Madness and the Family, Part III: Practical Methods for Transforming Troubled Family Systems

Editor’s Note:
This is part three of a three-part series.

When we consider that psychosis often results from the failure to experience healthy individuation (as discussed in Part Two), we can see that a kind of intrapsychic split has developed, where a person feels terribly torn between a longing for freedom and autonomy on one side, and a longing for love, belonging and nourishing connection on the other side. Or to consider this same dilemma from the perspective of fear rather than longing, we can say that a person feels terribly torn between a fear of loneliness and isolation on one side, and a fear of being oppressed or “losing oneself” within relationship on the other side. When we recognize this tension lying at the root of a person’s psychotic process, we find that it offers us some very useful guidance in supporting a person working with experiences that may otherwise seem so chaotic and unpredictable. In particular, what we find is being called for is supporting this person in experiencing both healthy autonomy and personal empowerment, and also healthy connection with others. To begin laying down an effective framework for how we may best be able to do this, let’s first briefly touch into the concept of parenting styles.

Towards an Effective Parenting Style

There has been a lot of theory and research on different parenting styles over the years, with some styles being seen as more problematic than others. One relatively simple framework that a lot of people resonate with makes a distinction between authoritarian, neglecting, permissive and authoritative parenting styles, and I think it’s helpful to consider these different styles from within the context of healthy autonomy and connection as presented within this article series (see Figure 1).

With authoritarian parenting, there is little collaboration or discussion with the child regarding the setting of limits, and these limits are strictly enforced typically with punishment. The child’s autonomy needs are generally oppressed, and while there may be genuine love and affection from the parent, communication is generally poor, leading to the child’s connection needs also generally not being adequately met.

With permissive and neglecting parenting styles, limits are generally not discussed or even set, let alone enforced. While it could be argued that their autonomy needs are being met, in actuality, because developing children need guidance in understanding their limits and developing self responsibility for the consequences of their actions, the kind of autonomy developed with these styles often consist of poor impulse control and poor self responsibility, which in turn limits the ability to develop healthy relationships with both self and others. Regarding healthy connection needs, a significant difference between neglecting and permissive parenting styles is that the permissive style generally includes more healthy connection—the child is treated like a “loved friend”—whereas there is very little nourishing connection with a neglecting parenting style, the child being treated essentially as a nuisance to be tolerated with minimal effort on the part of the parent(s).

With the authoritative (not authoritarian) parenting style, the emphasis is placed on setting clear reasonable limits, using as much warmth, collaboration and communication with the child as possible while setting and enforcing these limits. The child is then allowed essentially as much freedom and autonomy as possible within these limits. Considering this style from within the framework presented here, it’s easy to see that this particular style is likely to be the most effective style in supporting the child in resolving the autonomy/connection dialectic and ultimately achieving mature individuation. And indeed, extensive research has demonstrated that children raised with this particular style are most likely to develop satisfying and nourishing relationships with self and others (Baumrind, 1989; Furnham & Cheng, 2000; Galambos, 1992).

Two sub-categories of the authoritative parenting style that are helpful to consider are attachment parenting and democratic parenting. These can essentially be seen as simply a sequence of two stages following the same pattern of maximal warmth, communication and freedom held within clear and reasonable limits, with “attachment parenting” typically referring to practicing this within the communication constraints of infants and toddlers, and “democratic parenting” referring to the practice of increasing communication and collaboration with the child as she matures and develops increasing life experience and critical thinking skills. The nice thing about this approach is that not only does it maximally support the child in meeting her autonomy and connection needs, but it naturally follows the child’s developmental process culminating in healthy adult individuation. [A couple of useful books that offer guidance to parents in developing these types of parenting styles are No-Drama Discipline, by Dan Siegel and Tina Bryson (2015), and Hold On To Your Kids, by Gordon Neufeld and Gabor Mate (2014).

While the concept of implementing such a reasonable parenting style as a means to support a child in developing secure attachment styles and ultimately adult individuation may seem simple enough, many parents will recognize that the reality is often far more challenging. When raising a child, we find that we typically encounter the unresolved developmental wounds of our own past, which can then result in powerful emotions that “hijack” us and compel us to behave in ways towards our children that we may later regret. One way to think of this is that when raising children, our own insecure/unresolved attachment issues show up and are easily transmitted to our children. The research suggests that insecure attachment styles are very often transmitted this way from one generation to the next, in spite of what may be the parents’ best intentions (Karen, 1994; Siegel & Hartzell, 2003).

Fortunately, the research also suggests that it’s never too late for any of us to work on increasing the security of our own attachment styles both in relationship to our self and with others, especially by utilizing the practices of mindfulness, creating a coherent narrative of our own lives, and seeking skilled relationship support (Siegel & Hartzell, 2003). And the research also suggests that parents who have been able to do this personal relational repair work, regardless of how troubled their own childhood may have been, are far more likely to raise children with secure attachment styles and the many benefits of this, as we’ve been discussing (Karen, 1994; Siegel & Hartzell, 2003).

So it’s all well and good to learn about effective parenting styles, and to try one’s best to implement them from the very beginning, but what do we do once we find ourselves in the midst of a crisis with a child/adolescent/young adult exhibiting psychotic or other extreme behaviors, and/or a family system that has already become destructive and out of control? The following are some of the most common problematic dynamics the recovery research suggests are found within such family systems, along with some suggestions for transforming these patterns from problematic to beneficial, or in other words, from vicious cycles into victorious cycles.

From “Power Over” to “Power With” 

As implied in the above discussion on effective parenting styles, it appears that developing a “power with” relationship with one’s child, rather than a “power over” relationship, is key. So often in family systems in which a child becomes diagnosed with a psychotic disorder, a strong “power over” dynamic has developed, typically between one or more parents and the child, though we can also find this particular dynamic within other aspects of the family system, such as between siblings.

Even if this particular dynamic was not prevalent initially, once the child is deemed “mentally ill,” the individuation fears as discussed above can become exacerbated, leading to increasing tension within the autonomy/connection dialectic for the child and hindering even further her movement towards individuation. In this case, out of natural concern, the parent may well become increasingly critical, demanding, overprotective, etc., further undermining the child’s autonomy/connection needs; and the child is likely to experience increasing self doubt, self fear, etc., increasing her ambivalence of moving towards healthy individuation. This situation is likely to further increase the “power over” dynamic at play, even further interfering with the child’s individuation process, and we find that a kind of positive (self reinforcing) feedback loop (i.e., “vicious circle”) develops, in which the system can become very entrenched within this particular dynamic, with the child unable to go any further towards individuation and remaining hyper-dependent upon the parents indefinitely.

Unfortunately, the mainstream mental health care system often further exacerbates the situation, by adding its own “power over” structure to the already existing “power over” dynamic occurring within the family. It does this by generally insisting that the youth “accepts” that they have a brain disease,  insisting that they remain “compliant” with psychiatric drugging, and generally behaving in a way that is likely to exacerbate whatever trauma the youth has already experienced and even further encouraging the “power over” dynamics within the family (see my article here for more about these and similar problems within the mainstream mental health care system).

Breaking this vicious cycle requires first a willingness by all parties to recognize that this is occurring, followed by a concerted effort to gently make the transition from “power over” to “power with.” This includes the need for all family members to resist any tendencies to make demands of each other, and to instead make clear, doable requests, with a willingness to hear “no.” It also includes the need for each person to set personal limits and boundaries as would be done within any other healthy relationships, and to do their best to honor those set by others. In other words, if a person is behaving in a way that is directly harmful to us or our loved ones, we do need to set some personal limits and do our best to minimize that harm, which may entail attempting further communication with the person, or if this fails, then seeking external support or even limiting contact with the person, if necessary.

From Mystification to Transparency

The recovery research also suggests that transparency within our communication and our general self expression is also very important. Without doubt, one of the main factors that has made the Open Dialogue approach and other similar family systems approaches so effective is that they facilitate transparency, which we can define as first developing self connection (connecting with one’s own feelings and needs associated with a particular situation), and then expressing this to the relevant other openly and honestly. As discussed earlier, Bateson’s and Laing’s work in this area, with their concepts of “double binds” and “mystification,” offer compelling theories as to how the lack of transparency, especially between the parents and the child, can result in the child experiencing overwhelming confusion and distress, even to the point of ultimately developing a psychotic condition.

To be more specific, being transparent essentially means finding the courage to express our concerns, frustrations, fears, etc. directly to the relevant person—to clearly state what it is about the others’ behavior that is so distressing to us, and then depending upon what feels most appropriate, to either do some personal work on developing more tolerance for that behavior, or to open up dialogue with this person about what changes could be made to make the situation more workable for all involved. The other important piece to this is resisting the temptation to complain to a third party about a person’s behavior, and to instead find the courage to discuss the problem directly with that person. Murray Bowen refers to this—the tendency to form an alliance with one person against another—as triangulation, and his research has demonstrated it to be a particularly destructive relational pattern within families and other social systems (Bowen, 1993).

From Scapegoat to Canary

A common pattern we find within many social systems when they’re not functioning well is scapegoating, the tendency of the majority of members to attribute the brunt of the responsibility for the dysfunction within the system to a particular minority. We see this within the broader social systems in which minority members are scapegoated, in smaller social systems such as schools in which children who are perceived as “weak,” “nerdy,” or otherwise “weird” are bullied, and within family systems in which one member is perceived to be the “problem child,” or what family systems therapists often refer to as the “identified patient.”

It’s important to recognize, however, that this tendency is usually misguided and often very destructive, not only to the one who is scapegoated, but to the overall health of the family system, in that scapegoating may buy some security in the short term, but leaves the family system vulnerable to collapse in the likely event that the strategy eventually fails. It is for this reason that scapegoating can become so entrenched within a dysfunctional family system, with all members, including the one scapegoated, often striving to maintain this status quo in order to maintain the survival of the family system (although the family members are often not consciously aware that they are doing so). Unfortunately, this problem can  become even further exacerbated by a mainstream mental health care system that feeds this dynamic by generally being more than happy to diagnose and “treat” the identified patient, with many professionals sincerely believing that they have the expertise to declare that there is indeed something broken or diseased about the brains of such individuals, in spite of extensive evidence to the contrary (see this article or Rethinking Madness for more a more thorough discussion about this).

In order to pull ourselves out of such a problematic family dynamic, it helps to recognize that the “identified patient” is often merely particularly sensitive to the dysfunction within the family system, and therefore is vulnerable to acting as a kind of channel for this dysfunction, personally acting it out in a way that is likely to land her with the diagnosis of a “mental illness.” Therefore, it’s often much more helpful and accurate to see the “identified patient” as a “canary in the coal mine” rather than “mentally ill,” in that she is simply the first to perceive and openly demonstrate the toxicity within her environment.

From multiple monologues to authentic dialogue.  When we shift our perspective to see “psychosis” occurring within an individual as actually most likely being indicative of a problem occurring within the larger family and social system, then we recognize that it is only by honoring everyone’s unique perspective that we are able to acquire a view broad enough to lead to the resolution of whatever is occurring within that system. In order to do this, we find that we must face a somewhat daunting but not impossible task: To practice open and authentic dialogue with the others in the system, which requires a willingness to alternate between (a) honest self connection and authentic self expression, and (b) temporarily setting aside our own assumptions, beliefs, feelings, etc., so that we can listen to the others in a receptive and empathetic way.

When we are distressed, it is a natural tendency to become so inflexible in our own perspective and/or so absorbed in our desire to express this to the other, that we then are simply unavailable to genuinely listen to and digest the perspective of the other. This results in communication consisting of multiple monologues (i.e., multiple individuals essentially expressing themselves to “brick walls”) rather than an authentic dialogue. Yet, in order for the broken system to change in any fundamental way, the different members of that system must each be able to bring their voices to the table and be genuinely heard by the others so that a new and hopefully more harmonious and sustainable relational dynamic may unfold. I have found that a particularly simple and effective approach to such communication is Nonviolent Communication [NVC], developed by Marshall Rosenberg, student of the pioneering humanistic psychologist, Carl Rogers.

Secure Attachment as a Buffer Against Bullying and Other Adverse Childhood Experiences

As discussed earlier, we are all “hardwired” to strive to develop secure attachments with one or more primary caretakers from birth, and recall that such a secure attachment involves the experiential knowledge that we are deeply loved for who we are—that both our primary connection needs and our primary autonomy needs are securely held and supported. And when children and adolescents are unable to develop these with their parents, they naturally direct these attachment-forming instincts toward their peers. But since other children and adolescents are generally not able to take on the role of caring, mature caretakers for each other, what typically results is a situation in which the “blind are leading the blind,” or worse yet, the immature are leading the immature; and this in turn can set the stage for an absolutely devastating blow to occur at a very deep level when the youth is exposed to the experience of being harshly rejected by those with whom she or he is so desperately trying to attach. [See Hold on to Your Kids by Neufeld & Mate (2014) for a much more thorough discussion about these issues.]

Considering the situation from this perspective, it actually makes a lot of sense that bullying and peer rejection have been so well established to be a significant risk factor for youth developing psychotic disorders. It’s easy to see that when youth try to get their primary attachment needs met from other immature youth, this sets the stage for a catastrophic blow to one’s ability to sustain a tolerable experience with regard to the autonomy/connection dialectic.  But fortunately, it has also been well established that a secure attachment with an adult acts as a powerful buffer against the harm caused by such peer bullying and rejection.

One particularly striking study involved 90,000 adolescents from 80 different communities throughout the United States, and found that those who were securely attached to at least one parent were much less likely to exhibit the behaviors typically associated with problematic peer attachment issues—drug and alcohol dependency, attempted suicide, engaging in violent behavior, and risky sexual activity (Resnick et al., 1997). This study didn’t include psychosis as an outcome variable; however, given the established correlations demonstrated between poor attachment with parents, bullying and psychosis, I think it’s safe to connect these dots and recognize that secure attachment with a parent almost certainly acts as a direct buffer against the possibility of bullying and peer rejection precipitating psychosis. Furthermore, following a similar line of reasoning, I think we can safely say that secure attachment with a parent is likely to act as a buffer against most of the other psychosis risk factors mentioned in Table 1 below (explained in more detail in Part One of this article series).

From Blame to Shared Responsibility

As discussed earlier, it’s a very delicate matter to suggest that, in many cases, the parents of a youth who develops a psychotic disorder may have played some role in that occurring. This suggestion has resulted in a polarization within the field in which on one extreme we find an inappropriate degree of blame being placed onto the parents, especially the mothers, of all youth who develop a psychotic condition; and on the other extreme, those who suggest that family dynamics often do contribute to the development of psychotic conditions are themselves vilified.

To give one example of the first extreme, a term often used throughout the last decades of the 20^th century is “schizophrenogenic mother,” a term coined by psychiatrist Frieda Fromm-Reichmann in 1948 to highlight her belief that certain mothering/parenting styles are causally linked to the development of “schizophrenia.” Regardless of the intention of Fromm-Reichman and others who have found utility in this term, it can easily be interpreted as implying a kind of black-and-white blaming and shaming of parents whose children develop a psychotic condition, which I feel is likely to only reinforce the problem. The risk in the use of this kind of language is that it can understandably lead to many parents becoming defensive, which may then result in even further disconnection and disharmony within what is likely already quite a troubled family system.

On the other extreme, those who suggest that there may be something about family dynamics that can contribute to a child’s psychosis are sometimes referred to derogatorily as “mother blamers,” a term I feel is equally problematic, in that this term typically represents a complete deflection of any parental responsibility in cases where some responsibility by the parent(s) may indeed be warranted—if not direct responsibility for the onset of the child’s psychotic condition, then at least a certain degree of responsibility with regard to supporting their child through the recovery process.

Between the extremes of blaming and shaming parents on the one hand, and denying any responsibility whatsoever of the parent/child relationship on the other hand, I believe there is a middle path that we can follow that will allow us to have a fruitful exploration of this issue while not losing sight of the humanity of all involved. Very often, parents do love their children very much, and do strive to do the best that they can as parents, and yet their behavior and parenting style still unwittingly contribute to their child developing such a distressing condition. In many such cases, the parents were themselves raised as children in a similarly problematic environment, and are merely passing along what they have learned. Such problematic dynamics can become profoundly entrenched within a family system, often lasting for many generations and making it very difficult for the parents of any one generation to fully extract themselves from them. Furthermore, it must be acknowledged that many parents in the world today are forced to try to survive in the life-crushing conditions of poverty, isolation and/or political oppression, which in turn simply leaves parents with few remaining resources with which to nourish their children. Indeed, the literature is robust with evidence that poverty, discrimination and other forms of political oppression are highly correlated with the development of psychosis (Read, 2004).

So I think that rather than resorting to “parent blaming” and suggesting that parents in these cases must have malevolent intentions, it’s important to recognize that in probably the majority of these cases, the parents are simply ignorant of the serious harm that their behavior is causing, and/or they are merely passing down inter-generational trauma or relational dynamics that they themselves have inherited from their own parents and/or a dysfunctional society. Rather, what is likely to be more helpful than blame is to invite an attitude of open curiosity about what problematic family dynamics may be involved in the distress, and to encourage an attitude of shared responsibility among the members of the family and the broader social system with regard to repairing any harm done and transitioning to a more harmonious system.

Another point that needs to be stated here is that, as discussed above, the research is quite clear that many different factors may contribute to a person developing psychosis. Yes, relational factors, and especially childhood relational factors, do seem to be at play in probably the majority of cases of psychosis, at least those that have been thoroughly explored; but we are complex organisms, whose wellbeing is based on a multiplicity of factors occurring within multiple domains—physiological, psychological, social, environmental, spiritual, existential, etc.—and if we consider that psychosis is often a desperate strategy to cope with otherwise overwhelming experience, it becomes clear that multiple factors and experiential domains often converge to create such overwhelming conditions. So, in many cases, pointing towards any one single factor as the cause of a person’s psychosis is far too simplistic.

What this understanding implies, then, is that if we want to offer genuine support to people struggling with overwhelming distress, then all members of a particular family system and even the broader social systems need to acknowledge some degree of shared responsibility and to act from that place. However, along with this recognition needs to come the recognition that different members within these social systems do hold different degrees of power, and greater power naturally entails greater responsibility. Since it is the parents who typically hold the most power within the family system, it’s important that they acknowledge the greater responsibility that goes along with this. The same applies to the broader social systems within which we live, in that certain members hold greater power and influence—especially those who are white, male, relatively wealthy, and those who hold certain professional roles, with health professionals having a particularly high degree of power within the context discussed here. Along with this greater power comes the potential to cause relatively greater harm or benefit, a fact that can be particularly destructive if not consciously acknowledged and carefully held by these more privileged members.

Distancing When Unable to Repair

Soteria-style homes, The Family Care Foundation, peer respites, and other similar methods have demonstrated that when repair of a particular family system is not working for whatever reason, moving into a healthier environment can be very beneficial for a person’s recovery. Bowen’s research (1960) has demonstrated that even moving into an environment that is not so healthy (such as an inpatient ward of a hospital) can have limited benefits, depending of course on just how harmful the individual’s family system has been. Of course, most hospital environments, and unfortunately most mainstream residential homes, are themselves antithetical to a person’s recovery process when considered from the perspective presented here, in that they are typically highly oppressive and don’t particularly convey the message that “you are loved, accepted and valued for who you are.”

It’s unfortunate that in spite of the very hopeful outcomes demonstrated by the Soteria-style homes that were developed in the 70’s, they remain extremely rare and therefore inaccessible for most people. However, there are signs that the tide is turning, as new Soteria-style homes and other similar kinds of residences are being established, and the peer and peer respite movement is gaining steam. With increasing awareness of the tremendous benefits of such residences for individuals, families and communities, hopefully there will come a time when every community will have a “madness sanctuary” to offer much needed compassionate respite to those in crisis. [See my resource list here for some of the organizations and services that are available.]

Conclusions

As we draw near to the end of this journey through the research on the links between family dynamics, human development and psychosis, we can reflect on what we have learned and wrap up a few conclusions to take away with us:

1. Certain traumatic incidents, particularly many of those listed in Table 1, can directly or indirectly lead to a psychotic crisis.
2. We all share certain core needs and existential and relational dilemmas (see Figure 1 in Part Two of this article series), and when these are chronically unmet and/or unresolved, as can result from the traumatic incidents listed in Table 1, we may experience enough overwhelm that our organism initiates a psychotic response as a desperate strategy to tolerate what would otherwise be intolerable.
3. It’s likely that we all have a tipping point, a point at which we become overwhelmed to the point of initiating a psychotic response, although personal vulnerability to this may differ substantially from one individual to another.
4. Fortunately, there are a number of strategies we can implement to reduce the likelihood of ourselves or a loved one going down the path of psychosis, or to support recovery once someone has already gone down this path. What is likely to be of particular benefit is transforming problematic family and relational dynamics into more harmonious ones, including especially:
   • Striving to develop parenting styles with high degrees of collaboration, communication and nourishing connection.
   • As parents, developing and maintaining secure attachment with our children through adolescence, and then supporting them in transitioning towards increasing autonomy as developmentally appropriate.
   • Developing “power with” rather than “power over” relationships.
   • Working towards maximal transparency (rather than mystification or triangulation) and authentic dialogue (rather than multiple monologues) within our communication.
   • Letting go of blame and scapegoating, and working towards personal accountability and shared responsibility.
   • Recognizing the benefit of distancing from unhealthy family relationships and pursuing alternative nourishing relationships when we are unable to repair the family relationships.

Finally, it’s important to recognize that that we are profoundly social beings living not as isolated individuals but as integral members of interdependent social systems—our nuclear family system, and the broader social systems of extended family, peers, our community and the broader society. Therefore, psychosis and other forms of human distress often deemed “mental illness” are best seen not so much as something intrinsically “wrong” or “diseased” within the particular individual who is most exhibiting that distress, but rather as systemic problems that are merely being channeled through this individual. Furthermore, certain members of these social systems clearly hold more power than others; and those who hold the greatest power, such as parents and health professionals, also hold the greatest potential to produce both harm and benefit, therefore making it essential that the greater burden of responsibility that goes along with this greater power is acknowledged and carefully held. In spite of these power differentials, however, we must not forget that all members of a particular social system hold some degree of power—with every action we take, every word we utter, every vote we make, and every dollar we spend, each and every one of us plays a role in perpetually co-creating the social systems in which we live. So it’s up to each of us to ask ourselves what kind of world we want to aspire towards—a world filled with fragmentation, blame and disconnection, or a world of open dialogue, shared responsibility and nourishing support and connection.

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