Leaving Home

The Therapy Of Disturbed Young People

Jay Haley

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134867653
• Edition: 2
• Topic: Psicología
• Subtopic: Asesoramiento psicoterapéutico

Leaving Home presents a method of family therapy at the stage when children are leaving home. It includes a special classification of young people with problems, and tackles family orientation, the therapist support system, the first interview, apathy, troublemaking, a heroin problem, a chronic case, and resolved and unresolved issues.
Visit www.haley-therapies.com for additional resources by Jay Haley, including live videos of the pioneering therapist in action.

Chapter 1

Ideas That Have Handicapped Therapists

Therapy techniques for problem young people have been improving over the years. Many ideas that caused consistent failure have been discarded, and new strategies have led to more success. Discarding ideas and theories that one has learned in training from respected teachers is never easy. It would seem that only when the social milieu of a therapist changes is it possible for him or her to change ideology and behavior.¹ The illusion that the individual freely chooses his ideas and theories, no matter what his social network, is in itself a difficult idea to abandon. A review will be offered here of the ideas that handicapped therapists of young people, particularly those defined as schizophrenic, and which have been abandoned over the last twenty years, at least by therapists who learn from experience.

Whether an idea is useful for a theory of therapy can be determined on the basis of certain criteria. The most obvious criteria are the following:

1. The ideas should be relevant to a theory which leads to successful outcome. Not only should the theory lead to better results than some other theory, and to results superior to no therapy at all, but it should not lead a therapist to acts which cause people harm.

2. The theory should be simple enough for the average therapist to understand. When important issues are clearly understood, the therapist is not distracted by clients who are experts in complexity and obfuscation.

3. The theory should be reasonably comprehensive. It need not explain all possible eventualities, but it should prepare a therapist for most of them.

4. The theory should guide a therapist to action rather than to reflection. It should suggest what to do.

5. The theory should generate hope in the therapist, client, and family, so that everyone anticipates recovery and normality.

6. The theory should define failure and explain why a failure occurred when it did.

Given these criteria as the most obvious ones for a theory of therapy, their opposites are what a sensible therapist should avoid. A therapist should not accept a theory that prevents a definition of a goal, leads to poor therapy outcome, or does harm. He or she should avoid any theory so complex it is incapacitating, one that attempts to explain everything, one that leads to philosophical speculation rather than action, one that does not generate hope, or one that causes everyone to be uncertain about whether they have succeeded or failed.

UNFORTUNATE IDEAS

A few of the ideas which most handicap therapists who work with problem young people can be summarized.

Organic Theory

There is a tradition from nineteenth-century European psychiatry that there is something organically or genetically wrong with deviant young people, particularly those who have been diagnosed as schizophrenic. Although there are those in psychiatry, especially among clinicians doing therapy, who do not take this idea seriously, still it remains a major assumption in the field. The impression given in the literature and in the teaching of psychiatric residents is that there is solid evidence for a genetic or physiological cause of psychosis. That is simply not true. In fact, the literature contains statements that there are “indications,” “leads,” “expectable trends,” “possible pathways for research,” and “hopeful possibilities” in that direction. There is no physical test that shows that a person diagnosed as schizophrenic is different from any normal person, nor is there any solid genetic finding. The clinician who doubts this should ask that his patient be physically examined to determine whether he or she is schizophrenic or not. The response will be a discussion of vague hopes for the future.

Millions of dollars went down the drains of research laboratories to find evidence of organicity, and that research was necessary and important. Unfortunately, the public-relations job to raise money for the effort persuaded many professionals and the lay public that something must be physically wrong with people diagnosed as psychotic. Probably no class of people was ever so stigmatized on so little evidence. Monthly announcements continue to appear, saying that the breakthrough promised for a hundred years is about to occur; the biological and biochemical discussions have become more complex and mystifying; and the results remain negligible. (There is more evidence that being a psychiatrist, or certainly being a doctor, is genetic than there is that being a schizophrenic is genetic.)

Today the argument between the organic and social views is not a minor one. The consequences for adopting the idea that there is a physiological cause for madness have been significant.

1. The assumption of a physical cause for psychosis has determined the custody settings for many problem young people. They were called “sick” and placed in hospitals under the care of doctors and nurses, even though nothing was found to be physically wrong with them.

2. Because of a supposed physical problem, massive doses of medications have been used in ways which civil libertarians would not have allowed with any other deviant population, such as criminals. These medications have proved to be not only incapacitating in many ways, because of their side effects, but actually dangerous. Irreversible neurological damage, such as tardive dyskinesia, is being caused in thousands of people by both the irresponsible and responsible use of these drugs. Many medical people continue to drug people even when they would rather not because the focus on medication in their training has left them not knowing anything else to do. Nonmedical people are unable to prevent the use of these drugs because of the power of medical people in the field and because of their own doubts about whether the organic theory is a myth.

3. The organic theory required a family-oriented therapist to believe that a schizophrenic behaved in strange ways because of a mysterious disease and also in response to his family. That is, the disease theory held that the patient was responding inappropriately and maladaptively because he suffered from an internal defect. The family view held that the strange behavior was adaptive and appropriate to the person’s social situation. Attempting to combine these views led to a therapy of mystification and confusion, not only for the therapist but for the clientele. While taught that psychotics had an underlying biological defect which was incurable, the therapist was also taught that he should do therapy to cure them. This meant the client faced someone who was trying to cure him with a theory that he was incurable, which was a rather classic double bind and provoked strange and bizarre behavior.

4. The therapist with an organic theory would think of the schizophrenic as a defective person who was limited in intelligence or ability. Since such young people were typically failures, the organic theory seemed reasonable to young professionals, who thought there must be something wrong with someone who was not striving to succeed. If, however, one recognizes that the social function of young psychotics is to fail, in spite of having nothing wrong with them to give them the excuse to fail, their abilities deserve more respect. Such young people are more skillful interpersonally than the average therapist, and so they are able to fail more successfully than the therapist can cause them to succeed. A theory that they were defective caused the therapist to underestimate their interpersonal skill and so to lose in the struggle with them. To assume a crazy young person is defective, and then try to win in a contest with him or her, is like entering a chess championship match with the idea that your opponents are retarded.

These objections to findings that remain mythical does not in any way imply that a mad young person should not have a careful physical examination. There should also be the most sophisticated neurological investigations whenever they are indicated. One of the objections to psychiatry departments today is that they are so quick to assume a chemical imbalance as a causal factor that they do not carry out the obvious neurological investigations.

A final argument is that the medical theories and the medications that have followed from them have not solved the problem, and hundreds of thousands of young people continue to fail in life and behave in strange and bizarre ways. The wisest strategy for a therapist is to assume that there is no organic basis for mad behavior and to proceed as if the problem is a social one. His success will increase.

According to the criteria of a theory of therapy, the organic theory was obviously a disaster and has become a heavy burden to psychiatry. Since the approach confused social control and therapy, it did not lead to success and even prevented spontaneous remission in clients who would have changed if they could have gotten away from the professional. Treatment by custody, medication, and pessimism because of a supposed physical defect reinforced the need for custody, medication, and pessimism. The biological theories were not simple, and even medical researchers did not seem to understand them. No hope was encouraged in client or family, and the theory could not define success. If a person called schizophrenic became normal, he or she was said to be either temporarily in remission or to have been misdiagnosed.

Psychodynamic Theory

Another theory that proved unfortunate was an ideology which, like organic theory, was based on the notion that the individual had something wrong with him independent of his social situation. That was the psychodynamic theory of repression and the therapy that followed from it. Although it is difficult to describe that theory simply, without seeming to parody it, the relevant points for the therapy of young people can be mentioned. According to that theory, a person behaved as he did primarily because of past ideas and experiences that were repressed outside awareness. He was secondarily influenced by his current social situation, although the emphasis was largely on how he viewed that situation through the conceptions built into him by the past. The merit of the theory was that it offered researchers interesting explanations for different varieties of strange behavior. When the ideas were brought into the therapy situation, however, the theory was a handicap. With the theory of repression, it was difficult for a therapist to view the family members as interrelated in their responsive behavior. The unit was a single individual, not a dyed or triad. Each person was viewed as a repressed individual responding to projections and misperceptions. The symptoms of a person were not seen as responsive and appropriate to his social milieu, but as maladaptive, irrational, and a response to past experiences more than present circumstances. Therefore the present, which is all that can be changed, was not focused on as the area to be changed. How extreme this view can be is illustrated by therapists I knew who worked in hospitals and did therapy with individuals, and who were so focused on the past that they did not know if the patient was married.

It is difficult to take a positive approach in therapy with a psychodynamic theory, because the orientation is toward the negative side of people. It is the darker side that is repressed, including fear, hostility, hatred, incestuous passion, and all that. When the primary therapy technique available is to make interpretations to bring this repressed material into awareness, it forces a focus on hostile and unpleasant aspects of people. (I recall a family therapy team presenting a case with a schizophrenic. They reported proudly that after three years of therapy the mother finally admitted that she hated her mother. This seemed to me to be irrelevant to getting the son and family back to normal, but to them it was a triumph, because they operated from the theory of repression.)

Psychodynamic theory tends to encourage a therapist to be an exploring consultant to the family rather than someone involved in giving directives and getting changes to happen. The tendency of the therapist to explore the past leads to the parents being blamed, since the past was their responsibility. When past actions are the issue, the parents are implicitly accused of causing the young person’s problem. The therapist with a theory of historical causes often sees himself as a savior of the patient from parents who were a noxious influence, and so his exploratory interpretations tend to antagonize parents and make it difficult to win their cooperation. When the therapist observes their lack of cooperation, it confirms his idea that the past behavior of difficult parents caused the problem, and he feels he must save the young person from them.

Another therapy procedure following logically from the theory of repression was the idea that people would change if they expressed their emotions. It was thought that if people expressed their bad feelings to each other and got their anger out, even by screaming, everyone would be cleared of their repressed feelings, and the schizophrenic would go off whistling down the street.

The free expression of feeling might have merit in some situations, like religious revival meetings, but in family therapy interviews it was a misfortune which could prevent changes in organization. The experiential therapist trained to bring out emotions in artificial groups had no theory of organization and so did not know how to reorganize a family. A family member could avoid an issue or disrupt an interview at any time by getting emotional, with the encouragement of the therapist. Everyone had a catharsis and did not have to follow a therapeutic plan or achieve any goal. The young person, whose job it was to prevent conflict developing between the parents, could become self-expressive and upset whenever necessary, and so prevent the resolution of any parental conflicts. Sessions based on making behavior conscious and bringing out feelings tended to be incoherent, disorganized, concerned with defense and proof of innocence, abrasive, and interminable. They also encouraged a “communication theory” of the families of schizophrenics, because such interviews generated peculiar communication.

The theory of repression did not lead to good outcome, was not simple, did not guide the therapist to action (but rather to reflection), and did not generate hope, because the causes were rooted in unchangeable childhood experience. It did not define failure or explain it when it occurred.

Systems Theory

The organic and psychodynamic theories were carried over from the past, while the social theories developed at mid-century. The idea of family systems was based upon cybernetic theory, which was developed in the late 1940s.² With this theory it was possible for the first time to conceive of human beings not as separate individuals but as an ongoing group responding to one another in homeostatic ways, and so behavior had present causes. The family system was said to be stabilized by self-corrective governing processes which were activated in response to an attempted change. The idea that a family, or any other ongoing group, was a system maintained by feedback processes brought a whole new dimension into the explanations of why human beings behave as they do. There was the awesome realization that people seemed to do what they did because of what other people did; the issue of free will came up in a new form. Family members were seen to be helplessly caught up in sequences which repeated and repeated, despite the wishes and attempts of the members to do differently. Therapists too were caught up in these repeating sequences, both in endless therapy and in endless conflicts with fellow staff members in agencies and hospitals.

The chief merit of a systems theory is that it makes certain happenings predictable. The chief demerit of the theory for therapeutic purposes is that it is not a theory of change but a theory of stability. Family therapy, the attempt to change families, developed within a theory of how a family remains the same. As interesting as this theory might be for explaining animal and human behavior, it was not a simple guide to what to do in therapy. It even handicapped the therapist by leading him to believe that an attempt to intervene activated resistance, because of governing processes to keep the family unchanged. This led to the kind of pessimism that ideas of resistance in psychodynamic theory had led to. This theory also suggested that if you caused a change in one part of a family, there was a response in another part. For some therapists, this activated the old myth about symptom substitution and caused them to hesitate to take action to bring about change.

Systems theory, as it was applied to families, tended to describe participants as equals, which made the theory difficult to use when planning the restructuring and reorganization of the family hierarchy. To consider the power of a grandmother, or to support parents as authorities over a child, was difficult within a theory which tended to equalize everyone as responsive units.

A primary problem for a therapist is the way systems theory takes away individual responsibility from the participants in a system. Each person is driven to do what he does because of what someone else does. Interesting as that theory may be for a philosopher concerned with free will, family therapists seem, in practice, to need to emphasize individual initiative. So within a theory that people cannot help doing what they are doing, the therapist is suggesting that family members act differently.

Family systems theory did not seem to lead to good outcome. It also was not a simple theory, as one found when attending theoretical discussions. Often one did not understand what the speaker had said, though it sounded profound. The theory, because of the emphasis on high levels of abstraction, was even used to obscure the issue of whether anyone had really changed during therapy.

The Double Bind

Finally, there was the double-bind theory, published in 1956, which was not a theory of family therapy but became part of the enterprise. That theory included the idea of describing communication in terms of levels, with the possibility that those levels could conflict and generate a paradox, or bind, where no acceptable response was possible. The theory was an attempt to describe some of the processes in the learning situation of the ...