of human experience which leads to different clinical responses. Though a psychiatrist, I am uneasy with the medicalized language of psychiatry and psychopharmacologic agents in dealing with the problems of children and families. In my work with colleagues I am often promoting the use of family systems work and asking that the limits of medical bioscience be acknowledged, at least by family therapists. I am not saying, “Don’t use medication.” Rather, my message is, “If you work with families, medication will be less necessary.”

I know that medications can at times be helpful and are sometimes necessary, but rarely sufficient. Relationship is always necessary and sometimes sufficient. I know medication can “work”, I just don’t believe in it. When the chips are down, I don’t trust medication. But I do believe in families and trust the therapeutic process of family therapy.

In the Next Post….More About “Chemical Imbalance”