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?



Borderline Personality Family Dynamics The Parents Part I

In my post of 2/6/11, Dysfunctional Family Roles, Part I: The Spoiler, I opined that the basic problem in the "borderline" family (one that produces offspring with borderline personality disorder [BPD]) is that the parents in such families see the role of being parents as the end all and be all of human existence, but all the while, deep down, they either frequently hate being a parent or see their parent role as being an impediment to their personal fulfillment.

I also explained how the person with BPD develops the Spoiler role in response to the double messages that this emotional conflict leads such parents to give off to their children.

It's all well and good to try to understand the behavior of the individual with BPD in terms of a response to parental problems, but that just kicks the question of an explanation for the disorder back a generation. In order to fully understand BPD, we have to ask, "What on earth makes these parents so damn neurotic that they compulsively have children and then covertly resent them?" 

If the parents are not patients themselves, the only way for a therapist to get to the bottom of this is by helping the patient with BPD to construct a special type of family genogram.  A genogram is sort of an emotional family tree, and is a mainstay of the type of family systems therapy designed by family therapy pioneer Murray Bowen.

Murray Bowen

Using historical figures and geneology records as illustrations, the book Genograms: Assessment and Intervention by Monica McGoldrick and Randy Gerson describes how genograms can be constructed .

Monica McGoldrick

The genograms described by Bowen therapists are, in my mind, incomplete.  They concentrate on which relatives were overinvolved or underinvolved with which other relatives, and whether these relationships were hostile or friendly.  IMO, this leave out an awful lot of important information.  Two individuals may easily have a hostile and enmeshed relationships with each other over one area of functioning, say work or love, and yet still be very distant, friendly and uninvolved with each other over a different area of functioning. 

In other words, these genograms omit the content of the family squabbles.  When the content is added to the genogram, one can then look for the historical experiences of the family that may have created the picture that is taking place in the present.

While I have indeed seen the parents of adult children who exhibit BPD in therapy and traced their genograms, I have also coached patients with the disorder themselves to construct their family's genogram.  We try to go back as far as we can to figure out what family experiences led to the parents' conflicts.  Sometimes the story goes back more than three generations and we may lose the historical scent, so to speak, in that no one alive knows what happened way back whenever.  Usually, however, certain patterns come to the fore.

In Part I of this post, I will describe the one most common major issue, and the resultant behavior patterns, that I have discovered leads individuals within a family to develop a severe conflict over the parenting role.  In Part II, I will describe some other ones.

All of these issues may seem very common everywhere, and indeed they are.  Most families that face them do not produce emotional conflicts significant enough to create BPD pathology.  Rather, the issues in families that do have been magnified signficantly by an interacting tableau of historical events impacting the family and the individual proclivities of each and every family member and descendent. 

I will not describe the details of the magnification process here, but a full explanation can be found in my book, A Family Systems Approach to Individual Psychotherapy.

The most common cause of conflicts over the parenting role stems from cultural rules regarding gender role functioning.  Over the last century the opportunities open to women to explore their interests and ambitions have gradually expanded, and having a lot of children certainly put a damper on their ability to do this.  If a woman came from a family where the women were very bright and had a natural proclivity for being ambitious career-wise, this would often create difficulties for them since they lived in a male-dominated culture that was at best unfriendly to female career ambitions. 

To demonstrate how this might play out in a hypothetical family, I often discuss the evolving role of women in the United States since World War II. During the war, when all the men went off to fight, women in the United States entered the workforce in large numbers for the first time - in order to build the airplanes and tanks.  This phenomenon was known as "Rosie the Riveter." 

Some women found the experience of a career exhilerating, but when the war ended, they had to go back to just being wives and mothers once again.  The US govenment even made propaganda films thanking the women for their important work, but then encouraging them to go home and get barefoot and pregnant once again.  I have seen some of them; by today's standards they are positively jaw dropping. But effective. The Rosies did what they were told, and that is why we had the baby boom.

Rosie the Riveter

The daughters of this generation came of age in the sixties, when the women's liberation had started in earnest.  Women were more and more torn between the earlier gender role requirements and the new cultural opportunities expectations, and some women (as well as some men) did not make the transition very smoothly at all - for a variety of reasons.  One common reason: the Rosie the Riveters, having had a taste of the career world, would vicarioulsy live through the career aspirations of their daughters, but at the same time be extremely frightened by them.

Having children could easily bring the whole craziness to a head for some families.  Even today, parents feel very guilty about not spending as much time with their children as they would like, and they are often criticized at every turn by their own parents as well as the Phyllis Schlafly's of the world.  (Phyllis Schlafly was a career woman who made a career out of bashing career women).

Phyllis Sclafly

In doing genograms, one can often see just how far a family's operating rules lag behind the current cultural norms .  In anthropology, this problem is called cultural lag.  The cultural progression in Western nations, which is mimicked within certain families, was thus:  First, women really could not have careers at all.  Then, they could have careers, but only when they were single.  Then - and here is where many families with BPD members are stuck - they could only have careers when they had not yet had children.  Then, they could have careers even if married with children, but they had to give priority to the husband's career.  Last, both men and women were entitled to the same freedom.

Gender role confusion and conflict can, given the right combination of ingredients, create a nasty intrapsychic conflict over the very act of procreating. 

In Part II of this post, I will look at the rest of the historical factors and patterns that can create such a conflict: Deaths and illnesses, financial reverses, religious demands, parent-child role reversals, being the eldest child in a traditional family, and having children to "save the marriage."

Borderline Personality Family Dynamics The Parents Part II

In my post of 2/6/11, Dysfunctional Family Roles, Part I: The Spoiler, I opined that the basic problem in the "borderline" family (one that produces offspring with borderline personality disorder [BPD]) is that the parents in such families see the role of being parents as the end all and be all of human existence, but all the while, deep down, they either frequently hate being a parent or see their parental role as being an impediment to their personal fulfillment.

In Part I of this post, I described the one most common major issue - gender role conficts - and the resultant behavior patterns, that I have discovered leads individuals within a family to develop a severe conflict over the parenting role. In Part II, I will describe the other ones.

To repeat a caveat from the previous post: All of these issues may seem very common everywhere, and indeed they are. Most families that face them do not produce emotional conflicts significant enough to create BPD pathology. Rather, the issues in families that do have been magnified significantly by an interacting tableau of historical events impacting the family and the individual proclivities of each and every family member and descendent.

Common issue #2 causing parental ambivalence over being parents: Untimely deaths. The loss of children, in particular, may make someone fearful over losing the others while, at the same time, may lead to parental resentment over the fears and insecurities created by the presence of the remaining ones.

For example, one grandparent of a patient in our clinic had lost 10 out of 11 children to disease; the 11th was the parent of the therapist's BPD patient. The grandmother was overprotective of the mother but at the same time avoided closeness for fear of the pain of losing yet another child. When the mother grew up and left home, the grandmother became depressed. The patient was then given up as a child to the care of the grandmother to help feel the void, and became the new focus of the grandmother's hyperconcern and insecurity. This is also an example of a parent giving up a child as a gift to a grandparent - the subject of my 10/15/2010 post.

Issues #3 and #4: Financial reverses and chronic illnesses - including severe mental illnesses. Because of the financial strains and general chaos caused by these considerations, the joy of raising children may be suddenly turned into a frightful burden, both emotionally and financially, and thereby generate parental ambivalence.

Interestingly, the presence of bipolar disorder - with which BPD is often confused these day by both incompetent psychiatrists and the public despite the fact that they do not look anything alike - in a parent may lead to the very chaos in families that generates BPD behavior in children. Children in such a family are at risk both biologically and genetically for bipolar disorder and environmentally for BPD.

Issue #5: Ambivalence over religious or cultural values concerning childbearing, child rearing and filial responsibilities may lead to parental ambivalence. Examples include:

• 1.  The Roman Catholic emphasis on large families in a day and age when children cost a small fortune to raise. This may lead parents to follow the church rules but be extremely unhappy about the results.
• 2. Children, often the eldest female in a traditional family, may be called upon to take care of younger siblings in large families. In doing so they are often forced to give up exciting adolescent activities in which their peers at school freely indulge. The result may be that they become identified with the caretaker role yet resentful of it. When they leave home and have families of their own, this history may lead them to resent their own children. 

I     I used to practice in Los Angeles where I saw many Chicano (Mexican American) patients.  I saw several females who had functioned as "mother's assistants" when they were growing up. They were the eldest sister in large families. They had to stay home and take care of their younger siblings, and frequently had to miss important social events in school such as their senior Proms. Their younger sisters, however, got to go to and do everything the olders sisters had missed. When these older sisters grew up and had their own children, this recreated the family of origin issues for them and induced ambivalence in them about their brood.



•  The eldest male in a traditional family, such as seen in some Asian cultures, may be called upon to take over the family business in a career that he may just happen to hate. The costs incurred in raising children may lead to continuing family pressure to keep the business going when he wants out. The anger of Son #1 in such a situation may be displaced onto his children.

Issue #6: Parent-child role reversals. If adults in the family become incapacitated for whatever reason, and the children are therefore called upon to take over heavy adult responsibilities prematurely, the children may become resentful in a manner analogous to the situation of the eldest female in a traditional family described above.

Such individuals often describe this state of affairs with statements such as “I never got to be a kid.” [This is not the reason, however, that Michael Jackson said that]. A similar situation occurs when parents who were infantalized by their own families of origin appear to be unable to take care of themselves. Their children then try to fill the power vacuum and take care of them before they are really equipped to do so.

Issue #7: A couple has a child to “save the marriage.” The child then becomes the reason that the parents must continue in their miserable relationship. The resentment within the marital dyad becomes symbolized by the child whose presence was supposed to make the relationship better, but instead has led to the continuation of the same old marital misery.

The child then begins to believe that the family problems are all his or her fault, and the parents do not seem to try very hard to counter this belief. Children in such a bind usually come to the conclusion that their very existence is the reason their parents seem to hate each other. They may also feel that it is their reponsibility to provide a distraction to the parents' anger at one another by drawing anger on to themselves. This is one of the functions of the spoiler role.

Two or even several of these issues can present themselves simultaneously to a family, thus increasing parental ambivalence over the presence of children almost exponentially. The whole family becomes embroiled in quite a stew, and the abuse and neglect of children that sometimes results from these conflicts becomes more understandable, although still not excusable.

Expressing empathic understanding of the family's behavior, without condoning it, is far more productive in helping a family to stop troublesome behavior patterns than raking them over the coals for their misbehavior.