What Goes Wrong In A Psychiatrist's Family?

From The Last Psychiatrist - February 2, 2007

So maybe I am generalizing a bit, but I'm trying to get at something that isn't easily explained by science: why do so many psychiatrist families go bad in the same way?

In my experience (see, there's my disclaimer) psychiatrist-parents go wrong in a very specific way. They judge behavior, not the person. It sounds like a good thing, I know. For kids, it's a disaster.

Psychiatrists identify the behavior, but then focus on changing not the behavior directly, but the underlying cause of the behavior-- which is still not something intrinsic to the person. If a guy with bipolar spends $10,000 in a week, psychiatrists link the behavior to the bipolar, and then try to medicate the bipolar. (NB: "the patient has bipolar," not "the patient is bipolar.")

The obvious problem here is that maybe the guy spent $10,000 in a week because he doesn't give a damn? Or he wanted to impress some girl? i.e. just because someone has bipolar, doesn't mean every breath he takes is related to bipolar. Psychiatrists are going to deny that they make it so simple, but in actuality they do: the moment you raise the dose of Depakote, you are sending the message that the behavior was related to bipolar.

The psychiatrists with children-patients handle their kids in the same way. They teach them what they are allowed to do and what they are not, what is acceptable and what is not-- but make no judgment on the kids themselves. This is a disaster, because doing this denies the kid's identity, which is the whole purpose of childhood to begin with. Rules then exist in an invented framework, or worse, in a vacuum. There's no internalization of the rules; there's no superego. Just some arbitrary limits on id.

If you tell a kid that a behavior is unacceptable, the kid has learned nothing about himself; he's only learned that this one thing is something he can't do. The information is in a vacuum. But if you make the kid own it-- make the behavior part of his identity, then he has a chance to change his identity. Instead of learning it is unacceptable to take his brother's potato chips away, he can learn that he has a choice: to be the kind of person who takes chips, or the kind of person who doesn't.

I understand the trickiness of this; you don't want to make the kid feel like he is a bad person. But you do have to find a way to teach him that if he does that thing again and again, then he is being a bad person. Is that what he wants? Who are you, kid? Who do you want to be? This also allows his to take personal credit for doing something good:

Your good behavior doesn't make you a good person; you are a good person, and that's why you did that. (NB: Sartre can go to hell.)

And you can see the creation of a future borderline here. For God's sake, will someone please tell me who I am? Give this storm of emotions some context? Right now, I get angry/sad/thrilled/terrified over nothing, it just comes over me-- I wish I could be angry/sad/thrilled/terrified over something. But all people ever do is tell me what I can and can't do. If I do something bad, people freak. If I do something good, no one even notices. No one likes me for me, they just overreact to what I do.

There's a second cause for disaster: parents' control of their affect.

The psychiatrist isn't supposed to get mad at his patient; but then he comes home, and tries very hard not to get mad at his kid-- just tells him the behavior is unacceptable, gives him a time out, whatever. But guess what? The psychiatrist is exhausted, eventually his patience runs out, and BAM! a tsunami of anger.

calm&firm...calm&firm...calm&firm...EXPLOSION.

The explosion part can come at any time, depending on how much patience the parent has that day. And that's exactly the problem. What does the kid learn? That this ethereal rulebook for what is acceptable and unacceptable only has two, binary results: no affect, or all affect-- and you never know what you're going to get.

In the biz, this is called inconsistent parenting.

What the kid needs to know are the rules of the game; they need the parent to be consistent, predictable, so that they can be safely chaotic, experimental, exploratory off of your foundation. You want her to know exactly how you'll react if she tries pot, you want a superego so well constructed you're superfluous. And you want levels of emotion, different things get you more or less angry. We know you went berserk because your boss is a big jerk whose been riding you all day, but your two year old thinks you went berserk because she spilled the milk. Geez, sorry. May as well try heroin, what's the difference?

It doesn't necessarily mean you have to be an angry parent-- your predicted reaction could be anxious acceptance or loving disappointment-- but it has to be predictable. And it has to be about the kid, not the behavior. The kid needs to know you're connecting with them, not what they do, or else they'll think that the only way to connect is by behaviors.

You can see the further development of a borderline here: what the hell do I have to do to get some emotional response from you? Kill myself? Keep pushing until you finally blow up? I don't even feel like I'm alive, but I'm not sure that you are either-- or is it just me, that I matter so little that I can't even get a little affect? You're insanely jealous if I talk to another guy, but you treat me like crap when I'm with you. At least with jealousy you're being real with me. Etc.

Trust me on this: at age 2, a kid feels your rage and your love the same. It's exciting, and they haven't yet learned to fully differentiate the two feelings. What counts is the amount of emotion, not which emotion. (Horror movies and porn are the same to a 14 yo for this reason.) Fast forward 20 years-- that all out screaming match with your boyfriend felt weirdly relaxing.

And so you have a scenario: busy psychiatrist, often tired, can't generate much emotion past anger-- and it can come at any time. No deep connection with the child as a person-- as their kid, yes; as the sum total of their behaviors, yes-- but not as a developing individual. The kid learns that as long as some things are done correctly-- e.g. school-- they can get away with other things that the parent won't notice, e.g. pot.

Oh, and this is the best part: when the kid (adult or child) becomes a psychiatric patient, they now have a bond with their parent-- and the parent's over-involvement in their kid's psychiatric care is the framework for a relationship. It's analogous to helping them build a go cart.

And that's all the kid ever wanted anyway.

February 27, 2007

Clarification On What Goes Wrong In A Psychiatrist's Family

Many intresting and varied reactions to my post, "What Goes Wrong In A Psychiatrist's Family?" It struck a nerve with a lot of people, and others couldn't relate to it at all. But I would like to clear up one element:

It's not that even handed, calm, unemotional criticisms ldirected only to the child's behavior is wrong; it is that no one does it well. And that's where it all falls apart.

SOME psychiatrists think try to do something noble (criticize behavior and not the child itself) but they are HUMAN, and get tired. They will eventually get angry, and, from a kid's perspective, when the parent gets angry is what matters. What did I do to piss Dad off?

The opposite of this, call it the non-psychiatrist parent, is calm, then gets a little angry, a little more angry, a little more angry, then yells, screams. There's a build up. A few years of this and you realize that there are some things that make Dad a little angry, and other things that make him really angry. There's normal, varying levels of human emotion to different situations.

But the child of a psychiatrist doesn't get that. He gets binary emotional states. "Lying is not acceptable behavior." Later: "Yelling loudly is not acceptable behavior." Later: "Picking you nose is not acceptable behavior." Later: "Stealing is not acceptable behavior." What's the relative value? A kid has no idea-- he thinks the value is decided by Dad, not intrinsic to the behavior. "Eating cookies before dinner is not acceptable behavior." Later: "Kicking your brother is not acceptable behavior." Ok, now here it comes:

After seven or eight or twenty five "not acceptable behavior" monotones, Dr. Dad can't take it anymore; he explodes. "Goddamn it! What the hell is the matter with you?! What are you doing?!!" All the anger and affect gets released, finally. The problem-- the exact problem-- is this: the explosion of anger came at something relatively trivial. Maybe the kid spilled the milk.

So now the four year old concludes that the worst thing he did all day was spilled the milk-- not kicking his brother, or lying, or stealing. Had he not spilled that milk, Dad wouldn't have gotten angry.

Add this up over, say, a year: mostly flat, neutral monotones, peppered with unpredictable yelling patterns, inconsistent explosions, and now the kid can't form a hierarchy of good and bad. In fact, what he learns is that good and bad are defined almost exclusively by the reaction he gets from others (e.g. Dad) and not the behavior itself.

You say: but the kid's not an idiot, he's going to know that stealing is worse than spilling milk. Well, how is he going to learn that, except from you? You say: just going through life-- every kid eventually learns it. Yes, they learn that it is worse, but not why it is worse. The conclusion is that the hierarchy of bad and worse is determined by the severity of people's reactions.

You say: the solution is that Dr. Dad needs to work on maintaining his calm all the time, and not exploding. Well, it's not going to work: he's human. Eventually the electric bill will be too high, or his wife cheats on him, or he has the flu, or he's stuck in traffic all day. And he'll explode (or, the alternative: check out. "I'm not dealing with this anymore.")

Consider this: a kid knows exactly how his father feels about a certain patient, or colleague, or friend, because he sees a consistent and predictable reaction in the Dad every time the person is mentioned. But the kid does not have that clear link for himself. There's more informational affect from Dad talking to a patient on the phone then there is when punishing you.

Contrast this with the reaction of, say, a hypothetical "angry Dad" who has six beers a day after work: he's always pissed off. Always. Even though he flips out over spilled milk, he flips out over everything. The consistency of his anger makes the anger attributable to him-- "Dad's insane"-- not to you or your behavior. You don't infer from this that what you did is good or bad-- you'll have to learn that elsewhere. What you might "learn" is that he hates you, that you are a bad person. This is clearly not a good thing, but the point is that you develop an identity from it, you get defined (though negatively.) The inconsistency of the psychiatrist-parent's anger is confusing; why this thing, and not the other thing? Why so much consistent (same kind and amount) affect talking to an auto mechanic, and so little affect-- especially consistent affect-- with me?

So you have a psychiatrist-parent, who works long hours; who tries hard to be neutral even in punishment; who gives little in the way of emotional information about a kid's identity, but is so obviously clear about other people; who once in a while explodes, inconsistently, over unpredictable things.

Here it is again, where it all goes wrong: the child develops an identity which is about the reactions of others. "People's opinions of me are based on how I make them feel."

Disclaimer again, and for the last time: not all children of psychiatrists go insane, not all psychiatrists suck as parents, I don't know what I'm talking about, Bush lied, etc, etc. Please understand I am not criticizing psychiatric parents, I'm trying to understand something.

You come home, and find your kid has spilled the milk. How do you react? Ok, now ask the kid: how do you think your Dad will react? The answer, ideally, should be the same. If it's not, and especially if your kid's answer is, "I have no idea how he'll react," you've got a problem on your hands.