Families: A Revolution  in Mental Health  by Andrea Schara

24bf42_9e648d3ba8b843fbb72777fbaa4b4b55~mv2Photo above from The Washington Post Magazine January 13, 2020


First, we saw only the tall green tree,

We were blind to the surrounding forest.

The earth was flat.

The forest, dark.

. . . They knew not what to do.


24bf42_68d1805704ca49e78d6620ed9c70372b~mv2

January 13, 2020, the Washington Post carried a very personal story of one family’s experience in the effort to find help for their son, Aaron. Reading this family’s misadventure through the blinding alley ways of mental health services, we can feel and see the struggles with their talented son and the state of mental health. Should we read the story and forget about the problems? Shall we accept the Mental Health Industrial Complex (MHIC) as it is, just because it is so entrenched, yet not so very useful to destressed families. (see Washington Post article, “What schizophrenia does to families — and why the mental health system can’t keep up.” https://www.washingtonpost.com/magazine/2020/01/13/what-schizophrenia-does-families-why-mental-health-system-cant-keep-up/?arc404=true)

Is there no protection from mental health issues? Seemingly it does not matter if you have a great deal of money or if you are successful in your profession. People fight, they worry, they criticize and misinterpret and blame each other.

Individuals vs. Families.  Because the system could only focus on Aaron, and not on Aaron’s family, the system, missed many opportunities for deeper understanding. . Aaron’s family was the context, the circumstances, where more can be understood as to Aaron’s condition and how the family offers both support and leverage for change.  Focusing on one as the problem is just how heath care systems work at this time.  Pockets of emotional problems exist in all families. But only one in five families seek help from the mental health system. And those that do often do not find answers, as the mental health system does what the family does, it focuses on the weak one and tries to fix them.

Diagnosed with schizophrenia in his teenage years, Aaron’s future was foreshadowed. After reading their story I wondered how the mental health world seems to have such trouble talking to families, and about what might make a difference. The conventional individual focus which guides most of psychiatry today misses the systems view and most of psychiatry doesn’t see mental illness that way.  Some might say there is no way to know how things might have been different. But just imagine if any one they talked to could have coached the family to focus on how each family member was contributing to the situation, i.e., to maintain a self-focus in an other-focused world? Or to see how disconnected the family was from the larger extended family fueled the intensity of the problem.

Knowledge: We have known since the fifties that the family is a reasonably predictable emotional unit, automatically managing anxiety by focusing negatively on the weaker ones in the family. [i]The mental health system is NOT set up to follow the family emotional process. Both the mental health system and families worry and focus on the weak ones and usually prevent the family from looking at itself. How does a family member find a way to focus on their role first, instead of others–to focus on the role of each self in the family system?  How does one begin to reappraise the situation they are in?[ii] Right now most family members are on their own to figure out what to do when mental illness arises.

Relationships Sink Holes: Those with psychological issues are very sensitive to the way people act. They can react in intense ways to suggestions or commands as their boundaries are not firm enough to keep out other’s anxiety. If the doctor or family member says YOU MUST take your medication, that is enough to start a fight.  Telling sensitive people what to do does not work out well. One by one family member can begin to break patterns by communicating differently: 1) lowering one’s own anxiety 2) becoming a better observer of interactions 2) being careful to say 4 or 5 positive things for each negative 3) asking questions to find out more about the other without judgment 4) being willing to interrupt habits, like being worried about the sick one 5) getting in better contact with extended family 6) being able to stay steady when people tell you: “Change back, you are not as nice as you use to be.” Family Systems theory has effective strategies to improve people’s functioning. It is just not natural to become an observer instead of a reactor and therefore requires a disciplined effort.

Murray Bowen, MD called this effort be aware of multigenerational family patterns and to alter the way triangles (side-taking as in two against one) form in families, as the effort to work on becoming a more mature or differentiated self. This effort completely changes the way people communicate and interact. That is one person tries to relate to others in a more objective and neutral way. There are many new discoveries as to how changing one’s behavior changes the brain promoting better relationships.[i]

Aaron’s mother says, “Protecting the mentally ill, you become mentally ill just trying to get it all together.” How did she come to believe that protecting was the way to go? She also describes the effort as the “We can fix it stage.” The push to get them to do it right seems to override the effort to manage her-self and manage boundaries. Is the “We must do it” statement hazardous to the mental health of everyone in the family?  The tightness in the family, the cut off with extended family members, often leaves people to struggle alone with little useful knowledge.

From the Washington Post: A Family History: The parents marry early and have Aaron. Seventeen months later a daughter, Alishia is born and then Amanda three years later. The father joined the Air Force, trained as a dental hygienist and the family moved often. A gifted athlete, Aaron was also at the top of his class in high school. But the move to college seemed to present challenges that he was unprepared to take on. His reactivity showed up in saying he wanted nothing more to do with the military and choose Arizona State University.   When he failed to be given a football scholarship his senior year he fell apart. “That broke his spirit.” He quit the football team. We have no knowledge of how the family related to each other during this time. We do not know if they took sides, blamed someone for his problems or if they worked on being more thoughtful, independent individuals, letting Aron take responsibility for his actions. Two weeks before his graduation Aaron talked in a threatening way to other students and was expelled. The parents thought it must be drugs and no one really considered the psychiatrist’s view that Aaron was having a psychotic break.

The family history revealed that there was suicide and abuse in his extended family. If there was any strength in the extended family, we did not hear about it. Instead the mother is tasked with “helping.” They thought tough love would work. Sometimes it does help to set boundaries but sometimes it is just a way to try to control others. How do you know the difference?

What If: Perhaps an effort to be a more defined self could make emotional room for the other individuals to grow. Think of the trees in the forest if they are too crowded then there is little room to grow. Possibly as one person in the family settles down and thinks carefully about the situation there will be more room to grow.

The family in the Washington Post article asks, how can it be that in our country we have underfunded treatment facilities, jails that serve as treatment facilities, and a lack of advancement in medication?  The unmentioned and equally harder problem is how to provide useful knowledge about what family members can do about themselves, based on the evidence we have that using the family-based approach produces better outcomes than those other methods. Today insurance companies provide reimbursement only for one, the “sick one.” [ii]

Motivation to Understand Family Emotional Process: After WWII my parents collapsed with drinking problems. It was 1952 when we were adopted by our maternal grandparents. Our family was well off and could provide many things, like education, but they had no knowledge of the family as a system. Butch, my brother two years younger, earned the label of paranoid schizophrenia in May of 1974, just three days after our mother died. The family was turned upside down but eventually I found a job in a psychiatric hospital, the beginning of a long-term effort to understand the family as a system and to define “who am I, and who are you.” The result?  All the family anxiety was not directed at Butch – and both of us became a bit better defined. Butch was not hospitalized for mental problems again for 40 years until a few months before his death, November 2, 2019.

The fact is that anxiety spreads and people have hard time thinking for themselves: How can one be better at observing the family interactions, seeing the family patterns and not take them too seriously? When one person can just listen and speak about the way they see the family situation, that person is outside the love lock of the system. Rabbi Freidman explained a love lock by saying: “Beware of peace over progress.”  When one can say, “This is where I stand” and without threats or fear of rejection let others know “This is the way I see things,” this makes more room for trees in the forest.   When one says, “This is what I am doing and or saying and it might not make sense to you, but this is the way I see the effort I need to make. You are free to do what you believe best, too,” there is more room for trees in the forest.  Say what you think in any group, and they will react and pressure you to “change back.” Anyone can alter the part they are playing, by making a plan just for themselves.  That could have helped Aaron’s situation.

Today the family is seen as a problem: they are weak and difficult and talking with family members is wrong. The medical world isolates the individual with barriers like HIPAA rules. No one in the family can find out what is going on with the patient unless the patient gives permission. Society has rules to protect the person from the family, so how can families know what to expect or correct their part in any problem if they know little to nothing?

In stark contrast, family system’s knowledge allows us to describe the multigenerational relationship system that surrounds each person—and how that informs and determines current conditions.  People become aware of family patterns over generations. They can learn how they innocently participate in side-taking and telling others what to do—repeating old patterns without even realizing it. They can get to know people in the family and find emotional support there.  Overall there is much to learn as the more open the family system is, the greater the opportunity each individual has to be responsible for their own life. All said there is a long and winding road through the forest, where one must go to gather knowledge about the family as a system.  That kind of light coming through the canopy helps trees to be able to grow up healthier and stronger. Here one can see and appreciate the tree and the forest. Here one can see the crucial influence of the family environment in the development of the brain and behavior.[iii]

24bf42_4ed2b8e568b5445ba232bd39ce231a06~mv2

Footnotes

[1] https://www.nytimes.com/2015/10/20/health/talk-therapy-found-to-ease-schizophrenia.html

[1] Rethinking Feelings: An fMRI study of the cognitive regulations of emotionsWe humans are extraordinarily adaptable creatures. Drawing upon a vast array of coping skills, we can successfully manage adversity in even the most trying of circumstances. The cognitive transformation of emotional experience has been termed ‘‘reappraisal.’’ In both experimental and individual-differences studies, reappraising an aversive event in unemotional terms reduces negative affect with few of the physiological, cognitive, or social costs associated with other emotion- regulatory strategies, . The goal of the present study was to use functional magnetic resonance imaging (fMRI) to elucidate the neural bases of reappraisal.https://www.researchgate.net/publication/10978423_Rethinking_Feelings_An_fMRI_Study_of_the_Cognitive_Regulation_of_Emotion

[1] Steve Porges, PhD:

When you want to calm a person down, you smile and talk to them in a soothing way. The nervous system detects these cues and down-regulates or inhibits the sympathetic nervous system. But when the sympathetic nervous system is activated as a defense system, it turns off all those social-engagement behaviors. Clinicians are aware of that. But what they often don’t understand is the role of the vagal system in shutting down as a defensive strategy in response to a life threat. When someone is immobilized, held down, or abused, the vagal system is triggered, and they may disassociate or pass out—or perhaps drop dead or defecate. It’s an adaptive response.

Social communication has little to do with syntax and a lot to do with intonation, gestures, and a cluster of behaviors we would call biological movement. The face is moving along with the voice and hand gestures. The behavioral features trigger areas of our brain outside the realm of consciousness and change our physiology, enabling us to feel closer and safer with another.

Good therapy and good social relations, good parenting, good teaching, it’s all about the same thing—how do you turn off defensiveness? When you turn defense systems off, you have accessibility to different cortical areas for more profound understanding, learning, and skill development. https://www.pesi.com/blog/details/967/wearing-your-heart-on-your-face-the-polyvagal-circuit

[1] From an oral history interview with Vince Kelly, MD and Andrea Schara, the effort to communicate family ideas to insurance companies in the 1960’s.  Vince Kelly: I`ll tell you an anecdote which may explain some of that which is insurance. I was on a committee for the Washington Psychiatric Society…what`s the name of the committee…it was psychiatric practice dealing with early administration and insurance and so the issue came up in meetings of family therapy and couples therapy. I guess because of what I did they decided that I should meet with Blue Cross Blue Shield people and the purpose was to educate them about what this was all about. Family therapy, systems theory. So I did it over the course of months and they responded, “Oh ok…” and finally when that was finished I think he… he had a big role at Blue Cross Blue Shield, it might have been nationally. And I can`t remember the details of what he said, but basically what he said was, “We really appreciate meeting you because we understand much better than we did before we started meeting with you. But it`s very complicated so what we’ll suggest is just call it individuals therapy and apply for reimbursement on that basis.” (Laughs) But I said, “that`s what we`re doing already and we want to do it more honestly so you know what`s happening”…but it was too complicated. That was the end of my effort, but at least they said that they understood it better. So I guess [Addendum:2018_27_06 VK … I used that as a justification for billing in the name of one person].… Andrea: There’s no reimbursement for thinking family…. That`s so funny. There was an article in Sunday`s opinion in the New York Times and it was about schizophrenia, about the British Psychoanalytic Society saying diagnosis, labeling people, doesn’t help them, it doesn`t help you to treat them. And then Tom Insel who`s at NIH was saying the same thing. http://murraybowenarchives.org/interviews/vincent-kelly/

[1] In this chapter, emotion regulation, a key intrinsic process and transdiagnostic marker of mental health with defined neural correlates, is developed as an exemplary nodal point for demonstrating the crucial influence of the environment in the development of brain and behavior. https://link.springer.com/chapter/10.1007/978-3-030-25816-0_7