When the Family Is the Patient

I recently got a chance to read Laura Delano’s memoir “Unshrunk” which tells the moving story of one young women’s mental suffering, her eventual recovery, and her relationship to the psychiatric establishment. She was labeled as sick, with multiple diagnoses and medications attached to her. She talks about reading Robert Whitaker’s Anatomy of an Epidemic, and how the book transformed her thinking about what was happening to her.

As I read Laura’s troubling account, I thought of the many families who have called me, distressed about their child’s depression or their out-of-control behavior. The difference is that when a parent calls requesting therapy for the child, I don’t see the child alone. And I don’t have the family bring the child. I have the child bring the family. Sometimes I even (semi-jokingly) thank the child for bringing their parents to see me. I recognize that the child or young person is reacting to a dysfunctional family dynamic, and they are often unconsciously asking for help for their family.

I know this because of my long experience as a family therapist. Having trained with one of the creators of the field of family therapy, Dr. Salvador Minuchin, I inherited the knowledge, theory and dynamic clinical thinking of these masters who spent years studying how family dynamics created mental health disturbances in one person. As a clinician, I have seen many families where the child’s behavior seems worrisome or out of control. I, and family therapists like me, treat the child’s behavior as if it reflects and responds to the dysfunction in the family, rather than being the cause of it. The child is off the hook. The family is the patient.

I spend the initial session connecting with each family member and observing their interactions with each other. I learn about the family’s operating system, the unconscious rule system governing the family, in order to understand the distress of the young person. (All families have unconscious rule systems which they follow without knowing it.) I spend the initial meeting observing the family. Who speaks first? Where is the power center? How does each family member describe the family distress? What stories do they tell? How are they with each other? Formal, informal, stiff, loose? What is the vibe? Is there humor in the family? Warmth? Where are the coalitions? Who sides with whom? How do they handle differences? What are the tensions between the parents? Is parental conflict out in the open, or hidden? These are all important indicators of a family’s mental health.

In this first session I would also ask the parents about their own background. I want to know who is in their family and a bit about how they were raised, as well as the current state of their family.  This is important, since it offers clues as to family pain points, any parental trauma, or problematic patterns in their own background that may get projected on to the children. For example, the mother may have been raised in a home with a violent or alcoholic parent. This is where she may have learned to be a peacemaker, to fear and overreact to conflict, and consequently differences and disagreements are seen as dangerous and are squashed, often subtly. This helps to create a static, rigid dynamic in the family and sets the stage for symptoms of mental health distress.

The language in this meeting is different than that of a biologically oriented psychiatrist. Questions about relationships and family stories, rather than symptoms, set the stage for the family to begin to think differently about their child. The mood of the session is supportive, looking for family strengths, as well as being mildly disruptive in the way it challenges the idea that the child is the problem.

The following is a brief snapshot of an initial session:

The L family was referred to me by their family doctor. When the mother, Ayla, called me she said her thirteen-year-old daughter, Jasmine, was completely out of control and Ayla didn’t know what to do. She wanted to send Jasmine to see me but I said she should come with the family. We set up an appointment for the following week.

The first session, which included the parents and the two children, turned out to be pivotal. The family dance was on full, unattractive, display. Ayla and Jasmine did indeed go at it. Wow. Sparks flew. These battles looked well-practiced, repetitive, painful for everyone, and unending. This was what being stuck in a family impasse looked like.

Ayla treated her daughter like an adversary, responding to every trigger by going into battle mode. It was almost as if she couldn’t wait to prove Jasmine wrong. The mother, who seemed like an otherwise mature person, regressed to the level of a thirteen-year-old when battling with her daughter. She stopped just short of name-calling. Eyes nearly bugging out of her head, Ayla, hissed “How dare you?” in response to some inflammatory comment from her daughter.

Jasmine, indeed, had become a real expert in button-pushing. She was certainly a handful: She rudely mocked her mother right in the session, scornfully belittling her mother’s demands.

“My mother is a crazy woman. She doesn’t know what she’s talking about,” she sniffed dismissively.

This mini drama was disturbing to observe. Jasmine was right out of Central Casting, playing the role of Terrible Teenager. Their son William, a thoughtful-appearing eleven-year-old, maintained an air of anxious stillness while the battle raged. I guessed he had seen this play out many, many times.

Beneath all this drama, however, I could sense that Jasmine was clearly longing for her mother’s love. At times this young girl would let a bit of vulnerability show, in her speech or her looks toward her mother; after all, she was only thirteen, she still very much needed a mother’s love. Ayla, for her part, seemed to have painted herself into a corner, not allowing herself to “give in” as long as her daughter treated her rudely. She talked about how she was raised in a traditional Turkish home, where, she said, children showed respect to their parents, no matter what.

We also talked about the father, Frank’s background and how he was raised. He talked about his father’s death when he was a teenager and how is mother struggled to raise him and his brother on her own. He described his mother as “tough” and talked about how Ayla and his mother didn’t get along. This was clearly a source of pain for him.

Part of my standard repertoire in an initial meeting with families is to ask the kids what they worry about when they worry about their parents. I have heard some very poignant comments from children as young as five. While sometimes reluctant to respond, the effect on the kids usually appears to be one of relief, that someone knows about their worry and is taking them seriously. And the effect on parents is typically one of, first, surprise, followed by a therapeutic moment where they absorb their child’s anxious observations.

At my invitation, Jasmine spoke openly about how she saw her parents’ marriage. That’s the good thing about having adolescents in the therapy setting: They are usually fantastic observers of the marital dynamic, have sharp radar when it comes to parental hypocrisy and don’t usually mince words. Jasmine seemed like she couldn’t wait to weigh in.

“My parents are both wrong and they don’t know it. It’s horrible to watch. My mother is always picking on my father, and he doesn’t say anything! It makes me sick.” She paused; “I do worry about them though. My mother seems really lonely. And my father is a terrible fighter.” She paused again. “And I worry about my mother’s health. I want to see her get better.”

I wondered out loud, rhetorically, not expecting an answer, “I wonder if you’re trying to show your father how to fight?” Though she didn’t say anything, I could tell that Jasmine heard me. These were subtle tensions, not part of this couples’ social persona. The couple maintained the outward appearance of calm.

Looking at Jasmine, her father countered, “We’ve got a good marriage. In fact, we’re the envy of all our friends,” he said with a self-satisfied smile. I call this the Mask of Family Unity. The parents appear to be on the same page, but in fact cover over their disagreements with a polite, socially acceptable mask.

What had happened with this family is that the parental battleground had shifted from the couple to mother and daughter. As we soon discovered, the daughter was a proxy in the underground war between the parents. The daughter had picked up on her father’s upset with his wife and had unconsciously decided to fight the father’s fight.

Where was Frank, you might ask, when Ayla and her daughter were slugging it out? Frank saw himself as a bystander, a self-appointed referee between his wife and his daughter. But truth be told, he mostly sided with his daughter. He did this indirectly, by not correcting his daughter’s over-the-top rudeness, or by openly admonishing his wife for her behavior toward their daughter.

“Calm down, dear,” he said, laying his hand on his wife’s arm.

I watched as Ayla stiffened at her husband’s rebuke.

Frank, intelligent as he was, was blind to his own contribution to this ongoing, antagonizing conflict in his family. His self-image as a good guy, a peacemaker, kept him from seeing what family therapist Betty Carter used to say in our classes: the peacemaker is the cause of the war. The session ended with my framing Jasmine’s behavior as part of “the family operating system,” a reflection of pain in the family that hadn’t been addressed. The family, in distress and eager for help, seemed to be okay with this formulation. I believe they felt my caring during the session and saw that I was tuned in to the dynamics of this difficult family dance. The couple said they’d like to come in alone, without the kids, for the next session. I wasn’t sure what they had in mind, but I agreed.

The therapy lasted about eight sessions spread over the period of a year. The parents, Frank and Ayla, used this time to dig into long-standing issues in their marriage which they had swept under the rug. Frank revealed some simmering resentment toward Ayla for being too tough on his mother, on the kids and on him. Ayla was relieved to hear Frank finally opening up about his feelings instead of avoiding or placating her. They enjoyed a new level of intimacy. The fighting between Jasmine and her mother diminished greatly.

When a family engages in therapy, it may be dangerous to their cherished beliefs about themselves, but it can be life-giving in terms of their happiness and well-being. Some long-standing, unacknowledged tensions are opened up. The child is no longer the scapegoat or sick, but rather a kind of hero, a child who is hurt because the family was hurting, who tries to do something about it.

The session with the L family is a variation of a common story in my family therapy office, and in family therapy practices across the world. The magic of this framework comes from the way it humanizes people’s pain, rather than pathologizes it. It makes distress interpersonal. It involves exploration of the pain behind the pain, what the symptom means in terms of family relational patterns and how they got stuck. Furthermore, this kind of therapy does not take years. Often families, and children, feel a rather quick sense of relief when they realize they are part of the human condition, and that they can change their living patterns for the better.