The reciprocity between parents and their child’s mental health treatment systems, Family Systems: A Journal of Natural Systems Thinking in Psychiatry and the Sciences, 14:2, 2020

Jenny Brown. PhD

Excerpts

Any treatment may achieve some symptom relief for a child even if it does not address the underlying parental process. This can occur through anxiety reduction in finding an ally in the clinician, the effects of medication, and impact of some self-regulation strategies. Bowen acknowledged the kinds of improvements that sound, child-focused treatment can achieve, noting that “as these child focussed [sic] projects have continued over the months, there have been decreases in symptoms, improvements in school work, and a decrease in overall family anxiety, but basic patterns were not changed” (Bowen, 2004, 38). It is unlikely that a deeper progress would be sustainable unless there is a genuine reduction in focusing on the perceived sickness in the child. This shift is clearly described by Dr Kerr:

The child functions in reaction to the parents instead of being responsible for himself [herself]. If parents shift their focus off the child and become more responsible for their own actions, the child will automatically (perhaps after testing whether the parents really mean it) assume more responsibility for himself [herself]. (Kerr & Bowen, 1988, 202)

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Clinical implications: Allowing parents to come up with their own discoveries

Bowen writes of learning the lesson to not oppose parents in the projection process or to instruct them to change. Rather he would avoid getting clinically entangled in the process of debates around diagnosis and instead shift to calm conversations with one or both parents about their willingness to take responsibility for their part in the anxious child focus. This change in treatment direction does not promise a quick fix for a child and family and indeed may require parents and clinicians to tolerate some short-term regression in the child:

My own approach is to defocus the child as quickly as possible and to give technical priority to getting the focus on the relationship of the parents, at the risk of a temporary increase in the child’s symptoms. (Bowen, 1978, 298)

Rather than instruct parents, Bowen worked to clearly define his position to parents and would “quietly refuse to participate in action designed to fix the problem in the patient” (Bowen, 1978, 135-6). Parents would discover how they could make a project out of themselves in order to be helpful to their child. Bowen noted in his NIMH research that “the family’s awareness of their behaviour was a first step in their efforts to unfold the layers of the underlying problem” (Bowen, 2013, 111).

This is consistent with the findings of this parent research study, in that those parents who discovered their own solutions through investigation of interactional process reported sustained hope six months after discharge (Brown, 2018). Two thirds of the parent sample reported indications of increased agency-based hope, with one third remaining discouraged with a continued focus on finding a medical fix. The value of questions that explored emotional process was noted by the parents who shifted from their investment in a medical fix to addressing their part in reinforcing the child’s vulnerabilities:

We were always asked the questions and we were always asked to think for ourselves. It wasn’t like walking into a class room and learning parenting skills, it was more questioning us and making us come up with answers.

Her questions helped me see that I was just building up more stress with what I was doing.

It gave me a chance to sort of step back enough to be able to help the situation. 

It was very clear that we had to come to our own decisions and work things out ourselves.

I guess it was the realisation of me coming to that myself rather than them having to tell me. I guess they sort of painted the picture and I finished it.

Parents who discovered some personal agency during their treatment involvement spoke of the value of gaining a more objective, observational vantage point to consider their interactions with their child:

It was actually giving you the chance to look at things differently. So you’re actually answering your own questions, so therefore you’re not being put down.

I think because we were so caught in the situation and it’s so heated and so tight… you don’t ever look at the situation from a distance to see where you’re going wrong.

In our meetings we were asked lots of questions about how we were doing things, like, “How do things happen in the morning? And what are you doing?” And it opened your eyes up, like, seeing it for the first time sort of thing.

The value of a clinical approach that takes a research attitude to enable parents to make their own discoveries fits with the way Bowen viewed the parents in his original research:

In my opinion these families are not really helpless. They are functionally helpless. … When there is a family leader… the family can change from directionless… to a more resourceful organism with a problem to be solved. (Bowen, 2013, 101)

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CONCLUSION

Having consulted to child and adolescent mental health teams for some decades, this author has observed a common stalemate in achieving positive and sustainable treatment outcomes for many cases of mentally unwell children and young people. Many highly competent clinicians can work with children and at times with parents and family, to bring about various degrees of symptom alleviation. Often symptom improvements seem short- lived and either the young person’s symptoms accelerate after discharge as developmental stage expectations increase, or another sibling emerges with serious symptoms. This is a particularly common experience in tertiary treatment where the young person has not had treatment success at a primary support level.  In my experience clinicians in child and young people’s mental health services are aware that the family dynamics play an important part in the “stuckness” of symptoms, but they struggle to find a way to translate their treatment approach into a family or parenting intervention. Bowen himself described this state of affairs in young peoples’ mental health services as a substantial problem that will not be easily resolved:

The family’s use of the medical structure of “examination-diagnosis and treatment” to further the cause of the family projection process is a monumental problem for which there are no easy answers. (Bowen, 2013, 145-6)

This paper has considered parent qualitative research data to shed light on the way that interactions with clinicians and treatment programs can easily fuel their investment in addressing the perceived “sickness” in their child. The data has also revealed how more relationship/process-focused interventions show potential to assist parents to begin to make a project out of adjusting themselves. Bowen’s original research and writing about the family projection process provide a map for making sense of parents’ experiences with their child’s mental health treatment. The interplay of the family anxieties with the medical model can maintain a complex reciprocity in the field of child and adolescent mental health. Within such a child-focused treatment offering both unsound and more logical, evidence-based interventions, either of these approaches can perpetuate the process that reinforces the young person as an infantilised patient. This paper has explored the possibilities that can be achieved if a treatment program shifts its focus from the individual child and assists parents to explore their relationship process with the child. When clinicians can assist in facilitating such a shift through focused questions about relationship/emotional process, there is promise for different outcomes in the field. Bowen himself called such a shift “parents who could make a project out of themselves” (1978, 96), and this was a turning point in the theory and practice of family psychotherapy. With a systems theory map to guide clinicians in engaging parents away from diagnoses and expert medicalised treatment, there remain many possibilities for clinicians to discover such a profound turning point in their practice.