1998 Keith Family Therapy, Chemical Imbalance, Blasphemy

Family Therapy, Chemical Imbalance,
Blasphemy and Working with Children
David V. Keith
This article reflects on my experience of being a hard-core family therapist disguised as a
child psychiatrist working with families and children in a cultural climate that sees no reason to
question the limits of “biological psychiatry” and its promotion of the concept of “chemical
imbalance” as a way to explain human emotion and its behavioral concomitants. At this point in
cultural time family therapists who work with families and children can feel vulnerable from
several angles. They run the risk of being dismissed both by other mental health practitioners and
by families. But additionally, and this was true before biological psychiatry, work with children
inevitably touches strong emotional (transference) currents in the self of the therapist.
Family therapy with children and families induces deep self-reflection in the therapist.
When the psychotherapeutic work goes well, the experience is profoundly gratifying; we learn
about love and healing. But when anxiety or ambiguity or both are high, especially at the
beginning of treatment, or if the treatment does not go well, we find ourselves in touch with
disturbing feelings of self-doubt, more specifically, impotence, naiveté, confusion, despair,
isolation, and frustration. My impression is that in the last 15 years, fewer and fewer family
therapists feel capable of working with children in the sense of being therapeutic to a whole
These feelings, of course, are transference feelings (nonrational relationship responses),
fantasies about what will happen to the family, to the child, to us, if we don’t get it right. These
feelings and fantasies are not trivial. Transference, whatever it is, runs the world. Transference
feelings are intensified in any therapeutic situation, but the voltage increases when working with
marriage, increases again when we add children, and goes into the red zone when combining
marriage, children and more severe disturbances (depression, OCD, ADHD, eating disorders,
bipolar disorders).
Family therapy and modern psychiatry
“Chemical imbalance” is a persuasive metaphor freely used by modern psychiatry to
support the use of psychotropic medications in all sorts of clinical situations where children are
being disturbing or creating anxiety. This metaphor is also used to shore up the perpetually
unsteady image of psychiatry in medicine. The logic of “chemical imbalance” persuades both
patients and practitioners that context and subjective experience are not important. But that logic
interferes with the task of deciphering the not-enunciated pain behind the pain. Biological
psychiatry’s simplified formulation of human problems is derived from an epistemology (rules
for knowing) that underlies medical bioscience. Family therapy/ecosystemic thinking represents
an alternative epistemological system, with a different view of human experience which leads to
different clinical responses. Though a psychiatrist, I am uneasy with the medicalized psychiatry
of DSM-IV and psychopharmacologic agents in dealing with the problems of children and
families. In this article I am not attempting to establish a competition between two
epistemologies. I am promoting the use of family systems work and asking that the limits of
medical bioscience be acknowledged, at least by family therapists. I am not saying, “Don’t use
medication.” Rather, my message is, “If you work with families, medication will be less
I know that medications can be helpful and are sometimes necessary, but rarely
sufficient. Relationship is always necessary and sometimes sufficient. I know medication works,
I just don’t believe in it. When the chips are down, I don’t trust medication. But I do believe in
families and trust the therapeutic process of family therapy.
Family therapist as child psychiatrist: A double agent
I belong to a child psychiatry organization and was recently invited to join its Committee
on the Family. At my first meeting, the discussion focused on educating families about childhood
psychiatric disorders. I commented that it sounded as though by focusing on educating parents,
my colleagues were by-passing the family’s participation in the problem. They hinted I was out
of date and out of order with my “old fashioned” family therapy ideas that ignore research on
child psychiatry disorders and “blame parents.” And in light of recent scientific certainties, child
psychiatry had to be careful not to blame families. I was being unfairly characterized and
dismissed. But I have been around long enough to know when to back out, and to be amused
when we meet at these borders of epistemological contradiction. I left the meeting reflecting on
the contrast between their assumptions and mine. On the one hand they were right; I do not trust
science when it comes to explaining behavior. But I was bothered by the allegation that I blamed
Obviously, part of the appeal of the “chemical imbalance” metaphor is that it interferes
with guilt on both sides of the treatment relationship. And in some situations that can be of great
help. The problem with it is that it neutralizes those disturbing, but important, questions children
stimulate. These are questions that increase awareness and consciousness. Children force us to
integrate multiple levels of experience, not tomorrow, not when it will be more convenient, but
now. When we do not do this, children become symptomatic. Our language, logic, and
intelligence, so adequate in the process of dividing, fail us in the effort to integrate. However,
children induce this integration. Children make us (parents and therapists) face our ambivalence
about ourselves. Maturity is the ability to embrace this endless ambivalence. The problem with
the chemical imbalance metaphor is its persuasive power which is intimidating and represses
imagination. It suggests no one should feel impotent. No one should feel pain. From Bateson,
quantification is used to avoid perception of pattern. This over-simple theory blinds us to
problems of context that may threaten our ability to care for ourselves. It represents a thought
system based too much on conscious purpose and objectivity, both of which limit what we are
allowed to see. The illustration will give an example of this problem.
Meditation on blame
The notion that I blame families was not new for me. I had heard it from individually
oriented therapists, general physicians, nurse practitioners, and social workers. To suggest I was
blaming families questioned my intent. I, on the other hand, wondered if the child psychiatrists
were protecting the families or their own thinking pattern. It was interesting to discover that
“blame” comes from blaspheme, “to speak evil of, to speak irreverently or profanely of or to
[God or sacred things].” Blaspheme means to defile something sacred. Blaspheme also implies
there is something sacred that cannot be questioned, an absolute truth. When “scientific
objectivity” is used to assess children, the conclusion has the quality of an absolute truth. But
existential heathen that I am, I believe it is not possible to be objective about people, especially
children. When I am accused of blaming or blaspheming, it implies indifference, not caring.
When there is caring, the kind of questioning and commenting we do in clinical work with
families is therapeutic. And I do not look at family therapy as a way to decide what is wrong
with a family, or who has done wrong. Rather, I look at a family in the interest of trying to
understand what interferes with the healing of their wounds.
I have an idea about why the psychiatric world is cautious toward family therapy. It is
related to what happened in work with schizophrenia in the early days of family therapy. The
hypothesis emerged that schizophrenia was a by-product of family processes. And clinicians,
who can be very impulsive in applying simple solutions to complex and troubling problems,
began to blame families. The idea failed because it blamed families (accused them of evil or
intentional wrongdoing). But if you are able to see the pain behind the symptoms in families with
schizophrenia, it changes what you do and how you go about it. Harm happened, not because the
theory was wrong, but because of over-hasty application by anxious practitioners.
There is a challenge in working in the delicate realm of family therapy with children. The
challenge requires hubris in the way we ask questions, but humility in the how we handle the
answers we get. In some way therapists must acknowledge the existential struggles they share
with all humans, and decline the powerfully projected role of high priest(ess) of superior
knowledge, or untroubled saint. As a therapist, I am like a guide. I am experienced in traveling
through the wilderness of subjective experience. On the trip I use my past experiences. I am an
expert on myself and my experience. When I am a physician, I have superior knowledge of the
medical database for diagnosis and treatment of disease.
In the world of modem psychiatry, I am concerned about two issues. First, disease
entities are not so clear as they are in orthopedics or infectious disease. Second, the medical
model induces iatrogenic illness when it fails to acknowledge its limits, and when it fails to
acknowledge the biological impact of relatedness. I suppose that would be viewed as
blasphemous in certain settings. Blasphemy implies competing realities, one good, one evil. The
difference in the realities I am considering here is not so much their inherent quality, but rather
their impact on the perception of human experiences. One, the medical model, decreases
ambiguity, and the other, family systems, increases ambiguity. Increased ambiguity means
acknowledgment of the unknown, and it also questions whether life means anything at all. In my
system of experiential belief, when we embrace this unknown, we increase our awareness of our
lives and our relationships and feel the odd thrill and apprehension of the unbearable lightness of
our being. My point is that working with children in family contexts raises ambivalence in the
family and in practitioners. Ambivalence about self and about meaning makes us reach for any
solution that comes along - or it deepens our experience of our lives and our relationships.
The medical model is a powerful epistemological system in our culture, but when its
efficacy is unquestioned, it dilutes meaning and emotional experience in the name of logic and
clarity. The medical model uses an epistemology that leads to the conclusion that medication is
necessary and sufficient. My epistemology, and I imagine yours, is a thinking pattern in loose
terms called “family therapy,” “family systems theory,” or “ecosystemic theory.” It assumes that
there is inevitable pathology in how families handle the distress and ambiguity of living, and that
pathology in place over long periods undoubtedly induces physiologic distress and distorts
physiologic adaptations. But these pathologies in families are virtually never born of intention. In
great part, they grow out of the parents’ emotional hunger, naiveté about relationships, and
tendency to compromise too much. When the hubris in our questioning leads to the humble
acknowledgment of the unknown, we work on integrating more levels of experience.
Psychotherapy affects the organization of experience, but also produces, or lays the groundwork
for, experiences that may have healing physiological effects. In other contexts, my colleagues
and I have talked about symbolic experiences, which probably affect serotonin re-uptake.
The child psychiatrist’s position in my example suggests that parents should not have to
feel any pain or guilt about their child. But let’s face it, they do. “If you can’t stand guilt, don’t
have kids.” Innocence doesn’t go with parenthood. To go further, it is guilt, and its concomitant,
avoiding blame, that make practitioners scramble for an intervention/solution even when they are
unclear about the pain behind the pain. In my role as physician/ therapist, I feel guilty and
discouraged when a case is not going as I hoped. I inevitably begin to question myself. Did I care
enough? What is wrong with how I think? Am I mature enough to do this kind of work? What
would Michael White or Betty Carter have done? I feel responsible because I am engaged, I care.
I agonize when my caring is not enough.
In the following case example, the family came seeking a second opinion at the
suggestion of the family physician. The child had been diagnosed with a “chemical imbalance”
and inside the medical treatment model was being managed appropriately with medication for
the boy and parent education for the mother. However, despite the use of a variety of
medications, there was no change. I and a psychiatry resident worked with the family. During the
course of treatment (six sessions in ten weeks) the family physician stopped the medication. The
child’s symptomatic behavior faded to a non-toxic level. A chemical imbalance was treated with
family systems therapeutic methods. If the family felt blamed, they also felt gratified, confused,
angry, and appreciative.
A case of chemical imbalance
When Ellen M. called for an appointment, she wanted a second opinion about her son
Allen’s hyperactivity. As usual, I asked her to bring the family, which included two sons and
their father, from whom she was divorced. “Would the father come?” I asked. “Yes, he would,
but he is very unreliable.” I suggested she invite him. Mrs. M. and her two sons, Nick, 12, and
Allen, 9, came to the first interview. Mr. M. said he would come, “but he is always late.” He
never did arrive. Ellen, 40, was well dressed, energetic, handsome, articulate, Italian, and Roman
Catholic. The boys attended a Catholic school and were neatly dressed like little men in white
shirts with neckties and navy pants. Nick was Mother’s favorite and her valued partner, the one
she “depended on.” He got all A’s. He even talked about how he was trying to help Allen get
along better with his mother. Allen, 9, was enigmatic. Mother did not know how to relate to him
and his moodiness. And despite his being on Ritalin and Clonopin, the school had daily problems
with him.
Mother was obviously responsible and cared deeply for her children. She was organized,
smart, and attentive to details. But she was moralistic and did not like double meanings. Her
thinking was clear, but too clear. There was a lack of equivocation and no sense of irony (irony
deficiency). She hid from ambiguity. For example, when I asked her about her family of origin,
she acknowledged distress, but avoided details about pain. The picture was one of considerable
rigidity and emotional restriction.
As we neared the end of the interview. I told her to tell Father, from me, that it was
important that he be included, and she should warn him to be careful because I was already mad
at him for standing me up this time. Mrs. M. blushed, tears appeared in her eyes. “I’m sorry, I
wasn’t telling the truth. I didn’t tell him about the meeting. He is a liar; I didn’t want him to
come.” She confessed she had not told him about the interview because he was so smooth. “I
was afraid you would not be able to see my side of the story. That’s why he isn’t here. I’m
sorry.” She was embarrassed. The boys looked at her, puzzled by her upset, not comprehending
the cause.
Father, Jim, age 40, came to the second interview. He was handsome, simultaneously
anxious and cool. An accomplished athlete, he was a local hero from his college days. He got
caught up in some ‘80s schemes for making fast money with stocks and bonds and did two years
in a federal penitentiary. My impression was that he had been humbled by his encounter with the
law and jail, helped by Alcoholics Anonymous, and was working at being honest with himself
and his sons. He was not the con artist I expected from Mrs. M.’s description. In fact, with Father
there, Mother, whom I liked a great deal, suddenly seemed harsh and over-rigid. She sounded
like a Mother Superior who did not believe confession really mattered because the priests were
too soft-hearted. (Ironically, she worked as a claims manager for a managed care company.) She
was good at saying “no,” there was not much “yes” in her. She was good at making certain the
rules were followed. It was hard to avoid her concrete requests for advice and questions of
medication and side effects. But in order to shift the focal point, it was important to palpate
regions of pain and disappointment.
Father was earnest in his concern about Allen. In Allen he saw fragments of himself as a
boy and he feared Allen would turn out like him. Allen was like his father, he had his natural
athletic gifts, but he also had his penchant for sudden temper outbursts. Father worried he never
did enough with the boys, and on the other hand, he was concerned his involvement with them
was harmful, and interfered with Mrs. M.’s relationship to the boys. Many question my
interviewing method which involves talking about the kids while they are in the room. The fact
is, every one gets put into the third person at some point during the therapy. Children gain a great
deal from hearing themselves talked about.
Allen was always well behaved in my office. But based on his demeanor and the stories
they told about him, he seemed like a pet wild cat. The young man looked and sounded as if he
had the “it” we call ADHD. He had a nervous energy, an alertness about him that suggested a
nervous system never at rest. Yet, he sat like an altar boy on the sofa, legs stretched out, not
touching the floor, throughout each interview. His mother had difficulty talking about anything
other than him. Their anxiety about him shaped my transference to him. But my assumption,
which I shared with them, is that a kid like Allen is in more pain than anyone realizes.
In the third interview, Mrs. M. was reiterating her great concern that Allen would turn out
like his father. I said, “Well, it could be worse you know.” “What do you mean?” she asked. “He
could turn out like you,” I answered, poker-faced, tongue in cheek. She looked puzzled, started
to ask a question, then physically flinched, as if flooded with awareness of how lonely,
constricted, and bored she felt.
In the fourth interview, I learned the boys had spent the weekend with their father and his
new woman partner. At one point, Father discovered Allen lying in the driveway behind the car.
He was upset about something and said he wanted to die. Father was shocked by this. In the
interview he wanted Allen to say more about what he meant. Allen reiterated that he wanted to
die. The parents looked to me for reassurance that he did not mean it. I did not give it to them. “I
think he hurts a lot. You can only underestimate his pain about this. What do you think would
happen to your family if you died?” I asked. His hands, palms together, were between his knees.
He clasped his hands tightly with his knees and shrugged, holding his shoulders up to his ears for
a long time. He didn’t say anything. “When children are suicidal it is because they think
someone wants them dead,” I said to the parents. Then to Allen, “Do you think someone would
be happy if you were dead?” He lowered his shoulders and with head down, but eyes on me,
nodded yes. “Who would it be?” I asked. He held his hand against his chest surreptitiously
pointed at his mother. She gasped. “Allen, no!” He nodded yes again. “How could you think
such a thing? The father said he thought Allen was just being manipulative. “I don’t,” I said. I
liked it that Jim was uniting with his ex-wife, even though I disagreed with him.
During the course of six interviews in ten weeks, the family doctor weaned him off the
medication. I was apprehensive that when the medication was stopped I would see another child,
this might be the case that would force me to see ADHD as something intrinsic, and little
affected by family relationships. By the fifth interview he was no longer on medication. Nothing
untoward happened. In fact, they had one of the best weeks in the last year and a half in all
relationship vectors. Father was still concerned that Allen was being manipulative, and I
disagreed, emphasizing the danger in that position because it underestimated the pain of his son.
After the sixth interview, they decided not to come back. Things were going well enough. I
admit I was apprehensive about how they would do. Eighteen months have passed and I speak
with the family physician from time to time. Allen is doing well. Mother who used to talk about
him all of the time rarely mentions him. He sounds like he is still moody, but he is not
automatically impossible. Father and Mother have developed a parenting pattern that she finds
very helpful, and her anxiety about Father is much reduced.
This case is a sample from my clinical experience illustrating the use of family therapy in
the treatment of a boy diagnosed with a chemical imbalance. My message is not that medications
are inappropriate, but rather that medication produces a different outcome from family systems
work. While effective in reducing ambiguity, medication interferes with growthful integrating
encounters with the unknown. It also suggests that the indications for medication and the
indications for family therapy are in the practitioner.
Did this case force those humbling self-reflective questions on me? A few. I was
concerned the family doctor was too strong in his upset with the medication. I thought he was
seeing me as a champion of the anti-medication cause. Mother had this clarity about her, and had
been indoctrinated into the language of ADHD. I felt dumb about my poorly articulated
alternative view. I was also apprehensive about her connection to managed care. I felt that the
father from his business man/athlete’s view of experience was skeptical about me. The point is
that anything that causes me to second-guess myself and my methods leads to the temptation to
use the ambiguity-reducing medical system. This will sound churlish, but one of the advantages
of being a biological psychiatrist is that you do not have to question yourself and patients do not
have to question themselves. For family therapists the questions are unending and unavoidable.
David V. Keith is Professor of Psychiatry, Family Medicine and Pediatrics and
Director of Family Therapy at the SUNY Health Science Center Syracuse.
Originally printed in AFTA Newsletter. 1998; 72:21-25