Psychopharmaceuticals, the DSM-V and Family Therapy

A contribution by Maurizio Andolfi, Child Neuro-Psychiatrist, Director of Accademia di Psicoterapia della Famiglia in Rome, Editor of Terapia Familiare and Professor in Residence at the Williams street Family Therapy Centre in Perth.

In Europe, during the Sixties, a whole generation of psychiatrists rebelled against the logic subscribing to the internment of patients into lunatic asylums and other forms of physical and pharmacological restraint. Psychotherapy was born and developed from the ashes of real and actual lagers for patients, victims not only of their own infirmity but also of the psychiatrists’ ignorance and arrogance in the face of their own impotence in finding a cure.

It has taken fifty years to heal the relationship between normality and pathology and to allow the human being inside the illness, and in the minds of the experts on mental and psychological dysfunction, to emerge. Just as much time has been dedicated to discovering and concretely demonstrating that the cure is not only to be found within the person, but also within the family, in the environment where it manifests, in the social fabric, in meeting places, in human solidarity. We have experienced it in our clinical work, in both private and institutional settings, we have written about it in many scientific publications, documented it through video recordings of sessions and follow-ups with the clients themselves, we have spoken to administrators, politicians, department heads and the media. In our therapeutic work we have written about and experienced that the voices of children and adolescents must be listened to within the context of the family, the school and the places of treatment. Psychological and psychosomatic disturbances in a child are often strong indicators of familial distress that go beyond his/her present difficulties. Their body and a sometimes violent or regressive behavior alert us to a crisis in the parental couple, a family disconnection or still unresolved grief. Listening to their voices in therapy, with the family, often allows for important transformations to occur on many levels, as well as a much more rapid resolution of symptoms and adolescent or child distress by intervening on more relevant, and often dramatic, realities.

But where are we headed today?

We answer yesterday’s ignorance, with its hordes of psychiatrists intent on making mental illness disappear from the sight of normal people, with a much more concerning situation, because dominated by business and the ability to heavily influence even sane people to search for magic solutions, to prevent or eliminate sadness, unhappiness, loss of sexual desire, grief, old age, loneliness. All this through “scientifically tested” pharmaceuticals and manuals such as the DSM-V, which attempt to extend the medical model to include virtually all human behavior into a classificatory delirium.

“Diagnosis and the use of pharmaceuticals are out of control: 20% of the adult population suffers from some kind of mental disorder and 20% takes psycho-pharmaceuticals; the boundaries of psychiatry have been breached and normality is becoming ever more restricted”; these are not the words of someone opposing psychiatry but of Alan Frances, eminent psychiatrist, one of the editors responsible for the fourth edition of the DSM.

Furthermore, nowadays we have smart pills, designed to provide “cognitive improvement” to optimally fulfill our functions as surgeons, pilots or businessmen, not to mentions masses of students who fill themselves with amphetamines to face stressful exams. Beyond the effectiveness of these drugs, what is most concerning is the life philosophy and the “super hero” model underlying all this: man succeeding at all costs, without weakness or failure. But what are the ethical implications of these “scientific discoveries”? What are we teaching our children?

If fifty years ago we fought against the psychiatric establishment and sought other pathways besides that of control and restraint, nowadays, between post-modernism and political correctness, we are met by a deathly silence on all fronts, because if criticism does not come from those who ride the medical model to the bitter end, neither does it come from the world of psychology and other social disciplines.

Unfortunately, this predominant conformism is also reflected in scientific productivity and in the scarcity of strong ideas, as Edgar Morin put it, capable of shaking up certainty or introducing discontinuity.

In recent years we published a special edition of Terapia Familiare entitled “ The words of the Masters” which put together a series of articles by the Masters of family therapy; reading this volume makes us shudder because of the pertinence and foresight of those Fathers, in contrast to the paucity of ideas of successive generations, ever more conformist and subservient to the logic of the medical model. These Master Therapists chose to speak and take great personal and professional risks, placing themselves at the margins, outside of the current hypocrisy of being part of the flock and of giving in to colonization by the dominant paradigm, always more interested in “labeling” and treating psychological disturbances than in taking care of the person - and not just of their problems - and of the family in which they live. Back in their days, the magic words “evidence based” did not exists (evidence dominated by the medical model and certainly not devoid of strong economic and power interests).

Forty-five years ago I abandoned my role and profession as a child psychiatrist – including the strong economic advantages of a very well paid profession – because of the evidence I gathered in almost half a century of clinical practice that engaging the family in the therapy of their children is the best medicine for their treatment and cure.

For over three years I have been living in Australia, splendid land of kangaroos, where the relationship between Mind and Nature has fantastic potential. However, even such an extraordinarily beautiful and uncontaminated Country, where social interest and respect are inviolable values, has been contaminated by “North American colonization”. Not only has McDonald contaminated world eating habits by introducing trash food, the American Psychiatric Association with its bible, the DSM – especially in its more recent versions – has also contaminated the thought of entire medical institutions and of generations of professionals who are incapable of looking beyond the symptoms of the individual, fragmenting the family into monads and massively prescribing medication, such as Ritalin to children, because they have diagnosed them as being affected by Attention Deficit Hyperactivity Disorder (ADHD) or other relational or psycho-somatic dysfunctions.

What is never mentioned, but is well known, is that insurance companies only cover individual therapy and only when accompanied by a diagnosis. Thus it is that 90% of children are diagnosed in this way: what a pity that once diagnosed they are then treated accordingly! Perhaps many people are also unaware that, because the testing of pharmaceuticals on minors is forbidden, they are considered miniature adults and are therefore prescribed Prozac in dosages appropriate to their age and weight. Just as is done with Panadol, an antipyretic medication considered good for all, but in different dosages for adults and children.

In spite of the present attempt to negate adverse life experiences as human problems, by reducing everything to the level of disorders, psychiatric syndromes and neuroleptics, I would like to close with the description of a clinical experience. I do this in the hope of eliciting renewed faith in psychotherapy and its relational and profoundly human dimension in those of you who are still young inside, still capable of emotional responses and reflection in the face of changes considered impossible outside of psychiatric knowledge and practice.

Two years ago I was asked to attend a consultation with Patrick and his parents in the north of France. Patrick is 20 years old and an only child. He was diagnosed at birth with testicular agenesis, a rare and debilitating disease that causes an important hormonal imbalance and that translated into marked feminine traits in Patrick, creating intolerable relational problems at school and with his peer group. Repeated episodes of bullying forced him to prematurely abandon his studies.

From the age of twelve he was repeatedly hospitalized in a psychiatric unit, receiving a series of diagnoses over time: schizophrenia, borderline personality disorder, bi-polar disorder accompanied by frequent changes in medications. The parents, simple people, live in a small village in Normandy. Both work and no longer seem to hold much hope either in their son or in the possibility of a cure. The mother does everything for Patrick, but is hyper-protective and treats him as a small and helpless child. The father is sad, lacks initiative and is submissive to the frantic attempts by the wife to organize their son’s life. The treating psychiatrist sees him individually but also meets with the parents, and it is he who suggests a consultation.

I will not go into a detailed description of the session but will limit myself to two or three basic concepts.

From the very beginning I asked Patrick to write down on a piece of paper the positive aspects of his life, a request as unusual as it was unexpected for both himself and his parents. After a lengthy wait and much encouragement from myself the young man started to list some of his positive values – generosity, creativity, selflessness – confirmed, at length, by the parents, who were surprised at being asked such unusual questions by a psychiatrist.

The second phase of the consultation, having established an alliance with him in regard to his personal qualities, consisted in physically moving him close to me, outside of the triangle formed with his parents, and asking him to describe for me the story of his parents’ lives, both of whom had carried responsibilities and duties within their own families from long before his arrival, an event that happened after many years of marriage and considerable reproductive difficulties.

Patrick looked like a small child when sitting between his parents, but once “removed from that space” his behavior became much more mature, and he was finally recognized and listened to as a grown-up even by his parents, who were surprised by how interested and informed he was about their life histories, both of which had been very painful, with much loss, grief and adversity.

The consultation concluded with the hope that Patrick might find a job and create some distance from both parents and hospitals, considering also the fact that his mental faculties were absolutely unaffected. Obviously, in this case, the leadership of this psychiatrist, the first person who seemed interested in him as a person, not just as patient, and in his parents, was very important.

A little more than a year later I received a note from the psychiatrist who had been treating the family in which he communicated that Patrick was now living in an apartment in a small town 15 kilometers from his parents’ house, who now had a better relationship with him. He had recently got a job at the local Impressionist Museum. In the note, he mentioned that the family had a very positive memory of the consultation and that they would be happy to see me again when I next came to France, “to show me how Patrick had changed”.

Eight months later, having returned to Paris for a family therapy seminar, I invited the family and their psychiatrist to a follow-up session. In spite of many years of clinical experience I could not believe my eyes: the change in Patrick was visible not only in the way he spoke but also in his behavior and his new and positive attitude to life, while the parents finally looked as though they had woken from a nightmare lasting twenty years and seemed to have rediscovered a closeness as a couple that would have been hard to imagine.

We can then ask ourselves: if families can achieve such extraordinary changes, once their capacity to function well and to love is recognized, is it not also possible that the same “miracle” could happen to us, who take care of them?