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.

Marijuana Myths & Facts

Given the amount of damage that marijuana is perpetrating on NJ communities and the relatively recent influx of adolescents into addictions treatment as a result of marijuana use, the lax attitude many parents and the general community at large has toward marijuana continues to surprise me.

Marijuana is a drug, it’s dangerous and if your teen is using then it is reasonable to be concerned and take action.

The Office of National Drug Control Policy put out a really great pamphlet exposing many common myths about marijuana use.  No. There are no pop culture icons or really cool conspiracy theories referenced ….just science and solid research.



Socrates has a question for you…

photo by Eric Gaba
photo by Eric Gaba

which is weird because he’s dead.

Even so, his teachings still hold great value in treating anxiety, depression and a host of other issues.

The Socratic debate is something cognitive therapists use quite often in helping folks challenge thought distortions.  Questions driving the Socratic debate fall into six categories and are designed to push us away from certainty and towards curiosity and evaluation.  I’m not going to list all of the questions or categories here. I added a link at the end of the post to a page that goes through each category and lists examples of questions that can be asked.

I also posted a link to a sample thought record. A thought record is a tool that can be used in therapy to help folks identify:

1. The event(s) that trigger distress.

2. The emotions that make up the distress.

3. The automatic thinking (the initial conclusion(s)) we have as a result of the event.

4. Reasonable alternatives to our automatic thoughts

I’ll stop at #4 because that is where some folks get stuck and say “Well if I knew a more reasonable way of thinking about it, why the hell would I pay you?”

One way of determining whether a more reasonable way of thinking about a situation exists, is to engage in a process of self-dialogue that uses Socratic questions.  Next time you find yourself feeling highly anxious, angry, sad…”distressed” about something, step back and use the thought record to explore what’s really going on. In deciding whether a different way of “thinking about it” exists, use the questions contained in the Socratic Questions module.

Six types of Socratic Questions (University of Michigan)

Thought Record (pdf-PsychologyTools.org)

Understanding the Enabler

photo_18851_20100918 The term “enabler” is used to describe an individual who consistently acts in a way that protects another individual from the consequences of engaging in maladaptive behaviors OR actually encourages and supports that individual in their maladaptive behaviors. While the term is used heavily in understanding and treating families affected by addiction, it is a relevant concept in thinking about family systems that have a member struggling with an eating disorder, borderline personality disorder or other mental health issue.  For our purposes we’ll stick with addictions, understanding that much of what we talk about can be applied to other issues.

Some examples of enabling behaviors include:

-Parents who continue to provide their teen with a cash allowance despite knowing that their teen uses substances.

-A husband who calls his wife’s employer to inform them that she will not be at work that day because of a stomach bug when in reality, the wife is unable to attend work as a result of a drinking binge the night before.

-A wife frustrated with her husbands lack of motivation and lack of “production” in the household, takes over his responsibilities to avoid an argument and to just “get it done”

There is a strong tendency for folks who enable to equate their emotional well being with that of the individual struggling with an addiction.  Because of the hyper-vigilance typically created in families as a result of the addiction; one or more members may feel a need to anticipate or predict emotions and behaviors. This kind of relationship leads to rigidly entrenched patterns involving triggers, use and rescuing behaviors.  As a result of the rescuing behaviors, the individual struggling with addiction relies on the relationship as a means of maintaining the addiction.

Enablers possess certain traits that leave them vulnerable to taking on the role.  They tend to derive their sense of self worth from the opinions of the people they are in relationships with. As a result, they look to “over perform” in these relationships to receive validation and to satiate an exaggerated fear of abandonment. Within the relationship itself, enablers tend to modulate positional intensity poorly going from one extreme (passivity) to another (aggression).

Despite the substantial challenges, enablers can also possess and demonstrate many strengths.

They tend to present with a great deal of resiliency and while their actions have contributed to the problem they’ve also worked to protect the family. These behaviors can be viewed as survival skills that, from the enabler’s perspective, have strong short term benefits.  This up front benefit may be based in reality but the actions also carry higher long term costs.  This is not to say that what they do is always good or great, enablers have been complicit in some pretty bad horror stories.

They also tend to be highly resourceful and flexible in situations that demand quick action.  Enablers are often put into seemingly urgent situations where quick decisions feel necessary.  Granted, they are put in this position because they have accepted this role in the past but given their circumstances, they may feel their decisions were the lesser of many evils. When people feel obligated to make quick decisions on substantive issues or problems on a frequent basis, the likelihood of collateral damage to the rest of the system is high. photo_19387_20110127

The enabler is not the only person who enables – they just tend to do it more often and don’t quit.  Folks who struggle with addictions tend to have a revolving door of folks who, in some way, have enabled their behaviors. In some families, the larger family system may encourage the enabler to continue with their way of handling problems because not doing so may be viewed as disloyal. These are also the same people, by the way, who throw their hands up in the air and blame the enabler for everything that goes wrong.

Folks who struggle with addiction are probably not where they are because of the enabler.  The absence of a proximate enabler only makes the behaviors more difficult to perform which changes the cost benefit ratio of the behavior. While this may increase motivation for change, it is not a guarantee.  I’ve had more than a few clients tell me that they would adapt to any consequence their family may impose in order to maintain access to their drug of choice and actually followed through with it.

One of the biggest challenges in treatment is to help enablers redefine their role within the family as they may continue to use survival strategies that can unintentionally trigger urge inducing thoughts or emotions for the person in recovery. Enablers usually grow up in households where addiction was an organizing principle and so they are desensitized to many behaviors that would cause others to set hard boundaries up front or leave the situation altogether.  Because of this programming, they usually have to learn what healthy relationships look like before making any significant changes on the ground.

photo_27338_20130821 Enablers probably have tried to stop the other person from using but have been unsuccessful in their attempts. A priority in family work is to help the enabler stop many of the use controlling behaviors they exhibited during a persons active use because they are risk factors for sustained recovery.

One thing to keep in mind when working with family systems in early recovery is that the shame and guilt associated with addiction doesn’t stop with the individual who has the addiction. Enablers have morals and try to keep with their virtues like the rest of us. Many times what they feel they need to do to protect the system presents as a contradiction to their moral framework.  This tends to be the basis for the guilt and shame many enablers tend to carry when they enter treatment.

It’s also important to recognize their strengths and to view their actions within the context of their reality.  Dismissing the behaviors as simply pathological while demanding radical change oversimplifies the problem, hurts the therapeutic relationship and creates barriers to progress. People live according to equations that pertain to their histories and current realities – not a textbook.  Clients who struggle with addiction step in and out of different phases of recovery. Families have to assess whether they can trust the treatment process and the changes they may be seeing enough to let go of the strategies they believed have helped them survive not just their current relationships but the households they grew up in.

Clinicians can help family members develop a different understanding of love and loyalty; that how they are demonstrating love and loyalty in the current context is only making the problem worse.  This acknowledges, when appropriate, that the actions the family took came from a noble source they just weren’t grounded in the right skill set or logic.

Lastly, enablers need to get comfortable with self interest and identity formation.  I usually begin by describing how self interest is something that helps systems maintain accountability to and relevance for other family members. For the enabler, acting out of self-interest is a selfless act.

One step closer to the miracle…

T:  I am going to ask you a rather strange question . . . that requires some imagination on your part . . . do you have good imagination? 

C:  I think so, I will try my best.

T:  Good.  The strange question is this; After we talk, you go home (go back to work), and you still have lots of work to do yet for the rest of today (list usual tasks here).  And it is time to go to bed . . . and everybody in your household are sound asleep and the house is very quiet . . . and in the middle of the night, there is a miracle and the problem that brought you to talk to me about is all solved .  But because this happens when you are sleeping, you have no idea that there was a miracle and the problem is solved . . . so when you are slowly coming out of your sound sleep . . .what would be the first small sign that will make you wonder . . .there must’ve been a miracle . . .the problem is all gone!  How would you discover this?

C:  I suppose I will feel like getting up and facing the day, instead of wanting to cover my head under the blanket and just hide there.

T:  Suppose you do, get up and face the day, what would be the small thing you would do that you didn’t do this morning?

C:  I suppose I will say good morning to my kids in a cheerful voice, instead of screaming at them like I do now.

T:  What would your children do in response to your cheerful “good morning?”

C:  They will be surprised at first to hear me talk to them in a cheerful voice, and then they will calm down, be relaxed.  God, it’s been a long time that happened.    

T:   So, what would you do then that you did not do this morning?

C:   I will crack a joke and put them in a better mood.

The miracle question is an intervention created by the solution focused folks and is sponsored, today, by the letters DBT and ACT. Solution Focused therapy is based, in part, on the premise that folks usually have demonstrated capacity to solve their problems and that their current inability to solve a problem is temporal.  Solution focused therapy avoids the big picture questions and focuses on the parts of the big picture that, for one reason or another, get in the way of functioning and mood improvement right now- it’s a nice compliment to acceptance based work.

Answers to the miracle question usually take the form of statements that are easily translated into bite-sized objectives that are realistic and manageable, making it ideal for folks who are experiencing acute symptoms.  These objectives work to instill hope which increases motivation that can, in turn, lead to change.  The changes are incremental but they create a feedback loop that incentivizes more positive change.  Over time these small changes lead to a landscape that looks different and is more conducive to good mental health.  One of the best parts of the intervention is that it is something most folks can do for themselves with minimal risk.

The dialogue above and more information about Solution Focused Therapy can be found here.