A Relationship Imbalance, Not A Chemical Imbalance

As a family therapist, well-trained in the 1980s, I came of age professionally with an understanding of how symptoms of mental distress occur, and ways to address it. What most people don’t know is that we already found out a great deal about the causes of mental disturbance—but now we seem to have forgotten it. Psychiatry, along with the pharmaceutical industry, have been ostensibly busy looking for causes of mental distress but, unfortunately, they are looking in the wrong place. As many writers in this blog have attested, the source of mental illness has not been found, and is likely not to be found, in our neurotransmitters. We need to look at our relationship imbalances, not our chemical imbalances.

What happened to this knowledge? Let us turn the clock back to ancient history, the early 1970s in America. The culture in our country was emerging from the turbulent ‘60s, a dynamic era in American life, with “Question Authority” and “Free Love” as its unofficial mottos. This unstable, creative era provided endless and implicit support for wondering, innovation, dialogue, and challenges to conventional authority in many spheres. This was a period of chaos in American culture. Many institutions, psychiatry included, entered an appealing and invigorating state of tumult.

At that time, incorporating family systems theory into psychiatry was a new idea. A dynamic family systems movement developed and spread around the world, with powerful innovators creating new models of family therapy. Huge bodies of writing, clinical work, and research emerged from this invigorating period in psychotherapy. The clinical findings from this time showed how family dynamics were a powerful determinant of how symptoms of mental distress originated.

Groundbreaking works from this time included Salvador Minuchin’s book Psychosomatic Families, Jay Haley’s Leaving Home, and the Palo Alto researchers’ The Interactional View. These works, among many others, formed a backdrop to our understanding of how family dynamics contribute to poor mental health.

Alongside the rapid and exciting developments in the family therapy field, there was another burgeoning movement which felt like an institutional backlash to the 1960s and ‘70s. During this period, psychiatry had been steeped in an identity crisis, and leading authorities in the field began to speak in dire terms about psychiatry’s very survival. Its credibility as a profession came under serious scrutiny, exemplified by psychiatrist Thomas Szasz’s The Myth of Mental Illness.

Szasz’s widely read book characterized psychiatry as an instrument of social control whose main function was to eliminate social deviance and promote compliance. This cultural trend was symbolized by the popularity of the movie One Flew Over the Cuckoo’s Nest, based on Ken Kesey’s book, which had the effect of undermining the authority psychiatrists very much craved. In addition, the drugs that had thus far been developed had fallen on hard times in the eyes of the public, partly due to troubling side-effects, which further fed the anti-psychiatry mood of the times. Drugs like Valium had fallen into disrepute for their addictive qualities. Drug sales plummeted during this period, from 1973 until about 1980. Something had to be done if psychiatry was going to survive as a profession.

In his landmark book Anatomy of an Epidemic, Robert Whitaker noted that, since psychiatrists are unique in their ability to write prescriptions, there was “an economic landscape that presented the field with an obvious solution. If the image of psychotropic drugs could be rehabilitated, psychiatry would thrive.”

It is in this context that the “re-medicalization” movement in psychiatry was launched, aimed at bringing some of the uniformity (and power) of medicine into psychiatry. The aim was to return to being seen as a specialty founded on scientific principles, and thus it needed to develop practice patterns more familiar to physicians. Psychiatrists were now supposed to act like other doctors, with concrete, measurable diagnostic and treatment tools. The idea was to restore psychiatry in the public’s image.

When the DSM-III came out in 1980, everything that we knew about the impact of relationship dynamics on mental health was completely ignored. These valuable discoveries have never been invalidated or discredited. All that was revealed by the huge amounts of family therapy research became buried under the tidal wave of the pharmaceutical psychiatric industrial complex.

An old, unproven theory of a “chemical imbalance” from the 1960s was resurrected for its public debut when Prozac burst on to the scene in the late 1980s, soon followed by other similar drugs. Pharmaceutical companies focused heavily on marketing these drugs to the public, pouring enormous amounts of money into promoting these medications (spending far more on marketing than on scientific research). What we had learned about how troubled family dynamics created symptoms of mental disturbance was effectively buried.

What did these brilliant family therapy pioneers teach us about family dynamics and mental health? I will briefly outline three ideas that are crucial to understanding how problematic symptom formation occurs.

Rigid Patterns of Interaction: This is critical to understanding depression, mood issues, and behavioral problems in kids. The hallmark of healthy family interaction is flexibility, the ability to improvise, the capacity to adopt new roles, or to respond in new ways as the situation requires. Living is a dynamic process, characterized by change and growth. In families where someone develops mental distress, we typically see the families repeat the same inflexible interactions over and over.

For example, imagine a family where the father is always the expert and the mother’s voice is muted. She is discredited but doesn’t complain or call attention to her plight. She feels she has no power. The relationship never varies. The pain of this repetitive and non-life-giving interaction is felt as a wound in the family. When these relationship imbalances are not talked about or acknowledged, the stress of this static pattern may very well show up as symptoms of depression or other mental distress. Even kids who look “crazy” are often involved in an unconscious attempt to save the family from its unaddressed pain. These children often become the scapegoat for a pain that other family members feel but don’t acknowledge. The scapegoat carries the pain for the family.

This is a very common, though telescoped version of a much larger concept.

Conflict Avoidance: In most families where a member is in mental distress, conflict avoidance characterizes the family interaction. This doesn’t mean that the family members don’t fight, or bicker. They may. But this conflict is usually superficial and doesn’t resolve. Conflict avoidance means that meaningful discussion of relationship imbalances and the emotional pain stemming from these imbalances are avoided.

For example, imagine that the wife in a family develops alcoholism. She looks angry a lot of the time and her husband and children tiptoe around her. As the patterns between the wife and the husband are explored, we see that the husband has been upset by many of the actions of his wife over the years but doesn’t address them because he doesn’t want to upset her. He is a terrible fighter and strives for “peace” at all costs. This is typically a long-standing pattern which contributes to depression in the wife and her eventual alcoholism. She experiences her husband’s avoidance and “peace-keeping” approach as abandonment.  The husband withdraws instead of addressing his pain or upset. The couple becomes more isolated from one another, and the wife’s drinking worsens.

Variations on this theme are extremely common in families where one person is officially showing mental distress.

Over-Protection: This relational pattern goes hand-in-hand with conflict avoidance. We see this in the same case of the husband who avoids his alcoholic wife. In the great majority of families with a symptomatic member, we observe how over-protection masks conflict and prevents the acknowledging and working through of that conflict. What happens then is that the unresolved conflict or pain in the relationship gets stuck in the body of the family where it shows up as symptoms of distress in a family member. This person is often the most sensitive person in the family and feels deeply the problematic relationship imbalances in the family.

These three themes are, of course, a greatly reduced version of common dynamics in families with a mentally disturbed member.

How does treatment look when we imagine the case of the depressed and alcoholic wife? In the individual model where her mood is seen as a product of faulty brain chemistry, the wife feels solely responsible for her distress and believes that she needs to take a medication to fix her mood. She typically feels guilty for causing so much trouble for other people in her family. They are the victims of her depression and alcoholism. Her mood doesn’t even really belong to her; her mood belongs to something rather impersonal, her brain. While the initial appeal may be that this woman no longer feels “responsible” for her moods—after all, it’s her brain chemistry talking—ultimately this kind of medicalized treatment proves incredibly disempowering. The woman stands on the sidelines while the “experts” try to find a right drug to correct her mood. And the implication is that something is wrong with her. She is deficient, in need of fixing.

In a family therapy setting she is not seen as the patient, but, rather, her distress is treated as if it belongs to the relationship with her husband, not caused by imbalances in the brain. This has an immediate de-pathologizing effect. There is something amiss in her relationship, not in her. When the husband is seen in therapy with the wife, these patterns of conflict-avoidance and over-protection are exposed. The treatment comes dynamic. The couple, wife and husband, can do something about the wife’s misery. They both contribute to it. The wife’s depression belongs to both of them. It is revealed that the husband is equally miserable, depressed and lonely. He just doesn’t show it or express it. These people, with good intentions, have been accidently trapped by interpersonal patterns to which they both contribute. These patterns are usually subtle and below the level of conscious awareness. As they couple becomes aware of how they have “created” each other they are empowered to do something different. They expand their range of responses to each other, which in turn creates a livelier, more fulfilling, and authentic connection. The wife’s symptoms of depression subside.

In future blog posts I hope to tell some clinical stories of families which illustrate how this works. The important idea, however, is to recognize that we already know a good deal about how symptoms of mental distress arise. We just have to know where to look.