TRANSGENERATIONAL TRANSMISSION OF PSYCHOPATHOLOGY: FROM UNDERSTANDING TO TREATMENT

Periklis Antoniou Photo It was presented in a round table organized by HESTAFTA as part of the 9^thCongress of the Hellenic Society of Child and Adolescent Psychiatry

Abstract

The transmission of psychic life from parents to children and from generation to generation has been a subject of research over the past decades. In addition to heredity, important scholars, psychoanalysts (KAES R. & FAIMBERG H.) and family therapists (BOSZORMENYI-NAGY I. & SPARK GM, BOWEN M.) seek out transmission mechanisms and identify important vulnerable areas of psychic life such as values and loyalties, names, hidden family secrets, mental traumas, etc.

In clinical work with children and adolescents, psychopathology may occur at different developmental phases in various forms: disorders in early life, problems of puberty, conduct disorders, depression, suicide attempt, etc. There are often issues of the parents' and grandparents' history, leading to a better understanding of the psychopathology.

In the therapeutic work a systemic model of intervention is formulated, based on the understanding of psychopathology, the available therapeutic resources and the availability for therapy of family members. Collaboration of children, adults and psychotherapists in a network forms a multilevel intervention.

"Transgenerational psychopathology" and "transgenerational transmission of psychopathology”

We use the terms "transgenerational psychopathology" and "transgenerational transmission of psychopathology” to talk about the transmission of some phenomena of psychopathology from one generation to another, from grandparents and parents to children, in a specific way.

Child psychiatrists and psychotherapists, perhaps more than adult psychiatrists, are aware of the enormous influence that the environment, and especially parents, exerts on children,. A central issue in our daily practice is the formation of the psychic organ or the identity of the self.

In the bibliography on intergenerational psychopathology much has been written, especially the last 50 years (since the 1960s), on the part of psychoanalysts and family therapists. I think it is important that we briefly refer to what has been done in this area.

In the Laplanche-Pontalis Dictionary of Psychoanalysis (1967) we find no term relating to the transmission of psychopathology from generation to generation.

In the systemic Vocabulary and Sourcebook by Fritz Simon, Helm Stierlin and Lyman Wynne, (1985), we read in the entry on "Multigenerational Perspective/Families of Origin/Multigenerational Therapy":

"The interactional patterns of a nuclear family often prove to have been prefigured and established in the parents’ families of origin. Emotional and social disorders can thus be seen as the expression of problems that have been developed and passed on over the course of many generations… Specific rules and values of the family system have been established during the course of the family -co-evolution. In certain situations, the rules and values can result in conflict, tension and strain, which give rise to symptoms. With this in mind, it often makes sense to include parents and grandparents in therapy, either for diagnostic reasons or to change the relational patterns of the family.”

Heredity:

Of course, we must take heredity into account. In the other's phrase "you are just like your grandfather" there is a strong recognition message for the little child, but also a biological truth: the possible hereditary similarity of the form or of other physical and psychological characteristics.

Research into genetic and molecular biology cannot be ignored in our time. Few believe that serious mental disorders such as schizophrenia and emotional disturbances are due solely to psychological, social or developmental effects. On the other hand, geneticists also state that transmission follows complex genetic transfer patterns, and that what is being transferred is the fragility of the disorder, when environmental and family factors affect it.

A multi-generational perspective does not see the mother of a schizophrenic child as responsible for her child's schizophrenia. The mother is seen as one of many links in a long chain of many generations.

Anticipation of pathology

Studies have shown in some pathologies the phenomenon of the early onset of disorders in a new generation (anticipation), and in a more serious form than in previous generations. This phenomenon is of course  of clinical interest to the field of Child and Adolescent Psychiatry. The hypothesis of anticipation suggests that a disease is transmitted with increasing severity from one generation to the other in terms of both the intensity of the symptoms and the earlier emergence of the disorder.

This phenomenon has been observed in families with members with severe emotional disturbances (major depression and psychosis). What is it that plays a role in this phenomenon?

Anticipation may be due to dynamic chromosomal mutations in the genes involved, but also to the significant effect of non-genetic factors, such as environmental and family ones.

Transfer of mental life from one generation to another.

The issue of the transmission of psychic, physiological and pathological characteristics from one generation to the other concerns the formation of the psychic organ itself. For this formation, psychiatry resorts to the basic theories of development.

According to most —and the most credible— theories, the transmission of psyche on the axis of generations involves the predetermination of the subject by something that is more than his self: by the group. The child's psychic organ, which is under development, should organize its own inner intubation function, formed through an inter-subjective exchange with the important others within a group.

As René Kaës says in the introduction to the book he co-edited with Haydee Faimberg (1993): "The subject is preceded by the group. We have no choice but to join the team, as we do not have the choice of having or not having a body". And he continues: "in this way we come into the world, with a body and with a group and the world is a body and group".

Moreover, each person will have to incorporate the parental heritage in his evolving psyche. This is also emphasized by Freud when he cites Goethe's Faust's words that Goethe has him saying when he teaches his disciple: "What you inherit from your father must first be earned before it's yours" (Was du ererbt von deinem Vätern hast, erwirb es, um es zu besitzen). According to the same writer, "the subject is not the subject of a single group: there are numerous inter-subjective mental spaces whose structures and processes are transported by the mental path and which he inherits in various ways: through support, identification, integration, with the group's special requirements and the obligation to repel. Through the mediation of these groups, ideals, identities, values, ideologies and myths, defense mechanisms, rituals, are relayed and reconstructed".

The Importance of Intergenerational Transfer in Greek Mythology

The importance of genealogy can been found in ancient Greek literature. Greek Mythology studies in detail the passions of gods and humans. In the life of gods, heroes and mortals, ancestry is of prime importance while intergenerational transmission is ever present. Every person transfers and carries the virtues of his ancestors, but also has to pay for the mistakes they have made. Most of the times, tribulations come from the wrongdoings of previous generations. Genealogy explains the cause and sequence of events.

Oedipus, as a child, is sentenced to death by his father Laius, who orders the newborn's death to avoid the oracle that his own child would kill him after the curse of Pelops, whose son Chrysippus Laius had ravished. The effects of the previous generation’s wrongs are tragic and inevitable. The ancients introduce the concepts of insult (hubris) and catharsis, according to which destruction is inevitable for anyone who has violated the decisions of the gods.

The myth is understood and interpreted more easily through the study of the family tree. Laius must be punished for dishonouring Chrysippus, and with him Thebes, the city in which he is King, and all his kin. Oedipus must also be punished for his own immoral criminal acts (patricide and incest), even if he committed them unknowingly. The myth is woven upon suppression and non-knowledge of the real events by the protagonist, while its central targeting is the revelation of the truth. Catharsis occurs only when the truth is revealed and satisfactory punishment occurs (Oedipus punishes himself once he knows the tragic truth). The legacy also burdens the offspring of Oedipus, Eteocles and Polynices.

In this fable we see the central role of the secret, the transfer of guilt from one generation to the other, and the meaning of the name.

Multigenerational perspective in systemic therapy

In Systemic therapy, the multigenerational perspective has been specifically elaborated in the work of Ivan Boszormenyi-Nagy & Geraldine Spark (1973) and Muray Bowen (1976-1978).

Boszormenyi-Nagy and Spark

In their "Invisible Loyalties" (1973), Boszormenyi-Nagy and Spark define the non-visible loyalties as a cross-generational configuration of relationships involving several generations. Loyalty to one's origins, together with the questioning of this loyalty and the conflict that follows, are the two aspects of a reality: "We can say that the subject is always loyal to his origin. If he cannot do it openly, loyalty is presented in an indirect way in the form of symptoms". According to B-N and S., there is a legacy that includes both positive and negative elements and is transmitted with an imperative command. This command is an obligation for the younger person to fulfill it in the name of the previous generations.

Invisible loyalty between generations can be manifested through the repetition of the same role, of the same social situation, of a similar unresolved problem.

Bowen: The Family Systems Theory

Bowen developed the theory of family systems. He conceived the family as an emotional unit, as a network of interrelated relationships which is best understood when analyzed in a multigenerational or historical context. He believed that the impulsive force that stimulates the whole human behavior comes from the ebb & flow of family life, the simultaneous pushing and pulling between family members for "distance" and "coexistence". This attempt at balancing two forces - togetherness and self-differentiation - is for Bowen the central theme for all people. With a successful balance, individuals are able to maintain close warm relationships with their loved ones while they differentiate themselves as a person so as not to be overwhelmed by what happens in the family.

Bowen's theory of family as a system of emotional relationships consists of eight concepts. Six of them examine emotional processes that take place in nuclear and extended families. Two later concepts, emotional cutoff and social regression, are directed to emotional processes through generations, family, and society. All eight concepts are interconnected so that none is fully understood without  the others.

All are associated with the assumption that chronic anxiety is ubiquitous in life. Although it may manifest itself differently and to varying degrees of intensity, and depends on special family situations and cultural differences, chronic anxiety is an inevitable part of life - a biological phenomenon which B. believed that all people shared in all forms of life. From this perspective of physical systems, chronic anxiety is transmitted by the old generations, whose influence remains alive in the present, as families struggle with balancing their members’ coexistence and differentiation.

The individual experiences increased chronic stress as a derivative of reduced personal autonomy. Chronic stress then represents the basis of all symptomatology. The only antidote is liberation through differentiation, the process by which a person learns to map his own path instead of eternally following instructions from family and others.

According to the family systems theory (Bowen 1978), the eight forces that form the family function are:

1. Differentiation of the self

2. Triangles

3. Nuclear family system

4. Family projection process

5. Emotional cutoff

6. Multigenerational transmission process

7. Sibling position

8. Social regression

Clinical approach to intergenerational problems

In practice, we come across pathologies that can be approached with precision through the aforementioned theories. One can talk about a particular clinic of problems, focusing on key points associated with what is secret or not verbalized in a family, important dates and anniversaries, the pathology of the crypt and the ghost, the choice of partner, family attachment and detachment, invisible commandments, naming, transferred traumatic events to families and societies.

We realize the importance of these events in the understanding of the causes of the pathology and in the choice of therapeutic intervention. We believe that the perspective of the intergenerational approach helps to understand the psychopathology, is very close to the complex human reality and can therefore offer increased therapeutic possibilities for intervention in practice. The intergenerational approach seems particularly useful in understanding the psychopathology of the child and adolescent. Many of the problems of the child as an identified patient are understood if they are identified through a cross-generational perspective, i.e. their emergence, transfer and installation from generation to generation, from grandparents to parents and children, and other important persons with whom they interact. In the therapeutic context, we can also include parents, grandparents and siginificant relatives. To understand the intergenerational transfer, we are particularly helped by compiling and studying the genogram.

Apart from the parents, an important role is ascribed to the overall social group, the set of values in which the family history evolves (sociopolitical events in the country, religious beliefs), and the predominant signifiers (words, values, emotions) espoused by each family and group.

Facts and mental structures transferred across generations

Below are some beliefs and mental states or mental constructs that are transferred between generations and have particular importance in intergenerational transmission. These structures include influential ones that are of particular importance to the individual inasmuch as they shape one’s psychic world, and are usually associated with a strong emotional experience or trauma.

Attempts are often made to conceal and modify the transmission of experiences from one generation to the next, resulting in the transfer and appearance of psychopathology in the descendants, which cannot be "amortized" for generations.

We consider it particularly useful for psychotherapists and particularly those who deal with children and families to study and understand these structures. These are psychopathologies that we encounter daily among children in our practice.

A.  The general beliefs and mental structures which are trasnferred between generations may be:

1. Religious beliefs and their extreme forms of religious fanaticism

2. Political beliefs and political rivalry

3. Enmity between countries, factions, groups,

4. Traumas of loss (refugees-lost homelands, accidents, sudden deaths, natural and economic disasters).

These general beliefs shape the national identity of peoples and social groups while having a drastic influence on individual identity. Their attributes are studied by sociology and family therapy scientists.

B. Intra-family issues and mental structures which are transferred across generations may be:

1. Suppression & Secret

It may concern issues related to genealogy, especially adoption, issues related to physical and/or sexual abuse. In other cases, it may involve economic ruin or delinquent behavior and deprivation of a member within the family (fraudulent bankruptcy, unlawful enrichment, alcoholism, drugs, gambling, theft, murder, imprisonment).

Central to understanding this psychopathology is the existence of untreated trauma combined with its suppression and the creation of secrecy at the communication level. What is "suppressed" in one generation can become "non-representative" in the next. So what is silence for a parent becomes a secret for a child. Most of the time, the secret is associated with a sense of shame.

S. Tisseron, a French psychoanalyst, analyzes the mechanisms of the transmission of psychopathology in his book "Family Secrets" (2014): "The child as bearer of the secret, can thus unwittingly be identified with the part of the parental identity associated with the secret, or become the subject of a projective identification which his father had also suffered from a third party, in or out of the family. In some even more serious cases the child finds himself at the convergence of various complementary identifications, coming from different links in the generation chain. Thus, a teenager may be charged with key, shameful features from a deceased grandfather, and be also burdened by his living grandfather, his father and his uncles, since they are all carriers of the same painful secret". In other cases it is not about an unacceptable shame but about ascribing to the child the role a dear and admirable ancestor of whom no one speaks openly. This raises the problem of a possible return of the secret.

The unspoken, the unnamed, does not acquire its attributes from one moment to the next. It is hidden at the command by distant ancestors to the living family not to talk or even think about it, but at the same time there is the obligation that it is never forgotten. The transmission is sometimes modified. But the forgotten authentic word comes back. It is the return of the unspoken, of the unrepresented, of the secret in different forms and at different times.

Anne Ancelin Schutzenberger says of the unspoken: "intergenerational transfers are secrets, suppressed events, situations that are hidden, not discussed, in some cases even forbidden to think about, and are transmitted to the descendants without processing and overcoming them". So we see in our practice injuries, illnesses, physical and psychosomatic entries which can disappear if we talk, cry and work them out.

According to the family legend, the rule of silence often hurts the weakest and most anxious child of the family, who becomes the bearer of the unspeakable and of the secret. But the fact that one carries such a secret alters one’s existence. And this way of being is inherited, transferred from generation to generation, and returns in some new form (symptom). The lost word re-emerges because it cannot be hidden forever like an illegitimate child. At the end, there appears a person who is the ultimate authorized receiver, who will perform the intergenerational mission which fate kept secret.

2. Genealogy, Intergenerational continuity, gender

We all know the importance of belonging to a family line and the constitution of genealogical continuity, that is to say, the connection between generations over time, as well as of the place which a person occupies the network of genealogy, sometimes with another significance (as in the myth of Oedipus). Ceremonies are of particular importance in the intergenerational transfer. Through the ceremonies and rituals introduced by the ancestors and repeated by the descendants, the family and life itself goes on and continuity is ensured.

**3. Nomenclature (family name and first name)    **

When the same name is given from one generation to the next, we usually understand that it is about conforming to an established rule of legitimacy (custom, tradition); a structured habit that also relates to the unconscious struggle against the finite and death through the perpetuation of the name. Human weakness needs immortality. A family that ends can be a cause of unhappiness to those who end it. The burden of debt to ancestors is very heavy in the sense that you can kill not only the father and the mother but also all the ancestors. Parents' mourning is greatly assuaged when there is a descendant (who bears their name) to ensure continuity.

The name that is given and does not change is a symbolic act that refers to the family history and can be important for the fate of this child. The child can also be named after a hero, old or contemporary, a religious or historic figure or an artist who means something to the parent who chose it according to the attributes that he imagines. (It is not neutral to name your child Spartacus, Laocrates or Mohamed).

4. Position in the generation. A child born to fill a gap.

One’s position in a generation and the moment of birth play an important role. In some families, a child born after a death —usually of a previous child, or sometimes of someone else in the family— comes to replace the deceased. Often this child has been linked to death, because in the unconscious of the family his position is with the dead (since through this child they keep the dead alive rather than care for the life of the newcomer, in cases when there has been no mourning). This child will find it difficult to find his place in the family, or will risk becoming a "ghost" instead of acquiring his own personal identity.

A latter-day "mythical" person, Salvador Dali, was such a child: Dali had an older brother, much loved by his parents, who died three years before his birth, and Dali was given his name (Salvador). Dali says in one of his delightful interviews, "my whole life was defined by the existence (death) of this brother. I was pretending to be a genius from my young age because I was forced to kill my dead brother every day and prove that I would not have the fate of this brother and that I would live".  (Http://www.ina.fr/video/I00008168 Interview by Salvador Dali).

5. Professions, anniversary dates

In a genogram, (listing names, ages, dates), we often see important phases of a generation that may be related to events that occurred in the previous generation or anniversary dates.

Written by Anne Anceline Schutzenberger (1999): "The human being has an "elephant's memory," and marriage customs, number of children, and often even age at death or choice of profession are passed down  in a conscious and spoken manner. One often becomes a farmer, engineer, doctor, teacher, notary, baker or military officer from father to son, and without knowing it, we often get married and die at the same age, sometimes at the same period or date. Many people do so either consciously as part of a project, or by some prediction, unconsciously through an Invisible family loyalty".

6. Choosing a partner (spouse)

When people get married, they often choose partners belonging to a family constellation similar to their own family of origin, suffering from the same illnesses, of common roots, with matching names or having suffered similar traumas in childhood.

7. Relationships, family cutoffs and family myth

The family legend includes beliefs about family members and how they relate. These beliefs may be accepted a priori, despite any obvious deviations or violations. Family myth is a product that is produced collectively rather than individually and specifies the roles and attributes that a family member undertake in their mutual interactions. It seems that the family undertakes to ascribe roles to each of its members. From an intergenerational perspective, some members may assume the role of some ancestor.

8. The invisible loyalty

According to Boszormenyi-Nagy, in families there is a kind of big ‘ledger’ in which family relationships are recorded. It records the values and debts that have accumulated from both sides of a couple, and gives an account of assets and liabilities. If past generations have accumulated debts and injustices, the newborn inherits a heavy heritage. By legacy, B-N. means an intergenerational mandate. Heritage includes positive and negative elements. And the mandate is a duty, a function that is given from one person to another to execute in his name. Even geographical distance and the departure of a descendant does not release him from his debts to the family.

"When people repeat the same attitude, they do not change, and remain stuck in their roles, this usually serves the needs of the family obligations’ network", says B.-N.

Invisible loyalty between generations can be characterized by the repetition of the same role, the same social situation, a problem that has not been resolved, as if we have to remain loyal towards someone because we have been commanded by an ancestor.

From understanding to healing

We refer to beliefs and mental structures that are passed on to children intergenerationally. Identifying these situations is important for understanding the problems that are being transferred to the child. The drafting of a genogram in the assessment interview helps to identify the intergenerationally transmitted psychopathology.

According to Bowen, the therapist should avoid calling the family for merger and triangulation. The reduction of anxiety is the primary duty of the therapist. B. usually works with both parents. He should demonstrate objectivity and calmness, ask direct questions, focus on a self-defining ego-position. The therapist then asks each of the parents to look at their own involvement in relationships. It aims at emotional autonomy and the disengagement from emotionally loaded triangulations. It can work best with one, choosing the one who is more emotionally diversified and can get things moving.

When it come to revealing secrets and heavy intergenerational legacy (trauma, inherited problems), we try to disengage the child from family burdens, depending on his age. This disengagement can proceed through the processing of the verbatim material in a combination of working with the child and with the married couple or each parent separately.

In any case, we proceed carefully and with respect to the family. The secret (e.g. a suppressed adoption) can only be revealed by the people involved, not by the therapist. However, in case of toxic, dangerous secrets, and when the child/teen is in danger of establishing serious psychopathology (e.g. delirium in an adopted teenager), the therapeutic intervention should be stronger in the direction of removing toxic secrets.

Case study

Fivos, a likeable and physically robust 15-year-old boy, is brought to our Service by his mother for inappropriate behavior at school. He does not pay attention in class and he gets involved in quarrels. Recently he hit a child and threatened his parents. He has already had to do the same school year twice. He hangs out with older children outside school, does not care about schoolwork, defends the weak. His new school threatens to have him expelled and calls for the intervention of our service. Fivos says he is interested in his father's job and he is not interested in school.

He is the second of three boys in the family. The father’s family has a lot of power and a macho mentality: the father has a nightclub, makes a lot of money and wants his boys to follow in his steps. The grandfather was financially strong but lost his fortune by playing cards. The mother, a foreigner from a distant country, fell in love with the father on a trip to Greece and she stays at home to look after the boys.

The family’s first boy, according to information given by the mother, left the house, studied in a country in Western Europe and communicated emotionally only with her, having been rejected by his father. He lost his life three years ago at the age of twenty (due to substance abuse, disorderly life, road accident or something). The father, frustrated by the fate of his first son who was not worthy of him, took F. near him and wanted to make him a successor in both business affairs and manners. Fivos, adopting the parental transmission, is uninterested in school, goes into the nightlife, works out, makes older friends, has affairs with girls of the night.

The father was ill at the time of referral, and his death after a few months in middle age changed the family situation but also Fivos’s course and life choices. We never met the father. The request for help was no longer only from the school and the mother, but from Fivos too. He is struggling between his life so far and a new start. He has to choose between what the father proposed and a new way of life. He shows skill in dealing with therapists, approaches his mother. At the beginning, In the course of treatment the teen's need emerged to stay true to the memory of the father, embracing his legacy. The key to the treatment was the revelation of the family's "secrets": the unexpected death of the brother, the father's suspicious work, and the difficulties of the parental couple.

The treatment included a combination of sessions with the adolescent and of sessions together with the mother. The mother, released from the bonds of male power, was supported in accepting the adolescent's autonomy through new choices in tune with his age. The teenager was supported in the treatment of his father's mourning, to break away from the nightlife and find an acceptable attitude and position in school, re-opening the door to an autonomous course. One and a half years after his father's death, he is able to metabolize heavy intergenerational messages, illuminate the dark areas of family history, and carve his own way.

BIBLIOGRAPHY

BOSZORMENYI-NAGY I. & SPARK G.M. (1973): Invisible Loyalties. Harper and Row, New York.

GOLDENBERG I. & H. (2000), Bowen's Family System, in Family Therapy an overview, Brooks / Cole Ed.

GOLDENBERG I. & H. (2000), Contextual Therapy, in Family Therapy an overview, Brooks / Cole Ed.

KAES R. & FAIMBERG H. (1993): Transmission de la vie psychique entre generations, Dunod, Paris.

SIMON F., STIERLIN H., WYNNE L., (1985), A Systemic Vocabulary and Sourcebook, Family Process Press.

SCHUTZENBERGER ANNE ANCELINE, (2004) Secrets, Secrets de famille et transmissions invisibles, in, Secrets, Secrets, Cahiers critiques de thérapie familiale et de pratiques de réseaux, N. 33.

TISSERON SERGE (2004), le secret ne s’ oppose pas a la vérité, mais a la communication, in, Secrets, Secrets, Cahiers critiques de thérapie familiale et de pratiques de réseaux, N. 33.

ΕΛΛΗΝΙΚΗ ΜΥΘΟΛΟΓΙΑ (1986), Ο Μύθος του Οιδίποδα, Οιδίπους, Λάβδακος και Λαβδακίδες, Τόμος 3, σελ. 84-97. ΕΚΔΟΤΙΚΗ ΑΘΗΝΩΝ. Αθήνα.

TISSERON SERGE, (2014),  Οικογενειακά Μυστικά  . Εκδ. ΑΓΡΑ, Αθήνα.

http://www.ina.fr/video/I00008168. Interview of Salvador Dali.