The Wild and Recent History of Schizophrenia and Family Therapy
The Wild and Recent History of Schizophrenia and Family Therapy
Murray Bowen and a forgotten era at the NIMH
If we are going to understand how folks diagnosed with psychotic disorders are thought about and treated in 2024 it’s really useful to understand that it was VERY, VERY DIFFERENT back in the 1950s, 60s and 70s. It took the biopsychiatric revolution in the 1980s to bury some very promising threads of work for us to rediscover all these years later, much of it in the realm of what is known as systemic family therapy.
The striking thing about the family therapy movement is that it’s had a lot of professional success and it’s ideas are taught and used in many different mental health contexts, but in the realm of “serious mental illness” and “schizophrenia” it’s nearly impossible to find anyone who publicly talks about the importance of working with complicated family dynamics. It’s taboo, and the reasons it’s taboo are complex, but really worth examining if we want better outcomes for people who struggle in the realms of psychosis.
Back in the 1950-70s there were plenty of people not only practicing with these ideas, but doing funded research on family dynamics and schizophrenia, and I’m going to briefly tell you about one of them right now.
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When I was a student in social work school in 2015, one of the big stories in mental health at the time was that the National Institute of Mental Health (NIMH) was withdrawing support for the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V.) Their reasoning was that the DSM wasn’t scientific enough for research. In our current era, the people at the NIMH believe that the future of mental health work is in genomics and neurobiology, and the study of biomarkers. While there might be some useful potential in these scientific avenues, the ideas are not great for thinking about how humans interact with each other, and how to relieve psychic suffering. The DSM is different but equally as clunky and alien, a product of pharmaceutical company interests as much as anything. It’s the same old story with so many modern human endeavors: the idea that we can solve social and political problems with technology and big business often gets us into a lot of trouble.
Anyway, scratch under the surface and there’s this wild history waiting to be discovered: it turns out that there was a family therapist named Murray Bowan who was the director of the National Institute of Mental Health from 1954-1959 and he did years of very practical research with families:
“Within five years, Murray Bowen had come to understand schizophrenic psychosis in a patient as a symptom of an active process involving every member of a family (Bowen, 1959, 6). The family was a unit rather than a collection of individuals, and individual behavior was viewed through the lens of the emotional unit. True to his training in science and medicine, Bowen collected data from the psychiatrist who also served as the families’ primary care physician, evidence that allowed him to see the phenomenon of the reciprocal relationship existing between family members and their health…And out of this project came the development of a set of systematic principles based on his research.” (Butler, J., ed. The Origins of Family Psychotherapy: The NIMH Family Study Project. Lanham, MD: Jason Aronson, 2013) pp 3-4”
All these years later, undergraduate psychology students learn about Bowen, because it turns out many of his ideas were incredibly on target. He was talking about trans-generational transmission of trauma decades before we knew anything about epigenetics. He popularized the language of “triangles” as a way to describe how family members end up in emotional tension and conflict, that all two-person relationships are unstable; and that eventually a third person is involved to calm the anxiety between the two. His language of “differentiation of self” in the context of family systems, turns out to be very useful when trying to assume responsibility for one’s own distress, contain one’s own needs a little better, and blame others less.
But for some reason these ideas don’t seem to get talked about in the clinical realm of working with people diagnosed with schizophrenia and bipolar disorder or other psychotic disorders. And there’s something very disconcerting to me about this disconnect, because the underlying message I hear is that there’s something fundamentally different about people like us—something biologically different, something about our brains, that means we need to be on drugs and not talk about our family dynamics. The contemporary “family therapy” for psychosis I know from working in the first episode world is a manualized set of “evidenced based” psychoeducation modules that “educate” families about the biological nature of psychosis and the need to take antipsychotic medications.
Am I the only one who thinks there’s something odd going on here?
Meanwhile, when you scale out a bit and look at the pre-biopsych era in which Bowen was working there’s a literal goldmine of incredibly practical clinical ideas and visions for working with psychosis and family dynamics from people like R. D. Laing, Carl Whittaker, Jay Haley, Virginia Satir, and Gregory Bateson. Some of it is flawed and dated, but much of it is so perceptive and creative, so far beyond the behaviorist models that are popular today. All of these people left brilliant lineages just waiting to be rediscovered and incorporated into a new way of working with people diagnosed with “SMI.” It just seems so obvious. I aspire to write a lot more about this subject and I’m more than happy to correspond with anyone who has thoughts about it. If you want to learn more about Murray Bowen’s work in particular there’s a lot of great stuff online and here’s one place to start.
Family Systems, Internal Family Systems and Working with Psychosis
Anyone who reads this blog knows that I’m a practitioner of Internal Family Systems, which was developed by Richard Schwartz after decades of working as a systemic family therapist. In many ways I think of IFS as the model that captures so much of the wisdom from all the models and people I just mentioned above, including the Bowenian model.
In my explorations of Murray Bowen’s ideas, I’m struck by the relationship between “Differentiation of Self” and the language of “Self” that we use in IFS. Last night I came across a bunch of writing on the idea of “differentiation of self” including this scale. I hold it all lightly but it’s becoming so clear to me that there are ways we can reintegrate family systems thinking in how we talk about and work with what gets called “serious mental illness.” As far as I can tell, there are only a handful of people out there working with IFS in the realm of psychosis. And while I see examples of family therapy institutes working with psychosis in systemic ways, there seems to be so much fear of falling into the trap of “family blaming” that it strikes me a lot is being left out. I’m inspired by the model of Open Dialogue, which has its roots in systemic family therapy, and I also see that it needs more company and to be part of a larger movement. We desperately need a new popular paradigm for thinking about psychosis, and a way to train lay people and clinicians in using it. I think IFS has an important role to play in this regard.
It feels like this is the kind of project that’s going to take the rest of my life, and if you read the rest of this blog it will put into context the politics of what we’re working with. Times are rough out there for the people labeled with “psychosis” and “SMI.” But I think it’s incredibly important that we maintain a vision of transforming society with our work, and recognize that how we think about “mental illness”: individual, biological, disease, disorder, dysfunction…it’s going to have to change so that we can evolve as a species. My message for you, if you’ve gotten this far, is that we have so much incredible research and thinking to work with SO MANY creative ideas and visionaries like Murray Bowen, so many paths that might currently be covered under the cultural (neoliberal/biopsych) brush, but are just waiting to become trailheads to the future.
For as long as there has been repression, there has been resistance. A longstanding strategy for undermining this resistance has been to pathologize those who challenge the capitalist, colonial status quo. This practice has deep roots in the history of the mental health field, from labeling those who sought to escape slavery with the psychiatric disorder of drapetomania, to labeling Indigenous peoples as “primitive” “savages” who must be mentally deficient to resist “civilization,” to diagnosing Black men who participated in civil rights demonstrations with schizophrenia in a phenomenon known as the protest psychosis. Today, amid multiple ongoing genocides and widespread organizing against colonial violence, activists are commonly threatened with institutionalization as a result of their protest activities – including those fighting for a free Palestine. The pathologizing of resistance is part of a global pattern of discrediting, undermining, and incarcerating those who dare to speak out against injustice.
On Thursday, April 25, IDHA will continue the conversation with Decarcerating Care: The Pathologizing of Resistance. This seventh installment will explore how the mental health industrial complex has pathologized acts of resistance throughout history, and how this plays out in the present day. A panel of activists, survivors, researchers, and providers will discuss the ways in which the fields of psychology and psychiatry have been wielded as a tool of domination by oppressive actors – and the impacts in current policy, research, and service delivery contexts. Grounded in lessons from decolonial liberation struggles from Turtle Island to Palestine and beyond, we will share strategies for care workers, healers, and other advocates seeking to push back on these carceral dynamics. We will also hold space for the wisdom of madness in this time of mass crisis and grief.
After registering via Eventbrite, you will receive a confirmation email with details on how to dial into the Zoom webinar. We will also send you a reminder email the day of the event.
This article features the work of Neil Gong who I know from the early days of the Icarus Project and is the author of the recent book Sons, Daughters, and Sidewalk Psychotics: Mental Illness and Homelessness in Los Angeles
Could the U.S. force treatment on mentally ill people (again)?
APRIL 16, 20246:30 AM ET
One of the most difficult and expensive questions that a society faces is how to care for those who cannot care for themselves, and how to pay for it. Over the last century, the United States has radically changed how it answers this question when it comes to treating people with severe mental illnesses. Now we appear to be on the brink of another major change.
In the mid-to-late 20th century, America closed most of the country's mental hospitals. The policy has come to be known as deinstitutionalization. Today, it's increasingly blamed for the tragedy that thousands of mentally ill people sleep on our city streets. Wherever you may stand in that debate, the reform began with good intentions and arguably could have gone much differently with more funding.
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I'm 81 now and I lived and went to university in San Francisco during the 60s. I'm retired now but I cut my clinical teeth on family therapy, systems therapy, network therapy, etc. and am more than familiar with it's history; I lived it during it's flowering. One thing that most people don't get (but that the early family therapists soon realized--especially Jay Haley) is that individual therapy and systems therapy are two different epistemologies with different assumptions about how to look at the world. It has to do in large part with your unit of focus. If the focus is an individual it is a language based on what's going on inside someone's head; the other is about the relationships between people. Haley is one of the best sources about this difference and how it informs how you make an intervention. Haley used to lecture at medical psychiatric institutes but discontinued doing so because the psychiatrists were so brainwashed/indoctrinated. I remember when I was at UC Irvine doing a post doc and one psychiatrist told me incredulously when (at a lecture Haley was giving) he asked Haley what he would do with a schizophrenic. Haley said he wouldn't let that be defined as the problem.
I feel our entire family has been abandoned by the mental health system. Our daughter, diagnosed with a psychotic disorder was institutionalized for six, consecutive years and forcibly drugged, just long enough to be brainwashed into thinking that her only route to recovery was to accept that she is biologically inferior to 'normal' non psychotic individuals and that she must compensate by being on drugs for life. Now that she has been home for six years, things are gradually improving, no thanks to the publicly funded mental health system,, the one that most of us working folks use. The only times our family was helped as a unit, was was when we were lucky enough to receive support and encouragement from people with lived experience of psychosis. It is incredibly difficult to find clinicians who are informed by people with lived experience and it is even harder to find clinicians who have been on the sharp end of the needle. If one is lucky enough to have a few hours leftover each week, one is compelled to serve as an individual advocate to help keep OTHER people's children from being stuffed into the psychiatric meat grinder, and finally, a systems change advocate so future laws and public policies will protect the right of individuals and families to access humane, VOLUNTARY recovery-oriented services, including family therapy. A cursory look through any public mental health directory will turn up ample numbers of marriage and family counselors, even those trained in family systems therapy but very few of these are willing to wade in the water we live in every day. When a family member or caregiver makes an appointment with an average family therapist, one must waste precious time convincing the therapist that psych social approaches to psychosis are more effective than involuntary, biological approaches and that this is well documented. Exhausting, time consuming, and disheartening. It shouldn't be my job to remedy the second class higher education every family therapist receives! I'm just trying to hold things together on my end! We are one of the richest most powerful nations on earth. It shouldn't be this difficult to get effective help!