Blame, Guilt, and Family Dysfunction

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When I discuss family dysfunction, the question of “who’s to blame”– the adult children or their parents – frequently arises. Emotions then tend to run wild. I believe this is the wrong question. The fact is that all family members are beans in the same soup, acting out patterns that have been building up for generations and are being passed down. The right question should always be, “How do we FIX this?”

The question of blame is often the subject of vehement defensive reactions by the community of parents in the US, who gripe about anyone who engages in“ parent blaming” and “parent bashing.” They want to believe that they have absolutely nothing to do with their children’s problems, which they like to think are all genetic or all caused by peer groups at school.

Many mental health practitioners have sided with these nonsensical ideas. I’ve written before about a time when, at a nearby child and adolescent psychiatric hospital, juvenile delinquency and even suicidal thoughts were blamed entirely on heavy metal music. That way, parental guilt could be assuaged so they would pay for their kids to get “treated” for listening to Judas Priest. Well, at least until their insurance ran out.

So are these folks saying that even physical and sexual abuse by parents has nothing to do with children’s insecurities? Or their acting out? Even here, the answer seems to be a sort of yes – people falsely opining that the incidence of this abuse is actually minimal and that almost all of these accusations of such are false. Really?

It is true that if a therapist makes a parent feel guilty, they are less likely to look critically at their own parenting practices or seek help, so therapists have to figure out a way around this paradox. My therapy model attempted to do just that with patients who were adult children facing this conundrum.

I have also written about the massive increase in recent years in parental guilt caused by cultural changes in gender roles. In reaction, this has led to an epidemic of so-called helicopter parenting. That this type of interaction is a major correlate of adolescent depression, which means probably with the rate of suicide as well, has been recently demonstrated in studies (for example: Wattanatchariya K, Narkpongphun A, Kawilapat S. The relationship between parental adverse childhood experiences and parenting behaviors. Acta Psych. 2024(243).  While correlation and causation are two different things, I believe on the basis of my wide clinical experience that in this case these studies are indeed about causation.

Another complication of parent guilt was described in the 2/27/24 column by advice columnist Carolyn Hax.  A mother described herself as being wracked with guilt because her teenage children suffered from anxiety and depression, despite her and her spouse loving them immeasurably and doing their best every day to support, listen to and nurture them. Ms. Hax of course tried to tell her that she did not screw up because “kids everywhere are having an extraordinarily difficult time right now” and that “depression and anxiety are way up, stress is up, mental health resources are strained, and schools are overburdened, underfunded and understaffed.”

My fear is that Ms. Hax’s advice for her to stop beating herself will fall on deaf ears. As I have described in previous posts, parental guilt has become more widespread, and parents often feed into the guilt of other parents – especially if the parents try to set limits with their kids instead of helicoptering. I can recall other families giving us a hard time when we wouldn’t give our kids away at college unlimited funds to do whatever they wanted.

Besides stopping parents from setting appropriate limits with their kids or disciplining them properly, another big problem is one that I have seen clinically but which is not described in the mental health literature: the kids see their parents feeling guilty all the time even when there is no obvious reason for it, and take this to mean that their parents need to feel guilty. They may therefore act like they are more impaired than they actually are so that the parents can continue to indulge this need. The fact that the guilt remains omnipresent in this situation confirms their beliefs!

In a column the very next day, Ms. Hax answered a letter in which a wife in an abusive relationship will not leave for fear of harming the kids.  The letter says “But I read so much about how kids thrive in stable families and are damaged by splits or divorces other than in highly abusive situations. My partner is not physically abusive but checks a lot of other boxes: yelling, vicious anger  name-calling, silent treatments.”

How anyone can possibly believe that subjecting kids to this sort of abuse is better for them than coping with their feelings about a parental divorce is beyond me. And kids are smart enough to wonder about that themselves. So how do they then interpret Mom’s refusal to leave? Perhaps mom is using the kids as some sort of excuse because deep down she thinks she needs or deserves her husband’s abuse? I know that sounds bizarre, but you would be surprised.

In fact, although obviously I can’t say in this particular case on the basis of a letter to an advice columnist, there may even be an element of truth in this idea. The answer to what might be going on can often be obtained by a therapist using the Adlerian question: “What would be the downside of successfully getting out of this bad relationship?” A common answer: "My parents would blame me and tell me I should go back to him and be a better wife." I kid you not! Maybe because those parents themselves are in a similar relationship. If so, we’d have to find out whether this is indeed the case, and then ask the Adlerian question to the grandparents about why they continue their relationship.

When people feel guilty, it leads to defensiveness, which can lead to fight, flight or freeze reactions which cut off conversations about how to solve problems. Since the problems go back many generations, I have always suggested that we just put the blame on Adam and Eve, and be done with it.

 

 

 

 

 

In a new video, I discuss family issues that feed into guilt in women trying to balance career and family

https://www.youtube.com/channel/UCPjK28Du95eX2ZdWTT5_6TQ

Hidden Altruism in Repetitive Family Interactions

 

In a recent Dear Abby advice column from 10/26/21,  a mother who had been an addict when her daughter was young complains about the guilt trips the daughter always seems to lay on her. Abby’s interpretation as to the possible motives for the daughter’s behavior is the seemingly common-sense one that most people – and most psychotherapists for that matter - would come up with: that the daughter was acting out of selfish needs.

 

Being the contrarian that I am, I discovered that selfishness is often actually a cover for altruistic self-sacrifice, and that the daughter is giving mom what mom seems to need from her. The mother’s obsessive guilt and her repeatedly and nearly constantly trying to fix her daughter might very well be the reason the daughter is doing this.

 

Now of course, from just a paragraph description in a letter I can’t be certain of my interpretation in this particular case, and there might be several other issues operating simultaneously that might be making this situation far more complicated than my formulation would suggest. The daughters’ brothers being perceived as the favorites, which is mentioned in the letter, might be one of them. The mother may have gender issues which might conceivably be involved.  And we don’t know anything about Mom’s former behavior, let alone her family dynamics

But if we could get the truth out of these people – always an iffy proposition -  I’d be willing to bet that I am at the very least on the right track. I have put in italics the part of the letter that I think gives it away. My hypothesis would be my starting point as her therapist in trying to understand what exactly is going on, and why.

 

ABBY: I'm the mother of a 36-year-old daughter. She claims I treat her younger brothers better than I treat her. I am a recovering addict -- clean for 20-plus years. I was in active addiction for nine years when she was a teenager, and she has never let that go. She constantly tells me how "unfair" I am, that I never make time for her and that I don't validate her feelings. I have apologized many times and tried to show her I don't treat her siblings differently. I schedule "us" time, but this is an ongoing battle, and I'm at a loss about how to fix it. How do I show her there's no difference in the way I treat any of them? How do I reassure her that her feelings are validated? This has caused me many tearful nights. -- WANTING SERENITY BACK

 

In reply Abby says she thinks this mother “created an emptiness in her daughter “that the mom may not be able to fill,” and that the daughter is “punishing” the mom for her former behavior. I submit that the daughter is actually giving Mom what Mom's endless guilt seems to be begging for: More and more guilt! Mom’s obsessive apologies would then trigger this pattern again and again, leading to the daughter heaping on more and more guilt leading to more apologies and so on in a vicious circle.

 

Each member of the duo thinks the other one needs this interaction while discounting their own contribution to the pattern. They have to cover up their own role in order to continue playing it effectively, both for the stabilization of a parent. Mom’s history of substance abuse and neglecting children would, under this scenario, be a role she was playing for her parents.

Patient Advocates, or Unwitting Drug Company Shills?

In my post of May 3, Preying on Human Misery, I discussed how big Pharma took advantage of the parental desperation that I described again in the recent (February 26) post, Couch Potatoes Unleashed.  Many of today's parents absolutely panic whenever their kids start acting out or having even the most inconsequential of emotional problems.  They at first obsess about whether or not they might have done something terribly wrong to cause it, but soon begin to look for something else to blame - anything else - that might account for the problem that does not involve family relationships.

Thinking their children's problems might be due to family discord tends to make them feel even guiltier and even more panicky. Often they do not realize that it is their own guilty and panicky behavior which feeds into their kid's problems and makes those problems far worse then they might be otherwise.  And thus, a vicious circle is created.  More parental guilt and anxiety leads to more acting out and more emotional distress in the child, which leads to more parental guilt and anxiety, and so forth.

A few years ago, Big Pharma took one look at the Child and Adolescent Bipolar Foundation (CABF) and decided that here was a great population to exploit in their continued efforts to expand the definition of bipolar disorder in order to sell more atypical antipsychotics to unsuspecting patients (See my post of March 22, The Zyprexa Documents).

They helped fund the CABF and used their paid-off "experts" like Joseph Biederman, as well as their sophisticated psychological marketing techniques, to spread the word that  a brain disease was the source of these children's problems, and that their medications were the solution.  Soon, entire families began to label their members with various and sundry psychiatric disorders, a few of which were completely bogus, and others of which they simply did not have.

To their credit, CABF eventually stopped accepting drug company money.  But by then the damage had already been done.

Big PhARMA's strategy of using advocacy groups to increase sales was by no means limited to CABF, and by no means limited to psychiatry.  This marketing strategy is ingenious, hard to catch, very sneaky, and very effective. According to a new study in the American Journal of Public Health, not-for-profit patient health advocacy groups like the American Diabetes Association also get money from drug companies in the form of grants that—more often than not—are not disclosed to the public by those groups. 

These grants are not made because the drug companies have the best interests of the common man at heart.  What they want is for the patient groups to help push their drugs and medical devices.  It works.

The National Alliance on Mentally Illness (NAMI) has been a major target for Big Pharma.  This group was already on the warpath against psychotherapists - particularly family therapists and psychoanalysts - for unfairly blaming major mental illnesses like schizophrenia and autism on poor parenting.  Many members were all too anxious to absolve dysfunctional family interactions of having any role at all in any psychiatric disorder or behavior problem at all for the reasons discussed above, and so became easy targets for the pharmaceutical industry.



Like the famed Pied Piper, the industry played a tune that members of the advocacy group were delighted to hear - that they had absolutely no control over the way their children acted or turned out, and that the proper medication would solve all of their problems.
 
The website ProPublica reports: 

"From 2006 to 2008, the group took in nearly $23 million in drug company donations—about three-quarters of its fund-raising. At the time, NAMI’s executive director told The New York Times that “the percentage of money from pharma has been higher than we have wanted it to be” and promised greater disclosures.

In the area of neurosciences, [drug company Eli] Lilly gave NAMI $450,000 for its Campaign for the Mind of America. NAMI has advocated that cost should not be a consideration when prescribing for patients. 'For the most severely disabled,' insisted NAMI, ‘effective treatment often means access to the newest medications such as atypical anti- psychotic and anti-depressive agents. . . . Doctors must be allowed to utilize the latest breakthrough in medical science . . . without bureaucratic restrictions to the access for life-saving medications.’ To the degree that NAMI’s campaign succeeded, the market for Lilly’s neuroscience drugs expanded."

PhARMA marketing departments often seem to know more psychology than many mental health providers.

Parents of Patients With Schizophrenia Can Stop Feeling Guilty Now

Schizophrenia is not something I really wanted to focus on much in this blog.  Certainly, family dysfunction (and a variety of other stresses including someone just leaving home for the first time to go to college or join the military - an extremely common scenario) may trigger or exacerbate a first psychotic episode in a vulnerable patient, leading to the hallmark delusions and hallucinations. 

However, the vast majority of neuroscientists, physicians, and psychologists no longer believe schizophrenia to be primarily a "functional" (psychological or behavioral) disorder.

As I have mentioned several times, given the current state of our knowledge about neural networks in the brain (100 billion nerve cells with over a thousand separate connections each), the idea that schizophrenia is a brain disease is extremely difficult to "prove" beyond a shadow of a doubt, as some mental illness deniers insist we must. 

It would be hard to believe that the brain is the only organ in the body that is immune from any chronic developmental disease that would cause microscopic deterioration to its parts - in this case its neural network connections.

The fact that our current treatments for psychosis suck big time, while an important issue in itself, is not really relevant to the argument about the nature of the illness. 

Still, because some of my readers keep bringing schizophrenia up, I would like to describe a new study that I think should finally lay at least one argument to rest.  The study is brilliantly designed and the results very clear.

In my post Antipsychotics Are for Psychosis, Not Insomnia, I discussed an earlier study that looked at the role of antipsychotic medications in the development of severe brain shrinkage (cerebral atrophy) that is seen in many severe cases of chronic schizophrenia.  That study concluded that both the underlying disease and the medication both contributed to this phenomenon.  The study was not conclusive, however, because there was no actual control group.

At last, we now have the very first prospective study about this issue by Andrew M. McIntosh, David C. Owens, William J. Moorhead, Heather C. Whalley, Andrew C. Stanfield, Jeremy Hall, Eve C. Johnstone, and Stephen M. Lawrie.  It has been published on line in the journal Biological Psychiatry. 

A prospective study is one that follows over time a group of similar individuals (cohort) who differ with respect to certain factors under study, in order to determine how these factors affect rates of a certain outcome.  In this case, 162 individuals at high genetic risk of schizophrenia and 36 healthy control subjects were followed over 10 years. 

The high risk subjects had at least two first- or second degree relatives affected with schizophrenia.  None of the subjects in the study had any psychotic symptoms or other evidence of schizophrenia at the beginning of the study.

Participants received detailed clinical and up to five MRI scan assessements at 2-year intervals. The results?  17 of the 146 high-risk subjects who were scanned developed schizophrenia over the 8 years of the study. People at high genetic risk of schizophrenia had significantly greater reductions over time than the control group for whole brain volume and left and right prefrontal and temporal lobes.

Greater prefrontal reductions were shown in high-risk subjects who subsequently became unwell compared with those who did not. These changes were significantly associated with increasing severity of psychotic symptoms.

In other words, cerebral atrophy was developing in these patients before they had been treated with any antipsychotic medication.  In fact, it started to develop before they even had any symptoms!  So the atrophy is clearly present in the absense of any treatment at all.

Oh, and guess what?  The study was not funded by the drug companies, nor do any of the authors declare any drug company connections.

So, if you are the unfortunate parent of a person with schizophrenia who is dead set on blaming yourself for the condition of your child, I would ask two questions.  These are rhetorical questions, since I have no way of evaluating the accuracy of your anwers:

First, were you an abusive or neglectful parent or the spouse of an abusive or neglectful parent?  If not, what on earth are you feeling so guilty about?



Falling Off the Wagon

When it comes to assessing one's personal role in family dysfunction or even domestic violence...

Blaming oneself or others in a moralistic sense is toxic for problem solving and makes problem resolution impossible.  It almost always leads to fight, flight or freeze reactions, rather than useful communication.  In order to resolve and stop repetitive dysfunctional family interactional patterns, one should focus on only three questions:  What are the patterns, what are they for, and how do we put a stop to them?  Leave questions of guilt and innocence to the justice system.  If a family member (or even you yourself) has been abusive, ask yourself this:  What is more important?   Is it punishing the guilty and making them eat crow, or putting a stop to the abuse and reconciling?

It pays to remember that it is impossible to forgive someone else who refuses to acknowledge what they did, denies ever having done it at, or puts all the blame for their own bad behavior on you.  Step up to the plate and look at your own role in problematic interactions.  You'll be glad you did.

 

Don't Ask, Don't Tell

I had the following exchange with another psychiatrist in the midst of a discussion on a Medscape blog about the frequent misdiagnosis of bipolar disorder:

Me:  I am saying that someone may appear bipolar when in fact he or she is really just acting out in response to family chaos or other environmental disturbances.  Mis-diagnosis stems from a failure of the practitioner to evaluate what is going on at home and under what circumstances the patient acts up, and to consider alternate possible explanations.

Family members will not usually volunteer the whole truth during a superficial visit with a doctor. Anyone who thinks that family members act the same way at home as they do in front of an authority figure, or that they will be totally honest about things like family violence or abuse, needs to get out more.

Psychiatrist #1:  This broad statement essentially implies and equates pediatric mental disorders with the family abuse and neglect. Misconceptualization of pediatric pathology is characteristic of orthodox thinking that always looks for proximal cause. The reasoning goes along the line "if child has problems, someone in the family caused them". And if the family does not offer any evidence of maltreatment,they are lying. A fundamental fallacy, in my opinion, that for decades prevented psychiatrists from understanding the nature of mental disorders.


Family, as the cause of psychiatric illness is a dangerous fantasy. Suspecting family members of hiding "the whole truth" is a regrettable statement from a professional.

Wow.  I never said I was equating pediatric mental disorders with family abuse and neglect, or that I assumed that if a child has a problem, someone in the family caused it.  I just said the family situation needs to be evaluated just like everything else.  It sounds to me like it is the writer who is saying that poor discipline or even child abuse is never an issue at all!  Family a cause of psychiatric illness?  How about behavior problems being mistaken for psychiatric illness?

Suspecting a family of hiding the whole truth in a superficial interview a regrettable statement?  Obviously this psychiatrist has never done any serious psychotherapy, or he would know that a patient may not reveal absolutely essential information about their situation until they have been seeing a therapist for months.  I once had a patient who did not reveal until one year into therapy that her father had been a junkie during her entire adolescense.

Let me see.  The other psychiatrist must think that his patients are all experts on psychiatric symptomatology so they can just volunteer all the important clinical information necessary for the doctor to make an informed clinical judgment.  They are so well read in psychiatry that they just know all the relevant factors a doctor needs to know about their home situation right off the top of their heads, even if they are not asked about something specifically. 

Of course, no one ever withholds information because they are ashamed of something, or guilty about something, or because they are not sure they can trust a complete stranger with their deepest darkest secrets and the skeletons in their family closet.  And all parents are completely aware that their trouble setting limits and saying no is feeding into their children's temper tantrums.  And we all know that people who are guilty of child abuse just love to tell everyone they know about it, especially someone who is legally obligated to turn them in to child protective services!  Why, everyone is just chomping at the bit to have their children taken away from them.

Oh, and one study showed that only 10% of the parents of children who are given complementary or alternative medicines tell their pediatricians about them.  The whole truth in a superficial interview?  I think not.

I know it is just a television show, but ever watch Supernanny?  When a family calls for her to come help them with a family problem, is she ever surprised by what she finds when she actually watches them in action at home?   Unrealistic or staged?  I doubt it.

I treat many patients who cut or otherwise injure themselves, and most of them know better than to tell the average doctor about it, because the average doctor will freak out.  Even psychiatrists.  They may get thrown in a mental hospital when being there would make their mental state even worse than it had been before they got there.  Who feels better being thrown in with a bunch of psychotic people?

Many of my patients have been abused and betrayed by almost everyone in their lives they were supposed to have been able to trust.  Yet when they are not completely open with a new doctor, who again is a complete stranger, they are accused of having pathological "trust issues."  In truth, they would have to be completely crazy if they did trust anyone implicitly after what they've been through.

When it comes to specific problematic or dysfunctional family interactions which trigger a patient's bouts of depression, panic attacks, impulsive acting out, or mood instability, in my experience people will not volunteer this information unless specifically asked about who says what to whom about whatever problem they bring to treatment.  It's a case of don't ask, don't tell.  If the therapist does not ask, they do not think to tell.

Since I was initially trained in psychotherapy by psychoanalysts, I was never trained to ask questions like, "What does your mother say about your being so depressed all the time?" or even "What does your father-in-law say about these fights you and your husband keep having? "  Once I started to ask questions like that, a whole bunch on new types of information I had never heard before came flowing out of patients.  The type of psychiatrist who calls all mood swings evidence of bipolar disorder never asks this type of question.

In the Medscape discussion, a patient jumped in added her two cents to the discussion about doctors believing everything they hear:

I am a survivor of domestic violence. My husband and I were going to marriage counselling. During counselling my disclosures about our marriage led my husband to decide that I had to be committed to our local hospital's mental health unit. He completed the necessary paperwork and told the psychiatric staff that he believed I had bipolar disorder with persecutorial delusions about him. The consulting psychiatrist believed him and his "proof" of my deteriorating mental health and I was given a confirmed diagnosis of bipolar disorder with persecutorial delusions. I was hospitalised for five weeks based on this confirmed diagnosis. During this time I was told that unless I took medication (zyprexa) I was not going to be discharged. When I contested and challenged the diagnosis, I was placed on an involuntary treatment order because I was so unwell I lacked insight into the severity of my unwellness.


I do not have bipolar disorder with persecutorial delusions. If the psychiatrist had not been so quick to diagnose and had had a watch and wait approach as well as performed a more thorough case history into my domestic situation and life with my husband, then I would not have been given this mis-diagnosis.

I would of course want to hear both sides of the story before I made up my mind about anything.  Shame on doctors who think they can read minds and perhaps that the only people who should not be believed are the ones who claim they are being abused.

All Joy and No Fun

An article in New York Magazine from July 12 contains a cover story by Jennifer Senior on why a lot of parents today seem to hate parenting. People often think, before they have children, that having them will make them happier. Instead, they find that taking care of them is a pain in the ass. A study by Dale Kahneman, a behavioral economist, was quoted in the article as saying that on a survey of 909 working Texas mothers, child care ranked 16th out of a list of 19 as a pleasureable activity. Housework was rated higher.

There are some interesting statistics given in the article. In spite of the rush of women into the American workforce, both parents actually spend more time with their kids today than they did in 1975. Today's parents have less leisure time. In one survey, 71% of married mothers and 57% of married fathers crave more time for themselves. Nonetheless, 85% thought they still didn't spend enough time with their children!

The amount of time married couples spend alone with each other each week has also decreased - from 12 hours a week in 1975 to 9 hours per week today. (Parenting columnist John Rosemond points out that parents neglecting the marital relationship is bad for the children).

All of this time spent with kids led one psychologist quoted in the article to exclaim, "[children] are a huge source of joy, but they turn every other source of joy to shit!"

The author of the article suggests that cultural changes may have fundamentally changed the nature of raising children for the worse. Two career families, the view that children need to be groomed, the idea that you have to spend an inordinate amount of time talking to children, etc. Or maybe we should be more like Scandinavia, where affordable child care, once you go back to work, is free with state subsidies, and where people are no longer "wondering how to pay for your children's education and health care (because they're free)."

On another blog called The Last Psychiatrist (http://thelastpsychiatrist.com/2010/07/why_parents_hate_parenting.html), the blogger has a different explanation. He points out that "... you know, no Scandinavian women ever kill themselves at double the rate of Americans."

He thinks the issue is parental narcissism. Parents are upset because they see their children as mere extensions of themselves instead of as separate people. If the kids don't act the way the parents think they should, the parents go bananas. Another comment: "The author of a parenting book still cannot help but see children as a reward, as a cherry on top of a cake, not because she is brain damaged but because for 40 years she has been told by people, like herself, like New York Magazine, that they were."

His advice is simple: "Your kid doesn't want to be around you that much. No one does. This isn't because you're a bad person but because you're an ordinary person. You are not such a unique, creative, intelligent or even interesting person that the kid benefits from constant exposure to you. When you have something to offer, maximize and concentrate that time, and then get the hell out of the way."

I don't remember wanting to hang with my parents all the time when I was a kid, so I think I know what he means. This doesn't mean, of course, that parents should completely ignore their children, either.

I have my own ideas about what maybe going on here that I go into detail about in my new book. The summary I give here may come across as more simplistic than it is because I'm being very brief, but I think the bigger picture is an explosion of parental guilt. Among the sources of guilt, and there are many more: The Phylis Shafley's of the world (a career woman who made a career out of attacking career women) and their ilk constantly bemoaning the loss of the stay-at-home mother. Studies that purport to show that children of two-career families tend to do worse in some respects on average than children where one parent stays home. Old school grandparents who feel that their grandchildren are being neglected and then criticize their working daughters - while simultaneously envying the hell out of their careers.

The parents come home tired from work and guilty and try to make up for lost time by giving their kids everything the kids want and giving into their every whim. Then they wonder why the kids throw temper tantrums when they don't get their way. So their kids are out of control and never do what they're told, and the parents' guilt starts to get mixed in with rage at their kids. The rage then makes the parents feel even more guilty as well as inadequate, so they give the child even more of themselves, if that's even possible, and a vicious cycle goes on and on.