Unintended Consequences of Progress

Robert Goddard - First Rocket

Cognitive Behavioral Therapy is difficult work and part of that has to do with the distress progress can create in a family system.

Yeah, that’s right.  We’re looking at how CBT can potentially impact a family from a systems perspective.

Exciting, right?

CBT is also a short(er) term modality, involves homework and the idea of concrete change is on the table sooner than folks may expect.   To consider how this might impact the larger family system, we need to understand Homeostasis:

The concept of homeostasis means that the family system seeks to maintain its customary organization and functioning over time. It tends to resist change. The family therapist can use the concept of homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change. link

That’s not only on the internet, it’s also out of a medical dictionary ……..on the internet, so it must be true.

This does not mean that the family is the primary contributor to the client’s issues. It can mean that, but it can also mean that the issues the client struggles with has, in some way, shaped how the family works.

Due to the (relatively) rapid and (sort of) roller coaster type progress CBT initiates in a client, the family system the individual lives in can become a bit confused and disoriented.  Family members may feel an individual is getting worse when he/she may simply be more distressed as a result of the changes they are trying to implement.  Other times, family members may feel and express disappointment to their loved one when a lapse occurs after a stretch of noticeable progress. This can feel disappointing to a client who is being asked, in therapy, to focus more on process in defining success. Family members may also fall back on historical patterns in interacting with their loved one. This may lead to increased feelings of frustration in a client and can create an environment that is more conducive to relapse.

This isn’t to say that family members want their loved one to remain stuck, it may be the product of habit.  Family members, like clients, develop workarounds to symptoms in ways they can live with and these workarounds may be time consuming, intricate and exact.

Therapists should always leave the option of family involvement on the table for clients. It’s even appropriate, at times, to include it as a condition of treatment.  With adolescents or young adults who do not wish to have family members involved, therapists may wait until the client feels distressed enough about the family’s “push back” to bring the matter of family involvement up again.

Once a family is in the room, I avoid reviewing the nitty gritty details of our work. Usually, I speak to the treatment logic that is being used and, in general terms, talk about how families can act to help or hurt the process.  Family members may need therapy themselves to adjust to the changes especially if the issues are tied to loss or addiction.

The intended takeaway here is that family members typically want their loved ones to do well, but may not be clear on their role in the treatment process.  If not addressed, a family system may interpret or react to certain changes they observe in their loved one in ways that may be unhelpful or counterproductive.  Usually, this “pull back” is not willful or malicious, but comes from concern and is a natural reaction that systems have when experiencing increased distress and uncertain change.  Depending on the level of involvement a person’s family has had in helping their loved one manage or work through their symptoms,  psycho-education that includes typical projections around progress can be helpful for both the family and the client.

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