The Right Way For Doctors To Address Family Dynamics

When a psychiatrist or physician is treating a young person, and they realize that what the young person really needs is strong parental discipline, what’s the right way to present it?

Today we’re answering a question from Dr. Donna, a psychiatrist from Boston, Massachusetts. She writes:

I listened to your latest Podcast this morning about apologies. This is something I have thought about many times. I’m a psychiatrist and have a small handful of patients that I find myself thinking the most helpful thing I can do for the family is to tell the parents that the kid needs the shit kicked out of him. The path of least resistance is to collude with the family and pretend the problems are all biochemical in nature and continue to do medication trials. What advice would you have for a therapist who wants to give the "kick the shit" advice, without saying it in a way that I will be reported to the medical board? Do you have a succinct way of getting this across?

Thanks for your question Dr. Donna, good to hear from you. I love your question because the answer is right in the sweet spot of family therapists. But, let’s back up a bit and ask why you think your young adult patient needs a good kick in the butt. I’m sure it’s because you’re seeing them be irresponsible, unhelpful, and disrespectful towards their parents. Maybe they use and abuse alcohol, pot, or other drugs, while being supported by the parents with room, board, use of a car, phone and data plan, maybe pocket money; am I on the right track here? Of course I am. I see it all the time and it irks you to see a young adult getting a free pass with their rotten behavior.

And you don’t want to pretend that this is a biochemical problem that will be solved as soon as we find the right pharmaceutical cocktail when what’s really needed is for parents need to establish and enforce clear limits. Excellent, right on!

Is this a time for pharmaceuticals?

All right, let’s take another step back. When does a pharmaceutical treatment work? When does it become a cure for a feeling and behavioral problem? Well, you’re the doctor and I’m sure you can determine when a person needs and can benefit from medication.

But the operative term here is benefit because the only time medication will ever help is when your patients are doing their best and are taking responsibility for their own wellness.Click To Tweet For instance, if you have a depressed patient and they spend their time watching daytime TV, eating high sugar-low nutrient foods, and don’t exercise or engage any social connections and support, you’ll be a frustrated psychiatrist with the burden on you to solve their problem.

Is their depression causing their unhealthy behavior, or is their unhealthy behavior causing their depression? It's probably a bit of both and I’m guessing you have good skill in getting them to look at and change their self-destructive ways. I’m also sure you don’t say, “get your ass off the couch and dump the sugar.” I’m sure you’ve taken a solid history and learned the origins of their unhealthy behavior, childhood trauma leading to an identity of unworthiness, and perhaps unresolved issues of loss. In addition, you’re empathetic and either providing the psychotherapy, in addition to the medication, or you’re having them see a therapist to do that work with them. If not, well you’re colluding with them to believe that it’s all biochemical and should be solved with medication alone.

It’s the same with our under-functioning, disrespectful, irresponsible young adults and their enabling parents. How did they get into this pattern? What’s the history? Was this a sick child? Did they have learning disabilities that the parent needed to advocate for and it led to excuse making? Was the enabling parent unsupported as a child and compensates by being overly indulgent with their child and the pattern extended into the young adult years? Is Mom sympathizing with the young adult because the father was mean and she divorced him and she now feels guilty, or even lonely? Does she now hold on to her young adult because unconsciously, she doesn’t want to be alone?

The Control Battle

All this is to say that there are underlying psychological issues that have evolved into a pattern that is destructive and interfering with growth and development. And the underlying psychology has spurred dynamics that became a rigid family pattern, something that I call a Control Battle.

I call it that because regardless of the specific dynamic or pattern and regardless of the underlying psychological issues that drive it, family members are struggling at cross purposes. For instance, in a recent case with a common dynamic, Mom wants her young adult to get better and keeps hoping that the medication will help. They have a close relationship and she listens to and supports his feelings. The young adult wants more resources from his parents, claiming that it’s the lack of resources that cause his depression. In other words, give me the unrestricted use of the car so I can go out and connect with friends, etc. even though I smoke pot all day. Dad gave up on his young adult son because he’s so rude and disrespectful that he gets enraged and explodes and ultimately, Mom sides with the young adult. That’s a Control Battle.

Addressing the Battle

So Dr. Donna, let’s ask the question, “What is the productive way to tell the parents to quit enabling their son”?

Step one: Identify the Pattern as the problem, the Control Battle Beast.

Everyone feels stuck and helpless. Mom is frustrated that all her support and protection of her young adult isn’t moving things forward and she lives with chronic stress between her son and her husband. Dad is frustrated because he wants his son to move on in life both because he cares about his son and he wants an opportunity to have an empty nest and a relationship with his wife. Our young adult is frustrated because his parents won’t give him what he wants and are trying to “control or change him”.

I show the family how their pattern is keeping them stuck.

Step two: Identify Positive Goals

Point out that they all share positive goals. They all want the young adult to be happy and successful. The young adult, Mom, and Dad all want that, they just differ on how to get there.

Step three: Young Adult Potential

I offer that our young adult has far more potential than he is utilizing. He is using his energy to try to get what he wants from his parents, rather than create a strategy to get it for himself, and that “feeds the beast.”

Step four: Parental Accountability

Next, I point out what each of the parents is doing that feeds the beast. I help them to all get on the same page for how to utilize parental resources. These resources serve to only support happiness and success, as opposed to immediate gratification, which in turn, feeds the beast.

Step five: Healthy Next Steps

Sessions then focus on our young adult taking healthy steps forward. Those include respectful, cooperative behavior at home as well as healthy progress out of the home in areas such as work, and education. Parents offer resources only for behaviors aligned with their standards and expectations.

How to Move Forward

So Dr. Donna, there we have it. You don’t have to advise kicking the shit out of the kid and you getting reported to the medical board, and we don’t have to collude with the myth that the right psychotropic cocktail will fix things.

After your evaluation and when you see the family dynamic as a barrier to wellness, you can say something like the following:

“Yes, your son has depression and that is a factor in holding him back. I can offer medication to help with that, but that’s just one element that needs to be addressed for your son to get well. He needs to take responsibility for his own growth and happiness. Sitting around smoking pot and waiting for meds to work isn’t going to do it. He’s stuck and you are stuck as a family; it’s unclear to you how to help him move forward. I can offer ideas but if it were that easy, you’d already be doing it. I will suggest a few things:

Young adult, you need to find a way off of pot. It’s a powerful de-motivator and is a factor in your depression and lack of progress.
Mom and Dad, you need to get on the same page for establishing healthy standards and expectations, and accountability to those standards and expectations.
I’m referring you to an experienced family therapist who will help you do just that. Without that, medication is shooting an elephant with a pea-shooter and I don’t want to act like medication will solve the problem, when it won’t.

Keep in mind...

So, whether you are a psychiatrist, a family doctor or pediatrician, a therapist, a tutor, a nutritionist, physical therapist or a parent — children, teens, and young adults will do well and medical treatment, adjunctive support, and simply parenting will all go well, when our kids are doing their best to benefit from your help.

When they are resisting, and relying on you to do all the work, that’s when a compassionate, honest look at addressing family dynamics needs to be part of the solution.Click To Tweet

Thanks for tuning in today everyone and special thanks to Dr. Donna for her thought-provoking question! Do you know someone struggling with raising a teenager or have a child entering the teen years? If so, why not get them a copy of my book, Ending the Parent-Teen Control Battle? Many parents have told me it was the least expensive and most effective therapy session they’ve ever had.

And please remember, take care of yourselves; you need it, you deserve it, you’re worth it. Bye for now.

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