As family therapist I often have families referred to me with an “identified patient”, a person who has troubled behavior, or is troubling to the family in some way. This person may be the object of attention and concern. Sometimes this person, a child or adult, fills the role of the scapegoat. The scapegoat is the person who attracts and absorbs the scorn, anger, or disapproval of the rest of the family. The family often says, “If it weren’t for X (this person) everything would be fine.”
What the family doesn’t know is that this “identified patient” is probably the healthiest one in the family. This person acts as a lighthouse, revealing what the family doesn’t want to know, desperately pointing the way to the wounds and power imbalances in the family. A little-known feature uncovered by the early family therapy researchers is that what may look like “crazy” behavior is often an attempt on the part of that person to help the family.
In families where a child is in mental distress, you can be sure that that child knows everything that is going on in the family. They see where the power imbalances are, where the suffering is, who doesn’t have a voice, and, with their behavior or mood, are registering distress that no one is acknowledging it, or doing anything about it. They are often the hidden family doctors of the family. As a family therapist I have seen many, many cases like this over the years.
One of the central truths about mental health that I learned when I began my studies in family therapy is that symptoms don’t belong to just one person. Symptoms are interpersonal. Our symptoms of mental distress are created by disturbing relationships, or life situations, not problematic brains. Our brains react to our feelings. Our feelings are, for the most part, contextual. We react with our feelings and with our bodies to subtle patterns in our most intimate relationships. Often these patterns are outside conscious awareness. But these relationship patterns are powerful. They are the primary source of our feelings of well-being, or ill being.
What this means in practical terms is that, as a family therapist, when someone is referred to me for depression or any other symptom, or a child is disturbing the family with their behavior, I see the entire family together. I treat what psychotherapists call “the presenting problem” as if it belongs to the family, not just the person with the label of “patient”. From the first visit on, I look for patterns in the relationships that are creating the symptoms that are the cause of concern. The initial session with the family always involves a reframing: I wonder openly about how this symptom came to be, how does this symptom belong to the whole family, what does the symptom mean in the context of the dynamics of the family? And crucially, how is the “patient,” by their behavior or mood, trying to help address the hidden suffering in the family?
In a previous post I talked about what these disturbing relationship patterns are made of. All families have rule systems which are largely unconscious and develop over time. These rules systems are often passed down in part from previous generations. A healthy functioning rule system involves consistency and stability, plus spontaneity, creativity, and change, as needed. A healthy family rule system appreciates both individuality and togetherness. A healthy family rule system allows for conflict, for the airing of differences and grievances which are acknowledged and resolved. The family with a member in mental distress lacks these things. These families are typically characterized by rigidity in their rule system. This is often subtle and outside the conscious awareness of the family. They may appear healthy and “normal,” but family members’ roles and ways of communicating are locked in. They maintain their rigid rule system through conflict avoidance and a kind of unhealthy over-protectiveness. These patterns help to create the climate in which symptoms of mental distress occur. Enter the scapegoat, the symptomatic one, the person who is trying to call attention to the fact that all is not well at home. But the family is threatened by this, worries that they will have to change, their secret distress will be exposed, their suffering unmasked.
The following story illustrates what this looks like in the therapy setting.
Seventeen-year-old Melanie and her family were referred to me by their family doctor. Melanie had been practicing the dubious art of anorexia for several years, and at the time of our first meeting she was consuming a carefully controlled four hundred calories a day. She had stopped menstruating, a classic symptom of anorexia. If she kept going in this direction, Melanie would end up in the hospital. She had just begun working with a nutritionist. The parents reluctantly agreed to call me for a consultation.
My first couple of meetings with this well-groomed, picture-perfect family was both intriguing and infuriating. The mom, Emma, was a Belgian-born beauty with porcelain skin and brown hair swept up in a knot. She radiated an anxious need for approval and harmony. Each time she spoke she looked at the family for signs of confirmation. She clearly didn’t want anything to disturb this image of lovely family harmony. Her husband, John, cooperated by appearing to agree with everything his wife said. “Agreement” was his middle name.
John was born in Germany. and in his late forties. He worked in advertising for an international finance magazine. He looked like an aging punk rocker. This was his second marriage. He described his previous wife as “unstable.” He had a twenty-five-year-old son, Frederick, from this marriage who continued to be what John described mournfully as “a handful.” Frederick had been hospitalized for drug addiction and was struggling to stay clean. John appeared to carry a lot of guilt toward his son, whose behavior created a fair amount of disruption in the early part of John’s marriage to Emma.
During the first few meetings with this family, I felt at times like Alice in Wonderland, trapped in an absurd world where normal responses are regarded as suspect. The dictates of the family culture, unconsciously promoted by the parents, looked to me something like this:
- No one will disagree.
- No one will raise their voice.
- We will be happy.
- We will have fun.
- We will think alike.
- We will love each other all the time.
This pattern first appeared when I noticed that every time Melanie spoke, her parents and 15-year-old sister, Lucia, disqualified her. Melanie, an academic super achiever, was enrolled in an advanced high school for bright, hardworking kids. She was hugely perceptive. She spoke to her parents in an almost hyper-respectful, controlled way but her point of view didn’t gain any traction in the family. Melanie had zero credibility. She was a poster child for what a scapegoat looks like. Scapegoating, of course, is a relatively common phenomenon. Anyone who has worked in an organization has seen it—how everyone focuses on one person as the problem to avoid looking at larger institutional dysfunction. It’s the same in families. The subliminal function of scapegoating is to avoid responsibility: as long as THAT PERSON is the problem, we don’t have to address the underlying problems of our group.
In her family, Melanie would try to lobby for some relatively mild change related to her own privacy. This was an “open door” family; they lived in a loft—one big, open space—and the parents, especially the father, would often keep the bathroom door open when he showered. Privacy and individuality in this family were seen as an affront, an act of aggression toward other family members. In one session, Melanie weighed in on wanting her parents (i.e., mother) to treat her differently, to let her spend time in her room alone instead of magically appearing in the living room to watch a popular television show with the rest of the family.
“Sometimes, Mom, I just want to be left alone, to do my own thing. I may not be interested in that show.”
Melanie as always, expressed these preferences respectfully, in an almost hyper-mature manner. No adolescent pouting for her. But she was clearly out of step with how this family did things. She apparently hadn’t gotten the memo. Any comment about a personal preference was treated like an assault on the family. The slightest challenge to her mother was responded to as a betrayal. Melanie doubled as family scapegoat and troublemaker. I was pretty sure that her eating disorder related to her inability to have an autonomous voice in this family of super-togetherness.
As I gathered information about the parents’ individual backgrounds, one feature stood out. Emma had been raised in a home where her own mother acted as the peacemaker, constantly softening her husband’s rules to accommodate the children. Apparently, Emma’s mother spent much of the time containing her husband, worried that he’d be too hard on Emma and her brother, and always ran interference between the children and their father. Emma’s mother wanted to avoid conflict at all costs. I never found out how she learned this, but it must have come from some trauma or pain in her own past. It sounded like Emma’s mother didn’t want any anger, or even heat, coming from her husband. When Emma turned sixteen, she started giving her father a hard time by staying out late and disobeying his rules. Of course, Emma knew her mother would back her up.
I spent the first few sessions of the therapy hoping to disrupt the stifling togetherness of this family, sharing my observations in a way that challenged the family norms. I used my whole being to try to create a sense of differentiation in this family. I encouraged, begged, for different opinions, different voices. I chided the father John for his “Mr. Agreement” persona.
I told him, “You know, I’m having trouble telling what you’re really thinking. It looks like you’re worried about having a different brain than your wife’s.”
Naturally, he disagreed with me.
I knew that to help Melanie, and the family, I wanted, needed, to challenge the mother’s hyper-peacemaking. A big part of my work as a family therapist is to disrupt the dysfunctional patterns that families have inadvertently created. This is not always easy. I addressed the mother Emma directly:
“You have a Band-Aid for everything. It looks to me like no one should ever be upset over anything. No one should ever feel hurt, or angry.”
Every comment I made that had a bit of tension in it was blocked by Melanie’s mother. If I challenged the family togetherness Emma would look around innocently, like I was an invader coming to hurt her tribe. This was her version of overprotectiveness. Emma didn’t want to believe that there was a problem in how the family was operating. Melanie was the problem. Couldn’t I see that? This pattern was (inwardly) infuriating for me. I began to feel like Melanie. Nothing could get through in this family. It was one voice or no voice at all. Then we had what I thought might be our final session.
The parents showed up with just Melanie. They decided to leave their younger daughter at home, stating that something had happened over the weekend with Melanie that they wanted to discuss “privately.” (I inwardly took this as a personal challenge, since I made it clear that everyone needed to be at our sessions. I decided not to take the bait.) Emma recounted her version of what happened.
“We had an uproar at our home a couple of days ago,” she said. She went on to describe an argument with Melanie that ended with Melanie smashing a plate on the ground and throwing some silverware for good measure. The family was calm (of course) when recounting this story.
Emma, Band-Aid in hand, said, “We had a good discussion afterward.”
I thought that this might be some health breaking through. Melanie’s anger turned outward instead of inward, openly directed at her parents. It sounded more dramatic than dangerous. I asked about what transpired that led to the escalation. Melanie volunteered her version.
“I came down after dinner and felt quiet. I just didn’t feel much like talking. My mom wouldn’t leave me alone. She kept asking what’s wrong, what’s wrong, what’s wrong. I didn’t know what was wrong. I just didn’t feel like having a big smile on my face.”
Bingo! I wanted Emma to explore her daughter’s perspective, but her mother shut it down. She didn’t want to go there. Instead, Emma tried to redirect her daughter to a “happier” thought so I stopped the conversation.
“Melanie is trying to help you to understand what she needs as a 17-year-old. It sounds like she needed some space.”
Emma, of course, took this as a minor insult, and kept anxiously talking, mostly ignoring my comment.
I stopped her again and said, “Nothing gets digested in this family” (semi-intentional metaphor). “Melanie is incredibly perceptive and caring. Your daughter says many important, valuable things that would help you to know what she needs from you. She is her own person, with her own ideas, her own desires, her own needs. But nothing gets digested. You just keep going without stopping to learn anything from her. You’re missing a crucial opportunity.”
I insisted on a few minutes of silence. I felt that if I could amplify Melanie’s voice, she might gain some real, healthy control in her relationship with her mother instead of the pseudo-control of starving herself. I could almost see the steam coming out of Cassandra’s ears. I knew she was furious at me, and I wanted to tease her a bit.
“You know, I feel like such a Scrooge with your family. I feel like the bubble-buster, the one who came to rain on your parade. The groove-blower. I feel like ‘Angry Guy.’” I called myself out with a smile and the tension lessened.
Then Melanie launched into a gorgeous soliloquy that contained so much wisdom, and so much health. I felt like I had a front row seat at a powerful Broadway show. She looked at her mom.
“It’s not that I don’t want to be part of this family. I love you. I WANT to be in the family. But if I say I want to do something myself, like wake myself up in the morning, you say, ‘Well, then you can just do your own laundry.’ You act like if I want to do something my way that I’m hurting you. And then I feel guilty.”
This soft-spoken young woman continued in this vein for a few minutes, telling her folks everything they needed to know for healing to begin. If I could have applauded, I would have. But I did the next best thing and held my hand up for silence. I nodded, signaling my respect for Melanie and her courage. I didn’t want Emma to move in and smooth over her daughter’s comments. I wanted to let Melanie’s description of her experience in this family ring out in the room without distortion.
Since we neared the end of the session, I thought it was a good time to end. I could see that Emma was mad. She refused to look at me. I was interfering with the script that she had so meticulously honed. I knew she saw herself as the family doctor and my support of her daughter’s troublemaking probably offended her pride, at the very least. But I greatly admired Melanie and wanted to help her stop hurting herself. I had to risk her mother’s animosity if we were going to get anywhere.
We ended the session without scheduling another one. I didn’t know if I would see them again. I heard from their family doctor that they were “shopping around” for another therapist. Then the mother called two days later.
She said, “You know, I was very angry at you the other day. We interviewed some individual therapists for Melanie, and they all told us to stick with the family therapy.” She added, “This is difficult for me. It’s not at all what I expected. But I’m starting to think it’s very helpful. So, we’ll stick with you through this painful journey.”
I could hear the smile in her voice. I was glad to have the opportunity to affirm her. Despite her exasperating ways, I liked Emma.
“I’m impressed by how you’re responding. I know our meetings feel difficult, but you’re an intelligent and thoughtful person. I’m impressed.”
She needed that from me, and I was glad to give it to her.
“I know our other daughter doesn’t want to come, but I’m going to make her attend. I don’t care if she’s mad at me. That’s what we’re supposed to do as parents, right?” Now it was my turn to smile.
At the end of the fourth session, Melanie and her family reported that she was now eating 1,200 calories a day. She looked much better.
I continued to see them for several visits, about seven sessions in all. One improvement went unnoticed, except by me. When I first met them the two sisters were fighting so intensely that they could barely leave the house as a family. According to John, the family couldn’t go to a movie or restaurant together without the daughters battling so fiercely that the parents nearly collapsed in shame. This led to them avoiding family outings.
That problem resolved quickly, by the third session. I knew that the source of the conflict between the sisters had to do with the fact that Lucia was playing on her parents’ team, correcting and criticizing her older sister, which, of course, Melanie resented. I needed to rebalance this relationship and get the sisters back on the same team. Lucia needed to stop protecting her parents, which was both bad for her and continued to isolate Melanie.
I lightly chided the younger daughter for her goody-goody ways with her parents.
“Lucia, you’re only 14 but you sound like you’re 40. You know, you have a very cool older sister. You can learn a lot from her if you’d just open yourself to it. She’s much cooler than the old folks over there,” motioning to her parents sitting on the couch.
Lucia had unfortunately picked up on the instruction manual that called for disapproval of Melanie. Lucia was embarrassed by my comment, in a good way, which eased tensions between the sisters.
Our sessions ended with a whimper, not a bang. School was over, summer had begun, and the family planned to leave town for a couple of months. Emma she would call when they returned. I did not hear from them again.
I’m not sure if I adequately conveyed here what it felt like to sit with this family. The invisible rules mandating conformity in all things felt intense and oppressive. My approach to diagnosis includes both observation of family interactional patterns and my experience of being with a family, testing both for points of rigidity and of flexibility. By flexibility I mean self-questioning, imagination, curiosity. The more flexibility, in general, the more health.
This story illustrates the sharp contrast between treating a mental disturbance as a relationship problem instead of question of faulty brain chemistry. Melanie clearly benefitted by reframing her distress as related to dysfunctional family dynamics, not some personal deficiency that needed to be fixed and medicated. She no longer carried responsibility for the family dysfunction. She was off the hook. She could now begin her own journey toward healing.
