Under My Skin: Family Counseling


A dermatologist’s office may not be the ideal site for family therapy, but it’s often a good place to see how close relatives interact, and even to influence their relationships a little. Many family combinations come into our offices: parents and children, husbands and wives, now and then even three generations in the same room.

Most kids and even teens don’t talk much. Asked why they’ve come, they shrug and look sideways, as if to say, "This wasn’t my idea – ask her." Once in a while, though, the child opens his or her mouth and speaks forcefully while Mom or Dad look on, probably an attorney-in-embryo or politician-in-training. Either way, the old folks probably have a tiger by the tail.

Most of the time, however, the parent does the talking while the child chafes in silence. What’s at stake is what is always in play between parents and children: control and autonomy. Mom is concerned; Junior rolls his eyes, wishing only to be left alone. Counseling in this context often calls for splitting the difference a little: letting the kid know he can eat pizza (Flash of triumph – "I told you, Ma!"), while encouraging the healthy diet that Mom feels is her probably futile but inescapable obligation to encourage. After exonerating soda and pizza, I often turn to the adolescent patient and add, "And always do your homework and listen to your mother." Mom always smiles. Sometimes the kid does, too.

Higher stakes call for greater finesse. One example is the adolescent with severe, cystic, scarring acne, whose parent has heard bad things about isotretinoin and just can’t come to terms with letting the child take it. Coming on strong is neither effective nor necessary. Delicately handled, most such tales have happy endings for both generations.

Sometimes when you meet a family you sense a particularly unhealthy dynamic. I think of the 5-year-old whose mother criticized her every time she moved. The little girl bit her lip and looked down, as her mother pronounced, "Doctor, she has to learn to behave properly." Seeing unhappiness develop before your eyes and being able to block it are very different things.

Often married couples come jointly, most of the time, but not always sharing the same exam room. Aspects of their relationship come right through: playful, tolerant, sometimes flat-out domineering. Watching a 75-year-old man treated like a child is not comfortable. ("Just show the doctor your back, will you?") At times, it’s the husband whose concerns about his wife’s scaly scalp or submammary keratoses are not shared by the spouse who actually has them.

In general, to be a long-married male is to be treated with well-meant and mostly-benign condescension. ("Doctor, he never uses sunscreen when we go to the beach. Tell him to use sunscreen.") I turn to the man and say, sternly, "Use sunscreen." But I put a wink in my voice. All of us understand each other.

Sometimes little kids are accompanied by both a parent and a grandparent. Contrary to the sentimental stereotype of grandma as a sagacious, even domineering matriarch, most grandparents in my office seem docile and deferential, even – or especially – the ones from an Old Country. Back in the house where language is no barrier, they may act differently, but somehow I doubt it. This is America, where youth brings wisdom, and e-mail is so last decade.

My favorite family visits are those of people married a very long time. Two months ago, I had on the same day not one but two couples, psychologically intact and living together, each pair married an astonishing 67 years.

I pointed to my student and said to one of the elderly women, who seemed especially sharp, "My young friend here is about to get married. Can you share with her any secrets of marital longevity?"

Without missing a beat, she said, "Deafness! He says, ‘Why?’ and I say ‘When?’ He says ‘What?’ and I say ‘Later.’ So we never argue."

I looked at her husband, who was smiling brightly. I don’t think he heard her.

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