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.

Triangles and Family Systems

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“Triangle” is a term out of Bowen Family Systems theory used to describe a phenomenon in family systems whereby a third entity (not always a person) is used to stabilize conflict and distress in a relationship between two people.  Triangles are generally thought of as undesirable because it is a communication avoidance strategy or pattern that resolves the distress surrounding an issue without resolving the issue.  Triangles involve shifting alliances among three entities; these alliances always leave one of the three on the “outside”.

Triangles exist because the relationship between two individuals in a family system is regarded as the most unstable. If a significant issue between two individuals doesn’t get resolved a consistent thread of distress in the relationship that bleeds into the day to day life of the relationship can develop. This may bring some hefty long term consequences to the table (lack of intimacy, lack of communication, avoidance, infidelity etc.)

One classic triangle involves the person struggling with addiction, the rescuer and the substance. This is a useful example because the relationship between these three is usually in a consistent state of distress during the latter part of the addiction and it is during these times that triangles become more noticeable.

During times when consequences of the use or addiction is contained to the family system (work is going okay, no legal issues, etc.) the person with the addiction and the substance form the inside relationship.  The rescuer typically utilizes nagging and other use control behaviors to try to prevent the person who is using from using.  These behaviors are typically ineffective and create more distress in the relationship. In some ways it can, in the addict’s mind, justify increased use as a means of “dealing with it”.  This places the rescuer in the role of “outsider”.

Eventually the person with the addiction is going to face an external consequence for their behaviors (bank notes as finances deteriorate, employment issues, legal troubles). Each of these consequences presents as a threat to the inside relationship the addict has to the substance; he/she cannot use if they are in jail or do not have the means of supporting the addiction.  As a result of the distress created by the anticipated negative consequences, the person with the addiction may increase proximity to the rescuer to engage their help in avoiding the consequence (bailing them out, calling work with excuses, etc.).  Sometimes, the rescuer doesn’t wait to be asked; seeing that the person with the addiction is about to face a damaging consequence they may decide to step in to solve the problem.

This process acts to lock the triangle as the rescuer prevents the person with the addiction from facing the natural consequences that may act as a catalyst for treatment and sobriety – the long term changes that may be needed in order for the real problem to be solved.

Another thing to keep in mind is that one triangle usually creates more triangles, it can be lonely being the outsider and eventually folks will need to figure out some way of dealing with the distress of the issue driving the triangle.  Typically, if there is one entrenched triangle in a family there are probably several others.

Sort of like cockroaches.

Gross.

Some of the most devastating triangles are those that involve children as the go between two parents who have severed communication. Children acting as messengers or negotiators between two parents can be harmful even if efforts are made not talk “bad” about the other parent; as the inability of one parent to speak to another can carry with it certain meaning to the child and places an added level of distress the child has in their communication with each parent.

All that being said, every family triangulates sometimes and sometimes it can produce very good results.  The key is to make sure that the patterns of triangulation aren’t entrenched; that direct communication is typically how a family deals with problems – triangles should really be an exception to the rule.

Because triangles are difficult to identify and family relationships are typically our most proximate and comfortable, getting caught up in them isn’t too hard.  A general rule of thumb in avoiding triangles is to be mindful of problem ownership.  If you don’t own at least part of the problem then there isn’t much you can do about it. You can be supportive but getting directly involved provides an easy entry point into bad dynamic. If you’re going to someone else about an issue and they weren’t involved to begin with, be clear as to whether their involvement is appropriate and tame your expectations with regard to what you feel they should and can do about it.

And They’re Off!

The pursuit-distance phenomenon is a concept born out of systems theory and is used to describe a pattern that occurs between two individuals who, as a result of emotional fusion, are unable to gain healthy proximity in a relationship.

The tendency towards emotional fusion is inherited from a person’s family of origin. People who are fused are triggered to emotional flooding by the emotional reactions of other people. This flooding negatively affects a person’s capacity for reason and objectivity. Typically, couples who find themselves in the cat and mouse game (pursuer-distancer) react to this flooding differently. The pursuer seeks stability and connection while the distancer seeks space and isolation. rowing race

Flooding is the force that upsets the ability of members to successfully negotiate the normal tension that is the product of an individual’s desire to belong and his or her desire to act from self interest.

The pursuer tends to value proximity and can come across as clingy and needy. The distancer usually comes across as detached or cold. The manner in which the pursuer seeks proximity from the distancer causes the distancer to move away, frustrating the pursuer who reacts by increasing their effort in the chase. While the distancer appears calm and detached it’s important to understand that he or she is operating from the same “stuff” as the pursuer. It’s also important to note that a pursuer in one context may move to distancing behaviors in another even in the same relationship. A pursuer at home may be a distancer at work; one who distances him or herself when it comes to emotionally supporting a spouse may become a pursuer when it comes to finances or sex.

This chase becomes problematic when the pattern results in a family member escalating to a point where they act in ways that cannot be ignored (screaming, aggression, leaving the house for extended periods of time). It can also be the stuff that triangles (something we’ll talk about soon….I promise) are made of as the distancer will seek a third object to escape to and the pursuer will seek a third object in getting their needs met. It also creates problems for the pursuer as, depending on how the behavior manifests itself, it can create greater vulnerability to be manipulated and controlled. If you come across as needing me more than I need you, I can use that in ways that are less than noble.

One way to break the pattern is for the pursuer to just stop pursuing; this tends to make it safer for the distancer to approach as perceived expectations and intensity are ramped down and the distancer feels that he or she can gain proximity on more mutual terms. Obviously, the other way to break it is for the distancer to remain present and tolerate hearing the pursuer’s needs; this could reduce the pursuer’s need to chase and works to reduce the anticipatory anxiety they experience leading up to the pursuit that can make their presence feel overwhelming to the distancer.

For some folks this is like telling Little Debbie to stop making delicious snack cakes.

Just stopping the pursuit doesn’t mean changes will happen immediately or that the change will be enough for all parties. One reason skills are such a big part of the work with couples and families at my shop is that increased capacity to tolerate the urges or desires that drive maladaptive relationship patterns are many times necessary before people feel change, even small change, is realistic. Thanks for checking in!

Opposite Action to Current Emotion

One of the DBT handouts I frequently use is “Changing Emotions by Acting Opposite to the Current Emotion” (Linehan-“Skills Training Manual for Treating Borderline Personality Disorder”) which deals with four common emotions or emotional states that folks struggle with – fear, guilt/shame, sadness/depression and anger.  The short of it-

photo_19230_20110106 -Overcoming fear involves doing the thing you’re afraid of over and over again (desensitization).

-Resolving guilt involves either making amends if the guilt is legitimate or doing the thing that creates shame repeatedly if it is not.

-Mitigating sadness means getting active, approaching and engaging in activities that build mastery.

-Anger involves avoiding or acting opposite the anger through acts of kindness.

A common question that comes up (and it did again today) is whether we are suppressing anger by avoiding it?

It’s less about suppression and more about tolerating your anger when it is pushing you towards aggression, rumination or vengeance and it’s pretty consistent with what CBT and DBT teaches when it comes to assertiveness. In tolerating the anger you’re acknowledging it’s presence and what’s causing it while working to mitigate its negative impact on yourself and your relationships.

Intense anger is a flood; don’t swim in a flood – wait for the waters to calm and gently step in. Dealing with something that causes anger is different than acting from a state of anger.  Another DBT concept that might be useful in thinking about this is RAVEN (McKay, Wood and Brantley-“The Dialectical Behavior Therapy Skills Workbook”).  Before acting out of anger you may want to check yourself across these factors-

Relax – Are you able to tolerate disagreement calmly? Can you access your reasonableness?

Avoid the Aversive – Are you in the best state possible to avoid the verbal (mocking) or behavioral (eyes rolling) jabs that can escalate the discussion?

Validate – Are you ready to hear and understand the other person’s position, even if you may not agree with it? Are you able to access empathy and negotiate?

Examine- Are you able to act consistent with your virtues in your treatment of the other person? Will you be able to maintain your own boundaries reasonably? Are you able to respect the other person’s boundaries?

Neutral Voice – Can you maintain consistency between your tone and the emotion surrounding the issue without contempt or betraying disproportionate anger?

Once you’re capable of addressing the issue within these parameters you may be more effective in addressing the issue. In other words – don’t let it go just because you feel calmer.  Anger is an indicator of when something feels wrong; it’s not always a good indicator of whether it is wrong or how wrong it might be.  It’s a cue that something bothers you and that something requires further examination.  It’s your assessment of the issue that should determine further action – how to go about that assessment is material for another day. Thanks for checking in.

Good Manners and Mixed Messages

alpinist rope I do not work with young children but being a parent of two young girls has caused me to become more interested and active in researching different aspects of development during this time frame. I found that I have some real disagreements when it comes to how the larger culture expects young children to act and the assumptions that drive the thinking behind these expectations. I recently came across this article, which appears to be a re-post of an article written for Parents Magazine a year earlier, on manners. There were a few items on the list of manners in the article that caught my eye.

Do not interrupt grown-ups who are speaking with each other unless there is an emergency. They will notice you and respond when they are finished talking.

Never use foul language in front of adults. Grown-ups already know all those words, and they find them boring and unpleasant.

When an adult asks you for a favor, do it without grumbling and with a smile.

emphasis added by me

The last one almost made me spit iced tea out of my mouth and onto my screen.

One thing that my work with trauma survivors has taught me is that programming kids to automatically respect people because they are older can open up some bad doors.  Automatic respect based on some arbitrary value like age leaves folks open to being more vulnerable.  Teaching young children who are still not fully aware of “how the world works” to live according to this idea pushes their thinking about relationships away from reason, reciprocity and evidence to values that may not only be irrelevant to context but even dangerous.

Manners are rules of engagement that are expected to be followed in social situations. In order for them to have any meaning or value, everyone in the game needs to play fair.  Being that there is no “enforcer”, this expectation is built on nothing more than blind faith.  As adults I know we all understand this but young children don’t think that way.

Which brings me to my next point about manners; they set up expectations on how other people will behave. Young children have not yet developed the capacity to understand the whole idea behind “trust but verify”.  When you tell them this is how people should act, they assume that this is how people will act which can create confusion when the expectation falls through.

This is not to say that the items on the list are always bad or always wrong; in fact I have probably talked to my kids about most of what is on there.  I think the problem is more about having a list of “to-do’s” with regard to social relationships that are expected to be followed without consideration of context or relationship.

So I decided to come up with a different list.  These aren’t a list of manners; it’s more about how I handle my parenting when it comes to social expectations and relationships.

I don’t compel my children to refer to adults as “Mr.” or “Mrs.” .

I know the argument. Using “Mr.” and “Mrs.” teaches kids to respect their elders but, what are you teaching your child when you compel them to demonstrate a higher level of respect to someone who hasn’t yet earned it in any meaningful way?  My kids refer to adults, other than their family members, by first name.  We explain that the titles they call family members have more to do with roles they play in the family – whether they grow to respect, trust and love their family members will be a product of the relationships they have with each of them.  Our kids go to private schools and so we are clear that referring to their teacher as “Mr.” or “Mrs.” is a rule that the school has – it is a sign of authority but that authority has limits and it is accountable to a higher authority, namely their mother and I.

I don’t compel my children to disclose to adults or show affection to them if they do not want to.

The relationships my children have with their extended family are probably no different than what you would see in other  families. It is clear, however, that they are more open and trusting of those who have been more present for them than those that have not. Our children have the freedom to make those decisions and act accordingly. They have the right not to like everyone they are related to even if we like them.  We don’t force them to kiss family members or hold conversations with people they are not comfortable with, regardless of who they are.  Forcing kids to behave in ways that feel disproportionate to the real value and meaning of the relationship teaches the lesson, again, that their investment in relationships does not need to be earned.  We also run the risk of confusing the decision making surrounding acts of affection or disclosure of information.

I don’t compel my children to return a strangers “hello”.

We tell our kids time and time again not to talk to strangers and then I see parents pushing their kids to interact with complete strangers on the check-out line at shop-rite.  Parents can effectively model resisting behaviors for their kids by telling strangers who attempt to strike up conversations with them something like “Hey, nothing personal but we teach our kids not to talk to people they don’t know.” “Do as I say and not as I do” isn’t always a bad principle – there are things adults can and should do, that young children should not be allowed to do.  But, where possible and relevant, modeling allows kids to observe the behaviors we ask them to engage in.

I don’t compel my children to “share” with people  that have not historically returned the favor or who have been mean to them.

This is about self -respect. Children can learn early on that relationships are not a one way street. Pushing children to go above and beyond in their generosity to others without expectation of return may set them up for some pretty nasty relationships later on.  This also reinforces unrealistic expectations about relationships for the other child – sending the message that they could be mean and still get what they want. I get there’s a whole lot of theology working against me here but given what I’ve learned about relationships over the years, I’m going with my conscience on this one.

I encourage my children to be assertive in telling anyone about a behavior or action that they don’t like.

Allowing them to be open to adults about how they feel and having permission to set boundaries makes them less of a target. It also provides rich opportunities to develop key interpersonal skills. If they go too far, you can talk to them about bringing it down a bit after the fact- I want my kids to make authentic mistakes because it opens the door for authentic and substantial growth. I know it’s a lot harder than telling them to follow a list of rules but the payoff down the road will be well worth it. I have to understand that how my 4 year old sets a boundary is going to look a lot different than how I would, but my job is to praise the courage she demonstrates when communicating the need while providing guidance on how it ought to be done in a given context.

I allow my children to face the natural consequences of their relationship mistakes.

If my daughter acts badly towards another child and becomes upset when that child no longer wishes to play with her I try to explore, using language she understands, the cost of her behavior.  She can continue doing what she’s doing but she runs the risk of losing friends and getting in trouble with teachers.  I also inject our family’s values into the discussion and tie their importance to the current situation, reinforcing the idea that values have pragmatic benefits as well as costs that need to be balanced according to the situation in front of them.

I don’t let table manners get in the way of dinner.

My oldest is 4 years old (this list applies mainly to her at this point) and to be honest, my table manners leave a bit to be desired..but I’m doing ok for myself.  Do I point out egregious behaviors or pick on moderate to minor infractions here or there? Sure.  But my goal in life is not to appear on some sort of reality TV show as the poster parent for good manners.  When I’m on my death bed, “My children had impeccable table manners” is not the crowning achievement I hope to have rolling around in my mind.  Table manners are fine but the real value to meals is the relationship building that happens during them.  Part of it, of course, is negotiating and modeling respect in the way we conduct ourselves at the table.  But, like any other social situation, being relaxed and rolling with the punches is equally if not more valuable to the purpose of the interactions taking place.

I remember that my children are young girls.

I constantly explore whether I would let a behavior go or actually encourage a behavior if my children were boys.  I have to be mindful that I was raised in a culture that had very different expectations of boys and girls.  Some of these I agree with and hold onto because they have wisdom and make practical sense to me but some of them are just plain horrible.  I tend to be most mindful of the urge I sometimes have to push my kids to show more restraint, be less active or be quiet which has helped me bite my tongue on more than a few occasions.

I try to point out, reinforce and model the idea that being polite doesn’t mean you like or trust a person.

This one is hard to explain without using an example.  About a year ago I had a really annoying situation with my bank.  I received a notice that my car was going to be repossessed because they failed to have me sign a form when I purchased my car.  I never missed a payment; in fact I pay early and usually pay more than what is required.  When I went to the bank I expressed my dissatisfaction with the way they handled the matter and indicated that I was strongly considering changing banks as a result.  When we left, my daughter looked at the bank employee and said

Bye-Bye little guy

I had her apologize for the remark and later explained why the remark was hurtful. I also explained that we can be angry and firm with people without being insulting.  That by insulting others, we could make things worse for ourselves.  Lastly, I explained that the bank rep didn’t really have anything to do with what happened but that I communicated my aggravation with the whole thing to him so he could talk to the people who made the decisions.  I reminded her that I shook his hand and thanked him for his time.

The intended take away for this post isn’t that you agree with how I do things or that you buy into my values.  It has more to do with encouraging folks to drop “lists” or rigid expectations as a way of teaching kids how to behave and to focus more on value informed thinking and self interest while actively seeking opportunities to help children negotiate these principles using situations and problems as they come up. My list isn’t a “what you should do” but more an example of how to approach the issue in a way that is both value driven and contextual.