Thursday, January 7, 2016

Parenting & Psychotherapy

There are many books out there about how to be a better parent.  The fact that this genre is popular is, in my opinion, a good sign of societal health:  perhaps part of parenting well is being interested in learning about ways to parent well!  It speaks to a cultural change as well, in which quality of parenting is considered important as a societal theme.

Demographics have changed over the centuries, in a way which bodes well for the earth's future:
 At this point, there is about 1.1% of population for each year of age, up to 1.6% per year for people in their 50's (the baby-boomers), then declining gradually for elderly.  In general, the population pyramid now looks more like a "solid bar" rather than a triangle, indicating that people of all ages are more equally represented in the population, rather than young children being most common.

This means that each family with children, on average, can invest more time, attention, and resources, with each individual child. 

What is the evidence about the merits of different styles of parenting?

Here we have the very surprising finding that differences in "shared family environment" have a much smaller impact on most phenomena, such as personality traits, intelligence, and mental illnesses, compared to differences "non-shared environment" (i.e. the environmental factors unique to the individual) and to differences in genetics.

 Yet, these findings refer to population averages. It is obvious that extremes of environmental experience will obviously influence outcomes much more.  An atmosphere of severe abuse and neglect is likely to have a damaging effect, while smaller differences in home environment within the "average" range in the society are much less likely to have significant effects.

People tend to focus excessively on the "smaller differences" side of things, with respect to parenting and home environment.  Provided that the home is secure, safe, relatively stable, with access to reasonable social and educational resources, it is probably true that variations within one or two standard deviations of the mean of parenting style are unlikely to make very much difference, in terms of subsequent illnesses, intellectual achievement, or overall well-being among children who grow up in such family environments.    The key thing is the avoidance of extreme negatives such as abuse or neglect.

Is there any other parenting variable that clearly matters?

I believe it is simply time, involvement, and availability.  Better parenting does not necessarily require parent education groups, expanded community resources and collaboration, better activity groups for the children, more efficient time-management strategies, etc.

Rather, better parenting simply involves being joyously, affectionately present for your children!

Presence and availability alone are not enough.  The availability has to be provided with a spirit of joy and delight.  Child-rearing cannot merely be a chore or a technical skill -- it must be nurtured as a joy of life.  Children who see that their parents actually enjoy parenting, enjoy laughing and playing and working together, are much better off than those whose parents spend equal amounts of time, but with a spirit of stress, negativity, or conflict.

I wish to make an analogy between parenting and psychotherapy.  I know it is an imperfect comparison, in many cases at least.  Some patients do not desire or need any such dynamic with a therapist, and it could be intrusive or presumptuous for the therapy relationship to have some kind of unwelcome "parental" quality.    For other patients, there is a more overt "parental" dynamic in therapy frames.  In any case, I think that there is a direct analogy between optimal "parenting strategy" and optimal "psychotherapeutic strategy."

Most of us, examining evidence of psychotherapy, emphasize technical differences in the therapy style or actions (e.g. using CBT vs. psychodynamic approaches).  Yet, evidence about relative advantages of one technique vs another is actually very minimal.

I do think there are technical elements which are important.   For example, I think principles of behavioural therapy must be called upon for management of any condition or problem -- it is like prescribing exercise to strengthen a muscle -- all the talking in the world cannot replace the need to actually practice something actively to become stronger or more skilled.   Similarly, a parent does need to literally teach a child to speak, to throw a ball, to ride a bike, to read, etc.  Time and togetherness alone are not usually enough to help a child acquire these skills.  

However, the biggest factor of all, in psychotherapy, is just like with parenting:   it is all about being available, and offering time and attention.  But just like with parenting, time and attention are not enough:  the time and attention must be provided with a spirit of joy, interest, and engagement, and with stable, healthy, safe boundaries. 

Nowadays, we have pressures upon medical and mental health care which seek to "optimize" care delivery.  Evidence is gathered about efficiency of care.  This tends to push medical and psychotherapeutic practice towards shorter visits, less frequent visits,  limited numbers of visits (for example, 6 month limits on courses of therapy), and indirect visits (e.g. through video links).    Most of the evidence supporting such methods is short-term. 

Imagine instructing a parent to become "more efficient,"  encouraging briefer interactions with children, less frequently, and for no more than 6 months at a time, particularly if it was found that the children's "symptom scores" had reached a particular threshold.

Optimal psychotherapeutic care requires time, patience, and availability.  In a setting of impoverished resources, there may be less time and availability to be shared.  But sometimes, such as in Canada, we do not actually have an impoverishment of resources.  It is "pseudo-impoverishment."  If it is difficult to access resources, the solution does not need to involve spartan rationing or obsessing about "efficiency."  It may mean that it is worth considering, for society as a whole, that it is good to invest more of our nation's vast wealth to offer personalized, patient, ongoing empathic care to those who desire or need it. 

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