Tuesday, October 19, 2010

A backdoor way of getting at the family dynamics

I am posting this article from today's New York Times. The subject is anorexia, not schizophrenia, but the article brings up some interesting points that are relevant in handling schizophrenia. The Maudsley method, which I have heard about before, claims a better success rate than one-on-one therapy for anorexia.

The Maudsley Method is considered family based treatment, but claims it does not go into the family dynamics that may have led to the behavior on the first place. According to a parent: "The family method gave her the skills and confidence to approach her daughter’s anorexia the same way she would approach any other disease, whether flu or cancer. If you had medicine for your child, you wouldn’t let your child take half a dose,” Ms. Ranalli said. “I would say to her: ‘This is your food — this is your medicine. You’re not leaving the table before you eat it. We will get through this together. I will hold your hand and support you through this.’ ”

Unlike traditional approaches, the Maudsley method “says we don’t think the parents are to blame for the problem,” Dr. Le Grange said. “We think they’re part of the solution, and should be center stage.” Their job is to be calm, supportive and consistent. . . .Caregivers need to speak with one voice, he said; one parent cannot be telling the child to eat while the other says, “Just give her a break tonight. The parents need to be on the same page — not just the same page, but the same line and the same word and the same letter,” Dr. Le Grange said.

This all has a familiar ring to me because of tired assertion that anorexia is like a disease. It takes the same "parents are not to blame" assertion that you hear from drug companies, NAMI, and most psychiatrists.  But when you look at what it is actually doing, it is sneaking in the idea that the parents are not on the same wavelength and it introduces the idea of low Expressed Emotion. It seems to work because the parents are not allowed to disagree about the approach and are forced to present a consistent, calm front to the person with anorexia.

Psychiatry could be as clever as the Maudsley method when it comes to schizophrenia if it really wanted to do something useful (I've been doubting this for years) and would be willing to drop the force feeding of drugs.  If the truth is too unpalatable for most parents to swallow, it appears that they would be willing to buy the back door approach.


  1. There recently was an article about a very similar approach to "anorexia" in the Danish press (although the Maudsley method wasn't mentioned explicitly). The article specifically focussed on "anorexia" in young children, about age 10 - 12, whose "symptoms" according to the article were different from those of older children. What struck me, reading the article, was that on the one hand it stated how important it was to have parents see and respect their child, and then, a few lines further down in the text the importance of "boundary setting" was emphasized.

    "Boundary setting" is a term that has become incredibly popular lately. I saw a Swedish doc about this, well, you might call it a fad, some time ago. The doc included scenes from "Supernanny" as an illustration of what "boundary setting" should look like in practice: Following the instructions of "Supernanny", a father dragged his crying, screaming, and desperately resisting 3-year-old daughter into the corner of the room they were in, and ordered her to stand there, face to the wall, and think about what she'd done wrong until she was ready to apologize. A 3-year-old! That is not "boundary setting", it isn't parenting at all, it's plain child abuse. The doc btw was very critical, showing how "the pendulum has swung back", from poisonous pedagogy, to antiauthoritarian methods, back to poisonous pedagogy, or, as it today euphemistically is called, "boundary setting".

    I wonder for how long we will keep on focussing on our children not respecting our boundaries, before we realize that they impossibly can be able to respect anybody's boundaries as long as we ourselves remain incapable of respecting both our own and everybody else's, our children's included, boundaries. The term "boundary setting" has me cringe.

    Also, reading that younger children suffering from "anorexia" often don't report that they think they're too fat, that they want to look like a model, as a reason for not eating, had me realize the, IMO, obvious: some people lose their appetite, others resort to compulsive eating, due to experiencing stressful life events... And no, the Danish article didn't mention stressful life events either, but referred to "anorexia" as an illness too. But yeah, there is at least a potential in such methods to get at family dynamics.

  2. To me, boundary setting such as you describe, seems pretty humane. Parenting children brings out the worst in many of us, unfortunately. We all have noble thoughts until the situation actually presents itself. Better to put a child in a corner to think about it than to risk something worse. How would you handle a screaming toddler?

  3. Rossa, it was clear from the clip that much of the little girl's screaming was a reaction to her father dragging her to the corner. Same problem as in the mh system: the initial conflict doesn't get de-escalated, not to mention solved, but on the contrary it is pushed to extremes. Such approaches are not about respect, but about power, physical power included. Also, I find it grotesque to expect a 3-year-old to have the maturity to reflect about their behavior/the situation, as the girl was asked to do.

  4. Okay, but again, what would you do with a screaming toddler? What methods would you use that don't look grotesque? Most people would never consider it grotesque to put a toddler in a corner and ask them to think about it their behavior.

  5. "Most people would never consider it grotesque to put a toddler in a corner and ask them to think about it their behavior."

    No. Just like most staff in the mh system doesn't consider it grotesque to restrain, isolate, and force drug people. That's the problem. They should. The interesting thing is that the girl's father was visibly uncomfortable with the situation, and repeatedly hesitated and looked at "Supernanny": "Is this really what you want me to do to my daughter?" So, intuitively, we know very well that such methods are violent and inflicting additional pain on the other.

    I don't think force ever can be a sustainable solution to conflict. It may seem to put an end to a conflict here and now, silencing any protest, but unless the reason for the protest is investigated in a dialogue, nothing will really be solved, and all you've created is fear, not respect. I wouldn't want my children to fear me, to be afraid of letting me know whenever anything (I do) is upsetting to them.

    Easier said than done, I know. Especially since we all more or less are raised in fear.

  6. Marian - Is it possible that you just don't accept anything that comes with the word "parent" attached because you see parents as the source of all that is wrong with the world? Again, what would you? Supernanny is called in, one presumes, because the parents have been inconsistent and abusive, and they are looking for help to de-escalate an all-round horrible situation. You are arguing for de-escalation. They are doing it. Picture that parent and the screaming toddler 10 years down the road if left to carry on as they had been doing. Most people would not agree that putting a screaming child in a corner is child abuse. It is also very difficult to determine how individual children will react to certain situations. Lots of children absolutely want boundaries and will do everything in their power to make sure they get them. Others can handle the ambiguity. It takes a lot of trial and error to figure out who wants what.

  7. Rossa, I can't see how a demonstration of (physical) superiority ever could de-escalate a conflict, how abuse ever could remedy abse. Children want boundaries, yes. I just don't agree that crossing their boundaries is a suitable way to teach them respect for boundaries. On the contrary, it will teach them that boundaries are there to be crossed whenever you have the power to do so.

  8. P.S.: This is not something that is specific to parent - child relationships. It can and does happen in all interpersonal relationships. So, no, I don't see parents as the source of all that's wrong with the world. I know parents who do respect their kids, and who wouldn't dream of dragging them into a corner, ordering them to stand face to wall until they were ready to apologize, like it was the custom 100 years ago -- and where did it get humanity? Did people become "better" persons because of it? Did it end all violence, wars, oppression, exploitation? Did it make the world a better place? It didn't get us anywhere. Just as the laissez-faire of the 1960ies and 70ies didn't get us anywhere, because it replaced one kind of violation of boundaries with another one.

    It's not parents who are the source of all that's wrong with the world. I never said that, and will never say it. It's unconsciousness.


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