The Problem
Within the past decade and a half there has been increased interest in the study of the father, both in the context of child development and in the life cycle of the father himself (Cath, Gurwitt, and Ross, 1982). Interest in and knowledge about fathers has, however, lagged behind interest in the individual child, the mother-child unit, or the mother alone (Howells, 1970). The reasons for this neglect are complex but in some part involve the difficulties in understanding the role of father and the sorts of activities that constitute fathering. These conceptual difficulties are greater with activities that constitute fathering than with activities that constitute mothering. Mothering is usually thought of as involving the experience-close caretaking, that is, feeding, cleaning, physical soothing, of the mother-child dyad. It is clear for purposes of observation and study what at least some of the activities are that constitute mothering and how they may be observed.
For fathering, though, there is seldom this sort of clarity. Fathering may involve parenting that is experience-close, but by and large the activities that fathers themselves consider to be appropriate fathering are experience-distant, and difficult to capture convincingly in observable terms: provision of support, protection, discipline, a sense of justice, and a sense of leadership. Few of those activities can be reduced to observable behaviors between father and child that are suitable for study. The problem of studying fathers, then, is inseparably linked to the problems of studying whole, or even extended, families. The data are complexly interactional, difficult to define with certainty, and contained in units of observation that may be both large and fluctuant.
How a father is evaluated by himself and by othersâwhat kind of job he does, and in what kind of esteem he is heldâis often as much of a measure of the marriage (i.e., of support or sabotage from mother) as it is of the fatherâs activities considered alone. Volatile, strife-ridden marriages may be taken as evidence of a fatherâs weakness, even if it is the mother who erodes the sense of stability with activities and commentaries that undercut the familyâs sense of stability. In a better-bonded marriage, mother may compensate for a weak or even remote father. Hence, fathering has to be studied in the full family context, whereas significant aspects of mothering do not. To these complexities must be added the ubiquitous fantasies about what is wanted from parents: âI want my motherâ is usually a regressive wish appealing for caretaking and exemption from responsibility; âI want my fatherâ usually reflects a wish to master the world, not to avoid it. Some of these conceptual difficulties explain why until recently there was a dearth of academic and clinical interest in fathers and, in particular, why there has been a paucity of information on the psychiatrically disabled father in the role of father. As a matter of fact, a literature search failed to turn up a single source on the hospitalized patient as father. This communication is an attempt to approach the topic.
Obviously, any major illness will have a substantial effect on the fatherâs performance of his role, not only because of the consequent limitations on the fatherâs actual functions, but also because of the strength and power that the father gives to the family in the fantasies of family members and of the father himself. Thus, in addition to impairing the instrumental contributions of the father, illness also inflicts narcissistic injury on the father and on the family as a whole.
A study of family systems usually shows that predicaments or crises that present as clinical disruptions follow a change in family equilibrium. Disruption follows the sudden upsurgence of previously disowned infantile elements in the family system. This may happen, for example, when the family homeostasis changes after the birth of a first child. The combination of added demands on father, a decrease in attention from and caretaking by the new mother, and competition with the new arrival may change a previously well-compensated family system to one that is dysfunctional. The same may happen if physical illness in an older father necessitates his wifeâs employment and occurs at a time when children are also becoming financially independent. The narcissistic issues often subsumed under the vague and overused term âself-esteemâ are found to be intimately related to the parental role and are crushingly disturbed at such times of disequilibrium. Less well studied is the relation of psychiatric symptoms to the role of father. Such symptoms include psychotic episodes, suicidality, violence or intimidation, episodic substance abuse, and depression. I do not presume that difficulties with the role of father cause any of these symptoms, but only that the symptomatology itself is intimately bound up with the role of father in a way that is difficult to study yet is crucial to understand in any treatment strategy.
Because in the Family Treatment Program families are seen in every case and the index population is largely adult and male, the setting is optimal for observing the difficulties of the hospitalized father. Yet, for reasons not apparent on first glance, most fathers were loath to comment on their difficulties in functioning as fathers. Identifying their difficulties in other ways, they spoke of voices, drinking, violence, being suicidal, depression, anger at their wives, or anger at children. The staff on this program, highly sophisticated in the treatment of hospitalized patients and specialists in family psychiatry, also had difficulties focusing on the paternal role. Part of the staffâs difficulty arose from clinical apprehension that the issues were too threatening to the patients and could be brought up only with the risk of mortifying the patients. Staff had countertransference difficultiesâemotional difficulties with men who were felt to be broken or defective; and they had unusual difficulties maintaining focus on these men on the paternal role. There was, then, a diffuseness of focus on difficulties in the paternal role, not only on the part of fathers, but also in their families and in the people who treated them.
This generalized diffusion of awareness to difficulties in the paternal role could not be attributed to mere ignorance or lack of focus on the problems of hospitalized fathers. Rather, it seemed to be a defensive process of overwhelming magnitude, one that came into focus only gradually. I use the term âdefensive processâ without any presumption that the origin of the patientsâ basic difficulties was basically interpersonal or that the treatment was basically dynamic or interpretive. I am, rather, presuming that any approach or sensible treatment strategy must consider what sort of emotional struggles keep the areas of great difficulty so much in darkness that they cannot be examined, discussed straightforwardly, and diminished.
A view of the clinical picture is blurred by this diffusion of awareness. For that reason, it is important that we be mindful of the concrete particulars of the setting in which the issues faced by hospitalized fathers come into focus. Our treatment staff went through an unfolding awareness of the central role of shame and narcissistic mortification in these men and of the high cost of maneuvers to protect themselves from such mortification. These defensive maneuvers included the diffusion of awareness of difficulties in the paternal role. The more we understood these fathersâ struggles, the more their struggles seemed always to include one between concealing to avoid being seen and seeing oneself as defective and the opposite effort (with which we wished to ally our efforts)ârevealing and clarifying the issues so they could be faced. Our knowledge of the plight of the hospitalized father grew with the deepening of our understanding of conflict and defense tied to shame.
As a general psychiatric inpatient unit with around-the-clock staffing, we at the Family Treatment Program were in a good position to observe the general disruptions that range from psychotic decompensation and its attendant symptoms to suicidal thoughts and actions, violence and intimidation, and episodic and continual substance abuse. We have come to see many of these symptoms, however chaotic they might seem, as the patientâs attempt to restore an optimal distance from supportive persons, both to keep them at a distance and to lock them into a relationship with the patient. We have a clear view of the impact of illness on the fatherâs role.
The intake meeting is used for examination of the circumstances leading to hospitalization and a workup of the family from an intergenerational perspective. Family sessions continue weekly and explore conditions under which the temporary containment by the hospital can be replaced by containment outside the hospital, by the patient himself, by the family, or by other support systems. These sessions may evolve into ongoing family psychotherapy sessions.
We have come to conceptualize the hospital as a temporary container for chaos when such containment cannot be provided by the patientâs personality system or external support systems, including the family. We have also come to focus on the benefits and difficulties of the symbiotic relationship created by a few months in the hospital. The temporary containment and relief from responsibility are often offset by the enormous shame the patient feels when he sees himself as needing the hospital for well-being, by the resultant envy and hatred, and by the controlling maneuvers (such as binge drinking, suicidal gestures, or violence) that forestall discharge and preserve the relationship with the hospital. They also divert attention away from the hospital dependency that so upsets the patient. Often the patientâs controlling maneuvers exhaust support systems. Family may become depleted and exhausted and may give up on the patient. We have come to see the absence of family (Lansky et al., 1983) as a source of data with major diagnostic and prognostic significance, never as a variant of normal.
To focus further on the problems of hospitalized fathers, we began brief (30 minute) intergenerational interviews for all fathers admitted to the ward who consented to have them. These interviews were tape-recorded sessions with a three-generation perspective. Each patient was asked first about his father: what the relationship was like, what was good, where it fell short, how any shortcomings were felt to have affected the patientâs subsequent life and his own ability to be a father. Next, they were asked about the women in their lives: wives, ex-wives, mothers of their children or step-children and whether they helped or hindered the paternal role. Lastly, they were asked about their own relationship with their children: good points, regrets, role of their illness, what they might need to help them.
A group was offered to hospitalized fathers. Patients had received the first offer of a group with much enthusiasm, but the group was very poorly attended. The few who came were very chronically ill men with years-long relationships to the hospital and damaged self-images. All were chronically suicidal. All were directly involved with their own childrenâs care, usually with some help from an ex-wife. A second group was formed from men who had had the intergenerational interview (40 fathers were offered the group). About 12 participated, but most of them attended for only a short while and then dropped out, most saying explicitly that they could not handle the upset that the material stirred up. The majority were divorced. Most felt rage, helplessness, and depression at the small or absent role they played with their children. Many had been ordered by courts to stay away either because of attempts to intimidate the family or actual violent episodes, or because they could not provide the support for the family mandated by law. All felt helpless, humiliated, and untenured. There were varying degrees of acceptance of responsibility. One man complained bitterly and vociferously of his ostracism from the family, but neglected to mention that in a fit of rage, he had beaten his infant son to death. The group was designed to be exploratory and supportive rather than confrontive, but all the men found it painful, anxiety provoking, and humiliating to talk about their difficulties and lack of status in the family. Those who were not directly involved with their children dropped out; several asked for (and were given) sessions conjointly with children to help with the issues raised.
The intergenerational interview and the father groups gave us considerable insight into the diffusion of awareness around problems of fathering. These hospitalized fathers were so overwhelmed with shameâthe pain of seeing themselves, and of being seen, as defective in the fathering role and deprived of statusâthat most could not bear to address their difficulties. Over 90% of the hospitalized fathers agreed to be interviewed, and most of them showed interest in the fathersâ groups; however, less than one-third attended, and most of the fathers that did attend left, saying that the pain was too great and the hopes of improvement too dim to warrant further suffering.