Dave: I was at child psychiatry meeting where a discussion focused on the value of working with families. I was encouraged. But the theme that emerged attended to the importance of educating families about childhood psychiatric disorders. I commented that it sounded as though by focusing on educating parents, they were over-looking the family’s participation in the problem. Several hinted I was out of date and out of order with my “old fashioned” family therapy ideas that ignore research on child psychiatry disorders and “blame parents,” and in light of recent “scientific certainties”, child psychiatrists had to be careful not to blame families. I was being unfairly characterized and dismissed. But I have been around long enough to know when to back out, and be amused when we meet at these borders of epistemological contradiction. I left the meeting reflecting on the contrast between their assumptions and mine. On the one hand they were right; I do not trust science when it comes to explaining behavior. But I was bothered by the allegation that I blamed parents.
Obviously, part of the appeal of the “chemical imbalance” metaphor is that it interferes with guilt on both sides of the treatment relationship. And in some situations that can be of great help. The problem with it is that it neutralizes those disturbing, but important, questions children stimulate. These are questions that increase awareness and consciousness. Children force us to integrate multiple levels of experience, not tomorrow, not when it will be more convenient, but now. When we do not do this, children become symptomatic.
Children make us (parents and therapists) face our ambivalence about ourselves. Maturity is the ability to embrace this endless ambivalence. The problem with the “chemical imbalance” metaphor is its persuasive power which is intimidating and represses imagination. It suggests no one should feel impotent. No one should feel pain. Gregory Bateson, brilliant English anthropologist and cyberneticist observed that “quantification” is used to avoid perception of pattern. This over-simple theory blinds us to problems of context that may threaten our ability to care for ourselves. It represents a thought system based too much on conscious purpose and objectivity, both of which limit what we are allowed to see.
Meditation on “Blaming Families”
The notion that I blame families was not new for me. I had heard it from individually oriented therapists, general physicians, nurse practitioners, and social workers. To suggest I was blaming families questioned my intent. I, on the other hand, wondered if the child psychiatrists were protecting the families or their own thinking pattern. It was interesting to discover that “blame” comes from blaspheme, “to speak evil of, to speak irreverently or profanely of or to [God or sacred things].” Blaspheme means to defile something sacred. Blaspheme also implies there is something sacred that cannot be questioned, an absolute truth.
When “scientific objectivity” is used to assess children, the conclusion has the quality of an absolute truth. But existential heathen that I am, I believe it is not possible to be objective about people, especially children. When I am accused of blaming or blaspheming, it implies indifference, not caring. When there is caring, the kind of questioning and commenting we do in clinical work with families is therapeutic. And I do not look at family therapy as a way to decide what is wrong with a family, or who has done wrong. Rather, I look at a family in the interest of trying to understand what interferes with the healing of their wounds.
As a family therapist, I’m aware of the implicit challenge that comes with working in the delicate realm of family therapy with children. This challenge requires hubris in the way we ask questions, but humility in the how we handle the answers we get. In some way therapists must acknowledge the existential struggles they share with all humans, and decline the powerfully projected role of high priest(ess) of superior knowledge, or untroubled saint. As a therapist, I am like a guide. I am experienced in traveling through the wilderness of subjective experience. On the trip I use my past experiences. I am an expert on myself and my experience. When I am a physician, I have superior knowledge of the medical database for diagnosis and treatment of disease.
The medical model of psychotherapy is a powerful belief system in our culture, operating to dilute the meaning of emotional experience in the name of logic and clarity. The medical model uses a belief system that is designed to decrease ambiguity about our experience in living. This model leads to the conclusion that medication is necessary and sufficient. My belief system increases ambiguity. Increased ambiguity means acknowledgment of the unknown, the ability to tolerate our own confusion and feelings of incompetence; indeed, to question whether life means anything at all.
For me, the therapeutic process invites families into this territory where curiosity and uncertainly about oneself creates an opening for change. In family therapy, we assume that there is inevitable dysfunction in how families handle the distress and ambiguity of living; when that dysfunction persists, unacknowledged and unresolved over long periods, symptoms like anxiety and depression can show up in one or more family members. These disturbing patterns are virtually never born of intention. In great part, they grow out of the parents’ emotional hunger, naiveté about relationships, and tendency to compromise too much.
The unspoken implication in much of the child psychiatry world suggests that parents should not have to feel any pain or guilt about their child. But let’s face it, they do. “If you can’t stand guilt, don’t have kids.” Innocence doesn’t go with parenthood. In a misguided effort to “protect” families from feeling guilty, or blamed, practitioners may scramble for an intervention/solution even when they are unclear about the source of the distress in the child. In my role as physician/ therapist, I feel guilty and discouraged when a case is not going as I hoped. I inevitably begin to question myself. Did I care enough? What is wrong with how I think? Am I mature enough to do this kind of work? I feel responsible because I am engaged, I care. I agonize when my caring is not enough.
A Case Example: the family came seeking a second opinion at the suggestion of the family physician. The child had been diagnosed with a “chemical imbalance” and within the medical treatment model was being managed appropriately with medication for the boy and parent education for the mother. However, despite the use of a variety of medications, there was no change. I and a psychiatry resident worked with the family. During the course of treatment (six sessions in ten weeks) the family physician stopped the medication. The child’s symptomatic behavior faded to a non-toxic level. A chemical imbalance was treated with family systems therapeutic methods. If the family felt blamed, they also felt gratified, confused, angry, and appreciative.