Families in Psychiatry
What is it about families that makes our patients so upset? Why can our patients not just walk away from conflict? Why do they get so bent out of shape when family members do not say or do what they expect them to do? We all have families that are less than ideal and struggle with how to manage difference.
This column gives psychiatrists a framework for thinking with families about the universal dilemma of managing difference. This dilemma can be viewed from the perspectives of the individual, the family, and society: Identity is formed in the crucible of the family, where parental introjects become a model for the child’s development and can be rejected as an adolescent or adult as individuals shape their own identity. Processes within the family shape family members’ relationships and, therefore, their expectations of one another. Strong boundaries provide safety for those inside the family versus those outside the family.
Individual perspective
Family members’ perspective and expectations of others depend on their family position. Children or young adults want to please the parent, and to be accepted and recognized for who they are. They want their unique qualities to be valued, they want to be loved, and they want to feel that they belong.
Dr. Alison Heru
Parents want their young adult to reach what they consider a successful life, and to be fulfilled and healthy. When their child strikes out on his or her own, the parent may not understand, and may feel let down or angry. The parent may say: “She married him to get back at me.” “Why is my son so rejecting of the business our family spent generations to build?” “How can my child reject our family values that we brought from the old country?” “How did it happen that my son is gay?”
Siblings have an idea of who their sibling should be, and this idea often is fixed and immutable. They may ask, “Why won’t my sister help me out?” “Why can’t she be a good sister?” “Why is my brother so jealous of me?”
Family elders may wonder why their adult children do not want to return home to care for them or why they want their parents to go into a nursing home.
These dilemmas are easy to understand as conscious expectations. More difficult to understand are the unconscious projections that tangle up families.
Unconscious psychological processes
The two main unconscious psychological processes that tangle up families are projection and projective identification. Projective identification is an unconscious process in which aspects of the self are split off and projected onto another person. In 1946, Melanie Klein introduced the term “projective identification” as follows: “Much of the hatred against parts of the self is now directed toward the mother. This leads to a particular form of identification which establishes the prototype of an aggressive object-relation. I suggest for these processes the term ‘projective identification’ ” (Int J Psychoanal. 1946;27[pt 3-4]:99-110).
Mutual projective processes can occur in committed relationships. The following scenario helps illustrate this: Ms. A. projects onto her husband her own feared and unwanted aggressive, dominating aspects of herself. The result is that she fears and respects him. He, in turn, comes to feel aggressive and dominating toward her, not only because of his own resources but because of her projections, which she forces onto him. He may, in turn, despise and disown timid and fearful aspects of his own personality and by a similar mechanism of projective identification force these unwanted aspects of himself onto his wife. Ms. A. is then composed of timid unaggressive parts of herself as well as his projections, and she carries these feelings as her part in the relationship. Some couples, like Mr. and Ms. A., live in such locked systems, dominated by mutual projections, with each not truly married to the other person but to the unwanted, split-off, and projected parts of themselves.
In this scenario, the husband becomes dominant and cruel, and the wife becomes stupidly timid and respectful. These marriages are stable, because each partner needs the other for narcissistic pathologic purposes (see “Some Psychodynamics of Large Groups” in “The Large Group: Dynamics and Therapy” [London: Karnac Books, 1975] and “The Ailment and Other Psychoanalytic Essays” [London: Free Association Books, 2015]).
Marriage offers an opportunity for individuals to work out these types of issues, or, in the case of Mr. and Ms. A, not work through them. Instead, they exist in tight mutual projections.
Family process perspective
Families function as a system or unit, and each person in the family has a role or function. When change occurs, basic rules of systems theory apply. For example, if the mother functions as the emotional barometer, no one else needs to pay attention to emotions, as that is the mother’s job. If she leaves or becomes ill, someone else will take on that role or the family will fall apart. If the father becomes depressed and unable to function in his role as a parent, the oldest child may have to step up to become the parent. When he gets better and his depression resolves, there may be tension – as the older child may not want to give up that role. There may be a disagreement in the family vision.
When the children grow and develop their own identities and lifestyles, the family has to adjust to include the adult children or cut them off. Individuals also may cut themselves off from the family if there are significant disagreements. There are variations, such as “semi-cutoffs,” where there is little contact except at ritualized holidays and significant family events. Therefore, tensions arise most clearly at these times when family members come together.
Boundaries protect the family
A family functions like a pack. As with most species, families and parents protect the young until they are able to care for themselves. The marriage contract specifies that spouses care for each other but additionally that they join extended families together. Family cares for family before caring for strangers. It is the elder’s role and responsibility to keep the family together, or the family members may drift apart or be subsumed into other family groups.
A clan is made up of related families that form a larger extended family unit. Historically, strong alliances, as in clans or family dynasties, become dominant socially. In recent history, the idea of clans has become less attractive as the idea of individualism has become the American ideal.
Modern families tend to be individually oriented and do not need their families for protection as much as primitive tribes did. Modern families have fairly loose boundaries, and problems can arise when the family tries to define boundaries and values.
Families also change composition with the impact of sociocultural influences, such as migration. However, the primitive social drive still forces us to form families and clans. This drive can explain much of the need for identifying people as “in or out” of the family. The Amish intentionally address this dilemma. At adolescence, the ritual of Rumspringa allows the young person to experience 1 year out of Amish life in Western life. The adolescent can then decide to be in or out. If the adolescent decides to be in, conformity to Amish lifestyle is required (“Serving the Amish,” Baltimore: Johns Hopkins University Press, 2014).
Lastly, our families provide memories of where we have come from and where we are going, both as individuals and as a clan. Powerful stories serve the next generation with a sense of belonging and a specific orientation to the world. The studies of third-generation Holocaust survivors attest to the power of family narratives. Individuals can choose to embrace the family narrative or alter it to allow individual growth.
Explaining families to families
When helping patients work through issues with their families, it is helpful to provide them with context. Among the important points we can make are:
● Families came into existence as a way to protect our young; this is true across the animal kingdom. Humans congregated into clans or tribes that demanded conformity and obedience to the chief. There was a clear sense of who was in and who was out. Many of the difficulties that we experience are tied to the primitive tension of needing to decide who is in and who is out. This is a normal function of families.
● These days, families have much looser boundaries, and individuals have the freedom to strike out on their own. Families have to grapple with their collective identity only when they get together at holiday times or transitional events like marriages, births, and deaths. So, is it worth getting upset about this? If so, ask patients what they would like to change – and why.
● With this background, the family can dive deeper. Ask your patients, “Is the issue a problem with roles within the family? Has there been a role transition? Has there been a death, serious illness, or birth? Has someone left, retired, or joined the family? How would you as a family like to proceed?”
● Lastly, is there a complicated tangled web or relationship that might be explained by mutual projective identifications? If so, refer to a colleague with family therapy skills.
Key points to keep in mind
1. Families should be placed in the context of clans and tribes.
2. Transitions and family events cause families to question their family identity, boundaries, and values.
3. Patients should explore their individual expectations about what families should do. This conversation can be extensive, and include cultural and generational flash points.
4. If there is a tangled web that makes no sense to you, refer to a colleague with family therapy skills.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.