Book Text: Part I General Issues: Parenting the Mentally Ill Adolescent Wendla A. Schwartz, MD

Part I: General Issues: Parenting the Mentally Ill Adolescent 

(Cont'd from May 7th)

Wendla A. Schwartz, MD

1. Good Enough
I met Judith when her son, Adam, was about 13 years old and was first diagnosed with a severe psychotic disorder. He had been very hard to deal with for some time but she and her husband had found it difficult to acknowledge there was something medically wrong with him. They had spent many years trying a variety of behavioral approaches, diets, exercise plans and the like. When he began to hallucinate and developed clearly delusional thinking, they blamed themselves. Judith was especially hard on herself. It seemed impossible to her that her son could be so ill and she could not somehow be responsible for his state. Judith became obsessed with parenting "perfectly,” with finding the right treatments and doctors, with behaving correctly in the complex situations that confronted her family daily. She wanted to be sure she was handling these situations correctly at home, responding to her son in ways that were most helpful to him and providing the best type of environment possible. The standards she set for herself were high, very high. She felt overwhelmed with guilt at times for not being able to live up to them.

On one particular afternoon when Adam was about 16, Judith called me very upset. She had lost her temper with Adam and screamed at him in the car.  She had picked him up from school and told him "No, she would not take him to the video store to buy a new video game". He attacked her verbally from the backseat, calling her names, accusing her of all sorts of evil intent. Likely, harboring paranoid thoughts that included his mother, Adam was behaving in an entitled, demanding and vicious manner. Judith was exhausted and really angry.  She just lost it. She turned around over her shoulder and told him to "SHUT UP" and then said a few more words, somewhat out of character for her. Judith was stricken with guilt over the episode. She wondered if Adam would be traumatized, if he would forgive her. She was plagued with thoughts that her words might cause a full psychotic episode. I let her know that one episode of parental "losing it" was highly unlikely to cause a psychotic episode. Nor was it likely to cause Adam to think his mother didn't love him or traumatize him for life.  As we talked Judith came to understand that her behavior was really OK. Parents are, fundamentally, only human.  We are not perfect and we are not required to be perfect for our kids. We are only required to be good enough. There might even exist benefits to being `imperfect’ and only ‘good enough.’ For example: Adam needs to have his extremely inappropriate outburst responded to negatively. The rest of the world will not respond to it well. Why should his mother? Granted, it is probably not therapeutic to scream or curse at a 16 year old psychotic person but, on the other hand, it is not helpful to beat oneself up for doing it after it has happened.

The original idea of 'good enough' mother applied to infant development and was originated with Donald Winnicott (1896-1971), a London Pediatrician and psychoanalyst. Winnicott wrote that the infant required the presence of a 'good enough' mother to develop his or her own sense of self as an independent being. He saw the role of the 'good enough' mother as gradually "failing" to provide for every need of the baby thereby allowing the infant to learn to adapt. Winnicott wrote:

"The good-enough mother...starts off with an almost complete adaptation to her infant's needs, and as time proceeds she adapts less and less completely, gradually, according to the infant's growing ability to deal with her failure" (Winnicott, 1953)"

(Of course some experts have taken Winnicott's work to imply a requirement of excellence in mothering in order prevent problems due to forcing an infant to adapt too quickly. Winnicott himself actually took pains to empathize with those who could not provide adequate parenting. However, for our purposes, this argument is not relevant.) Winnicott was not referring to adolescents but rather to infant development and how that relates to psychotherapy later in life. He probably never had any intention his work be referenced in a book about parenting adolescents. With that in mind we are  borrowing the concept and loosely applying it to teenagers in this way: We cannot continuously and perfectly provide for an adolescent's needs, demands and requirements. We will fail sometimes. It's inevitable. It's the nature of being human. Failing in small doses (like the Winnicott 'good enough' mother) is OK. The adolescent with mental illness often has failed to attain the same level of independence as the typical adolescent and is still working toward an independent self.  Therefore they may demand more, require more and need more from us than a more typical child of the same age. We may, therefore, find ourselves with more opportunities to fail. The ideas behind 'good enough' can get complicated and wordy. Suffice it to say:

The Rules for Good Enough Are:

1. We do not have to be perfect but only Good Enough

2. Good Enough means failure in small doses

3. Failure is inevitable

This text will be published in sections over the next several months on this blog in the hopes that it will provide ongoing support and information for families in need.

Wendla A. Schwartz, MD Board Certified Psychiatrist Child and Adolescent Psychiatrist and Psychopharmacologist