Pathways to problems - the evolution of 'pathology'

Rudi Dallos (a), Alistair Neale (b), & Marcos Strouthos (c)

Journal of Family Therapy, 19, ps 369-399



This paper describes a qualitative research study which compared accounts from interviews with families where difficulties had evolved into serious problems with those where an escalation into pathology has been avoided. These accounts confirm that family life is commonly seen to be problematic and stressful, particularly during transitional stages. Specifically, it appears that it is not simply the severity of the initial stresses and problems that distinguishes families, but the meanings that these evoke and the corresponding patterns of responses, especially the 'attempted solutions' that are set in motion. These responses, fuelled by external interventions, can launch families along pathological pathways. It is suggested that the meanings ascribed to difficulties and the ensuing responses are predominantly shaped and constrained by three factors: the dominant societally shared discourses of mental health and distress; the emotional resources and attachments of family members; and systemic interpersonal processes. Some therapeutic implications, especially the importance of assisting families to resist pathologising processes are indicated.



Although many clinicians acknowledge that there is no such thing as a 'normal' family there have been relatively few studies attempting to explore how families manage to avoid pathology. Rather than being curious about how families are able to overcome problems, the main focus of systemic theory has been on the relationship between problems and family dynamics. Yet many people who experience serious distress do not receive professional help. Instead it seems that there are many roads leading to and away from pathology. Community surveys indicate that as many as 80% of cases of rigorously defined cases of mental illness might in any random sampling of the population have not received any psychiatric intervention (Gottesman, 1991).


In this paper we will attempt to offer a tentative model of some of the processes in families, and between families and professionals whereby ordinary difficulties may escalate into major problems, or alternatively dissolve and perhaps remain as relatively minor irritations. First, we will draw together some relevant ideas including earlier sociological theories of labelling, role theory and more recent ideas from social constructionism. We suggest that systemic concepts of recursive actions complement these theories by emphasising the dynamic processes whereby family members may attach increasingly negative and pathologising meanings to actions, leading to one or more members becoming identified as ill, pathological and deviant. Second, we report a preliminary study that compares accounts from young people and their families where there has been a progression to serious 'pathology' as opposed to its avoidance. We then discuss the implications of our findings for work with families. In particular we will consider how therapists may unwittingly collude in producing pathological identities.


Goldberg and Huxley (1980, 1992) suggest that whether people receive treatment depends not only on the severity of their symptoms but also on responses at a number of filters or stages. The first of these is typically the initial responses of their family to some indications of distress or 'abnormal' behaviour. In turn these responses may be governed by the psychological state of other members of the family and also by their transgenerational traditions of response to distress. Some families have learned to cope by calling in outside professional assistance. Initially this is most likely to be the family doctor whose responses may include: not perceiving any real difficulties; detecting a difficulty; and/or offering some form of intervention. Scott and Ashworth (1967) had earlier described how the parents' prior experiences of 'mental illness' in other family members can result in intense levels of anxiety or a sense of catastrophe being generated by apparent indications of mental distress or crisis in their own children. One consequence can be a process of 'closure' whereby their child comes to be seen as having irreversibly changed, accompanied by an overwhelming sense that they will never recover.


At the onset of perceived disturbance therefore, important decisions may be made about the nature and severity of the problem and in some cases referral to other specialists initiated (Goldberg and Huxley, 1980, 1992). During this period labelling the difficulties as signs of 'mental illness' and resulting changes in relationships and roles may be already occurring. This may lead to a closure whereby the person becomes consigned to an 'ill' identity:

"Closure occurs. . . Henceforth the parent performs a ritual of concern for the patient. . . but. . . has a firm conviction that the patient will never recover."

(Scott and Ashworth, 1967, p. Ill)


Kleinman (1988) has written eloquently about how not only psychological but physical forms of 'illness' are accompanied by a range of powerful narratives which shape a person's experience. For example, a 'physical' disorder such as a serious heart condition may be experienced in a wide variety of ways. The reactions of family, friends and physicians are important and may serve alternatively to develop an identity and accompanying set of narratives centred on notions of being chronically ill, degeneration and despair or a sense of coping, acknowledging possibilities and feelings of support:


"[I]f a person is defined as sick, his failure to perform his normal functions is 'not his fault' and he is accorded the right to exemption and care. At one and the same time, however, the sick person is enjoined to accept the definition of his status as undesirable and the obligation to get well as expeditiously as possible."

(Parsons and Fox, 1952, p. 32)


Foucault (1967) described how people are 'conscripted' into pathological identities and suggested that this was a feature of the dominant Western scientific and medical discourse. This invariably involves the use (and abuse) of power to impose such meanings on people, and in turn to apply sanctions, such as exclusion or even enforced treatments. Foucault suggested that these processes are played out in interactions; for example, between family members and importantly between family members and the professionals. The formation of a pathological or deviant identity can be seen as not simply a one-way but a recursive process. Similarly, Becker (1974) proposed that deviant identities may be created by a labelling process in which a person and significant others in his or her life come progressively to give meanings and to shape actions. He argued that some actions that are 'normal', but a 'bit unusual' can become repeatedly and increasingly 'labelled' and defined as deviant. In time the person or 'patient' may come to accept and internalise these definitions, especially since they allow some escape from painful responsibilities and duties and, at least initially, may be accompanied by sympathy, support and care. Scheff (1974) further suggested that one implication is to encourage us to ask questions about the pathways of problems and how people may also avoid pathology. This idea of meanings and an identity being shaped through a recursive interactional process is consistent with systemic theories.


However, Becker's (1974) labelling theory, as it came to be called, has not been without its critics. Gove (1970), for example, cited early studies, such as one by Yarrow et al. (1955) which involved retrospective interviews of women whose husbands had become hospitalised for mental illness. The wives reported that they had taken action to have their husbands hospitalised only after their behaviour had become impossible to deal with. However, such studies leave open the question of what happens to all men who show similar behaviour but do not necessarily end up being hospitalised. An important question is how some of the labelling processes may be resisted. Scheff (1974) suggested that the characteristics of the person, their race, class background and gender guide the perceptions and reactions to the indications of 'deviance'. Access to resources, such as money, education and social status, may help people to avoid or resist negative labelling processes. Alternatively, such resources facilitate treatment rather than enable people to avoid labelling (Gove, 1974).


A model


Out aim is to explore how a family's resources, such as money, extended family support and friends, may shape the process of labelling. From our clinical observations we suggest that these processes involve a form of increasing 'selective attention '. Initially this may be triggered by particular sensitivities, such as a history of 'psychotic' disturbance, or recent loss or distress (Scott and Ashworth, 1967). Subsequently this may be coupled with a psychiatric diagnosis and the family may be encouraged to interpret behaviours as illness, setting up an escalating loop of increasingly pathological identification of the difficulties. The effect of such processes is that eventually the personal assigned as the 'problem' may increasingly come to organise his or her identity around the label, leading to a 'psychiatric career' (Laing and Esterson, 1964; Scheff, 1974; White, 1995). This is seen to be shaped both by the meanings that others attach to the person's behaviour, their own internalisation and, at least partly, voluntary compliance with these. However, once established, the extent to which people are capable of voluntarily altering their pathological labels is questionable. Psychiatric labels are powerful in that they can impose a definition which leaves little prospect for fundamental change. For example, despite considerable evidence that a substantial proportion of 'schizophrenics' only have one psychotic episode (Birchwood et al., 1987; Haley, 1989; Harding et al., 1987) the view of schizophrenia as 'organic' in origin and largely incurable has been highly influential in mental health services (Gottesman, 1991; Leff and Vaughn, 1985). Powerful consequences of such a view can follow, including legally enforceable actions, such as medication or confinement, leading to processes of exclusion, disempowerment and marginalisation.


Transitions and difficulties


Haley (1973, 1980) has employed the concept of the 'family life cycle' to describe how families need to adapt to a variety of demands for change, for example, due to the natural biological processes of growth and ageing, changing expectations of family members and societally shared ideas of family life and progression. These demands are seen as becoming critical during major transitional stages, such as the birth of a child, children leaving home, and bereavement. Ambivalence, mixed feelings and incongruent communication, rather than invariably pathological, are seen as a natural and inevitable feature of family life, especially at the key transitional stages. When a young adult attempts to leave home, for example, the parents are likely to feel both protective and concerned about whether he or she can cope, but they will also want to encourage the child to leave in order to help them on their way. Hence their communications may at times contain elements of a double-bind: 'we want you to go but we also want you to stay' (Bateson, 1971) .If the ingredient of unusual or extreme stress is added at this point, for example, if one or more of the family members is ill, experiencing conflicts elsewhere, such as work or school and so on, then the communications, interactions and attempts to negotiate the transition may be disrupted. In effect the symptoms and problems can be seen to arise from the 'cards that fate deals' to families at particular points.


Family beliefs and explanations


Until recently, the perspective of the family on what it feels like from the 'inside' to experience a mental health problem in one or more of its members had not received much attention. Yet above all, people in families can be seen to be trying to 'make sense' of what is and has happened when one or more of them appear to be experiencing distress, or is acting in 'unusual' and 'disturbing' ways. Family life can be seen to be shaped by the interplay of narratives or stories which function to make sense of events and shape their actions (Dallos, 1991; Eron and Lund, 1993; Procter, 1996). The family's narratives serve to clarify, to make meaningful explanations, including causal connections between their actions over time (Antaki, 1989). Narratives offer a continuity which both helps to explain the past through a family history, but also serves to make sense of the present and to predict the future (White and Epston, 1990). However, narratives may also become 'problem saturated' excluding evidence of competence and 'well-being' (Anderson et al., 1986).


Processes of constraint of explanations and narratives


A critical question is how and why a family's repertoire of narratives and explanations may come to be constrained, sometimes to exclusively one dominant story which features individual pathology. Bateson (1972, 1980) suggested that the selection of ideas may follow processes similar to evolutionary selection whereby from a large creative pool only those ideas are allowed to endure which 'fit' the interpersonal contexts. In addition, White (1986) suggests that the selective process is shaped by the common cultural beliefs or discourses which define what is or is not acceptable. Based in part on our anticipation of how others might react to our ideas, we may apply some internal censorship, for example, when we dismiss some of our ideas as too 'odd' or 'unrealistic'. More broadly, families and other groups act to encourage some ideas and discourage others by reactions of criticism, ridicule or encouragement and support (Anderson et al., 1986; Dallos, 1991, 1996; Leff and Vaughn, 1985). In summary, we suggest that the processes of constraint can occur at three levels: the societal, personal and the interpersonal.

Culturally shared beliefs and narratives

The explanations formulated by families can be seen to be based on their internalisations of versions of the competing professional and popular conceptions of mental illness; predominantly these feature versions of medical, individualistic and interpersonal theories. Family members may hold contrasting preferences for one or other explanation, though frequently there is a general acceptance, for example, of an individualistic or medical view.


The explanations generated have implications for the actions or solutions which families may attempt {Watzlawick et al., 1974). Where families hold a belief that they have in some way caused the problems, they may themselves become distressed, anxious, mutually blaming or passive. In contrast a medical view tends to absolve the family of guilt and can place family members in a more active, caring role. However, an accompanying result may be that the person becomes labelled as ill, stigmatised and seen exclusively {totalised) as sick, incapable and not-responsible (Johnstone, 1992, Kleinman, 1988). Individualistic views may have the effect of ascribing more blame to the client, seeing him or her as 'weak' or 'inadequate', and in need of discipline or 're-education'. Alternatively families may engage in endless historical searching to try to identify the original causes of the problems leading to inability to formulate any consistent plans of action for dealing with the problems. The choice of attempted solution has varying implications for the client: being regarded as 'ill' or 'inadequate' may reinforce a negative labelling and lead to them becoming fixed in the sick role. Although accompanied by a concerned, caring position, this may serve to pathologise and conscript the person to become helpless and hopeless {Kleinman, 1988; White, 1995; Wynne et al., 1992). Alternatively, the confusion and anxiety that may result from the family assuming blame may aggravate their distress or even encourage attempts to prove that they really are 'ill' in order to absolve the others.

Emotional processes and attachments

Cognitive theories of emotions suggest a recursive link between feelings and beliefs (Brewin, 1988). Cognitive therapists such as Beck (1967) have suggested, for example, that depression arises from an over-selective cognitive focus on negative life experiences and a rigid, helpless view of the impossibility of effecting any change. Conversely, powerful emotional states, such as depression or anxiety, appear to make it difficult for people to think and may lead to 'tunnel vision' or rigid thinking (Beck, 1967; Oatley, 1992) .The basis of these theories is an informational processing view which emphasizes that in extreme emotional states we may become extremely distracted by increasing awareness of our internal sensations such as peripheral activation, heart rate, tremor, poor digestion and sweating. This preoccupation may consume so much of our attention that we become less able to think - to formulate alternative views and evaluate ideas (Brewin, 1988). Similarly the level of expressed emotions in families (Leff and Vaughn, 1985) can be seen to support the view that a high level of emotionality may not only maintain but produce thought disorder.


In turn, the level of emotionality or stress in a family may be related more broadly to the nature of their attachments, which stem initially from the parents' own childhood experiences. Bowlby (1973) has argued that the patterns of attachment established in childhood can be seen as 'working models' or a set of beliefs or expectations about what we have learned to expect from relationships, especially the extent to which we feel we can trust and rely on others. These beliefs and expectations may operate largely automatically and outside our conscious awareness. The nature of these attachment models links to how secure or anxious a child is generally. For example, Bowlby showed that securely attached babies were more able to spend less time with their parents and more time in experimental play, using the parents to return to as a secure base. These attachment models established in childhood have been found to playa significant role in the types of intimate relationships established in adult life (Bartholomew, 1993).


More broadly, our ability or inability to contemplate alternative explanations and answers to problems and willingness to use them to generate alternative solutions may be intimately related to our experiences of relationships. For example, depressive states are associated with excessively negative and pessimistic narratives about self and others (Beck, 1967; Brewin, 1988) .In turn, systemic perspectives have indicated that these feelings and perceptions are related to the nature of our relationships. Since our explanations and ideas about what to do about our difficulties typically involve other people, it is possible that the similar patterns of attachment may be seen in our attachment to our narratives and explanations. For example, familiar but unhelpful explanations and narratives may be held on to in an insecure and ambivalent way. Since the person cannot trust their relationships with others, they may not trust themselves and their own ideas, yet be frightened of abandoning these. In such cases a person may anticipate that expression of any different or challenging narratives will incur rejection or contempt from family members.

Interpersonal processes

Eron and Lund (1993) propose that problems develop as a process of co-evolution of family dynamics and beliefs. For example, the father in a family may come to be seen as distressed or depressed and this view then guides various 'benevolent' actions. However, this can set a process in motion which has quite the reverse effects. Attempts made by his wife and children to 'help' him may in fact have the effect of making him feel worse; that he is incapable, a burden on others, is inadequate, and so on. It is possible that he may therefore become worse rather than better and the cycle of 'helping' and 'failure' may lead to exasperation in the family members' attempts to help. It may also contribute to the escalation of a 'difficulty' into a 'problem', since failure to get better may in turn be seen as confirming evidence that he really is ill, leading to a polarisation of positions within the family. The family member who has started to become identified as having the 'problem' will also come to be regarded as increasingly different from the others, for example, that he or she is 'ill' as opposed to the others, who in contrast are 'well' (Dallos, 1997; Procter, 1996). This process of polarisation of the meanings or narratives surrounding the difficulties results in the 'ill' member being increasingly and rigidly assigned to this deviant position.


One consequence is that behaviours which might otherwise be regarded as relatively normal, for example, reluctance to get out of bed, concern with alternative lifestyles or expressions of anger, might be construed as signs of the 'illness'. Alternatively, it is even possible to see such actions as attempts by the person to escape from the 'ill' position. A dilemma for them may be that to be seen as 'well' may involve being held responsible for their previous actions and thereby incurring blame and anger for the fuss he or she has 'caused'. When this is overwhelming, there is a strong incentive to return to the 'ill' position where 'all may be forgiven' and confrontations are avoided. Once firmly established it may be increasingly difficult to escape from an 'ill' position. Frequently, the 'illness' is seen to have caused considerable strain, sacrifices and inconvenience for the rest of the family and this is forgivable only if the illness was 'genuine'. If it later turns out not to have been a 'real' illness this may imply blame. The person may be seen as malingering, weak, attention-seeking or awkward.


The study


Our intention was to compare families where serious problems had arisen to those where difficulties had been managed in alternative ways. In order to do this we compared two groups of people: one where there had been a prolonged history of mental health interventions and the other where (to our knowledge) there had been no such history. We hoped that the inclusion of a non-clinical sample would allow us to start from a more fruitful proposition of problems as a continuum, rather than starting from the pre-emptive assumption that the clinical group was fundamentally different.

Guiding propositions

Our overall proposition was that families could be seen to develop pathways which either led to problems or alternatively led to their avoidance and resolution. More specifically we proposed that the paths which had been adopted had been determined by a number of factors:

(1) that dominant family beliefs had been influential in ascribing meanings to some initial form of difficulty or disturbance;

(2) that all our families would have faced some difficulties arising from the unfolding of common lifecycle transitional stages, unexpected crises and accidents;

(3) that dominant family beliefs guide the solutions attempted to resolve ordinary difficulties. In turn these solutions could function to aggravate or attenuate difficulties;

(4) the level of social and practical support;

(5) the emotional atmosphere in a family, especially negative feelings of anxiety, stress and crisis;

(6) the emotive atmosphere in a family is influenced by social and economic resources.



More specifically, we hypothesised critical differences between the content of the accounts in tile two groups:

(1) the clinical sample would differ in revealing an early, predominantly negative and pathologising framework;

(2) there was less evidence of support having been available for the clinical families in terms of:

(a) emotional capacity to contemplate alternatives,

(b) financial resources available to make significant changes, such as moving, change of schools, and so on;

(3) the input from professionals was generally seen to be less helpful in the clinical group, for example, occurring too late or being negative, and had been perceived as blaming. This had served to encourage rather than attenuate the development of pathological narratives;

(4) the clinical group might still be less able to contemplate alternative, non-pathological narratives about the difficulties.


The sample consisted of ten families each with a young adult member experiencing current problems of varying severity and a history of serious psychiatric problems, and eight adults who had no significant current problems and no psychiatric history (to our knowledge at the time). The identified clients in the clinical families were all young adults, aged between 16 and 25 who had attended or were currently attending an adolescent psychiatric unit. Four were women and six were men. All the members of the clinical group had a history (over five years) of serious clinical problems, including psychotic disorders, depression, self-harm and personality disorder. They had all experienced a variety of residential psychiatric care.


The non-clinical sample was intended to be representative of the 'general' population. They were all volunteers gathered from local educational and social networks whose ages ranged from 20 to 45 and covered a broad range of occupational and educational backgrounds. Four were women and four were men. This group had a higher level of educational attainment in that all had taken part in higher education. Somewhat to our surprise it turned out that several members of the non-clinical sample had experienced serious emotional or 'mental health' problems. This is consistent with various studies which have shown high rates of mental ill-health in the general population (Goldberg and Huxley, 1980,1992).




The study employed semi-structured interviews which were either video or audio tape-recorded. The interviews in the clinical sample included the whole family where possible, but due to various practicalities three of the interviews were with the young people on their own and two were with the parents on their own. For the non-clinical group the interviews were conducted individually. The information from the clinical group was supported by case notes and interviews with the consultant psychiatrist and nursing staff. Where possible, the initial interview was followed by a short second interview centred around their perceptions of our analysis of the initial interview.


These interviews were structured as follows:

(1) details were taken of the person's birth;

(2) families or individuals were asked to identify two or more critical positive and negative events/periods;

(3) people were asked to identify the key negative event/period; in the case of the clinical sample this was usually the onset of 'mental illness';

(4) one or more of these key critical periods were explored in terms of their content and nature of the preceding events;

(5) perceptions and attributions of the cause of the difficulties;

(6) an exploration of what events or interventions were seen as having been helpful;

(7) family members were asked to consider, in the light of their experiences, what alternative events, inputs or interventions might have been helpful;

(8) finally, families were invited to offer any advice to other families who were going through similar difficulties.

Life paths

A life path was used to focus the discussion (Figure 1) .Two or more critical significant positive and negative periods in their life were marked on the chart and judgements about the severity of the experiences were noted on a scale from +5 to -5.


A family genogram was also employed to facilitate a discussion of family relationships, traditions and beliefs regarding mental illness. It was also used to encourage a discussion of attributions regarding the causes of problems and sources of advice which guided the solutions attempted. This in turn revealed differences of opinion and family dynamics and conflicts surrounding the problems and their perceived causes.

Family dynamics and EE (expressed emotions)

An overall assessment of the EE dimensions - over-involvement, critical remarks and hostility - was attempted from an integration of the following:

(1) details of content and non-verbal aspects of the interviews with family members and individuals;

(2) overall independent ratings from observation of the video and audio tapes of the interviews.




It has been suggested that the EE dimensions can be reliably assessed from relatively brief extracts of family interviews (Vostanis et al, 1992).


Minuchin's (1974) structural dimensions - enmeshment, clarity of boundaries and power relationships - were also employed. The analysis was conducted independently by the three authors and this was followed by a discussion and led to a consensual description.



We will first present extracts from five of our interviews. These exemplify accounts of the formation and shaping of the problems. Typically, family members repeated these several times during the interview which suggests a degree of reliability.


The first, Andy, is from the non-clinical group who to our knowledge had no psychiatric history. Andy was chosen here to illustrate how reports of serious difficulties were frequently offered by the non-clinical group. This is followed by extracts from interviews from three of the clinical sample (Lionel, Andrew and Annie). Lionel, Andrew and Annie had all experienced serious mental health problems for over five years. They were all attending the adolescent psychiatric unit either on a part-time, day-care or residential basis. Their contact with their families varied, with Lionel and Annie having frequent contact and Andrew having had little contact. Andrew's position with his family was indicated by the fact that it proved impossible to convene the family for the interview.



Andy, 22, was a postgraduate student. He was living away from home and came from a strongly religious background. He described how as a teenager he had been very confused, partly as a result of becoming immersed in his (and his family's) conversion to Christian fundamentalism. At one stage he had experienced vivid visions and hallucinations (he did not use illegal drugs) .He started by describing his experience of a 'breakdown' which led to a suicide attempt.

ANDY: This weekend when it happened, breakdown, going bonkers, I was really angry, punching the walls, wrecking the rooms we were in. . . One day I went out in the woods and it just got insane. I started crying and screaming and there was this intense physical pain of being torn in two, literal pain, one arm and one arm grabbing me pulling me in two and intense pain in my stomach. . .there were two devils pulling me apart fighting for me. . .I've always had a very fertile imagination. . .what happened was I was in tile wood and there was a rope and I sort of tried to tie it around my neck but the rope was too thick. So it didn't work basically. . .it wasn't the first time I had thought about it. . . . I hadn't actually gone into the wood thinking I am going to kill myself. . . .

INTERVIEWER: How did you start, when did you start to interpret it as 'going bonkers'?

ANDY: I think when, later on that Sunday night when I returned home it all came out with my parents, we sat down and did lots of crying, tears . . . they sat me down and said, 'What is the matter with you? Just sit down and tell us.' And I just told them everything and they said 'either you are going to see a psychiatrist or the priest, one of the two.' And I chose the priest and from there the priest just took a very laid back attitude and said 'chill out, it's probably not what you think it is. Get your head together and these things will go'. . . . Previously I had seen another teacher, a Christian, a very sound bloke and I gave him all this spiritual rubbish stuff. And he said, 'You can't stop a bird flying over a tree but you can stop it landing and making a nest' Implying that you can't stop thoughts going through your mind but you can stop them lodging there.

INTERVIEWER: It sounds like your parents gave you alternatives, such as to see the priest or a psychiatrist. How do you think it might have gone if you had gone to see the psychiatrist? If you had gone down that route, rather than a Christian, church route?

ANDY: I think both would have worked. . . the thing I didn't want was to have on my medical records that I'd gone to see a psychiatrist. . . .


Some similar themes can be seen in these extracts. Andy seemed to have an awareness of some of the dangers for himself of going down a psychiatric route. It was also apparent from Andy's account that some helpful sources of support presented themselves: his parents, a concerned priest and a teacher. Interestingly however, Andy's distress partly seems to have been the result of being immersed in excessive religious fervour, and religion can offer a clear alternative pathway to psychiatry. This choice is directly articulated and presented by his parents. Even at the point of considerable personal distress and confusion his memory of this period features choices and some control over his life. Again significantly, Andy's account shows evidence of the importance of various 'voices' at the time of his distress. For him, however, the significant voices, for example, that of his teacher, are largely positive and accepting.



Lionel, 18, was one of the clinical sample. He had been attending an adolescent psychiatric unit for nine months following several suicide attempts associated with bouts of serious depression. He had also been repeatedly engaging in self-harming (cutting his wrists) and drug abuse. Lionel had achieved well at school and had been made head boy, but had become increasingly distressed during the last year of his A levels. Lionel's account featured a strong theme of keeping things to himself, of not being able to confide in others:


LIONEL: Becoming head boy was good but I was very stressed about it. I was raped when I was 10 and my grandparents died when I was 13. School was very difficult because I was blocking out so much. . . I could talk to my teachers better than my parents. When my grandparents died I went down all the time, head down in all lessons. . . . I didn't want my parents to see it so I put a lot of energy into blocking, not showing it to my parents . . . if I had a problem I would turn to a friend or my granddad. . . . The rape it looks bad, and of course not telling them, not anyone even my best friends. Didn't know what they would think, 'Oh my God is he gay? Was he looking for it?' So everything from then on, until my granddad died I could handle it. When he died it got worse, then my other granddad died and them my grandma. It was like through the floor. . . . I was really upset, one cry and then I bottled it up. I didn't think about it much until I lost my friends, friend across the road he moved on, friends at school I used to block them out. I never used to socialise, used to stay by myself. . .one of my best friends, Barry across the road, went to Ireland because their dad was beating them up. I didn't see him after. But his dad went over there, shot his mum, shot his older sister and shot himself, and Barry and his little sister saw it. So he's been through it, some sort of trauma as well. ...

INTERVIEWER: How do you imagine your grandfather might have reacted if you had confided in him?

LIONEL: I think he would have been very upset. . . he found out he was dying of cancer; he didn't tell anyone for seven years. He knew he was dying, he wanted to see more of me and go out and make the most of it what he had left. I knew he was ill, didn't know that he was dying but I knew that he was ill. I thought I couldn't tell him. . . .

INTERVIEWER: What about thinking about it now, looking back on it. What would have been different if you had told your granddad?

LIONEL: If I had told him. . . . I guess that he would have wondered what would happen, whether telling him then would have screwed me up so much I might have moved away from my parents and been taken into care or advancing things more, doing some of the things that I am doing now but doing them then.

INTERVIEWER: If you could imagine someone else in a similar situation to yours, what advice would you give?

LIONEL: Thought about this so many times. Firstly tell someone. counsellor then the police. Get it all on statements. Get justice out of the way, child protection, support, social services, if needing to be away from family option as well. So many options if you know about it at the time. I didn't. . . .


Lionel's story clearly revolves around the incident of his rape, and the loss of his one main source of support - his grandfather. However, it also contains the broader theme of keeping things to himself, of not having anyone whom he felt he could confide in. He indicates that in his thoughts, in his internal conversations, he anticipated how people would react negatively to his disclosure of the rape: 'Oh my God is he gay?' This isolation was compounded by his grandfather's death but he was not sure that he could have told him either, or whether telling him would have helped. In fact there seems to be a bond of silence in that his grandfather also kept things to himself and did not burden relatives with the news that he was dying. Furthermore, Lionel's story is saturated with distress; for example, the story of the murders in his friend's family. There is no clear outlet or alternative route apparent to him; he felt he could not talk to his parents, his grandparents died, the school had high expectations of him and he did not want to let them down. Above all he also indicates that he was cut off further as he could not tell anyone about his rape because he felt shame that it had happened and afraid of how people would feel and react. Finally, he offered the poignant insight that, though now able to contemplate alternative pathways, this was not possible for him as a 10-year-old child.



Andrew was aged 17 and had been attending an adolescent psychiatric unit for four months. His parents had divorced when he was 12, largely due to his father's alcoholism. At around the age of 14, Andrew began to play truant from school. He became involved in burglaries and he was regularly abusing a mixture of illicit substances. Since his mother became extremely worried that he was becoming uncontrollable he was placed on a supervision order and accommodated in a children's home. Subsequently, as a result of repeatedly breaking the supervision orders, he was moved to a secure unit and then to a foster home. When the last placement broke down, he went to live with his father. This did not work out because of his 'bizarre' behaviour and increasing social isolation. The following account comes from his parents as Andrew found it very difficult to talk about what had been happening to him. Although present at the interview he said little, apart from occasional swearing, and he eventually decided to leave.


MOTHER: Academically he has never had any achievement. He was never inclined to do any work.

INTERVIEWER: At what point did you think that things began to go wrong?

FATHER: Two years ago. . . but his behaviour was of a tearaway adolescent.. . . It was his attitude. . . .

MOTHER: It was three years ago. . . after we first moved. . . his father was in Scotland at the time. The teachers let him rest on his laurels because he came from a pre-school. Then he got involved with a ring of boys who were stealing. When he was suspended it was a turning point. He stayed at home in bed and he got continual suspensions.

FATHER: The school had a bad track record and they had a new headmaster.

MOTHER: It was around the time of the league tables. His brother was refusing and got into a bad set of older boys. . . Andrew tagged on to his brother.

INTERVIEWER: The kind of story that I get from both of you is that the problems come out of delinquency type behaviour rather than noticing any emotional or psychological problems?

MOTHER: We did not notice that. It was all criminal and drug-taking behaviour. . . angry teenage behaviour.

INTERVIEWER: What eventually happened to that behaviour? Do you see him having emotional problems now?

MOTHER: When he was at the secure unit he was making funny noises. They said it was because he was becoming institutionalised. In a way his behaviour got better. . . he was less unruly. They thought he might be psychiatric. . . .

FATHER: We were led to believe he is experiencing schizophrenia.

INTERVIEWER: How could things have been different looking back over the last three years, that would have been more helpful to all of you?

MOTHER: School. . . having more individual attention.

FATHER: Yes. . . that was his ticket, he was flunking. If I hadn't created the angst in the family, it would have been another influence. He had the experience but the school turfing him out was the ticket to say OK you do not have to do anything. There was no other avenue for him.


The account from Andrew's parents was pervaded with anger, denial, guilt and helplessness which is not unusual in a family that has experienced a major loss. Most of the anger and criticism was directed at the educational system, social services and health services. The parents felt that they had not been adequately consulted when important decisions about their son's future were taken. They also appeared to be quite critical of each other. His father seemed to be full of guilt as he believed that his own alcohol abuse had been something of an example to Andrew, who went on to abuse a mixture of illicit substances.


One of the most interesting points in this story is that Andrew's 'bizarre' behaviour increased while he was in a secure unit, where he was labelled schizophrenic. Although Andrew may have taken this label on board, his parents continued to see his symptoms as some form of extreme behaviour disorder rather than a schizophrenic illness. They felt strongly that if he had received more individual attention and had not been excluded from school, things might have been all right. This exclusion was seen as the start of a one-way downward path: 'there was no avenue for him.'



Annie's parents described her as having had a severe psychotic breakdown when she was 13 years old. She was living with both her parents at the time and had a younger brother Keith, who was described as relatively problem-free. The account of her deterioration suggests a vivid picture of a serious illness possibly with organic cause, yet at the same time her birth had aroused ambivalent feelings and she quickly came to be seen as somewhat 'difficult'.


FATHER: I was delighted to have Annie, we differ on this don't we?

MOTHER: I was depressed after her birth . . . sounds as if I was not delighted to have Annie, but I was very depressed for about six weeks. . . . I'm not trying to make excuses but I had an extremely difficult birth with Annie . . . it was horrific. . . . She was a very poor feeder and low weight and I think those things don't help. . . .

INTERVIEWER: Tell me a little bit about the period before the breakdown, what were the first signs, indications that something wasn't OK?

FATHER: She was going into herself.

MOTHER: She was depressed wasn't she, unable to understand what she was being asked to do, was getting confused. She was also saying things that were odd. . . .

INTERVIEWER: Which of you noticed that first?

FATHER: I remember having a conversation with Annie when she was reading the horoscopes in the paper and she wanted to know her signs, kept reading them and wanted to know about her personality in the paper and I told her she was getting too obsessed about it and that was bad. . . .And she was obsessed with religion at the time. . . .

MOTHER: Trying to get us to take her to church. . . .

INTERVIEWER: What did you start to do when you first noticed it. . . .

MOTHER: The trouble with Annie is that it coincided with puberty and I thought that when she was getting a bit dreamy and getting bad headaches and looking a bit pale, I thought it was because of getting her periods. ...

INTERVIEWER: Did you start to discuss and talk about it together?

FATHER: Yeah, we talked about it in the car one time and I said to her, 'I used to get a bit depressed when I was teenager as well'.

MOTHER: It was interesting that because I never used to get depressed. . . .

FATHER: And she said 'Oh did you?' She was interested in that as if that was the problem and it was; 'Oh that's alright then '. ...

MOTHER: It was like she was swamped in depression. We went on holiday one time with Dave's sister and her two boys and we remember knocking on their door and saying distinctly to them, 'you've got to see a change in Annie, Annie's changed', do you remember? We forewarned them that Annie had changed. . . she was so depressed, it was so apparent that I thought that they would wonder. . . it was as if we'd accepted that Annie had changed.

INTERVIEWER: Could you describe the 'breakdown ' for me?

FATHER: She went to bed with a headache. . . .

MOTHER: She was still getting headaches. . . .

FATHER: She got out of bed, this was in the daytime, in the middle of the afternoon, went to the bathroom, locked the door, started washing herself. . . .

FATHER: It took two hours to get her out. . . and she was walking round the house, she was even banging her head against the wall, things like that.

MOTHER: Sort of flopping back against the wall. . . .

FATHER: That's when we called the doctor and he came straight out.

MOTHER: She got down under the table. . . .

FATHER: The doctor examined her and said that she could probably go back to school. . . .

MOTHER: Then she started asking him about God and what he thought about God and I think he said that she ought to go and see a psychiatrist.

FATHER: Yes he did say that but he didn't make any arrangements. . . .

INTERVIEWER: So you took her to a psychiatrist?

MOTHER: She got so she wasn't even walking. . . . They wanted to check when she went into hospital that she hadn't any drugs, her pupils looked dilated. . . . She lay on the psychiatrist's floor all the time. . . . She seemed to be in a kind of a trance. I know it seems a strange thing to say, but when she was in that kind of a state it was as if she was not with us. . . .

INTERVIEWER: What's your understanding of the diagnosis and what professionals were saying about her?

MOTHER: We understood that Annie was getting very disturbed, before she got ill. . . . She was always such a girl you could rely on. . . . Annie suddenly became different, very different, incapable of coping. . . .

FATHER: But regarding the diagnosis. . . it was not that we could accept that she was schizophrenic right away, it took years. . . .

INTERVIEWER: How could things have been different or better in terms of the sequence of events . . . ?

FATHER: I don't know if it would have made any difference at all, but I suspect if she had seen somebody, sort of six months prior to the breakdown or even a couple of weeks perhaps that they would have recognised something. . . .

MOTHER: She was only 12 and three-quarters.

FATHER: It might have prevented. . . .

MOTHER: She was so young.

FATHER: Prevented the big breakdown.


Annie's was perhaps the most disheartening of our sample since her condition had showed little improvement over a period of six years and she had become identified as suffering from a serious schizophrenic illness. Many of the staff who had worked with her and her family had, after contemplating various possible explanations, conceded that perhaps hers was a case of a 'truly' organic and relatively incurable illness. None of the professionals who had been involved with the family (including attempts at family therapy) felt that they had been able to do very much to help Annie. Her parents' final comment in the interview was that though the various staff involved had been helpful, Annie was 'no better than the day she had broken down six years previously'.


However, in the parents' account it is possible to see how Annie's condition may not simply have been due to an 'organic' illness. It seemed apparent that she had started to gain an identity as a 'difficult' child from the time of her birth. Annie's early emotional experience of her family may have been ambivalent and contradictory. Prior to her birth, her father had been depressed but he was 'cheered up' by Annie's birth, whereas her mother became depressed and found her a 'difficult' baby. A sense of her being 'odd' or 'strange' appears to have persisted. At adolescence her interests in astrology were seen as 'obsessive'. Later the initial indications of problems were framed as depression which her father had experienced. This framing started to be widely used so that the parents forewarned their relatives that she had 'changed'. A theme in Annie's case is that people successively react to her actions within an increasingly pathological framework. There is no indication of influential alternative narratives, apart from her mother's view that she might have been suffering from normal teenage 'moods'. The parents suggest that an earlier intervention might have prevented Annie's condition from becoming so extreme.


The parents appeared initially to be trying to make sense of Annie's increasingly worrying condition through a tentative definition of her actions as normal teenage rebellion, frustration or anger. A slippage towards pathological definitions, however, could be seen in her father's confidence to her that 'I used to get a bit depressed when I was a teenager as well'. Alternatives to a medical or non-pathological view therefore appear only to have been briefly contemplated, then largely dropped. Although the parents indicated that when the GP was first called he was not immediately convinced that there was anything seriously wrong, he appeared to have quickly gone along with the idea that she needed to see a psychiatrist. It is possible that at such a critical point families need considerable reassurance and support if they are to contain such a disturbed youngster. However, like the professionals who come into contact with them, all may be caught in the widely shared dilemmas, such as whether to regard such distress as an illness or as some psychological problem.




Overall differences between the clinical and non-clinical groups

Although our groups are too small to allow us to form valid generalisations, one of the most striking initial findings was that the severity of the periods of difficulties and types of problems reported in the two groups did not differ as much as we had anticipated (see Figure 2) .This was surprising, given that our clinical group comprised youngsters and their families who had experienced severe problems. For example, out of the eight non-clinical participants six had experienced severe distress at some stage in their lives and six had experienced depression. Out of the six who had experienced depression, two had made suicide attempts and two of the women had been seriously physically and sexually abused in their relationships. Only two out of the eight participants reported having had no significant problems but of these, one woman had indirectly experienced problems in her family. The other stated that she coped by 'denying' her problems and adopting a position of emotional withdrawal following her divorce. Interestingly, only two had received any formal psychiatric assistance and two more had attended for counselling.


Range of explanations and alternatives that were contemplated

People in the clinical group tended to have a more fatalistic and one-track view of their lives (Figure 2). They generally appeared to find it hard to conceive of how their lives may have gone along different pathways, and especially what factors might have contributed to their being able to avoid entering a 'psychiatric career'.


Perceived sources of support available at the time of the onset of problems

The non-clinical group generally stressed that there were a number of people to whom they could turn for support or who came to their assistance in a significant way. In the clinical sample the picture painted was bleak. Their parents were reported to have been distressed and exhausted, absent, or even highly critical (Figure 2). Likewise, friends were seen as having either disappeared or as unable to deal with the problems.


Ability to articulate alternative pathways along which their lives could have proceeded

The non-clinical group was generally more able to articulate alternative pathways. Interestingly this did not just include positive pathways but also an ability to contemplate how their lives might have deteriorated if certain events had or had not occurred. This ability to contemplate alternatives may be related to the patterns of early attachments. For example, the more secure attachments evident in the non-clinical group seemed to offer a basis from which alternatives, including threatening possibilities, could be contemplated.


Perceptions of potential positive inputs

The members of the two groups showed some agreement in suggesting that a positive factor in preventing problems was the opportunity to talk about their problems to a sympathetic and patient listener. Giving advice was generally seen as not very helpful. Material help, such as accommodation, help with money and protection was perceived as helpful.


Perceived emotional stress

A common theme in accounts from the clinical group was that the parents had experienced severe emotional distress and became emotionally drained by the difficulties. The parents suggested that they would have welcomed and benefited from support at an early stage in the development of the problems. In short this suggested that in the clinical families there was a low level of emotional resilience or spare emotional capacity to help contain the anxieties associated with the onset of the difficulties.


Supportive relationships

What seemed to be a common theme in the non-clinical sample was the availability of one or more people who were considered as supportive during the person's time of major stress or 'crisis'. This is broadly in agreement with Brown and Harris's (1989) studies which emphasized the importance of social support in reducing vulnerability to depression. This support was not simply in terms of emotional reassurance but appeared to feature the ability of the person to offer alternative explanations and solutions to problems. Many reported that this supportive person was someone whom they trusted and who offered some alternative narratives. For example, Andy described how a priest said to him, 'You can't stop a bird flying over a tree but you can stop it landing and making a nest.' This helped him to perceive that 'odd' ideas and strange feelings might pass; they need not necessarily make a 'nest' in his mind. The ability to accept such alternatives appeared to depend on both the availability and the person's ability to make trusting relationships. Without exception our non-clinical sample could point to such people. In contrast, without exception people in the clinical sample could not. Lionel, for example, described how his grandfather had died, his best friend had moved away and that he felt distanced from his parents.


Contained in these accounts were examples of internalised conversations. There were also examples of imaginary conversations, for example, with parents. Perhaps what is deemed to be support, or the lack of it, is the availability to imagine positive rather than negative conversations with others. Lionel, for example, could only contemplate rejecting and humiliating conversations, even with his best friends, if he were to disclose his rape. Fear of negative interactions seemed to close off the possibility of helpful conversations with others even when positive support was available. This of course is consistent with the frequent observation that people with long-standing and serious problems are often very reluctant or unable to talk to others.




We are aware of the many limitations of our study. From such a modest sample we cannot claim to be able to make broad generalisations about the nature of the development or avoidance of problems in families. Our intention was to take a detailed look at the processes in a sample of families and individuals. The results from our clinical sample, however, confirm our extensive clinical experience.


Our evidence is based largely on retrospective accounts which may not be 'reliable' in that they are based on potentially distorted memories of distant events, actions and feelings. Moreover, they may contain distortions fuelled by attempts at retrospective justifications. However, we did compare the family's accounts with those given by professionals involved with the clinical families and prior case notes. These showed considerable agreement, including accounts of the emotional dynamics at the onset of the difficulties. Regardless of such questions of 'truth " our contention is that these accounts contain the belief system or world view that the families and individuals have evolved, as well as the consistent narratives and themes which have shaped their thoughts, feelings and actions. 'True' or otherwise, they can be seen to represent the map that has guided people's perceptions of their problems and shaped their avenues of actions.


The findings offer broad support for our initial hypotheses. Perhaps the most surprising finding came from our non-clinical sample in terms of the extent and severity of difficulties which people reported having experienced. Based on our study and the wider literature on the prevalence of mental illness, we suggest that it is likely that most, if not all of us experience some difficulties at some stage in our lives which constitute a crisis and which, 'but for fortune', could lead us into more serious 'mental illness'. This has considerable implications for clinical work. In effect, it appears that it is not the severity of the initial difficulties that is the key to how the problems will evolve, but a combination of circumstances and consequences. These circumstances appear to operate at all three of the levels we have outlined above: personal, interpersonal and societal. The prevalent societal discourses can encourage individuals to be conscripted into pathological identities since problems are seen as features of individual weakness or illness. If the person feels insecure and vulnerable, they may more easily succumb to such pathologising of their identity. In turn this depends on the nature of their relationships with other family members. Parents or other relatives who are able to offer support can help to offset such an escalation of problems. Conversely it appears that in many of the clinical families, either the parents were already in a state of distress and could give little support to their children, or alternatively their children's distress activated their own insecurities so that the distress reverberated throughout the family.


Many of those in our clinical sample describe a hostile dependency on their parents. They described having received rejecting messages from their parents from a very early stage, and yet because of their anxiety, they had clung to them even more tightly. This was also evident and supported by our appraisal of the family dynamics displayed in our family interviews. In contrast, the non-clinical sample described more positive relationships with their parents, but also, when faced with a crisis, they appeared to have more options available as a means of escape from progressive psychological disturbance. It is clear that the clinical group had a very limited number of explanations for their problems and were held back, or held themselves back, from developing alternatives by negative anticipations of how others would react, and specifically what they would say. In effect they seemed much less able to contemplate positive, validating and constructive conversations and interactions with others.


The explanations of their 'problems' appeared to have evolved rapidly and were then held on to by the family; for example, that a child had a 'weak' disposition or a medical condition, or even in one case that a child was 'evil' and in need of exorcism. For several of the young people early negative experiences of family relationships appear to have installed negative models of relationships overall. These in turn may have made it difficult for them to form attachments with others, such as friends or teachers, or to join organisations such as clubs or church groups for support and validation. Consequently they were likely to become increasingly thrown back on their parents with the result of increasing conflict and ambivalence, typically leading to the involvement of psychiatric services. Although potentially helpful, such progression could also mark their distress as 'abnormal' and 'pathological'. Once established, a psychiatric designation seemed to serve further to reduce the possibilities of the young people being able to imagine or engage in constructive interactions and conversations, since their inner thoughts and voices were designated as 'deviant', 'odd' or 'mad'. A possible consequence is that they became increasingly unable to talk to others, but also to themselves in new and constructive ways.


Impact on our clinical practice

This study has already resulted in a subtle but influential change in our work. Instead of looking for why and how a family is somehow 'getting it wrong', we are much more inclined to view their problems as common facets of the struggles that all families may have to face. Attending therapy can be seen as an important step towards being able to contemplate new narratives and ways of dealing with their difficulties; a first step that many other families may not be able to make. At the same time, attending for therapy may also result in beliefs about individual or family 'pathology' being supported. Our study has alerted us to how we need to try all the harder to avoid colluding with pathologising practices (White, 1995). We also see important links between family beliefs, including their models of attachment, emotional responses and how these both shape and are shaped by the patterns of actions and attempted solutions in families.


This study has made us more aware that families often experience great distress at the onset of difficulties. In a sense they appear hungry for information, advice and support. Where this is lacking in their family and social networks, the input of professional systems may be all the more significant. It is possible that some input, for example, an early and perhaps rigid labelling of the difficulties as medical, as part of an illness, may have the effect of closing down alternative narratives and pathways to resolution. It is also possible that too rigid a view of the difficulties as social as opposed to medical, or due to deprivation may likewise have adverse effects. This can seem like a dilemma: how to offer support without seeming vague and equivocal in our intervention? Perhaps it is helpful to remember Watzlawick et al.'s (1974) observation that 'how' and not just 'what' we communicate is important. Contemplating alternative narratives, remaining curious, but in a supportive, considerate way may perhaps go some way towards avoiding too early closure of possibilities and pathologising. .



We wish to thank Dr Jenny Crickmay and staff of the Young Person's Centre, Mount Could Hospital, Plymouth for their invaluable assistance with this study and Louise Brown for her assistance with the final stages of this paper. We also thank Alun Ford for taking part as one of our interviewees and for his comments and reflections on this paper.



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a, Clinical Course Co-ordinator and Consultant Clinical Psychologist, Salomons Centre, Broomhill Road, Southborough, Tunbridge Wells, Kent TN3 OTG, UK

b, Consultant Child and Adolescent Psychiatrist, Shrewsbury, UK

c, Senior Registrar, Child and Adolescent Psychiatry, Torbay, UK