Editor's note: Dr. Charles Raison, CNNHealth's mental health expert, is an assistant professor of psychiatry and behavioral sciences at Emory University School of Medicine in Atlanta, Georgia. He also serves as clinical director of the mind-body program and co-director of the Collaborative for Contemplative Studies.
(CNN) -- I want to address a spate of criticism I received for my suggestion several weeks back that family therapy might be a first intervention for a 6-year-old boy diagnosed with bipolar disorder who was demonstrating problematic behavior at home but not at school.
The heart of the issue is that many parents of children with mental illness who read the column felt that I was blaming them for their children's behavioral and emotional problems. Susan Resko, who is executive director of the Child & Adolescent Bipolar Foundation, put these feelings in strong relief in a letter she sent to me, which read in part:
"Your response to the poor mother harkens back to the days when doctors and society used to blame the mother for a child's psychopathology. ... Why do you draw mothers of bipolar children back to the Middle Age of child psychiatry? Please clarify your statement to the poor reader that you did not intend to fall into the old blame-the-mom routine."
So, the first thing I'd like to say is that I have felt a fair amount of guilt for writing something that so many people felt was unhelpful and downright damaging. My evenings this week have been haunted by the ghosts of patients past, a legion of young people I have seen over the years who through no fault of their own (or anyone else's) were stricken with catastrophic psychotic illnesses just as they entered the prime of life. Many of these were kids who had gone away to college with the brightest of futures only to collapse under the weight of symptoms that would almost certainly guarantee that none of their parents' fondest hopes and ambitions for them would ever be realized.
I can attest from much experience that the most severe mental illnesses often seem to descend upon the kindest and most caring of families. I've never seen hard data to buttress this clinical impression, but it is in keeping with increasing evidence that the genes that contribute to the development of conditions such as schizophrenia and bipolar disorder are so common in the human gene pool because they also promote the emergence of many highly valuable traits such as intelligence and creativity. In fact, under the right circumstances they are really "opportunity genes" that can actually protect against the development of behavioral problems, as demonstrated by a recent study (see Pauli-Pott U et al. Journal of Neural Transmission 2009: 116: 503-12). So, as a general rule I would suggest that not only should parents not feel guilty or responsible for their children with severe mental illnesses, they should also not feel guilty about passing down "bad genes," because these genes are not bad.
The ambiguity inherent in brief questions such as Christine's can be seen in the radically different ways that Dr. Ken Duckworth, Susan Resko and I understood the central issue of the case, which is a 6 year-old with a psychiatric diagnosis who behaves "perfectly" at school but is beginning to demonstrate violent behavior at home. I heard in this the possibility that factors in the home environment might be directly contributing to the isolated trouble at home. Duckworth saw this as likely reflecting the fact that "children diagnosed with a mental illness can hold themselves together during the school day, only to unleash troublesome behavior when they return to the safety and comfort of home." Resko in her letter asked "Did you ever consider that the mother was speaking in relative terms?" (i.e. that the child wasn't really perfect at school, only worse at home).
Both these scenarios are completely plausible, and in fact likely. It is also possible that the child's behavior more directly reflects tensions and conflicts at home, as I suggested. The ironic thing here is that if the three of us spent half a day watching the child and interviewing family and teachers, I suspect we would come to strong agreement about the key problems faced by this young child, as well as the most effective therapeutic steps forward. And it is not unlikely that a full diagnostic evaluation might point in very different directions than any of us have proposed from the brief question originally sent to CNN.
This highlights how essential knowledge is if we are to optimally help people struggling with mental illnesses. People are more than diagnostic labels and they are not islands. Often the most effective interventions are psychosocial and must involve entire family units. But people are not less than diagnostic labels either, and fobbing off disease-driven behavioral pathology on the possible shortcomings of family and friends can be a catastrophic mistake, both because it delays appropriate medication management and because of the psychological damage it inflicts on those in the shadow of a loved one's mental illness. So this is the tightrope someone like myself must walk in answering the questions sent to CNN. I greatly appreciate the opportunity provided by Duckworth and Resko to better balance the advice we make available around the particular question posed by Christine.