Why should I have to change?

Claudio Lerici Part of my job involves educating family members and loved ones about mental health issues.  This is an important part of what I do because family involvement and support can be keys to sustainable recovery.  Managed care companies and intensive treatment settings tend to push family involvement in higher levels of care (IOP, Partial Care, Inpatient treatment) because research consistently demonstrates strong relationships between family involvement and improved treatment outcomes.

Clients themselves typically desire family involvement and believe it could be helpful.

Seventy-eight percent (171 of 219) of the consumers wanted family members to be involved in their care, and many desired involvement through several methods. Consumers were concerned with the impact of involvement on both themselves and their family member. The consumer’s degree of perceived benefit of family involvement significantly predicted the degree of desire for family involvement after analyses controlled for service need (family conflict, family-related quality of life, and symptom severity), enabling factors (family contact and family capacity), demographic variables (age, gender, race, living with family, and marital status), and barriers perceived by the consumer. link

Not all clients need or want family involvement for a variety of reasons – many of these reasons are legitimate.  In my experience, a majority of folks in individual outpatient treatment do not require family involvement and in some cases involving the family can actually act as a distraction to the work being done.  However, if symptoms are acute, there is a consistent and/or recent history of acuity,  the family system ends up being the presenting problem or if the client is a child or adolescent; family involvement is usually indicated.

That being said, change is always difficult so here are a few things families can keep in mind or do to make the process easier.

Get an education

Understanding your loved one’s symptoms and diagnosis can help you understand whether how you’re trying to help is really helping. Trying to help a person with an addiction in exactly the same way you would help someone who struggles with depression (and vice versa) can back fire.  There can be a fine line between empathic support, control and enabling; understanding the differences as they relate to your family’s specific situation is hard work. To make things more complicated, family members usually need to shift in how present and supportive they are as their loved one moves back and forth on the recovery continuum.

One of the best ways to get information and guidance is to become involved in family sessions or medical appointments to the extent that such involvement is desired and/or needed. Putting yourself in front of the therapist or psychiatrist treating your loved one gives the provider community based options and flexibility in solving problems.  I also encourage parents of teens to read the worksheets and materials I give to their child so that they are aware of where the work is headed and are better equipped to help their child through the rough spots on their own.

Education can also help families gain insight into familial reactions to symptoms that can create problems for both the client and family.  School phobia (as an example) is often confused, at least initially, with a lack of desire to attend school because of laziness. As a result, families may push and prod a teen into attending. The goal on some level is correct; the more a person confronts what they are afraid of the more they become desensitized to it. The key to desensitization involves, among other things, increasing a person’s capacity to cope and providing the opportunity to retreat. By pushing a teen, or anyone really, into a situation that creates intense distress without doing anything to help them through it can actually have the opposite effect- resensitization. Folks usually end up feeling as if they did poorly and/or become symptomatic because they were not equipped to handle the trigger in more adaptive ways,  reinforcing the negative associations and interpretations they have about the thing they are afraid of.

One of the most important parts of family involvement in acute settings is a discussion around relapse prevention.  Family involvement can strengthen early warning systems clients are asked to use in mitigating relapse and ensure that plans clients developed for themselves in the event of a relapse are honored so that some degree of self-determination is ensured during the treatment process. Family intervention and support early on may lessen the impact of relapse on important areas of functioning – employment, social, academic, etc.

Be open to change

Families can become overwhelmed and intimidated by the investments they may be asked to make in evaluating how they work and implementing strategies therapists ask them to consider.  While this is completely understandable, it’s important to consider that these changes probably seem overwhelming because they are new and different.  Like any other skill the more practice and attention given to it the more natural and automatic it becomes over time. Over time these changes result in a net gain on time and emotional capacity because the family can work with their loved one in identifying and reacting to stressors and symptoms more effectively.

Some family members struggle with the idea of having to change the way they communicate or “work” out of principle -“why should I have to change…I’m not the one with the problem”.  

Family systems that operate from this perspective can act as barriers for clients in recovery because it communicates a lack of support and implicitly identifies them as the “weak link” within the family system.  If you’ve been following along, you know this isn’t necessarily true. In any case, could you imagine telling a person you love and live with who has diabetes, a heart condition or is pregnant the same thing?

“Hey honey, I know you have this whole pregnancy “issue” going on but that’s sort of your thing…so I’m going to keep doing my thing while you sort it out.  Who loves ya?”

Go ahead.

Try that.

Then you might want to get one of these  because winter is rapidly approaching and park benches can really mess up your back.

Ultimately, no…. you don’t have to change. Changing how you behave and communicate is a decision that will be determined by your reason- but not changing may mean repeating relationship patterns that create greater potential for relapse or conflict.  I’ve worked with clients who felt that they needed to make a decision between their recovery and relationships with family members.  That’s a pretty crappy position to be in. Usually, in these cases, family members refused to even consider coming to family sessions because it wasn’t their “problem”.  Unfortunately, as a result of their decision, the relationship they had with their loved one was cut off.  Many times these were temporary breaks and the cut off resulted in the family making a decision to reconsider their lack of involvement and attend but the fact that it took a break to motivate the family created more work in getting everyone on board.

Being asked to change speaks to skill not love or capacity

Sometimes family members interpret suggestions or requests for change as a judgment on how they handled things.  One common statement I hear in family sessions is “Well we did this with our other kids and they all turned out fine.” Generally we get that we have to relate to different people we come across in our jobs, social circles and even extended family in different ways.  For some reason the more proximate the relationship the more rigid we can become about our approach and positions- we become more defended because having to change may mean that we’ve failed.

In the same way a person with anxiety, depression or addiction has to re-learn their thinking and how they approach relationships you may have to relearn what having a relationship with that person looks like. This advances your interest, their interest and the interest of the relationship. Some of the guidance you receive may include taking a step back and not doing so much – that’s right you may be asked to do less work; but even then you may not like it. Change is hard and the person you’re living with or close to who is struggling with a mental illness or addiction knows this as well as anyone. Change means work. Change doesn’t mean you were a bad parent, sibling, spouse or friend.

The obvious exception here involves family systems that were abusive. On some level family involvement may actually be contraindicated unless the client is a minor and even then, depending on the sort of abuse that was perpetrated, involvement should occur after family members have worked on themselves, safety can be assured and the client feels that family work is necessary and that they are ready for it. In these circumstances therapy will seek to work on these issues directly which will probably involve an expectation on the part of the client that family members take ownership over the event(s) that happened.

I know that what I wrote here gives the impression that family involvement in treatment is laborious and intense. Depending on the issue it can be. Keep in mind that I had folks with higher level of needs or presenting problems related to their family system in mind when writing this.  Not all family involvement in treatment requires the sort of change the article speaks to – sometimes involvement is a one or two session deal. This may be enough to increase awareness and can act as the catalyst for small but substantial change that can help your loved one in their recovery.

Using Dialectical Behavior Therapy Techniques with Imago and Family Therapy

This article was originally published on goodtherapy.org on August 24th, 2011

I am not formally trained in DBT. My knowledge of it coming from texts, watching trained practitioners do it and gradually incorporating it into my practice. I’m comfortable with its use due to my background and training in similar modalities and have found the skills to be valuable for those who have a difficult time with more traditional approaches.

One area where DBT has been most helpful to me is in couples and family work as a compliment to Imago and traditional Family and Couples therapy.

Imago’s dialogue draws from communication skills such as “I messages”, Mirroring, Validation and Empathy. Most family and couples therapy around communication, regardless of modality, has included this skill set for decades.  In fact, it’s rare to read a book or manual on family therapy without any of these skills coming up. Many times couples and families who come to therapy become dysregulated in their communication and do not have the discipline to put them into practice. The “dialogue” does a good job in helping folks get communication on an empathic level but, in my opinion, falls short of helping them understand how to modulate intensity and the practical dimension of effective interpersonal skills. Lastly, clients often state that the skills seem packaged for “vacuum interactions” and most triggers occur unexpectedly; that although great in theory they do not feel the dialogue is a realistic alternative to their normal way of communicating. This is half true, in my opinion. The skills are useful in that, they give clients the tools to communicate but they do not increase or improve real world capacity to regulate this communication.

The Interpersonal Effectiveness handouts in the Skills Training Manual for Treating Borderline Personality Disorder  by Marsha Linehan has been useful in helping couples and families in my practice achieve the following:

  • Understand the building blocks of relationships and interpersonal skill development– Many times couples and families in therapy aren’t able to recognize the areas they need to be attentive to in order to improve their ability to effectively manage relationships.  Clients can have a hard time putting words to where the relationship is breaking down.  “The situation for interpersonal skills” handout allows couples and families to organize these components in a way that allows for a more straightforward self-assessment of their relationship.  This skill set provides a “what to look for” when it comes to interpersonal skills so that folks are able to at least get a baseline.
  • Understanding the purpose of interpersonal skills Many clients get stuck on meeting the concrete or representative/historical need at hand. The “Goals of Interpersonal Skills” handout allows couples and families to broaden their understanding to include relationship maintenance and self-respect as equal parts to the communication equation. This handout can allow folks to get away from just going after the widget and to consider other, equally important factors in delivering the message.
  • Understanding Legitimate Rights and Factors reducing Interpersonal EffectivenessThis allows couples and family members to receive “permission” to communicate a need and works to eliminate the barriers to interpersonal effectiveness (also included as a worksheet in Linehan’s manual).
  • Modulating IntensityThe “Options for Intensity of Asking or Saying No, and Factors to Consider Deciding” has been the most valuable tool in helping couples and families in my practice. It asks clients to consider the intensity they are applying to their communication around a need. It presents ten items they should account for in a very concrete, guided and understandable way. Many couples and families actually assign a number to each of the ten items to come up with a ball park average on how firm they are going to be in the face of a demand or in making one.
  • “DEAR MAN, GIVE, FAST”-I use the Imago dialogue within this framework across all three of Linehan’s communication worksheets. This helps couples understand why the dialogue makes sense while providing them a way to apply theory to how they communicate in very concrete ways.

Of course, going through the skills involves more than just providing the hand outs. Much of the information presented may not make sense to your client. The therapist should really have a strong command of the material before using it and should prepare to spend a full session discussing each hand out.

Adding the DBT communication module as a compliment to couples or family work can help folks feel comfortable in asserting a need effectively. I have found that applying the module lessens the learning curve around communication significantly. This has allowed me to move on to other issues beneath the surface more quickly. This occurs because the module provides clients with a much greater capacity to tolerate or communicate charged material that may be at the core of what brought them into my office.

©Copyright 2011