The Psychosomatic Family Child Psychiatry
.
In
Salvador Minuchin, M.D. and H. Charles Fishman, M.D.
Abstract. This paper contrasts the individual and contextual approaches to the psychiatric treatment of psychosomatic diseases of children. In contrasting the conceptualizations of the "self," the authors discuss an expanded self inherent in the family-oriented approach. An investigation involving psychosomatic and normal diabetic children and their families demonstrates this concept. The authors present a case of an asthmatic child and discuss and contrast approaches to the areas of diagnosis, etiology, maintenance of symptoms, ideas of change, and treatment.
In the first issue of Psychosomatic Medicine, the editors proposed that the object of this "new field" was to "study in their interrelation the psychological and physiological aspect of all normal and abnormal bodily functions and thus to integrate somatic therapy and psychotherapy" (Dunbar et aI., 1939, p. 3). Over the next 40 years investigators worked diligently in numerous areas following lines of investigation begun by such disparate thinkers as Cannon, Selye, Freud, Alexander, Wolf, and Miller. Yet, for all the effort expended over these years, all the careful work and brilliant hypotheses, psychosomatic medicine, to quote George Engel (1967), "has failed to deliver much more than platitudes and largely untestable hypotheses ... increased understanding has not been reflected by more effective methods of therapy" (p. 16). It is our premise that psychosomatic psychiatry as a field has been hampered by two dichotomies-the mind-body duality and the individual-context schism. Current thought has, at least for the time being, laid the mind-body discontinuity to rest; the individual-context split in which the person and his social field are viewed as discontinuous, however, is currently controversial. It ac-
Dr. Minuehin is Director. Family Therapy Training Center of the Philadelphia Child Guidance Clinic, and Dr. Fishman is Staff Psychiatrist. Philadelphia Child Guidance Clinic (#2 Children's Center, 34th & Civic Center Boulevard, Philadelphia. PA 19104), where reprints may be requested. 0002-7138/79/1801-076 $01.30 e 1979 American Academy of Child Psychiatry.
76
The Psychosomatic Family in Child Psychiatry
77
counts for two contrasting approaches to psychosomatic diseases in children-the individual psychodynamic and the family-contextual approaches. We will attempt to distinguish these two approaches and to elucidate differences in conceptualizations and treatment of a case involving a child with asthma. A child psychiatrist studies the child in the context of the family. He explores the significance of the infant-mother relationship in the later development of the child and is cognizant of the influence of the social environment on the unfolding of the child's potential. In general, he is aware of the dependency of the child, a developing psychosociobiological organism in a social field which is undergoing developmental transformations as well. Child psychiatrists, by the nature of their field of studies, are explorers of context. Adult psychiatrists discover children in the retrospective memories of adults in trouble. In the optimistic theorizing of the nineteenth century, the goal of psychotherapy became directed at enabling adult patients to overcome the disorganizing influences of their development as children. In this endeavor, adult psychiatrists and their adult patients relegated the patient's social context to the status of a mere backdrop against which the real drama was played: that of the adult struggling against the encroaching child inside of him or her. By the very nature of their field of study, adult psychiatrists have construed the essential characteristics of man as unrelated to his context. The specialty of adult psychiatry developed, historically, decades before child psychiatry, and lent to the new field a paradigm that carried with it an implicit separation between man and context. It is an artifact of the historical development of child psychiatry as a subspecialty of adult psychiatry that this child-context dualism distorted the observation of the inherent child-context continuity which, in our opinion , should be the focus of the field of child psychiatry. It is our view that the paucity of positive results in the field of childhood psychosomatics springs from the dichotomies that we have discussed. As the mind-body split did to previous generations, so the child-context separation has blurred our vision of the continuity of the child's inner and outer space. Grinker (1953) expresses the need to synthesize this discontinuity when he says, "our assumption that the human organism is part of and in equilibrium with its environment . .. bring[s] us to the realization that a large aspect of psychosomatic o rga n ization has been neglected by most observers. . . . The focus has been on
78
Salvador Minuchin and H. Charles Fishman
unidirectional, linear causal changes ... [but] the actual functioning of the organism cannot be understood except by a study of its transactional processes as occurring in a total field" (p. 153). Using this new paradigm, the child-in-context, to look at children, we find ourselves with a different field of observation. The family-oriented child psychiatrist studies the family in which the child is imbedded and speaks of the "psychosomatic family." This term points to the discrepancy in the two approaches and is obviously incorrect to an individually oriented child psychiatrist. For him, "psychosomatic" can describe only the identified patient, not the behavior of the family. The term "psychosomatic family" refleets the dilemma of the family-oriented child psychiatrist who inherited a vocabulary in which words reflect the description of individuals. If we use, instead of psychosomatic, the term "psychosomatogenic family," this would continue to place us in a linear framework, one which attributes causality to family and therefore makes the child the victim. However, a contextually oriented child psychiatrist wants to describe a different phenomenon, one in which verbs are more useful than nouns. Rather than describing personality or historical antecedents, the family-oriented child psychiatrist attempts to describe the interpersonal transactions between family members. More specifically, he scans the system and describes those transactions which organize the behavior of family members in dysfunctional patterns that lead to the manifestation of psychosomatic symptoms in a child. This approach assumes an epistemology that conceptualizes a harmonious integration of the child's inner and outer context. The family-oriented child psychiatrist sees the "self" as existing both inside and outside of the person: in this conceptualization, the self is expanded to include feedback from significant people in the person's social context. This notion of self is markedly different from the individually oriented approach which follows the intuitively evident observation that since an individual's body is surrounded by integument, his self must be similarly discontinuous from his context. Let us clarify the family-oriented practitioner's concept of self with a metaphor used by Gregory Bateson (1972). He describes a blind man walking with a cane down a street and presents the hypothetical question: Does the self of the blind man end at his hand holding the cane? Does it include the cane up to its end, but before it touches the sidewalk? Or, could we consider that it ends in the middle of the cane? This is clearly a different way of conceptualizing the individual so that the self is expanded to include the
The Psychosomatic Family in Child Psychiatry
79
feedback from the man's context. The self of the child at a given moment then would be the result of his previous experience plus the demand characteristics of his social context. Both the individual and system paradigms concur on the idea that the child develops his or her sense of self as a result of interacting with objects and significant others in a more or less constant environment. The child-in-context paradigm goes beyond the concept of the constraint of self by historical determinants to include the transactions with significant others in the present. These transactions represent an extracorporeal part of the self. The complex repertory of thoughts, feelings, and behavior, more or less formulated or felt, represent the child's multifaceted self. The child's significant context calls forth certain of these characteristics, while others become unattended and psychologically unimportant. Therefore, the child's social ecology makes prominent those aspects of the child's personality that are appropriate to the context. This concept would then encompass the self in its historical continuity and as a changeable and responding entity. Traditionally, child psychiatrists have focused on pathological characteristics manifested by the sick child, neglecting the rich repertories of personality traits which were learned along with the currently observed dysfunctional patterns. The child has a repertory of potential coping behaviors that remain quiescent as a result of the demand characteristics of his social field. For example, consider the asthmatic child who wheezes at home on weekends but who can ride his bike 6 miles with his friends; or the diabetic child who develops ketoacidosis while intervening in his parents' conflict but who controls his metabolism while visiting his grandparents. The child in turn affects his context: a figure-ground shift occurs as a result of the child's behavior so that significant people will interact with the child in ways induced, at least in part, by the child's response. But, of course, the behavior of the child was induced at the same time by the significant people. It is a circular process. In fact, it is the inherent circularity of this process of mutual affecting and reinforcing which maintains the fixed behavioral pattern in people who are viewed in this approach as immanently changeable. Since it is our premise that the demand characteristics of the family context in which psychosomatic children live playa major role in maintaining them as symptomatic, it is at least as important to change the child's social system as it is to modify and expand the repertory with which the child responds to stress. We are not,
80
Salvador Minuchin and H. Charles Fishman
however, advocating scotomata for the biological or psychological aspects of psychosomatic diseases. Certainly it has been well documented that the control of the contractions of the bronchioli in the asthmatic child can be accomplished on many levels: at the psychological-physiological level when the child recognizes an aura and manages to control the asthmatic attack by introducing voluntary control on his neurovegetative system or by transforming the patterns of mutual regulation between family members. The continuity of the physiology of the child, his psychological constructs, and his extracorporeal self were demonstrated empirically in a group of psychosomatic youngsters. These children appeared to be suffering from psychosomatically induced exacerbations of their diabetes mellitus. The following experiment, explained in detail elsewhere (Minuchin et aI., 1978), was performed. The children, along with their parents, were seen for a stress interview. During this interview, the child and both parents had intravenous needles through which aliquots of blood were withdrawn at regular intervals. The interview was divided into four parts. During the first two parts, the child was outside the room observing his parents through a one-way mirror. Following a baseline period in which the parents spoke about neutral topics with one of the investigators, the parents were asked in Period I to discuss problems in the family. In Period II, the interviewer entered and exacerbated stress by siding with one parent against the other. During Period III, the child came into the room and the interviewer left. In this part a characteristic transactional pattern is seen in psychosomatic families. The parents diffuse their conflict by involving the child. It is noteworthy that during the second part of the interview, the parents' free fatty acids rose steeply. When the child came into the room, the parents' free fatty acids fell, while the child's rose even more steeply. Period IV was a turnoff period in which the family related alone in a room without interviewer, nurses, or two-way mirror being present. If one assumes that free fatty acids correlate with stress, then the child can be seen as serving a function in the system. That is, in Period III, he functions to relieve the stress that his parents were experiencing. However, the cost to the child is clearly demonstrated in terms of the rise of his free fatty acids and his ensuing symptomatology. In this example, then, there is a clear demonstration of interrelationship between the child's physiology and the extracorporeal part of the child's self. These divergent definitions of the self lead to marked differ-
81
The Psychosomatic Family in Child Psychiatry
Figure 1 Comparison of Psychosomatic and Normal Diabetic Children and Their Parents:
Free Fatty Acid Responses to Family Stress
MEDIANS OF PARENT WITH HIGHER FFA RESPONSE AND INDEX PATIENT
:::;+ .......
NORMAL DIABETIC, n
.05
=
7
Highast ftnnt
BASE
C"
w
Een-
Q
.05
.10
~
~
....
~
PSYCHOSOMATIC DIABETIC, n
7
tJ + .25 IE+
.
In
Salvador Minuchin, M.D. and H. Charles Fishman, M.D.
Abstract. This paper contrasts the individual and contextual approaches to the psychiatric treatment of psychosomatic diseases of children. In contrasting the conceptualizations of the "self," the authors discuss an expanded self inherent in the family-oriented approach. An investigation involving psychosomatic and normal diabetic children and their families demonstrates this concept. The authors present a case of an asthmatic child and discuss and contrast approaches to the areas of diagnosis, etiology, maintenance of symptoms, ideas of change, and treatment.
In the first issue of Psychosomatic Medicine, the editors proposed that the object of this "new field" was to "study in their interrelation the psychological and physiological aspect of all normal and abnormal bodily functions and thus to integrate somatic therapy and psychotherapy" (Dunbar et aI., 1939, p. 3). Over the next 40 years investigators worked diligently in numerous areas following lines of investigation begun by such disparate thinkers as Cannon, Selye, Freud, Alexander, Wolf, and Miller. Yet, for all the effort expended over these years, all the careful work and brilliant hypotheses, psychosomatic medicine, to quote George Engel (1967), "has failed to deliver much more than platitudes and largely untestable hypotheses ... increased understanding has not been reflected by more effective methods of therapy" (p. 16). It is our premise that psychosomatic psychiatry as a field has been hampered by two dichotomies-the mind-body duality and the individual-context schism. Current thought has, at least for the time being, laid the mind-body discontinuity to rest; the individual-context split in which the person and his social field are viewed as discontinuous, however, is currently controversial. It ac-
Dr. Minuehin is Director. Family Therapy Training Center of the Philadelphia Child Guidance Clinic, and Dr. Fishman is Staff Psychiatrist. Philadelphia Child Guidance Clinic (#2 Children's Center, 34th & Civic Center Boulevard, Philadelphia. PA 19104), where reprints may be requested. 0002-7138/79/1801-076 $01.30 e 1979 American Academy of Child Psychiatry.
76
The Psychosomatic Family in Child Psychiatry
77
counts for two contrasting approaches to psychosomatic diseases in children-the individual psychodynamic and the family-contextual approaches. We will attempt to distinguish these two approaches and to elucidate differences in conceptualizations and treatment of a case involving a child with asthma. A child psychiatrist studies the child in the context of the family. He explores the significance of the infant-mother relationship in the later development of the child and is cognizant of the influence of the social environment on the unfolding of the child's potential. In general, he is aware of the dependency of the child, a developing psychosociobiological organism in a social field which is undergoing developmental transformations as well. Child psychiatrists, by the nature of their field of studies, are explorers of context. Adult psychiatrists discover children in the retrospective memories of adults in trouble. In the optimistic theorizing of the nineteenth century, the goal of psychotherapy became directed at enabling adult patients to overcome the disorganizing influences of their development as children. In this endeavor, adult psychiatrists and their adult patients relegated the patient's social context to the status of a mere backdrop against which the real drama was played: that of the adult struggling against the encroaching child inside of him or her. By the very nature of their field of study, adult psychiatrists have construed the essential characteristics of man as unrelated to his context. The specialty of adult psychiatry developed, historically, decades before child psychiatry, and lent to the new field a paradigm that carried with it an implicit separation between man and context. It is an artifact of the historical development of child psychiatry as a subspecialty of adult psychiatry that this child-context dualism distorted the observation of the inherent child-context continuity which, in our opinion , should be the focus of the field of child psychiatry. It is our view that the paucity of positive results in the field of childhood psychosomatics springs from the dichotomies that we have discussed. As the mind-body split did to previous generations, so the child-context separation has blurred our vision of the continuity of the child's inner and outer space. Grinker (1953) expresses the need to synthesize this discontinuity when he says, "our assumption that the human organism is part of and in equilibrium with its environment . .. bring[s] us to the realization that a large aspect of psychosomatic o rga n ization has been neglected by most observers. . . . The focus has been on
78
Salvador Minuchin and H. Charles Fishman
unidirectional, linear causal changes ... [but] the actual functioning of the organism cannot be understood except by a study of its transactional processes as occurring in a total field" (p. 153). Using this new paradigm, the child-in-context, to look at children, we find ourselves with a different field of observation. The family-oriented child psychiatrist studies the family in which the child is imbedded and speaks of the "psychosomatic family." This term points to the discrepancy in the two approaches and is obviously incorrect to an individually oriented child psychiatrist. For him, "psychosomatic" can describe only the identified patient, not the behavior of the family. The term "psychosomatic family" refleets the dilemma of the family-oriented child psychiatrist who inherited a vocabulary in which words reflect the description of individuals. If we use, instead of psychosomatic, the term "psychosomatogenic family," this would continue to place us in a linear framework, one which attributes causality to family and therefore makes the child the victim. However, a contextually oriented child psychiatrist wants to describe a different phenomenon, one in which verbs are more useful than nouns. Rather than describing personality or historical antecedents, the family-oriented child psychiatrist attempts to describe the interpersonal transactions between family members. More specifically, he scans the system and describes those transactions which organize the behavior of family members in dysfunctional patterns that lead to the manifestation of psychosomatic symptoms in a child. This approach assumes an epistemology that conceptualizes a harmonious integration of the child's inner and outer context. The family-oriented child psychiatrist sees the "self" as existing both inside and outside of the person: in this conceptualization, the self is expanded to include feedback from significant people in the person's social context. This notion of self is markedly different from the individually oriented approach which follows the intuitively evident observation that since an individual's body is surrounded by integument, his self must be similarly discontinuous from his context. Let us clarify the family-oriented practitioner's concept of self with a metaphor used by Gregory Bateson (1972). He describes a blind man walking with a cane down a street and presents the hypothetical question: Does the self of the blind man end at his hand holding the cane? Does it include the cane up to its end, but before it touches the sidewalk? Or, could we consider that it ends in the middle of the cane? This is clearly a different way of conceptualizing the individual so that the self is expanded to include the
The Psychosomatic Family in Child Psychiatry
79
feedback from the man's context. The self of the child at a given moment then would be the result of his previous experience plus the demand characteristics of his social context. Both the individual and system paradigms concur on the idea that the child develops his or her sense of self as a result of interacting with objects and significant others in a more or less constant environment. The child-in-context paradigm goes beyond the concept of the constraint of self by historical determinants to include the transactions with significant others in the present. These transactions represent an extracorporeal part of the self. The complex repertory of thoughts, feelings, and behavior, more or less formulated or felt, represent the child's multifaceted self. The child's significant context calls forth certain of these characteristics, while others become unattended and psychologically unimportant. Therefore, the child's social ecology makes prominent those aspects of the child's personality that are appropriate to the context. This concept would then encompass the self in its historical continuity and as a changeable and responding entity. Traditionally, child psychiatrists have focused on pathological characteristics manifested by the sick child, neglecting the rich repertories of personality traits which were learned along with the currently observed dysfunctional patterns. The child has a repertory of potential coping behaviors that remain quiescent as a result of the demand characteristics of his social field. For example, consider the asthmatic child who wheezes at home on weekends but who can ride his bike 6 miles with his friends; or the diabetic child who develops ketoacidosis while intervening in his parents' conflict but who controls his metabolism while visiting his grandparents. The child in turn affects his context: a figure-ground shift occurs as a result of the child's behavior so that significant people will interact with the child in ways induced, at least in part, by the child's response. But, of course, the behavior of the child was induced at the same time by the significant people. It is a circular process. In fact, it is the inherent circularity of this process of mutual affecting and reinforcing which maintains the fixed behavioral pattern in people who are viewed in this approach as immanently changeable. Since it is our premise that the demand characteristics of the family context in which psychosomatic children live playa major role in maintaining them as symptomatic, it is at least as important to change the child's social system as it is to modify and expand the repertory with which the child responds to stress. We are not,
80
Salvador Minuchin and H. Charles Fishman
however, advocating scotomata for the biological or psychological aspects of psychosomatic diseases. Certainly it has been well documented that the control of the contractions of the bronchioli in the asthmatic child can be accomplished on many levels: at the psychological-physiological level when the child recognizes an aura and manages to control the asthmatic attack by introducing voluntary control on his neurovegetative system or by transforming the patterns of mutual regulation between family members. The continuity of the physiology of the child, his psychological constructs, and his extracorporeal self were demonstrated empirically in a group of psychosomatic youngsters. These children appeared to be suffering from psychosomatically induced exacerbations of their diabetes mellitus. The following experiment, explained in detail elsewhere (Minuchin et aI., 1978), was performed. The children, along with their parents, were seen for a stress interview. During this interview, the child and both parents had intravenous needles through which aliquots of blood were withdrawn at regular intervals. The interview was divided into four parts. During the first two parts, the child was outside the room observing his parents through a one-way mirror. Following a baseline period in which the parents spoke about neutral topics with one of the investigators, the parents were asked in Period I to discuss problems in the family. In Period II, the interviewer entered and exacerbated stress by siding with one parent against the other. During Period III, the child came into the room and the interviewer left. In this part a characteristic transactional pattern is seen in psychosomatic families. The parents diffuse their conflict by involving the child. It is noteworthy that during the second part of the interview, the parents' free fatty acids rose steeply. When the child came into the room, the parents' free fatty acids fell, while the child's rose even more steeply. Period IV was a turnoff period in which the family related alone in a room without interviewer, nurses, or two-way mirror being present. If one assumes that free fatty acids correlate with stress, then the child can be seen as serving a function in the system. That is, in Period III, he functions to relieve the stress that his parents were experiencing. However, the cost to the child is clearly demonstrated in terms of the rise of his free fatty acids and his ensuing symptomatology. In this example, then, there is a clear demonstration of interrelationship between the child's physiology and the extracorporeal part of the child's self. These divergent definitions of the self lead to marked differ-
81
The Psychosomatic Family in Child Psychiatry
Figure 1 Comparison of Psychosomatic and Normal Diabetic Children and Their Parents:
Free Fatty Acid Responses to Family Stress
MEDIANS OF PARENT WITH HIGHER FFA RESPONSE AND INDEX PATIENT
:::;+ .......
NORMAL DIABETIC, n
.05
=
7
Highast ftnnt
BASE
C"
w
Een-
Q
.05
.10
~
~
....
~
PSYCHOSOMATIC DIABETIC, n
7
tJ + .25 IE+
