“There’s An Underlying Biological Illness”

April 24th, 2011

Zack’s psychiatrist said to me, “yes, all of those factors in the family are important, but there’s an underlying biological illness that we need to treat.” That was some years ago and I didn’t know how to get my point across. I knew that the difficulties in the family were relevant to my client’s difficulties but I did not find it easy to explain to people who were trained in mainstream psychiatry. So I didn’t continue the conversation.

I had been to the home of Zack, a new client, about 20 years old. He had been involved in the adult mental health service after a highly serious suicide attempt. Zack was psychotic at the time and so was put on anti-psychotic medication, and antidepressants, which is the customary response in mental health services. My role as a case-manager included monitoring his willingness to take the medication which is thought to treat a hypothesized problem with the person’s brain (the commonly speculated cause of psychosis.) If not a problem with Zack’s brain why would he behave as he did?

I met Zack with his mother Betty, and several siblings who were also home. Later I spoke to his father, who was at work.

Zack was shy, and appeared to have little interest other than playing computer games and smoking marijuana. He had a work history but not for some time. I noted that Zack’s mother was outwardly confident and capable when talking to me about Zack. She told me what had happened leading to the hospitalisation, the effect on the family, and what had been happening since returning home. My attention was caught by the fact that Betty still made Zack’s bed each day, and made him his sandwich for lunch. She did this for the other children home, who were older.

A Theory About Onset of Psychosis

One theory offered about the onset of psychotic behaviour has to do with the role and position of the individual in their family. Jay Haley, author of “Leaving Home: The Therapy of Disturbed Young People,” (See reference below) posits that ‘leaving home’ is a critical stage in some families. Where the family is one where difficulties cannot be talked about and solved, and the difficulties in the couple are serious (eg alcoholism, serious depression or suicidality) they manage, until the family changes.

The simplest example is where the last child leaves home, and the parents discover their relationship is empty. Many couples solve this, either by rebuilding their connection, or by separating.

However some couples can do neither. So what can they do when one or both partners are already functioning poorly, and they will soon be left with just each other? Perhaps desperately lonely and inadequate, one may deal with hidden suicidal thoughts through alcohol or gambling for example. The dilemma is worsened when acknowledging a problem and seeking help is taboo.

The young adult child may be caught, wanting more independence but ‘knows’ this may tip the parents into conflict or a divorce they can’t handle. [This ‘knowing’ may not be clearly articulated. As the child grows, makes friends, starts university or work, talks of moving out etcetera, there may be petty arguing / shouting between the parents, more drinking.] The couple may have found their problems to be unsolvable and so surface issues camouflage the real problems. Yet the unhappiness remains significant.

What does the child do where s/he cares but cannot find a way out of the dilemma? Remember, this family has a rule that problems are not talked about. One way out of the dilemma is for the child to abandon the goal of leaving home. This keeps the parents safe. However this is at a cost to the individual. Later if s/he ever ‘threatens’ independence, the home situation worsens inviting the child to become symptomatic and restore the status quo.

Imagine if you and your partner were on the verge of separating and your daughter had a motor vehicle accident and is critically injured – the separation would be put on hold – stability in a sense returns. Serious psychiatric troubles such as psychosis, suicide attempts, drug abuse can achieve this sort of stability in families where they cannot openly seek help. And an exacerbation of symptoms can occur whenever marital difficulty manifests again.

Haley says that these dynamics can occur and are more likely when the family is private about their difficulty – if they could easily admit their difficulty and seek help, there would no need for an indirect solution. Thus Haley speculates that a psychotic young adult will often indicate private family difficulty.

Haley’s Approach

For a detailed explanation of Haley’s approach with young psychotic individuals, his book (cited above) is excellent. The main elements are as follows:

– the individual’s problem are construed not as an ‘illness’ but as behavioural, since this is something that parents have expertise and responsibility around. Consequently Haley works with parents and staff to avoid hospitalisation and medication (or negotiates their discharge and cessation of psychiatric medication rapidly.)
– Haley works intensively with the parents (both parents are essential if they are together) to get them to clearly develop their expectations of their child’s behaviour, and articulate clear consequences for any breach. An important element of his success is ensuring the parents behave in a united fashion. Where disunity between the parents is maintained by any grandparents, they are included for part of the therapy. This similarly applies where siblings maintain the ineffective family arrangements.
– Haley expects that the symptomatic individual can behave normally, and the parents must expect normal behaviour from the outset.
– Haley states that most often the parents have significant private difficulties, but these cannot be the starting point for therapy. It would be disrespectful and insensitive to talk about private matters they have not raised, and so the focus is on the adult child. Once they are having success with the child’s behaviour, the parents’ problems soon manifest. The therapist is then invited to help because the parents have established a relationship with the therapist. However the therapist does not allow their issues to take precedence, and instead contracts that they defer their issues until they have achieved the goal with their child. Haley then works with the parents while making sure the child does not revert to being symptomatic to stabilize the marriage.

In his book, Haley details case examples where the therapist talks with the family for an hour about their specific expectations for a son to look for work; and for a teenage girl to help with housework. These conversations are the testing ground for the parents to learn unity, which puts the parents in charge. Children who were symptomatic respond normally when faced with effective parents. This goal is likely to require repeated conversations led by the therapist.

S/he utilizes a range of skills in working with such families. The therapist will frequently have family sessions, and direct who talks to whom and about what. The seating may be altered to control the flow of communication. Rapport must be built and maintained with all members of the family, despite arranging the parents to set limits and consequences.

There is no talk of ‘illness’ and limitation, but rather the focus is on the next step in their return to normal responsibilities. Therapy with individuals who have been psychotic may take 3 to 6 months, with the expectation the young adult will return to work or study quickly. The therapist must also have the skill to help the parents resolve their difficulty. Often this can occur without marital separation.

Imagine the savings through such an approach – ideally no admissions to hospital, no commencement of medication with the dangers of stigma and side-effects….and a speedy return to their usual peer group and role as student or worker.

When mental health clients are not helped to quickly resume their normal life, the tragedy is compounded by developing limiting beliefs about biology and genetics, disabling side-effects of medications, stigma, despair, use of illicit drugs, loss of employment / money / relationships, legal orders….

Haley’s book details case transcripts showing the subtle communications between family members, that when changed lead to more effective functioning in the symptomatic individual. [An excellent shorter introduction to this approach is in the journal article by Cloe Madanes, “The Prevention of Rehospitalization of Adolescents and Young Adults,” Family Process, 1980. pp 179-91.]

Clients Can Act Capably

All clients can act capably and do so regularly. This is a premise of Solution-Focussed therapy. However, people often do not notice the instances where they are acting capably, or they don’t regard them as significant. In the early days of training in family therapy with Michael White (Dulwich Centre, Adelaide) before he coined the term Narrative Therapy, I recall a client of his who casually mentioned he had a driving lesson. This was a significant departure from his very restricted lifestyle, living at home and never going out. Neither he nor his parents thought to mention this change. If Michael had not performed his ‘falling off the chair’ manoeuvre to highlight the significance of this change, the family would not have recognised the importance, and there would have been less likelihood of building on it.

Additionally a friend who worked in a psychiatric ward shared how he could overhear the patients use the public phone on the ward; he reported their conversation on the phone could markedly alter from their usual ward conversation. At times they could be markedly psychotic, and moments later they would be totally different. It was not that people were pretending to be ‘sick,’ but rather their behaviour changes moment by moment depending on the context.

I witnessed this first hand – in the midst of a serious conversation at a client’s house he was totally lucid when the phone rang. The instant he began conversing with his mother he was floridly psychotic; he returned to the role of a needy, incapable adult child who needed her ongoing help and supervision. This reversed when he ended their phone conversation.

The context of the person shapes whether they act capably or not.

As can be seen from the above example, just because a child moves out of home does not mean they leave behind the role they play in the parents’ lives.

I have had the fortune to meet a couple of clinicians who have been trained by or worked with Haley. They confirm the effectiveness of intervening in these ways. This supports the belief in people’s capacity to change – we should be optimistic.

What does this imply for the social construction of psychosis as a ‘mental illness?’ How is it that family approaches can reverse bizarre and disabling behaviour that many think must be treated with medication? [See “Some Thoughts on Psychiatric Medication” – soon to be posted.] Do we need to question the assumption that clients’ brains are faulty?

Not all clients will respond to Haley’s approach. Some no longer have families involved, or the parents are functioning so poorly they have no interest in participating in therapy. And some clients may enjoy the benefits of their “patient” status and favour it continuing. Yet the successful examples raise questions about the treatment choices we offer clients. Another question is whether it is beneficial to label individual’s problems as ‘illness.’ This implies there is a personal cause, which will likely limit the view of the clinician, who may miss much of what is relevant to solving the problem.

Zack, his Psychiatrist, the Family.

The psychiatrist at the beginning of this article was communicating his belief in a ‘personal illness’ – family factors were noteworthy, but “there’s an underlying biological illness that needs to be treated.”

It became evident in Zack’s family that his mother had significant problems, and she was so socially anxious that she was agoraphobic. The parents had come to an arrangement that the father would do the family roles that were away from the home (taking the children on holidays, sharing sport and hobby activities) and Betty would fill her life with domestic activities.

The above arrangement could work while the children are young, but is perilous as a long term solution – they will inevitably become adults and then what will the couple do?

I made the mistake of offering my perspective to the mother – this wasn’t invited and it was threatening. It was also at odds with what the psychiatrist was saying. I lost all rapport with her and I would not do it again.

Consider the mother’s position. What would she do if she was not to continue mothering her children? What else would she do that would provide purpose and involvement? And with her son’s problem construed as an ‘illness’ (not a parenting problem) she could wait for the medication to help her son, and the status quo continues.

When a family is educated to believe in a personal ‘illness’ there is no urgency for them to consider other factors; they can wait and try an unending list of medication options.

The Creation of Chronicity

When underlying problems are not recognised as significant they are not resolved. Staff and family can then get caught in transactions around surface issues such as symptoms, medication, side-effects and compliance. This can be never-ending. If the ‘patient’ does not want to take the medication, there can be battles to make it happen, and to convince the person s/he is ‘ill.’ This is the beginning of chronicity.

Much of the resources of mental health services are spent on these activities. Families are coopted to convince their loved one to believe in the diagnosis, to convey messages that it is not their fault they are ‘ill,’ and it is not the worst thing that could happen (“it is equivalent to getting diabetes; you just need to manage it with medication.”)

These measures often are repeated over years. Families stabilise around having a sick member of the family. Expectations are lowered, and fulfilled.

In essence a pill can work to shift a crisis towards a chronic family pattern.

Some patients try to keep their non-compliance with medication a secret, which leads to ‘surveillance’ by parents, mutual distrust and arguments. These transactions further camouflage the real issues.

Some patients do not oppose the medication, but the side-effects and trials of multiple drug regimes can stretch treatment out to years.

Looking At It Differently

Perhaps some readers find it hard to consider that family factors can lead to bizarre symptomatic behaviour. It may help to consider the extreme opposite proposition.

Think of young children. If I suggested that families may treat their children in any way they wish, because it won’t have any impact at all….does that seem plausible? Obviously not.

We know that we are powerfully affected by the behaviours of people, especially those most important to us. So if a child’s mother has attempted suicide, for example, it would be understandable for the child to want to protect her. This may continue when the child becomes a teenager, or turns twenty, or turns thirty.

Does it sound plausible that families could operate in extremely undesirable ways, and this would not impact the individual child, even if now an adult? No. When family problems are apparent to the clinician, should these not be part of our formulation of why the individual has problems? It may not always be the case, but would it not make sense to consider such factors as the cause, before assuming some hypothesized biochemical cause?

For example, imagine a family who would not let their 30 year old son go out alone, have friends, or work, and insist he stay home and keep his mother company, while the father remains uninvolved in the marriage. Presume this is ongoing, yet the son is not allowed to comment or complain. Would we expect the son to be unaffected by this arrangement, and be happy and contented? No.

This is extreme, but does happen. And versions of the above can easily be seen in mental health caseloads. Yet if identified at all, this is not the focus of intervention. Nor is it very likely to be identified where the patient is identified as having a personal ‘illness,’ with its implied personal treatment (ie medication.) Families seldom opt for an exploration of family functioning, when they are led to hope that a pill can improve the problem. If clinicians do not recognise the relevance of contextual factors, they will not work to change them and thus improve the dysfunctional behaviour.

Conclusion

Haley’s ideas and others have potential, but the dominance of the ‘illness’ construction drowns out most possibilities of alternatives being tried and developed. Psychiatrists would likely face malpractice suits if they deviated from the customary treatment of psychosis. Until there is widespread and regular criticism of the ‘illness’ idea, alternatives will be underutilised.

One attraction of Haley’s ideas is the optimism that families can be helped to sort out their difficulties without singling out an individual, calling that person ‘sick’ and medicating him/her with resultant stigma and side-effects (some of which can be life shortening.)

What are the consequences for patients if we persist with the idea of a ‘personal illness’ independent of the context?

The individual may remain caught. The parents may remain unaided. The attempts by staff to assist the symptom bearer can often be of limited use, and fraught with setbacks. Frequent staff failure will likely lead to burnout, cynicism and limited capacity to assist clients. Then we resort to attempts at controlling clients’ behaviours, which is often futile.

Wouldn’t it be great for staff to feel they have the skills to intervene effectively and be optimistic with every encounter? With frequent successes how would that impact on staff’s interactions with clients and families? Imagine staff morale and enthusiasm.

Some find Haley’s hypothesis unpalatable; but the reverse – that the family/parents’ life is not at all relevant – is untenable.

Some clinicians express the fear that Haley’s approach may make parents feel blamed. Care does need to be taken. Families do the best they can. It does not assist anyone for parents to feel guilt; they need to be helped to be effective so they will feel better too.

Parents are essential to the success of therapy and Haley works to keep them on side. If there are underlying problems the parents are aware of them; we should assist them rather than being frightened of upsetting them. The alternative is often long-standing disability for the young adult, which also has major consequences for the parents.

(The End)

References

1. Jay Haley, “Leaving Home: The Therapy of Disturbed Young People.” (Second Edition, Brunner/Mazel, 1997)

2. Cloe Madanes, “The Prevention of Rehospitalization of Adolescents and Young Adults,” Family Process, 1980. pp 179-91.


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