Assoc. Prof. Dr. Dilarom Demiralay
1 PERSON WITH MENTAL DISABILITIES AND HIS MICROSOCIAL WORLD
2 THE INFLUENCE OF THE FAMILY ON THE ARISE AND COURSE OF MENTAL DISORDERS
1 PERSON WITH MENTAL DISABILITIES AND HIS MICROSOCIAL WORLD
The study of morbidity and the provision of psychiatric care to people throughout their life cycle show that some mental disorders arise predominantly during certain age periods, others can appear at any age, but at the same time they have features associated with the age-related capabilities of mental processes and personality at the time of the disease. The clinical picture of the disease manifests itself not only in the personal, but also in the interpersonal space of the patient’s life. First, this concerns his life in the family.
During early childhood, children especially clearly show signs of residual organic brain damage in the form of mental retardation or disorders of behavior and interaction with family members.
When a child is lagging in mental development, parents, especially those with low education and a low cultural level, migrants who have poor command of the English language and are poorly integrated into the life of the U.S. city, at first often categorically resist diagnoses for the child expressed by specialists, even in a presumptive form. During the child’s preschool childhood, parents, having agreed with the diagnosis of congenital mental retardation or mental retardation, often look for someone to blame for the delay, blaming each other with steadily increasing tension in the relationship. At the same time, the style of raising a child, especially on the part of the father, is often inadequate, overly demanding and even despotic. The mother usually takes a softer position in education, and the grandmother pursues a line of indulgent overprotection. Conflicts due to differences in parenting style move from the parental subsystem to the marital subsystem, leading to marital disharmony. The father gradually distances himself more and more from family problems and, while the child is studying in the primary grades of a correctional school, often leaves the family.
In families with a high cultural and (or) material standard of living, after the parents accept the child’s diagnosis, there often follows an exaggerated search for the “best” specialists and treatment, correctional and educational institutions with the goal of “full recovery.” Gradually, parents become convinced that their expectations, despite the efforts made, do not give the completely desired result, and the child spends more and more time in specialized institutions and is at home less and less, the child’s emotional isolation increases, especially since the parents may have another child, to whom they will transfer all their hope and love.
Behavioral disorders caused by residual organic brain damage in young children most often manifest themselves in the form of hyperactivity syndrome, increased aggressiveness, neurosis-like or autistic symptoms.
Manifestations of behavioral disorders change their structural and content characteristics during the growth and development of a child; and the upbringing style of their parents and grandparents, as a rule, remains unchanged. With a “democratic” structure of intra-family relations, a connivance or contradictory inconsistent style of education is more often observed. In a “dominant” way of life, a despotic-authoritarian style of education predominates. Moreover, if in the first year of a baby’s life close relatives quite adequately help the mother-child dyad to function, then during the early years of the child (as the difficulties of his behavior increase), fathers often begin to shirk educational functions, immersing themselves in work, hobbies, alcoholism, etc. During preschool childhood in extended nuclear families, grandmothers are actively involved in the upbringing process, because mothers go to work, and the child’s stay in preschool institutions can be complicated by the child’s complicated relationships with peers and teachers. The relationship between father and mother during this period becomes even more tense and functional, the boundary between the marital and parental subsystems is blurred, and the child’s behavior disorders are further aggravated.
In preschool age, children begin to manifest and record individual behavioral reactions characteristic of constitutional psychopathy, psychopath-like personality formations due to mild organic brain damage, or signs of path characterological formation of the child’s personality appear under the influence of an unsuccessful style of his upbringing in the family.
As school begins, the child’s behavior disorders are usually accompanied by problems with academic performance. Mother and grandmother are trying unsuccessfully to correct the situation with strict control and forceful methods. Gradually, the mother withdraws from parenting, citing the need to earn money and arrange her personal life. If a stepfather appears in the family, he often refuses to take part in raising the child after several unsuccessful attempts to intervene, declaring that this is not his child and since the mother raised him this way before, let him continue to raise and re-educate him. The mother, in turn, begins to blame the grandmother for the improper upbringing of her grandson. Teachers at school begin to treat such a child with prejudice in the form of a certain label, and classmates come up with a nickname for him in accordance with his leading style of unsuccessful behavior and relationships. Thus, such a reorganization at this stage of the life cycle of such a family without professional psychological correction and psychotherapeutic assistance often does not give positive dynamics in the development of more adequate behavior of the child.
In adolescence, the maladaptive behavior of such children is revealed with clarity. Accentuations of character become aggravated, and psychopathic personality traits appear to a significant extent. In children with hyperactivity syndrome, for example, during the years of study in the lower grades it is usually possible to achieve relative adequacy of behavior, but in adolescents their energy intensity again sharply increases.
The desire for leadership, chaotic plans, instability of interests and confusion of actions and activities. After leaving school, the adaptability of their behavior is associated to a greater extent with their social circle outside their family. Such people are often characterized by optionality and irresponsibility in business; they often change jobs, professions, wives, and friends. When communicating, they strive to suppress other people’s initiative, imposing their desires. They are stubborn, picky, irrepressible in various endeavors and, just like hyperthymic psychopaths, never lose heart when any plans collapse. They treat their own children lightly and superficially. In the second half of life, they often experience hypertension and myocardial infarction, but they treat their illnesses without deep feelings, despondency, or depression. Children with autistic syndrome due to organic brain damage during infancy do not cause much concern for most parents, but already at an early age from one to three years of life, the peculiarities of their contact primarily with the mother and other relatives, the lack of need to communicate with children, The uniqueness of play and non-play behavior encourages parents to seek advice from specialists. At this stage, parents usually act quite unitedly and actively, trying to cure the child. They try to find the “best” specialists, medicines, and institutions for this. However, the dynamics of adaptability and adequacy of behavior in such children usually proceeds slowly. The intensity of family members’ efforts around this problem is gradually weakening. During the period of the child’s education individually or in a school of one type or another, fathers tend to become more and more involved in their careers, formally paying less and less attention to their wife and child, and in the end, they often create another family. The mother makes great efforts to ensure that the child graduates from school; she tries, with varying degrees of success, to find him a job and get him married, but such attempts often end in failure. The mother most often refuses her remarriage and lives alone with her son, as if carrying her cross with a sense of sacrifice. In the families of some of the “new Russians,” the slow dynamics of positive changes in the child begins to irritate the fathers, and they plunge headlong into business matters. Mothers are increasingly beginning to take care of their personal affairs, entrusting the care of the child to a nanny, governess or grandmother. Resolving the issue of educating a child in the structure of a correctional school or in the form of home education further provokes such an attitude in them. Ultimately, such parents distance themselves so much from their child that they stop caring for him altogether, only allocating money for this to people who do this.
If a child develops a mental illness, such as schizophrenia, at an early or preschool age, especially against the backdrop of the patient’s intellectual development ahead of his peers, then parents, at the first diagnostic doubts of the psychologist or psychiatrist whom they came to for consultation, rarely seriously evaluate this possibility. Usually, they ignore the first psychopathological manifestations of the sick person, fixing their attention on the child’s high talent in some direction and rejoicing at his unusual successes and achievements. As the symptoms of the disease increase, often already during the school years of the sick person, parents finally realize the seriousness of the situation and agree to treat the child. During the treatment process, parents reveal an ambivalent attitude towards therapy. On the one hand, they are pleased with the disappearance of acute psychopathological symptoms, but, on the other hand, parents tend to regard the initial negative symptoms of painful personality changes and mental defects as an “overload” of medications and at home, often without the knowledge of the doctor or even contrary to his recommendations, reduce the dosage medications or completely stop taking medications, stop visiting a psychiatrist and psychologist, believing that the child has recovered and does not need any help.
At the same time, parents often demand from the child no less success in hobbies and educational activities than before the onset of the disease. Teachers at school, not knowing about the nature of the student’s illness, also express their displeasure about the increase in school failure despite his “good abilities,” and parents further increase their demands on him at home. The increase in maladjustment is accompanied by a gradual loss of former friendly relationships with peers.
However, the panicky attitude of parents towards the child’s illness, with the experience of hopelessness and futility of any efforts to counter schizophrenia, turns out to be just as unsuccessful. In such cases, parents can take an educational position in the style of pandering overprotection, believing that they must provide the child with everything possible now and satisfy any of his desires, since he has little time left to enjoy life. Or the pessimistic attitude of parents can lead to emotional isolation of the child in the family with parents focusing on their own personal problems.
In mature years of life, the essence of the patient’s relationship with a close circle of people can be approximately the same, despite the different content corresponding to the life of an adult.
Mental illness in old age is also accompanied by changes in the interpersonal relationships of the sick person with his environment. For example, with involutional psychoses, psychoses due to cerebral atherosclerosis, and with late-onset schizophrenia, affective and delusional syndromes very often become the leading psychopathological manifestations, in which everyday themes are woven into the plot of delusional ideas with the involvement of relatives as characters in delusional events. In the early stages of the disease, the patient’s delusions of persecution, jealousy, litigiousness or influence are often regarded by relatives, friends, and employees as an age-related sharpening of his character traits, so those around him first try to ignore the patient’s statements or try to dissuade him, but gradually, emotionally becoming involved in discussion of the plot of delirium, they begin to actively oppose the patient and conflict with him until the absurdity of the content of the statements and actions of the sick person is clearly revealed, after which his hospitalization occurs. However, after the patient is discharged from the hospital, people around him often remain distrustful and suspicious of him, because of which any of his questionable or obscure statements are regarded by them as painful with attempts to hospitalize the patient again (no longer justified), which sharply aggravates and even makes them hostile. the patient’s relationships with loved ones, turning him into a person suffering from misunderstanding and loneliness.
The problems of relationships between sick people of different ages and others that we have considered require their solution, and with successfully established comprehensive psychological, psychiatric, psychotherapeutic, correctional, pedagogical and rehabilitation work with the patient and his relatives, unsuccessful and unpromising options for their relationships can be avoided.
2 THE INFLUENCE OF THE FAMILY ON THE ARISE AND COURSE OF MENTAL DISORDERS
In the study of the influence of the family on the patient, one does not need to limit oneself to studying only the parents. The role of other family members (in the so-called extended family) must also be considered.
Information about the patient from family members is extremely important. Family members tend to report information about the patient that differs from the information provided by the patient, which is incomplete and insufficiently reliable, passing through the prism of his disturbed mental state.
The family should be considered by specialists when discharging the patient from the hospital. Information about what the disease is prepares family members for an adequate perception of the patient’s condition, setting them up for a certain apperception of it. This perception may or may not coincide with their own ideas about the disease or may reinforce these ideas.
Modern family researchers characterize it as the basic sociocultural unit through which traditions, approaches, habits, and relationships are passed on from generation to generation. At the same time, you need to understand the possibility of analyzing the family as a complex entity in several directions:
• research of family members.
• research of family subsystems.
• family life cycle studies.
• research into the interaction of the family as a group with other groups.
• research of the family as a complete system.
Studies of individual family members include focusing on the individual, his psychology, and the behavior of each family member. The family is considered as the accumulated result of the behavior of all its members. The family consists of members who together create a qualitatively new function of the family. The interactions of individual family members can be very different. For example, normal, functional interaction between parents and children is beneficial for the development of each family member. Here, more favorable conditions are created for realizing one’s potential and spiritual development, in contrast to the environment of a dysfunctional family. Other interaction options are also possible.
An example of the advisability of taking this approach into account can be the analysis of the image of Laura in “The Glass Menagerie” by T. Williams. The heroine, within her family system, lives in an unreal fantasy world, which can be classified as a serious mental illness, for example, schizophrenia. At the same time, understanding Laura’s role in the family, her interactions with her mother and brother, confirms the need for such behavior to maintain balance in the family. The tension that arises in the relationships between family members is relieved and controlled by the presence and behavior of Laura. “By taking the fire upon herself,” she prevents the family from breaking up. Thus, maintaining family unity is an unconscious goal for Laura, which she realizes in her behavior. Laura is one of the pathological “symptoms” of her dysfunctional family.
This shift from the study of individual pathology to the study of intrafamilial interpersonal relationships is not just a different way of studying pathology, but a new concept of pathology that expands the boundaries of traditional diagnostic thinking.
The study of family subsystems involves analyzing the relationships between spouses, parents and children, and siblings. Interpersonal relationships, emotions, roles played by members of subsystems in relation to each other, conflicts that arise between members of the subsystem are analyzed.
The study of the family life cycle includes an analysis of family events, such as birth, growing up, raising children, and children leaving home.
The study of the family as a relatively isolated group involves considering the type of hierarchy in the family, methods of communication, and role behavior. The interaction of the family with other social structures is studied, the family’s performance of specific life tasks, the family’s behavior in situations of stress, its use of social and other resources to resist stress, the experience of other families and its own experience are assessed.
The study of the family as a system is based on systems theory, according to which the family is perceived as a unit existing in a system, including intrapsychic, interpersonal, intrafamilial and extrafamilial events and perspectives that interact with each other as an integral system.
The study of the family must include the need to consider the culture of premarital sexual relations. Approaches to premarital relationships vary among different cultural groups, even those living close to each other. Attitudes toward premarital relationships among different generations may change over time, which may contribute to conflict.
Hoebel, examining attitudes toward premarital sexual relations in Europe and the United States, showed that the majority of respondents accept premarital sexual relations without objecting to them or giving them negative assessments. From the Murdock ethnographic atlas, it follows that of the 863 families surveyed, 67% did not object to premarital sexual relations. Permissive societies that allow such relationships are in the Pacific zone. Restrictive societies that limit these relationships are in the Mediterranean basin. Considering these factors is necessary when analyzing the hidden stress states that arise in patients as reactions to their violation of prohibitions on premarital relations. These conditions manifest themselves in different ways and contribute to the development of disorders such as adjustment disorders and decompensation of certain personality disorders.
There are societies in which marriages are graded by parents who enter premarital contracts in advance. Such societies include some eastern countries and countries of the former USSR. In China, for example, marriage contracts are concluded even before children are born. A case is described when the parents of a little girl in Taiwan, having dressed her in a traditional red wedding suit, sent her to live and raise her in the house of her future husband. The girl grew up with her future “groom”. The bride and groom were raised as siblings with the opportunity to experience a long period of intimate contacts with an incest taboo. Contemporary research conducted by Wolf in Taiwan suggests that most grooms raised in similar conditions were reluctant to marry brides who resembled their sisters. Moreover, these “suitors” were diagnosed with psychological problems that prevented them from getting married at all. These young people, maintaining friendly relations with pseudo-brides, married other women, often visited prostitutes, and entered into extramarital sexual relations. Thus, the diagnosed disorders included, on the one hand, a tendency towards promiscuity, and on the other hand, difficulty in sexual orientation with self-doubt.
In family subsystems, the husband-wife subsystem is primarily distinguished. From a psychological point of view, the purpose of marriage, according to Lidz, is to obtain the security that a marital union provides, making life easier for partners through sexual satisfaction, satisfaction from bearing and raising children, and other ways of interacting with each other. The basic nature of marriage is the fulfillment of ethical and moral expectations through which a certain membership of the partners in society is achieved with opportunities to satisfy biological, psychological, social, and economic demands. The marriage relationship can be viewed either as a binding contract for a long period, or as a functional entity based on the mutual satisfaction of needs and relationships. If emotional needs and relationships do not meet each other, spouses may end the relationship.
In the field of clinical psychiatry and pathological psychology, many persons with mental disorders have traditionally been described and understood as individuals who are characterized by one or another individual mental pathology. When considering the family, these disorders should be classified within the context of the family. Any disorder that occurs in an individual family member and has an individual manifestation, at the same time represents a certain sign reflecting the mental ill-being of the family, which could exist before the occurrence of this disorder or serve as a manifestation of the total psychopathology of the entire family. Individual psychopathology reflects the pathological functioning of the entire family. More thorough research makes it possible to diagnose a complex of dysfunctional relationships in the family that require intervention to eliminate them. For example, psychosomatic disorders of a family member make it possible to establish a connection between these disorders and the nature of the patient’s daily life in the family. In such cases, as a rule, rigid relationships, chronic stress and intra-family conflicts are diagnosed. If one of the family members develops a mental disorder, it is transmitted to one degree or another to another family member and, thus, one family member “infects” another with a mental disorder, which can manifest itself with clinical signs such as dissociation, conversion disorders, suspicion, psycho-emotional stress, delusional manifestations, etc. Analysis of the described contagious phenomenon in one of the family members indicates that the occurrence of a mental disorder in him is secondary. Sometimes such a diagnosis is possible only because of long-term observation in conditions of separation of family members, as a result of which primary mental disorders do not go away, and secondary mental disorders, induced in another family member, due to the influence of the “true” patient, disappear after some time. A process affecting two family members is called “disease of two.” If more people are included in this process, the term “family madness” is used. The largest number of such induced contagious mental disorders, including 103 cases, was analyzed by Granlick.
Gregory described the situation of transmission of such violations from husband to wife and vice versa. Waltzer provides anecdotal evidence describing a psychotic family in which an illness that arose in one family member induced illness in 12 family members. Tseng described a paranoid family in Taiwan in which a brother induced persecutory delusions in his sister, who “transmitted” her induced symptoms to her husband, subsequently inducing five children. A case is described of the emergence of a delusional idea of persecution in a Taiwanese man in relation to communists who were underground. The appearance of such symptoms was facilitated by real stress that took place in the patient’s life, such as theft, inability to get a job, and somatic illnesses. The emerging ideas of persecution were induced by all family members who considered those around them dangerous and took the necessary measures to protect themselves.
Studies reveal the presence of premorbid characteristics in family members that predispose them to the development of induced psychotic states. These premorbid features include certain biological determinants; the presence of strong emotional ties between family members that ensure their attachment to each other; presence of stressful situations.
The emotionally stable ties that exist in a family contribute to the emergence among its members of a desire for family unity, a desire to share family hardships among themselves, and to be closer to each other. Nevertheless, in such family’s conditions may be created for the induction of psychotic disorders. Induction often develops if a family member falls ill who has special authority associated with age, with intellectual superiority, and the habitually established system of intra-family relations contributes to the fact that all family members trust the sick person and, to some extent, depend on him.
The influence of the family factor can be traced in the induction of not only delusional disorders, but also other disorders, in particular social phobia.
Social phobia is characterized by a persistent, irrational fear of contact with other people, in which a person tries to avoid situations that pose a potential threat to him. Some time ago, this disorder was not diagnosed or was lost in the array of various obsessive fears. Currently, societies and social structures are identified in which social phobia occurs more often than in others. In Japan, social phobia is diagnosed as a fear of being afraid of people, which occurs primarily among young people and especially teenagers. The cause of the disorder is the concern characteristic of this age associated with the impression that the teenager makes on others. Preoccupation leads to fear of close contact, fear of verbalizing one’s thoughts in the wrong tone, with the wrong facial expression, with excessive emotional expression, etc.
An analysis of social phobia in Japan led to the conclusion that this disorder develops in “extremely sensitive”, reflective individuals who are discriminated against and lack a sense of trust in the family. The presence of factors that cause a socially negative assessment of the family is important. Such traits condemned by others include social failure, divorce of parents and all those situations that reduce children’s self-esteem and make them overly sensitive to evaluation by others. In a favorable environment typical of functional families, the development of social phobia is unlikely. Family factors predisposing to the development of social phobia are verbal and nonverbal communication errors that undermine the child’s confidence in the effectiveness of his communication with other people. For example, when communicating with visiting guests, the child tries to socialize by talking with them, trying to express himself in some way. Parents emphasizing the child’s behavior that is inappropriate, from their point of view, will contribute to the child’s future development of social phobia.
Experts more often declare than study the importance of family relationships in the occurrence of neurotic disorders. This results in very few studies addressing this issue. Xu, Cui, Tseng and Hsu, studying women with “neurotic” depression, found in them, in contrast to control groups of women of the same age, “less cohesion” of their families. Respondents who were dissatisfied with relationships in families considered them to be a poor example of adaptation. The researchers concluded that for the Chinese, a dysfunctional family is a stress factor that influences the development of depression. Lack of a sense of the protective function of the family predisposes to low mood. At the same time, the authors concluded that low family cohesion is more correlated with the development of depression than with the development of anxiety. Such patients present with neurasthenic complaints.
A study of the role of the family in the occurrence of eating disorders has shown that this type of disorder occurs in families with vague boundaries in the “parent-parent” or “parent-child” subsystems. These families are characterized by overprotectiveness; the desire to control everything that is possible and impossible; rigidity – the inability to change stereotypes, getting stuck on them; inability to resolve conflicts with direct or indirect involvement of adult children.
Johnson and Flach write that patients with bulimia are characterized by an altered perception of their own families, perceiving families as cohesive and not stimulating the independence of their members. For example, parents, on the one hand, strive for their children to be dependent, and on the other, they show a certain dependence and dominance towards each other. A high level of conflict is characteristic, along with frequent suppression of negative emotions.
The authors draw attention to the fact that anorexia in children raised in such families is associated with the desire for self-expression, in which the child thus tries to demonstrate to himself and his parents his volitional and emotional competence. The child views fasting as a heroic act that deserves recognition.
Transcultural studies examining the influence of a country’s socioeconomic situation on hunger and overeating show that eating disorders are more likely to occur in developed societies with a high level of welfare of their members and much less likely to occur in undeveloped areas experiencing greater economic need. The shortage of food, characteristic of economically undeveloped countries, leads to less fixation of the population on overeating and starvation. For example, in Singapore, Taiwan and Japan before World War II, there were practically no overweight people. With the improvement of the economic situation in these countries, the number of overweight people neglecting a physically active lifestyle has increased sharply.
The influence of cultural factors on the formation of a certain attitude of people with a desire to overeat has been proven.
This appears to be driven by a positive assessment of excess weight, which is culturally a sign of beauty, health, and well-being. Many cultures are characterized by the opposite tendency, the desire to follow guidelines for models that exclude completeness. In these cultures, chronic food restriction is more likely to occur, and pathological weight loss is considered an achievement.
Modern family psychiatry, when assessing painful disorders, considers as the cause of the disorder not the influence of individual individuals, but the family as the main carrier of psychopathology, based on the principle that the whole is always greater than the sum of its individual components. That is, members of a family consisting of several people, joining together, function as a new unit with certain relationships. This system is the result of interactions, without which its existence is impossible. Each family member within this system acquires new qualities.
Of particular importance for the formation of a predisposition to the development of mental disorders in the family is the phenomenon of mutually exclusive coercion, which can be characterized in the following examples.
A teenager, emotionally closely connected with his mother, receives a “message” from her that he must study very well. They perceive this as an incentive to learn. In response to her son’s message that he is going to the library, the mother “gives” a sharply negative reaction, excluding the first message and accompanied by the words: “How can you leave home, because you spend so little time with me.”
Second example. The father tells his daughter that he loves her very much. The daughter, guided by his verbal recognition, tries to approach him, and caress him, but he moves away from her. The daughter experiences a state of internal tension and misunderstanding.
Third example. A mother, angry about something, experiences sharply negative emotions towards her crying child. But in the process of approaching him, she is overcome by a feeling of guilt due to her negative emotions. Unable to suppress them, she outwardly shows the child a feeling of love, tenderness, care, and affection. In such a situation, the child perceives two “messages”. On the one hand, he feels that his mother does not love him, and on the other hand, he is confronted with the tenderness demonstrated by his mother. The feeling of falsehood provokes the development of a state of uncertainty and anxiety in the child.
An environment filled with mutually exclusive compulsions leads to the fact that a child, growing up, is poorly versed in communicating with people, not knowing what to expect from them. Such upbringing contributes to the development of suspicion, uncertainty, and leads to the desire to be socially isolated.
The phenomenon of mutually exclusive coercion is present in the structure of narcissistic relationships in the family. Thus, women with pronounced narcissistic characteristics experience dissatisfaction and internal irritation due to the husband’s inconsistency with the prestigious scenario. She expresses her emotions with reproach: “You are not active, you are not up to par, you are not successful. You have to succeed.” Such a verbal message is perceived by the husband, and he begins to achieve success. However, soon this behavior of the husband ceases to suit the wife, who sees an element of competition in this. Since this feeling is not entirely conscious, she shows indirect aggressiveness, using various methods of “subversion”, switching her husband’s attention to actions that impede success. As a result, the husband feels confused.
Consideration of the family structure of mentally ill patients from the standpoint of studying the presence of the phenomenon of codependency in these families has not yet received sufficient attention. The phenomenon of codependency has been well developed and analyzed only in the model of addictive behavior. At the same time, codependency also manifests itself in other disorders, acting, for example, within the framework of co-addictive disorders, in which we are talking about the interaction of several people suffering from addictions with each other.
Codependency can be considered both a form of disease and an addiction that goes beyond chemical and non-chemical addictions. Codependency is an addictive relationship in individuals with avoidance disorders, dependent individuals, and in families of patients with mental illness.
The first strategy used in codependency is control. It is impossible to consider codependency within the alcohol model without focusing on the control strategy that exists within it.
The control strategy is carried out by codependent people in families of mentally ill people and looks like this. Healthy family members, having received information that one of the family members is mentally ill, take on the functions of control over the behavior of the patient. This control can be quite strict. The role of controller is often very satisfying for a family member, giving special meaning to his life. The control exercised over the patient leads to the fact that various types of his activities, which have nothing to do with pathology, but are associated with his usual motivations, begin to be controlled and condemned if the patient’s behavior does not coincide with the scheme existing in the mind of the controller.
Control is characterized by suspicion, accompanied by questions like: “Where have you been? Who did you talk to? What did you do?” Such control has negative consequences for all family members, provoking the emergence of negative feelings both in the patient towards the controller and vice versa. A vicious circle of mutual negativism arises. Control leads to increased autism and behavioral passivity of the patient. It is also possible to provoke the aggressiveness of patients and actualize paranoid reactions.
Parents of patients with schizophrenia, having learned that such patients are characterized by a negative attitude towards loved ones, are in a constant search for such a negative attitude towards themselves, fixing their time and attention on this.
In addition, specialists should remember that ambivalent interpersonal relationships may be a sign of normality rather than pathology. “Looking out” for pathology in ambivalence can significantly worsen interpersonal relationships.
The second strategy option used for codependency is protection—protection, which is closely related to control. In the family of a patient with schizophrenia, this protection often manifests itself in the fact that the patient is protected from the possible consequences of his active behavior. The patient is protected in such a way that he does not have the opportunity to actively communicate with others, as this could undermine the authority and prestige of the family. Protection can also manifest itself in protecting the patient from performing production, academic and other functions. In these situations, professionals and family members act as members of the same team, for example, in the case of a decision agreed upon by both parties that it is better for the patient not to work or study for a certain period. The reasons for making such a decision are difficult to explain, since there is no convincing data on the negative effects of work and study on the course of an endogenous disease. On the contrary, information is provided that the use of the creative potential of the endogenous patient leads to an improvement in his condition. Even catatonic rudiments can be overcome in the process of creative work. Family members, picking up the idea of the need to refuse work and study, contribute to this style of behavior, being unaware that such a strategy will only harm the patient.
The patient’s problems associated with the pathology of his volitional function in an endogenous disease are only intensified due to the fact that he is placed within the framework of the need to carry out a strategy of passivity as a result of the use of a protection strategy by relatives.
The problems inherent in the family of a mentally ill person include the problem of marriage. If an adult son or daughter goes into remission or recovery, then the implementation of a control strategy leads the parents to decide on the need to realize matrimonial prospects. This desire of parents is usually based on their fear that their son or daughter will never get married. Therefore, when the first opportunity arises, you should implement it. Since persons with endogenous disorders, being introverted, have difficulty entering interpersonal contacts; the choice in matters related to the decision to start a family is often made for them by their parents. For such marriage contracts, parents often choose people who want to dominate, control, and intuitively feel that in the upcoming marriage their desires can be realized. A partner’s awareness of his own advantages over an unhealthy partner may appeal to a future controller. Parents are also satisfied with this situation since they finally have the opportunity to transfer to a future family member the functions of control and protection that are boring to them. With this choice, parents implement a strategy of concluding a marriage contract with lightning speed due to fear of possible negative activity of the patient and deterioration of his condition. Parents demonstrate the positive qualities of the patient with the artificial creation of situations that hide his negative qualities. In the event of the first manifestations of negative characteristics of the patient, contacts with the intended marriage partner are temporarily stopped at the initiative of the parents.
In alcoholic families, control has slightly different specifics. It lacks emotionality and is more formal. The alcohol addict does not receive sufficient emotional support. This background is layered with mutually exclusive coercion.
The importance of family factors in endogenous diseases cannot be underestimated. Sartorius, for example, emphasized that in underdeveloped societies, patients with schizophrenia have a better prognosis. One of the reasons for this fact is that family and clan support for patients is more pronounced in these societies. Research conducted in Beijing confirms that patients with severe mental disorders who participate in social and occupational activities have a more favorable course of illness than patients undergoing therapeutic treatment in hospitals.
The Australian-New Zealand model of family relationships confirms that treating patients with psychopharmacological drugs at home with a doctor’s visit is more effective than hospitalizing such patients. The use of this model in the treatment of patients suffering from endogenous diseases has led not only to a greater therapeutic effect, but also to economic efficiency associated with the unloading of psychiatric hospitals. Patients who were treated for a long time in psychiatric hospitals in England and then moved to Australia and were treated according to the local model noted its greater effectiveness compared to the English model. This was confirmed by experts and was convincingly demonstrated at the World Congress of Psychiatry of the World Federation of Mental Health in Dublin.
It has been noted that people suffering from schizophrenia and living in extended families that include several generations of relatives have a better prognosis due to the fact that such patients receive additional care from numerous relatives who are not part of the “nuclear” family. Nuclear family members are prevented from providing the necessary care for the patient by the control associated with their codependency, while relatives of extended families do not have this codependency. Additional family members try to reduce the patient’s social withdrawal and isolation.
It is considered advisable for patients with endogenous diseases to undergo social rehabilitation in hotel-type homes, which is extremely useful for such patients. In these “halfway houses”, patients participate in professional activities, self-care, and restore self-sufficiency skills. When implementing these skills at home, it is difficult to avoid the collision of patients with the phenomenon of codependency and control. While temporarily living in such houses, patients go to work, visit public places that arouse their interest, except for the opportunity to visit their home, so as not to fall under the influence of family controllers, since family influence can be not only positive, but also negative. Family support that turns into codependency is harmful to the patient.
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