Some observations on the effect of family and caregivers on individual health issues
Most people think of therapy in the following way: a session or course of sessions consisting of a one-to-one interaction between therapist and client in which the therapist calls on his/ her training and expertise to meet the challenge presented by the client. During each session the therapist employs various techniques and perhaps offers remedial exercises for the client as ‘homework’ until the next session.
At face value, you might agree: this exactly describes the client-therapist relationship. And yet there is a basic limitation with this viewpoint, something missing. When we look more closely we can see that there are some key assumptions – hidden baggage – within this scenario that have a profound effect on the nature and efficacy of treatment.
Ingrained in our thinking is a belief that illness, including any physically disabling challenge – whether to ourselves or someone we know – is fundamentally wrong and must be cured, ‘got over’ as quickly as possible. Concurrent with this unconsciously held belief is the idea that the client’s issues are discrete – disconnected not only from the client themselves but from everything else, in particular the client’s significant relationships.
The therapist who holds the view of illness or physical challenge as something simply to be eradicated is likely to have the perspective that the client ‘has a problem’ and, whatever the problem is, it is distinct and separate from anything else. From this doubly distancing separation the therapist will no doubt assume it is up to him/ her to ‘fix’ whatever the problem is. Quite unconsciously they find themselves treating people as if they were auto mechanics working on a car engine. If you think this has not happened to you, then ask yourself: how often have you thought of a client framed in terms of their presenting challenge – for example my stroke patient, my stutterer, and so on?
You might now be asking: what’s wrong with thinking about a client in such terms?
Whenever we identify someone in the way I have described, we are in danger of creating separation that is not helpful for the client. It robs a person of an essential healing tool which is their sense of feeling connected.
Consider, if you as a therapist hold the thought that your client has a problem that is separate from anything else, you are sending a powerful message. The client is likely to think of their challenge in the same way – as something separate within him/ her that needs to be ‘fixed’. It is then only a short step for the thought to arise that it is the person who needs ‘fixing’ and from there the idea of the person somehow ‘being wrong.’
Of course the therapist needs to know why a client has come for treatment in the first place, so it is natural to enquire into whatever the problem might be. If a practical solution is readily available so much the better. However when the issue goes beyond the mechanical, things are not so easily resolved.
I do not wish to give the impression that techniques and exercises are not important. They are and they help. However if treatment consists of only functional work presented as a one-way direction from therapist to client, results will necessarily be limited. There are wider issues to be considered.
A Body Resonance perspective
Imagine a universe in which everything is interconnected – a view almost inescapable given the discoveries in quantum physics over the last century. When we view life, health and disease as a network phenomenon then illness or physical challenge is not an event that exists in isolation as it impacts on more than just the person who is affected by the difficulty.
This means we cannot separate ourselves from whatever process might be taking place, either our own or a client’s, because we are part of a continuum in which everything is connected. Some of these connections have effects which are not so easily recognized. For example, the effect of an observer on the outcome of an experiment – first posited by Heisenberg (1) – which raises the question about the impossibility of being wholly objective. Or the understanding that this continuum includes not only our – and our client’s – present environment but also what is perceived as the past: the experiences, ideas and actions of all those who came before. Bert Hellinger’s Family Constellation work on systemic family problems has a great deal to offer on this topic. (2)
Given this viewpoint, disease or physical challenge becomes something more than simply a change in biological structure and functioning. The norm in current scientific medical thinking attempts to reduce the human experience to a clinical diagnosis; this disregards a host of contributing factors to any issue. Surely, a more comprehensive approach is called for – one that includes not only biology but also social and psychological influences.
In a previous article for Logo Thema magazine (2/2010) I wrote that the ability of a therapist to connect with his/ her client and the client’s sense of being ‘seen’ and valued as a person, quite apart from whatever challenge they may present, provides the greatest encouragement for significant and lasting change. From a Body Resonance perspective we do not treat the client as if they existed in isolation, we must also take into account the effect of those people who are the client’s support in everyday life – the client’s family and other relationships.
“The illness experience… is always culturally shaped.” - Arthur Kleinman, The Illness Narratives
Each of us is connected to other people in so many ways: through family and friends, at school or work. And these relationships influence us in ways that are not always obvious. We are all conditioned by family, school, friends, church and so on. This conditioning is like a cultural code that informs us as to how we should conduct our lives, what is okay and what is not, how we should be and a whole range of other ‘shoulds’ and ‘shouldn’ts’.
We have received understanding about a whole range of issues in our lives: things we simply take for granted and don’t question.
One of these cultural conditionings is our relationship with illness, physical challenges and, indeed, with anything that deviates from any ideas of what we consider being ‘normal.’ We are encouraged to view health as the only acceptable state; indeed, how often do we hide disease and death as if it were shameful somehow? As a society we have associated success with eternal youth living on a continent of wellness. We divorce ourselves from the ocean of disease that threatens our stability. Indeed some of us suffer from chronic wellness! Yet, surely health and illness are intimately connected.
As a therapist it is vital to recognize the assumptions you may hold because these directly affect how you are with your clients.
If it is true that the therapist’s assumptions about the client and their disease or physical challenge affect the outcome of therapy, then it is also true that the attitudes and assumptions of those who live with and/ or take care of the client also affect their progress.
“No man is an Island, entire of itself.”- John Donne, Meditations XVII
The effect of family dynamic
When a parent brings their child for therapy, there already exists a dynamic – between parent and child in this case – that affects the outcome of therapy. Perhaps the parent is in fear for their child, or they have a picture in their minds about how their child should be. The parent might be feeling responsible for what is happening, so they feel guilty. They may also be feeling ashamed by their child’s special need or their own feelings of inadequacy.
Undoubtedly these conflicting emotions are the source of a great deal of frustration and cause stress. The stress may be high enough that it interferes with the parent’s ability to listen to and connect with their child. In fact the very picture the parent holds for their child might be what is in the way of the child’s progress. The parent who is stressed in this way wants more exercises for their child; they might even seek out different therapists so that the child becomes engaged in a never-ending round of therapy sessions in a feverish desire to achieve the outcome that will mean the parent can rest in a certainty of not having to feel guilty. The child, of course, needs time to develop. And what will assist their development is not so much ‘doing’ but rather connecting on an emotional level.
I would argue that an affective dynamic exists in all cases whether child or adult. Consider the stroke patient: is he/ she not affected by what is happening at home with their spouse? Anyone who has suffered a stroke is not the same person they were before; their loss of physical abilities impacts on how they see themselves and this can be the cause of great suffering. They struggle not only with a loss of function but also their loss – real or perceived – of connection with family, friends, work colleagues, etc. Add to this the pressure of meeting the expectations – again, real or perceived – of family and/ or caregivers (who are most often a spouse or family member).
Including the care-giver
I am sure you recognize the situation I am describing. In my own experience I have noted that unless the parents and/ or family/ care-givers are included and valued for their struggles, there is much less chance of a breakthrough for the client.
The following examples from my practice illustrate this point:
Recently I saw a 9 year old girl who was brought by her mother because of panic attacks. It had got to the point where her fear of being abandoned included breaking out into a sweat and her heart racing when she heard her father simply picking up his keys on his way out the door to work. I ascertained that there had been no change in living circumstances, no change in work patterns, no trauma or anything that might indicate a source of the panic attacks. The girl said to me, “I know it’s not real but I still feel it the same.” The use of this language struck me because it sounded more like her mother’s words than the child’s. She was clearly a very bright person with a highly creative imagination, much like her mother.
Some time after the treatment I saw the mother and asked how her daughter was managing her panic attacks. It seemed as if there was an improvement which I was delighted to hear but it was what the mother said that struck me most. She said, “When you told my daughter that it was not unusual for kids at her age to have these kinds of fear, my daughter looked at me and I could see it was a relief for her – just knowing there were other people who had the same problems.” The mother continued by saying that she realized in that moment how much pressure she had been exerting on her daughter. “I saw her through your eyes and somehow felt it was going to be okay.” It occurred to me that what she meant was that it was going to be okay for her – quite apart from her daughter. This was the breakthrough: the parent’s recognition of the pressure they were exerting on their beloved daughter allowed them to take a step back and connect with her on an emotional level. Feeling connected at this deeper level, the child’s fear of abandonment was reduced.
In another case I was asked to treat a ten year old boy who, at the age of eight, had been diagnosed with idiopathic juvenile scoliosis. What was unusual for me in this case was that during the time I treated the boy, I also had occasion to treat a large number of the family members. This included the boy’s sister, both parents, grandparents on both sides, and even several cousins, aunts and uncles. The more I came into contact with the boy’s extended family, the clearer it became to me how much focus there was on the boy’s scoliosis. Every time I treated any family member, their first words at each session were expressions of what a terrible affliction it was for the boy. “I hope he is going to be alright,” they would say and each time I heard these words I could also hear their subtext which was that they were sure he wouldn’t be. It seemed as if the one thing the whole family agreed on was that the boy had an awful affliction that, somehow, had to be borne by the whole family.
When I first met him at nearly ten years old, he was under almost constant control by whichever family member was with him. He was restricted from behaving in any way that might be considered usual for any other ten year old. When I asked him why he didn’t run around with other children he replied that it was dangerous. When I asked him why he thought so, he said, “Because of my scoliosis. If I fall then I’ll break my back.”
The more I talked to him the more he told me about what he couldn’t do because of his scoliosis. His whole life seem to be centered around corrective therapies. His parents had consulted literally dozens of orthopedic surgeons, physiotherapists and healers of every stripe from all over Europe.
It would be fair to say that much of the parents’ motivation was a sincere effort to help their son, but also much was motivated by frustration and guilt. Both parents expressed to me that they feared for what their son might say to them when he had grown to adulthood. Their expectation was that he would be angry with them and blame them for not having helped him, for having done the wrong thing, for not having done enough. What they couldn’t perceive was how their fear and frustration was transmitted to their son, how much pressure he had to bear with his whole family’s narrative about his ‘affliction.’
The greatest challenge in this situation was to help the family let go of their expectations and fears about what might or might not be possible for the boy; to help them recognize their own biases about what they thought was happening as opposed to what was actually occurring. The more that individual family members let go of their own fears, the less the boy identified his curved spine as an impediment to his life, and the more his treatment progressed successfully.
“Soul is a force… [that] transcends our body and unites us with other people, for instance with our family. The family behaves as if it had a soul of its own [and] is directed by that soul and is united by that soul.”- Bert Hellinger (Holding Love Seminar, Sedona)
A dynamic relationship
The traditional medical scientific view assumes that the physical body is an isolated self-contained unit. Yet clearly the children in the above examples are anything but independent of the influence of their family and others. It would be more accurate to suggest that the body is in dynamic relationship with all other bodies through actual physical exchange – a biopsychosocial exchange that we could describe as a ‘biodance’.
If we are not separate, cannot be, it is necessary to acknowledge the impossibility of being wholly objective. Quite clearly there is a correlation between how we think and feel about an illness or physical difficulty and the outcome of any therapy.
And if we, as therapists, are to make connections as a way to create ‘space’ needed for healing growth, then we do so by including our subjectivity. We can be aware of our projections, our judgments and stories about how we think things are. This simple awareness can soften and open us to something deeper we had not noticed before.
More importantly, perhaps, we can help the families become aware of their own narratives and limiting beliefs. What greater support for your client could there be than helping their caregivers understand what the difficulty is, what it might feel like not to be able to speak for example?
After all, support from family/ caregiver is integral to any client’s health and wellness.
In every treatment there is an implicit challenge: that is, being able to recognize how you as a therapist – or your client and their care-giver(s) – participate in what is happening beneath the presenting difficulty. Exactly how are you – or they – helping or hindering your client’s healing process?
Citations:
1) Heisenberg: Uncertainty Principle postulated in 1927. From this principle emerges the recognition of the effect of the observer on any experiment. 2) Hellinger, B. (2003). Peace begins in the soul: Family constellations in the service of reconciliation (C. Beaumont, Trans.). Heidelberg, Germany: Carl-Auer-Systeme Verlag.
Article first appeared in LogoThema magazine January 2012 PDF 1.5M