The culture we live in and the thinking that is part of it (and drives it) strives to define all problems as tightly confined within the individual, and of course, finds data and information to justify the perpetuation of the construct. Symptoms are painfully real, whether as part of depression or “fibromyalgia.” Symptom relief is what the public demands and how physicians respond. The drug industry certainly has a vested interest in keeping the paradigm in operation.
Hospitals also play a part. Symptoms escalate to a point that they cannot be controlled on an outpatient basis and escalation of symptom management becomes part of the interaction. The hospital will do for the individual what he/she can’t do, or the family cannot or will not do. The hospital has the resources to respond to any level of aggressive escalation on the part of the patient – IM meds, 4-point restraints, high “management” wards and in the not too distant past prefrontal lobotomies. All of these practices affirm and confirm that the problem resides within the individual. “The symptoms and behavior have to be brought under control” and once the label is firmly in place, the person is more likely to be defined (by himself and others) by the label. Advocacy groups (NAMI) in their fights for parity and funding increasingly call emotional problems “brain diseases.”*
The mental hospital has a defined function that is part of the culture’s thinking. An interesting question is what will happen with the closing of hospitals and no one looking at the thinking or assumptions that drive the process.
Dr. Bowen’s letter of March 1984 touches on some of these themes. He is responding to a person’s request for information about hospital resources for a person with an “eating disorder.” He is optimistic in that there is a way to think about and work on these problems from a family systems perspective, which obviously is based on quite different assumptions than what is presently available.
* It is interesting to note that at a NAMI conventions groups of consumers are present to protest this labeling.
4903 DeRussey Pkwy
Chevy Chase, MD 20815
March 1, 1984
Dear Mrs.
Thanks for the tel call on Feb 19. It was good to hear from you again. There have been periodic reports about you, and good intentions to write, but the world wants more than good intentions. I heard, maybe from that you were having more problems with the cancer of the face. If travels ever make it possible for you to stop in Washington, I will make time for a visit. I remember ‘s death. It was during the Smithsonian week on something that had to do with “family”.
At 71 I am right where I have been since 1956, hobbled somewhat by a chest (aorta) operation in 1981, but I have pretty much recovered from that and back at my parttime practice, and teaching on a reduced level. Have been doing more professional travel in an effort to help the world toward a systems viewpoint. The situation has come father than I dreamed when I started all this 30 yrs ago, but it will take another 50 to 100 yrs before the average in the profession can really “hear” principle and theory.
I do not have much good news about and his wife. I think you said did not write down his name. I get and mixed up. His wife has an eating problem, probably psychological, which is common in young women, but relatively rare in older women. However it came about, the symptom probably opposes something “the other” unwittingly does. Neither he nor she want it that way, but there it is. If he tried to force her to eat, the symptom intensifies. If he forces her into the average hospital, they are likely to regard the problem as something entirely in her, which only arouses the basic antagonism to her eating. The more they “force feed”, the bigger the problem. Unfortunately most hospitals regard such problems as “pathological” in the patient, without a way to get at the other half in the important other.
I have not been able to find a hospital, or enlightened outpatient operation that can reliably focus on both sides of the problems. Over the years therapists have learned more about the problem but most hospitals still have a conventional view. It is terribly hard to find a place in which outpatient and in-patient procedures are in harmony. Most therapists go in one direction and the hospitals (motivated by the convention of the chief and anxiety of nurses) go in another direction, which is counter productive. Through the years I have tried to treat all these thing on an outpatient level without getting involved with the imponderables in institutions. It is essentially impossible to change the thinking of conventionally oriented people. If I do get involved with institutions I “work around them.” It has worked for me and I think others have pretty much done the same thing.
Over the years others have worked at this kind of problem, and I am sure there are those who have tried to gradually erode the posture of the institutions. You mentioned a hospital when you called. I began looking for some elusive place in which hospital principles were fairly consistent with family and systems practice. I did not find it. Some say they follow systems principles but that is more words than fact. There are two major places that have worked with “anorexia” in younger women, but even they are not consistent with hospital practice. A major authority on anorexia is Dr. who did her active life in New York City and Columbia Univ. She did a fabulous book, “The Golden Cage” I believe, which has never been equaled anywhere. I knew her well in NYC. Some 15 yrs in psychiatry. Now at about 80 she has Parkinson’s Disease (shaking palsy) which further limits her. I last saw her when I was in Houston a half dozen yrs ago. She is a kind of oracle around town. Another place that focuses on anorexia is the people around the Philadelphia Child Guidance Center attached to the U of Penn in Philadelphia. Dr. popularized that place, but they focus mostly on outpatient work and I did not find a consistent attitude about inpatient work. There must be other places but I did not find them. I would be cautious about places that talk a good line, without knowing more about how they do it.
The thing that is wrong with most hospitals is a “good line”. They usually have a conventional place with a young so called “family therapist” who is too lacking in knowledge who “splits too many differences” with the power structure to have the most effective program. Slowly these places will gain stature.
If I could help with and his wife on an outpatient level, I would be glad to see them for a consultation, and maybe more, if it would be of any help. The other choice they would have would be to struggle through with whatever is available on a local level and see where they come out.
My overall guess is the eating problem is the “tip of the iceberg” to an overall life problem, if they can find a way beyond the eating to the underlying problem. In the last analysis, it will be up to and his wife to make whatever they can out of it. A good family therapist there could help if such a person exists. I do not know of one personally.
I had a full week in San Antonio last week. It was the first conference that I have ever attended that went all the way from child and spouse abuse (the tip of the iceberg) to war. All the piled up work was waiting for me when I returned.
It was good to hear from you. Let me know what evolves.
Sincerely,
Murray Bowen, M. D.