My family is not my problem… or is it?

We can understand a great deal about nature from observing but what about our relationships with those we most care about, our family members?  Between the shootings at Sandy Hook and the Boston Bombing, once again people are wondering how we as a society understand and deal with disturbed individuals.   What can knowledge of family dynamics add to how we understand and deal with mental health issues today?

This week the NY Times reported that a court ordered outpatient program is saving New York State half the previous cost for “caring” for extremely difficult patients.  When you consider the current cost of mental health treatment, saving half that expense becomes millions of savings of your tax dollars.

 

According to National Institute of Mental Health serious disability affects nearly 60 million adults costing more than $300 billion per year.  If you consider that the average size nuclear family is affected by the “identified patient” with serious disability, the numbers of people touched by serious mental illness approaches 240 million. If you add the grandparent generation, the numbers of people affected by a mentally ill family member rise exponentially.

Such numbers can hide the personal stories, and the personal stores can hide the real issues facing the delivery of better mental heath service today. Anyone can understand the gratitude that one mother feels to the state of New York for developing a program which has been helping her daughter as told in the NY Times article.  But the current focus on the “identified patient” does not seem to provide possibilities for problem solving within the family itself.

Ms. Biasotti’s daughter became ill at 23. Now 41, she has been hospitalized more than 20 times, Ms. Biasotti said.  (Please take a guess of the cost to either the family and/or taxpayers of 20 hospitalizations.)

Before Mrs. Biasotti succeeded in getting her a court order under Kendra’s Law in 2002, her daughter would be hospitalized, discharged, “take medication for a few days and then decide, ‘What do I need this for,’ and then go off it and spiral down again.” Now, with a caseworker visiting her at least weekly and taking her to appointments and to receive medication injections, she works office jobs, has friends and functions better.

“I really don’t think she would be alive otherwise,” Ms. Biasotti said. “And we don’t know if she would have taken a couple of people with her.”  Such successes, say researchers and proponents, indicate that some patients respond to judges ordering them to comply with treatment, even though failure to comply has no penalty except being brought in to be evaluated for possible hospitalization.

In the state of New York in 2012,  $32 million was spent on a new program for court ordered increased outpatient care for the 2,000 to 2,500 people seen as seriously emotionally disturbed.  This averages out to a cost per person of $12,800.   Under the current law New York also spends $125 million a year for enhanced outpatient mental health services for others who qualify for treatment and who are often emotionally disabled. The successful out patient program provides “intensive monitoring” by caseworkers to ensure that patients attend therapy and adhere to medication. These patients were much less likely to end up back in psychiatric hospitals and were arrested less often.  Use of outpatient treatment significantly increased, as did refills of medication.^[1]

The article does not exactly pin point what the differences are that lead to this better outcome. What is “intense monitoring?” It could be people demanding that you change or it could be people relating to you with less fear, greater respect and more frequency.  How people relate to one another to create conditions fostering emotional maturity in the person and in the family is the central question. What is happening when people function better and will this information be useful to family members and the general public?

The possibility is that these trained workers can relate “better” to those emotionally challenged individuals who can and have befuddled their own family members. We have found ways to train people to deal with the mentally ill but still we, or the government or society seems to give up on or don’t know how to teach the families themselves how to deal more effectively with their mentally ill family members.

What responsibility, if any, does society have to the family members?  Clearly whatever family education or awareness is in place at the moment, has not been working.  As the above story demonstrates, the family members see it as an impossible situation for them and the patients’ problems have now become the states’ responsibility.

What are the professionals doing that family members cannot do? This is not a trivial question.  Imagine that family members could deal with those who were in crisis.  Suppose we were not baffled and driven crazy by those in our own families, those with strange ideas and behaviors, those who we cannot reason with. In fact, in most cases “reason” seems to make emotionally vulnerable people respond by acting even crazier.

The intense emotionality can go both ways.  First, the vulnerable people act out the anxiety that is in the system, and then the serious and logical family members become reactive and emotional. We saw pure reactivity on our a few months ago when the uncle of the Boston Marathon suspects shared his feelings by declaring that the two young men were “losers” and damaged forever the good name and the status of their family.  He was highly emotional. The uncle was at a loss about how his attitude and relationship with these young men may have been a part of the heightened reactivity and emotional intensity in the family and therefore a part of the gathering storm.

There are other families, like the one in Sandy Hook, where the son killed the very isolated mother, and then went on to slaughter many other people’s children.  Both of these families used cut off as a way to deal with the problem people in their families, believing that distance offered them some comfort from the “unstable” or “difficult” ones.  The paradox is that cut off from others is correlated with, and seemingly gives birth to, even greater violence.  The urge for revenge against those who wound or will not obey us is very deep.

It is also often beyond our ability to recognize that the way we deal with the disturbing behavior of a family member (which is both deeply instinctual in the family system and in individuals over the generations), affects the family constellation both in the here and now and in future generations.   The advantage to the family unit is that by focusing the anxiety on one or two weak ones, the symptoms appear “only” in one or two individuals. As far as evolution is concerned this might be an adaptive strategy for the family as an emotional unit.  Therefore we as individuals might be trying to swim upstream to recognize and alter ancient and at least semi-adaptive programming.

It is hard for many of us to deal with the fact that families in which people are extremely distant or cut off from one another are at high risk for symptoms or even of endangering others in society.  Those who engage in cutting off from difficult family members see that as their only recourse.  They don’t know what else to do.  And they don’t link cut off to increasing symptomatic behaviors in the “identified patients”.  My guess is they have no knowledge of the price that may be paid for cut off in current and future generations because they are more comfortable now (with the cut off from those “difficult ones”).

So yes, families and how they function automatically to deal with threats and other forms of worry and anxiety are implicated in the challenges that all of society faces in reducing senseless violence. Ideally we all have a responsibility to learn to manage ourselves in the face of unruly and threatening people.

I do not pretend that this is an easy problem for either society or families who have highly disturbed members.  I bring this up because it is a complex, challenging and important problem.  It is NOT useful for society to continue to claim we only have a responsibility to “help” problem people and to ignore or smooth over the underlying and ongoing dynamics in families.

Raising these questions may raise the hackles of some people since families are so relieved that someone or some program can do something to help them.

These family members have been and often still are in impossible situations and have lived with these situations for years.  I have been there myself and was fortunate that I could learn enough about the family as an emotional system to alter my behavior in relationship to others. Therefore it is perhaps easier for me to see that society is missing a crucial ingredient in health when we are blind to how the family might be utilized to bring about a more competent, long-term self-sustaining solution.

Knowledge of family will never replace all the good that is done with psychotropic drugs, mental health hospitals and out patient care, but the available clinical evidence suggests knowledge of family dynamics can decrease the intensity of problems and the projection of problems into the next generation.

One hard question to ask is whether society is doing families any long term good by taking care of problems and leaving the family in the dark both about how these kinds of problems may continue to appear in future generations and how to cope with the problems in the here and now.  The family, and maybe even society, is relieved when the responsibility for working with these difficult people is “offloaded” from families to professionals.  The problem, however, is that since symptoms are part of the larger family system, when the “identified patient” returns to his or her family, symptoms may return even if the “identified patient” has learned new strategies, his or her family have not.

It is very challenging and perhaps impossible to consider the cost to families who can no longer find ways to speak or reason with or even care for their own children, siblings, or even parents, once these family members are emotionally ill.

It is an emotional tug of war between feeling sorry for family members who cut off from others out of exasperation and anger, and the realization that family members are also failing to see and manage their reaction to those “difficult” others. It is often so hard to see the damage (current and potential to the larger extended family, not just individual family members), when family members feel so justified in cutting off with their symptomatic kinfolk because of the behaviors of those folks.

Seeing this played out on the television over and over again begs the question: Is cut off a leading indicator for emotional problems?  We know cutting off from troublesome others can buy us peace for a few years. But when we reflect on the family dynamics of the two families involved in the Sandy Hook shootings and the Boston bombings we have to consider intense emotional cut off as a warning sign of trouble to come.

Of course it would take time and resources to gather more than a few cases as evidence of the shape of family relationships in driving intense and aggravated forms of emotionally driven behaviors.

Prisons and hospitals cost all of us as taxpayers, to say nothing of the emotional cost to the families directly involved.  But what to do with and/or for families that can no longer help their own symptomatic members and often have no idea what help is? What is the value to the society, even when the costs are unknown, of helping the family deal with their own family members?

I have yet to see research demonstrating what might happen if families were exposed to ideas about how family dynamics work versus remain in the dark while family members are repeatedly hospitalized. Ideally one would want to look at the differences in families over a generation of two after they have learned about family system dynamics and perhaps have had some individual family members make some efforts to manage themselves and gain more maturity.

It may be that no research will be needed as gradually people come to see that emotional intensity, blaming, gossiping and trying to control or isolate others will be seen as destructive behaviors just like smoking is seen as destructive (though some people still smoke).

Some clinical research has been done looking at the different outcomes in treating the family and in treating individuals.  The original research on understanding and dealing with families with a schizophrenic member is recounted in a new book by Jack Butler, The Origins of Family Psychotherapy: The NIMH Family Study Project. (1954-1959)

Bowen noted that:  “No one knows what constitutes this thing we call symbiosis. No one has described it satisfactorily except a Tennessee Williams or a Frans Kafka: To be able to live with it is an achievement. To understand it scientifically is a goal.”  (Page 52)

Bowen originally had three mother-daughter pairs hospitalized, and asked the staff to avoid immature attachments to those pairs and avoid solving problems for the family members.  Group meetings called a family council were held to bring about “mature and open functioning” and over time this was achieved.  The US taxpayer paid for the research and there were no control groups at that time.

The greatest challenge for all the “helpers” was “the unwitting response to the immature side in spite of all efforts to control this.” (Page 49) They found that it was easier for the therapist to keep in open contact with the patient when there was an existing family relationship where the immature level was “lived out.”  Those outside the intense symbiosis could coach both sides of the immaturity.

This effort to enable the person to be more responsible for self was less successful when patients were cut off from family and could more easily force the staff into reactive or caretaking or over responsible positions in relating to the patients.  By keeping the primitive dependency needs within the family itself, the therapist was able to focus on relating to the mature side of the patient and the mature side of the parents.

The goal for the therapist was to stay neutral and to stay out of the conflicts between the family members and rather to define the dilemma that the individuals faced.  The job of the therapist was not to solve the family’s problems but to allow family members to solve their own issues.

Family members often presented as being inadequate and helpless, not so much from the reality of the situation but because they were partially blind to the situation they were in. They lacked the ability to take a stand for Self and therefore automatically focused on others, trying to force them to change and in so doing, creating more reactivity.

The researchers could see and communicate that both mature and infantile goals can exist side by side in the same person.  The challenge for the therapist or neutral coach is how to relate to the mature side individuals and enable them to figure out how to be a good father, mother, husband, wife, friend or responsible citizen.  Feelings of helplessness were not facts.   People could talk about and assume responsibility for: “the feelings of helplessness or even the intense longings: to be taken care of, the longing for freedom from responsibility, or to have “adequate, all loving, all giving, non-demanding figures always at your side.” (Page 47)   Over time by relating to the mature side of family members and patients, the mature side of each individual was more able to manage the immature side of self.

Perhaps as a society we have either forgotten or don’t know that this kind of detailed research exists. Just the other day a close friend told me of her brother’s sudden death.  He died from an overdose and she was distraught because of the position she had taken with her brother over the years.   She felt unable to relate to him without anger and she was upset both at him and her parents for enabling him.  Now she felt the heavy weight of loss.

Initially she felt justified in her actions. Now she finds she is questioning and judging herself instead of him:  What if I had done this or that?  He was a baby and I got mad and left him.  One could say that the regrets and the guilt are moving the anxiety around and creating other forms of emotional problems throughout the family.

We have the knowledge to help families, but in our public polices for some reason, family members are still seen as the enemy of the mentally ill and only caseworkers or other professionals are capable of entering into more mature relationships with patients. We assume that caseworkers enter into more mature relationships with patients, or so it would seem in the new research that the NY Times published.

People might agree that the family is burned out, overwhelmed and cannot figure out what to do, but perhaps people can still see the possibility that feelings are not facts and that by relating to the mature side of family members there is more possibility that the family itself can mature.  More mature family members will reduce the number of symptoms in the family by taking on the anxiety and managing themselves rather than focusing on others and trying to force them to change.

People can see that they have automatic habits that create weakness in the family through the way people relate to one another. People can also see that if they go to the emotional gym and get stronger they will be able to interrupt old habitual ways of responding and find deeper meaning in listening to and eventually understanding others, without agreeing with or labeling the other.

A simple example would be a family where a spouse is drinking or having an affair.  The automatic reaction is to tell the other to stop or else.  A family leader takes the time to look at self and decide what can I do about my part instead of trying to FIX “them”. It may be that the leader engages in paradoxical behaviors or it may be they cry about the helpless situation they are in with the other.  This is very different from being righteous and angry and cutting off from those who are doing things we see as harmful.

It sounds complicated but perhaps family members have just not been given the same opportunity as the caseworker, to learn how to manage emotional reactivity and to relate well to the patient without trying to control them.  The only weapon the caseworkers have, as noted earlier, is hospitalization. They have to figure out how to relate to the identified patient in order to get them into therapy or to get them to take their medication.

Perhaps just as we as a society educate the public about the risks of smoking, some day we might educate the public about the downside of intense self or other blaming, cut off and other recognizable patterns of emotional intensity.

There are many rational stumbling blocks to an educational approach to mental health.

Right now the education of the caseworker costs money and the caseworker usually pays for his or her training, or takes out loans to pay for it. Currently any motivated family member pays for the training he or she gets to develop his or her own maturity.   Given the state of mental health insurance and our medical system in general who will provide the training for family members, and how much will it cost?

“Mental health spending, both public and private, was about $150 billion in 2009, more than double its level in inflation-adjusted terms in 1986, according to a recent article in Health Affairs. But the overall economy also about doubled during that time. As a result, direct mental health spending has remained roughly 1 percent of the economy since 1986, while total health spending climbed from about 10 percent of gross domestic product in 1986 to nearly 17 percent in 2009.”^[2]

How much more money could society save if families were included in learning to manage these kinds of intense relationships in a more careful and disciplined way?   There is still a great deal of fear around family members becoming more knowledgeable and a great deal of relief but some dependency in holding onto the belief that someone else can do it for you.

It often seems easier to offload the problem onto a professional.  But the danger is that the problem “stays” within the “identified patient”, the family doesn’t see their part in it, and symptoms reverberate in future generations.  (It is more complicated than this, but this is one way to begin to see the big picture and to talk about it.)

Describing not solving others’ problems

A small but hopeful sign is research focusing on the reward center inside our brain’s pleasure center, which may explain the reason people are willing to participate in talk therapy and other kinds of self-disclosure.

It turns out the brain itself is wired to give you immediate rewards for talking about or even thinking about your self.  We are not sure yet what the rewards are for the listener, but we assume there are rewards for understating our fellow creatures. Evolutionary theory suggests that the value of understanding others is adaptive in forming cooperative relationships, building trust and therefore protection.

“An MRI experiment, the researchers asked 195 participants to discuss both their own opinions and personality traits and the opinions and traits of others, then looked for differences in neural activation between self-focused and other-focused answers.^[3]

Bowen’s early work on family relationships demonstrated that there are fewer emotional problems in families where there is less cut off and more ability to communicate openly with important others. Our brains are wired for self-disclosure. Now we just have to learn how to do communicate well with others without becoming dependent or overly responsible for solving others’ problems.

Hopefully people will find it useful to consider that we have more options than giving up on family members or turning one’s family members over to the state.   We are social beings and there is a price for us not being able to communicate and a reward for being able to communicate in a knowledgeable and thoughtful way with one another.

This summer my granddaughter, Madeline Mauboussin, and several other young people from CT traveled to Africa to work with children in the City of Hope (TCOH).  Although this blog focus on current events in America the issues that break families apart are in every nation. TCOH’s aim and mission, is to redeem and save young people who have been forgotten by life through unfortunate circumstances.  This project is about bringing hope to communities and to nations while changing lives for the better. http://teamworkcityofhope.com/about/