Elizabeth: Dr. Josephson, in your recent works in the Southern Medical Journal, you discuss child and adolescent depression and related problems from a unique perspective. First, could you share generally about how the central role of the family in these problems came to interest you as a child psychiatrist, when many in your field focus more so on biological causes and medication treatment?
“A previous generation of psychiatrists often looked at families as causing clinical problems, and some even blamed families. Now there is an emphasis on biologically based psychiatric conditions and children “have things” like depression or ADHD which “just happen”. Both extremes are not appropriate. In every psychiatric condition there is a combination of what you are born with (e.g., your physical constitution, your heritage) and what happens to you (e.g., what parents do and don’t do).
The family is the context for development and regulates development. Families provide what children need, attachment, security, structure, education, support. They can do too much of it, too little of it, or do it in an inconsistent way, which is where psychiatry comes in. Even if a child is biologically vulnerable, and predisposed to a condition like depression, whether she develops depression depends on how she is raised, and what she is exposed to. Further, like most psychiatrists I was trained in individual models of psychotherapy and medication use. What I have found is the importance of recognizing that these treatments can be undermined by family function and so I often intervene with the family as a whole.”
Elizabeth: You suggest that a high level of marital commitment and stability has an impact on children’s mental health; can you elaborate on the process through which a stable marriage provides these benefits?
“A stable marriage facilitates what families need to do from a developmental perspective: the most important thing for a child is to feel secure and attached. In lay terms, that he is loved. Consider a young boy who asks his father if he loves him. He asks 3 times. His father becomes irritated and asks why his love was being questioned. The boy says “Well, you told mom that you loved her too, but you left her”. What do you say to that?
When there is not a strong commitment, children will feel insecure. Two developmental principles are important: first, a strong marriage allows working together as a team to structure and limit children, and educate them in the values that the family adheres to. In single parenting this is difficult and with the support of a spouse one can more easily provide structure and discipline. A strong marriage also provides for complementary problem-solving, “Two heads are better than one”. The second thing is the gender issue, a controversial area. Men and women bring different things to the parenting table: biologically life is not possible without both, and it makes sense that psychologically the same be true. One of the things that gay parents often do when they are functioning well is to get someone of the other gender to help out. Women who are raising a boy will often find a father figure. Such couples realize that a boy may need something two women may not be able to give him. Marital commitment naturally gives those two different perspectives.”
Elizabeth: You also note that parents are uniquely influential as role models for their children, especially in the area of sexual behavior, in what ways can a mother or father best promote healthy sexual attitudes in their children?
“First, it is important to model mutual respect and care for each other, and an appropriate level of affection and enjoyment of each other. Children see that the special person in their parent’s life is a model for a relationship they may have in the future. Second, particularly these days, it is important to have reasonable control over the environment. For example, it is unbelievable what children are exposed to on television and the internet. To protect them from unwarranted information and ideas is an important way to promote healthy sexual attitudes; not being repressive, but being practical about what children need to see. Further, a positive view of male female relationships has to always be kept in front of them so that limits are seen in the context of something good. A brief theological point to note is that the Ten Commandments were given to the Israelites after they had been freed from slavery in Egypt, as guidelines for how to live life in freedom, not as mere restriction, but how to live life freely and well. Third, no child or adolescent has ever been hurt by restraint. Parents foster health by simply promoting the attitude that sex is for marriage, a wonderful part of life that will naturally unfold, and that no one is hurt by waiting. Those ideas are tremendously countercultural and at this point yet remain important.”
Elizabeth: You also emphasize that a family’s worldview can have an impact on the development of psychological issues such a sadness, sexual behavior and resulting problems. Why do you think a family’s worldview or value system has such a large impact on these issues?
“The worldview is a cognitive, belief construct, literally how you see the world. It really is the basis for answering the big questions: what is a good life? What should I spend my time working towards? What is right and wrong? And so on. Everyone addresses this in their own way, often drawing on religious or faith concepts they believe important.
There are two areas in which worldview has a critical impact: first, morality, what is right and wrong. When people betray each other for example, there are usually negative feelings involved. I recently saw an adolescent boy who was despondent related to his father having an affair. His father’s choice to break a commitment had great impact on his son’s development. Second, at any point in a person’s life they can begin to wonder what life is all about and any pursuit around meaning can lead to some dysphoria or anxiety. That type of depression is not treated with medication but with a thoughtful inspection of worldview”.
Elizabeth: It was interesting to note your comment that spirituality could be potentially either a risk factor or a protective factor in adolescent’s sexual behavior… what aspects of a family environment seem to make the difference?
“The link between spirituality and family environment are important. Spirituality is taught and picked up in the family environment. Specifically the aspects of the family environment that make the difference are a formal involvement in a religious or spiritual curriculum, which can be a tremendous protective factor because it communicates a view of how persons are to be treated. It diminishes the risk factor where sexuality becomes a means of using others and people get hurt, most faiths teach that because we are made in the Image of God we are not to treat others as objects.
Also, there is help by clear parameters about what is acceptable. In other words, the value of “don’t do this” is underestimated in society where we may over analyze many things. Laws are meant to protect and there are codes about sexual behavior that are meant to protect relationships.”
Elizabeth: Part of the Culture of Life mission is to understand the truth about the human person at all stages of life; I am wondering if you have any comments on how early sexual involvement impacts people into adulthood, married life, etc. from a psychiatric perspective?
“In terms of early sexual involvement there are a number of things that are particularly risky. One is that children are obviously not ready for this and males and females see things differently. I think old stereotypes do hold up in that girls think “he likes me” but boys may not necessarily be thinking that in early sexual experience. It is just a setup for depression, disappointment, demoralization in the young girl, and a certain type of irresponsibility in the young boy. He doesn’t learn to control his impulses and she doesn’t learn to respect herself. This is a tremendous risk factor for adulthood and married life.
It also seems that the more partners that are there for a young person the risk is increased. While early experience creates a certain risk, this might be recovered from but if there are 5 or 10 or 15 sexual partners something changes in the ability to establish meaningful longer term relationships. This is apart from the other issues of how sexual choices can impact the rest of life, most obviously pregnancy and disease. And while this is a controversial topic, whether a young person aborts or keeps a baby, each has challenging consequences.
I have been asked to testify in legal cases where some are trying to relax standards on access to abortion. One of the legal angles used is trying to allow adolescents to have abortions more easily, and I would literally get asked on the stand whether two bright 15 year olds who are successful at school and socially well adjusted could not have a healthy sexual relationship. While that is theoretically possible, it just doesn’t exist in the world.”
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