Insane Medicine, Chapter 9: The Worried Parent (Part 1)

Editor’s Note: Over the past few months, Mad in America’s Parent Resources section has been publishing selected chapters of Sami Tamimi’s new book, Insane Medicine. Dr. Timimi is a consultant in child and adolescent psychiatry at the UK’s Lincolnshire Partnership NHS Foundation Trust. His past works include the books Naughty Boys: Anti-Social Behaviour, ADHD and the Role of Culture, and A Straight Talking Introduction to Children’s Mental Health Problems, among others.

Following is Chapter 9, Part 1. All chapters are archived here. 

When parents are worried about their child, whether it’s their behaviour or emotional state or both, the emotional intensity in that relationship rises resulting in various knock-on effects.

Diagnoses (such as ADHD or autism) give beleaguered parents temporary relief, but invite everyone to commence the alienating process that encourages all to view their child as infected with a disease that results in them operating outside the boundaries of what is considered ordinary.

But parents have dilemmas of their own, given how much parenting has come under scrutiny. One of the most common things we hear working with parents in child and adolescent mental health services is how judged they feel by those around them when their child acts up in public. It’s easy to see how a diagnosis can provide temporary relief as the parent changes from feeling like they are judged as a failed parent to one who can now be seen as a heroic parent struggling with a disabled child.

I think that our compare-and-compete culture has made it difficult for parents and their kids to feel secure and competent. Failure to live up to something (whether for the child, the parent, the child about their parent, the parent about their child) stalks our lives. It’s harder than ever to be a “normal” kid or a “normal” parent.

This chapter cannot remedy the cultural and political milieu; it can only provide some reflections on what may improve some aspects of some families’ lives. Nor am I presenting a model of “normal” family functioning, or out to lecture anyone on what values they should hold. As I have discussed, models of child development and family forms vary across the world.

This chapter should not be used to pass judgement on the many families living under stress of inequality, racism, sexism, and all the other forms of disenfranchisement that can affect us. Your father being given a long prison sentence for a relatively minor misdemeanour, as happens to so many Black men in the mass incarceration ideology in the US, has knock-on effects for the family and their children that can follow them into adulthood. These issues require political action, not just the few tepid tips I outline in this chapter.

In my opinion, a sense of belonging and feeling that you are loved just for being, rather than for doing anything in particular, more than anything else leads to children growing up well and ready for the turmoil and challenges of adulthood. Of course, I could start deconstructing what meanings and indicators equate to “belonging,” but for now let me start the chapter with this thought: None of the ideas outlined in this chapter are as important as your child knowing that you love them and find joy in their existence, no matter what they do or say that worries or infuriates you.

The Relational Awareness Programme (RAP)

I, along with some colleagues, developed an approach we use with such worried parents, which is a diagnosis-free approach and mainly uses a group format to which we invite parents and their supporters who are worried about their child. We call this approach the “Relational Awareness Programme,” or RAP. The RAP approach was originally inspired by the ideas of the American psychologist Howard Glasser, who developed the Nurtured Heart Approach (NHA). RAP infuses NHA with systemic and solution-focussed philosophies.

I think of RAP as a “toolbox” of ideas. It has concepts and exercises that can be used in a flexible manner to suit different circumstances. They are not really designed to be applied as if they are the only possible “truths.” Real people are more creative and diverse than any single approach can allow. Only those who are living it can truly understand what challenges and opportunities their lives contain. In this approach, each parent/carer/family/school needs to figure out what is practical, helpful, and adaptable to their unique circumstances. They are presented with a series of concepts and frameworks and then decide whether and how any of these might be applied to their lives.

RAP isn’t a parenting, parent management, or parent-training programme. It’s more of a skill-based programme to assist good parents with those more “intense” children. It doesn’t involve telling people the details of what they should or shouldn’t do. RAP provides concepts and questions to help parents work out for themselves how they wish to proceed and adapt the ideas to their specific circumstances. Having said that, we have had some inspiring outcomes over the years where parents who have been accessing services for their children for many years have discovered something new about the relationship with the child they’re worried about, freeing them to create new “dances” and to view their lives through a new lens.

In RAP we focus less on how to control behaviour, which is fraught with dangers for the parent/child relationship, and more on how to build positive relationships in the family. It works well for all sorts of child caregivers, from teachers to foster parents. I refer to “parents” in the rest of the chapter, so as not to complicate the sentences. Wherever the word “parents” appears you can substitute all other potential caregivers. “He” and “she” are used interchangeably, not to denote the specific gender of the child, but for convenience and instead of writing she/he on every occasion. For similar reasons of convenience, where I have used singular (as in “parent” or “child”) that could also refer to the plural too (as in “parents” or “children”) and vice versa.

Some assumptions

Here are a few assumptions that help set some baseline for this therapeutic philosophy on the parent side of the relationship:

• Parents are motivated by positive intentions—parents who seek help are “good parents”; they want to see things improving for their child.
• It’s hard for parents when their child’s behaviour is difficult; they often feel judged and  like everybody seems to have an opinion about them and their child.
• All good parents spend most of their time feeling guilty about how they parent—should I have done this or not done that, should I have been stricter or softer, etc. I assume, like all good parents, they will continue to feel guilty no matter what!
• Professionals have some academic knowledge that might be helpful, but no one knows their child better than the parents and other involved caregivers. The RAP philosophy shares ideas, ways of thinking, and a framework for strategies, but it doesn’t provide specific advice on how to put them into practice. This is something each family needs to figure out for themselves based on their own knowledge and skills.
• Any relationship, by definition, involves at least two people who are contributing to how it works. Even if the contribution of a parent in their relationship with their child is not as influential as the child’s side, which side of the relationship do you think the parents have control over? In whom can you guarantee that change can be achieved? Focusing on what you, as a parent, can change is more likely to lead to relational change than trying to convince your child to change.

Here are a few assumptions that help set some baseline for this therapeutic philosophy on the child side of the relationship:

• Children are not born into the world all the same. Research shows that children, from their earliest moments in life, have temperaments, tendencies, and differences in the way they interact with the world.
• Some children later attract psychiatric and psychological labels, but these labels tell us little about what might be helpful for any specific child.
• Instead, we can simply recognise that with some children the intensity with which they interact with and experience the world and its people is greater than most other children.
• These intense children tend to produce strong emotional reactions from those around them, including frustration, anger, and worry.
• This means that whereas for most children the more ordinary approaches to parenting and managing behaviour of muddling through—a bit of consequence here and there and rewards here and there—tends to work, for those children who are that bit more intense, we may need to “up our game” and work at engaging them at a greater level of emotional intensity.
• You can think of these children as emotion-seeking (not “attention-seeking”). “Attention seeking” as a phrase suggests that children are thinking logically about what they do; however, in reality, children are usually just responding to how they feel and are seeking emotional engagement in response to this feeling.

Family relational dancing

Now we can look at some emotional drivers of parent/child relationships. Here are a few more assumptions:

• Emotions are viral! We tend to “catch” the emotions of those whom we are closest to (emotionally and geographically). Don’t be surprised with how quickly an emotion can ripple out into other family members. Laughter breeds laughter like anger breeds anger.
• The basic philosophy of this approach is that of focusing on building functional relationships rather than on controlling behaviour. Let the emotions we want more of spill out and be caught. Let us build up our tolerance and immunity toward the emotions we want less of.
• The concept of “negative” and “positive” emotions is not, strictly speaking, accurate. We just have a variety of emotions that are forms of directed energy that put us into an “action” rather than “thinking” mode.
• When parents are dealing with children who have challenging behaviours, they are often looking for strategies to try and control that difficult behaviour. They may hope that professionals can tell them that if they do A and then B the behaviour will stop. You may be looking to achieve the absence of undesired behaviours. The RAP philosophy will not tell you what to do to eliminate undesired behaviours—and for good reasons.
• One of the problems with focusing on the controlling of behaviour is that attempts to control behaviour can lead to further strain and tension in the relationship with the child, which can end up in a negative feedback loop resulting in further attempts to control behaviour, causing further strain on the relationship, and so on. The more that a young person feels alienated or “picked on,” the more they may try and defend themselves, the angrier they may feel, and the lower their self-esteem will become. A reinforcing negative loop can build up over time.
• By focusing on relationships to start with, you can build a better foundation for stronger relationships that involves some mutual appreciation.
• RAP tries to help with creating a new and hopefully more enjoyable relational dance.

The Emotion WARS

The idea of “Emotion WARS” is to help parents understand how “family relational dancing” can become problematic. It can be thought of as a framework for making sense of what is going on at a more unconscious level.

“W” is for Wrongs: The first assumption in Emotion WARS is that we are programmed to notice more what’s going wrong than what’s going right. Evolutionarily, our survival was related to our ability to scan our environment for signs of danger and respond to these. As this is an instinctual aspect, it means that the more stressed we feel, the more likely we are to activate this instinct to try to fix any perceived problem.

Becoming preoccupied with what’s going wrong means that, whatever the cause of increased stress, it becomes irrelevant compared to the actual experience of stress. So whether it’s difficult finances, problems in a marital relationship, the stress of school regularly ringing up, and so on, once we experience increased stress, we are more likely to end up focusing on what’s wrong, including with our children. Over time it becomes like an internal radar scanning the environment for signs of what next is going to go wrong, often missing those bits that are OK.

“A” is for Attachment: The next basic assumption is that children are born as “emotion seeking” creatures. Attachments are created through our emotional relationships and what we seek is emotional energy from those we are attached to. In an infant’s world, there is no such thing as good or bad emotion. For the infant and growing child, there is an instinctual drive towards seeking emotion so that any emotion (be that love, worry, or anger) that comes back to them from a parent is experienced as rewarding in some way. If you think about it, you can’t get your mind off someone you’re angry with, just as much as someone you’re in love with.

Emotional energy creates connection. Seeking emotional energy is a better way of describing what children do than seeking attention. This also means children will know the parent emotionally much better than the parent will ever know the child emotionally. A parent will have many things to consider and think about. A child will just learn instinctually (not logically) what gets them emotional energy from the parent.

“R” is for Relationships: Relationship dynamics are then built up through these emotional energy ties that family members have to each other and over time this develops into a dynamic—a relational dance, where the relationship follows a certain “rhythm” so that each person responds in a predictable way to the other.

“S” is for Scripts: Over time we each develop roles within any group and these roles are rarely ones we have consciously chosen, but rather emerge out of the collection of relational dances, “settling” into a certain recognisable pattern that everybody in the group (often unconsciously) recognises. For example, it’s a well-known phenomenon that if you have a partner, one of you will end up being the one preoccupied with tidying up, another one may be preoccupied with sorting out the bills or getting children ready in the morning, and so on. Many then find that even if you want the roles to change, it doesn’t feel “right” when you do.

So, for example, if you are the one who is concerned about keeping the house tidy and you yearn for your partner to also do this, when they do it, somehow they never seem to be able to do it in the right way and so you have to re-do it to what you consider to be the correct standard! This is a bit like each family member having a “script” that they follow which identifies their role, and should any member come along with a new script that changes their usual role, it throws everybody else off because it doesn’t seem “natural.”

There is thus a powerful and usually unrecognised emotional force from other members pushing anybody who goes “off script” back toward the script that everybody recognises—back to the usual family relational dance. If a child occupies the role of, say, “the troublemaker,” family members will often assume that this child is in some way involved whenever trouble is happening and the child will settle into that role and also expect it in themselves.

Emotion WARS thus uses the framework that we develop a family relational dance through the flow of emotional energy; wherever this is strongest, then this is what that relationship will “learn”—this will be their relational dance. As stress increases, then what’s going wrong will be noticed most. Over time a group of people will develop a set of relational dances that become the “family script” or the family relational dance.

When there is a child with challenging behaviour (for their parents), then over time the family relational dance may have settled into a pattern where that is the child’s role in the family script. As much as everybody wants and tries to change that, somehow (through the power of these emotional flows), despite everyone’s best intentions, it keeps returning to this script.

Your child’s portfolio

Imagine you are writing out an imaginary portfolio for how you would like your child to be in five years’ time. Now ask yourself these questions and see what comes out:

• What would you like to see in this portfolio?
• What qualities or values would you like to imagine are attracting her emotional energy?
• What sort of behaviours would you like to see them displaying?
• Scale these behaviours/qualities/values from 1 to 10 for how much they display them now, where 1 is never and 10 is always. Which of these behaviours or qualities have they got the most of already?
• How did you see this?
• When did you see them doing this?
• How much emotional energy did you give to them when they did this desired behaviour even if it was for a very short time?
• How might you notice and give emotional energy to any small examples of these behaviours/qualities when you see them?
• What else might you do to help shift one of those scores up by 0.5?

The Robot parent

In many ways, the children’s favourite toy can be a person, such as a member of their family. There is something very satisfying about a person who makes independent choices and has autonomous intentions and yet you are still able to “play” them and get them to react in a way that you know that person does not want to, whether that’s winding them up or getting them to concede to a demand that you’ve made.

Imagine that, as a parent, you’re like a toy robot with lots of buttons. When you push any button the Robot (you, the parent) gets animated and starts doing interesting things as you are emotionally worked up. Children have long since worked out your buttons. Now ask yourself:

• What do they do that pushes your buttons? What do they do to get you emotionally worked up?
• What behaviours or qualities in your child, when you see it, get you “animated” in this way?
• Are these buttons ones that you would want to stop working—in other words, buttons that bring out emotions you would rather not have—or are they buttons you want to continue to have—buttons that bring out emotions in you that you like?
• If you want a button to stop working, what might happen if you try to stop reacting when that button is pushed? Can you deal with your emotions when they try harder to get that button working again? Can you manage a situation involving managing risks without giving out emotional energy?
• Would you like to strengthen buttons that bring out emotions you like? Would you like more of these sorts of buttons? Can you give a score between 1 and 10 for how often you see these “nice” buttons (1 never, 10 all the time)? What might you be able to do to increase your score by 0.5 on any of these “nice” buttons?