Structural family therapyin chronic illness

Intervention can help produce a more adaptive family structure

JAMES L. GRIFFITH,M.D. #{149}MELISSA E. GRIFFITH, M.S.N.

1�- �

ABSTRACT: A strong argument canbe made that the family rather thanthe individual patient is the appropri-ate unit of treatment for the repercus-sions of chronic illness. Familystructures can be assessed in thelight of boundaries, hierarchy, alli-ances and coalitions, and repetitivebehavioral sequences organizedaround the symptom, so as to enablethe family therapist to design appro-priate interventions. Specific exam-ples are presented to illuminate thisapproach. At best, the chronically illpatient can be freed of considerableemotional suffering even when theillness cannot be cured.

Dr. Griffith is assistant professor of psychiatryand instructor in neurology, and Ms. Griffith isclinical instructor in psychiatry, both at the Uni-versity of Mississippi School of Medicine. Re-print requests to Dr. Griffith, Department of Psy-chiatry and Human Behavior, University of Mis-sissippi Medical Center, 2500 North State St.,Jackson, Ml 39216-4505.

Cbionic illnesses differ from acute

illnesses, even if the medical di-

agnosis seemingly is similar for both.

The two particularly differ in regard to

how each is experienced by the family

with an ill member. In an acute illness,

family living can be put on hold with

the expectation that the sick relative

will respond fully to treatment, and

then life will return to normal. In

chronic illness, there is no expectation

that the problem will disappear. The

disease and the sick family member

become part of a recast family.

The main reasons for the belief that

the family, not the individual patient,

should be the essential unit of treat-

ment in chronic disease are as follows:

1. While hospitals, physicians, nur-

ses, and other health-care profession-

als provide the bulk of care in acute ill-

nesses, families provide most of it for

patients with chronic diseases.

2. When treatment is based on the

family unit, unused family strengths

and resources can be identified and

optimally employed. This often im-

proves the quality of health care and

reduces the cost of treatment.

3. In recent years, powerful techni-

ques have been developed in family

therapy for changing the behavior of

an individual by first changing the be-

havior of the family to which the indi-

vidual belongs. This is particularly

useful when a patient shows behavior

that is maladaptive for health but can-

notbe easily changed by working with

that person (as in dementia), when

rapid change is needed, or when fam-

ily behavior itself is judged to main-

tam illness in the patient.’

A general approach to the family af-

fected by chronic illness has emerged

from family systems medicine, which

combines family therapy and medi-

cine . A systematic assessment of fam-

ily structure2 serves as the diagnostic

tool for understanding family behav-

ior organized around a chronic illness,

while evaluation ofthe stage of family

development3 contributes to a blue-

print for changes in structure to cope

effectively with chronic illness.

I Family structureFamily structures are the “relatively

enduring interactional patterns that

serve to arrange or organize a family’s

component subunits into somewhat

constant relationships.”4 Many prob-

lems arising in chronic illnesses are

due to dysfunctional structures that

develop as the family struggles to cope

with the illness.3’5

In order for the family as a group to

survive and for its members to grow

and differentiate, each family creates

an organization in which the subunits

take on different tasks, roles, and re-

sponsibilities.2 In the typical Ameri-

can family most of the executive func-

202 PSYCHOSOMATICS i

APRIL 1987#{149}VOL28#{149}NO4 203

tions are performed by a subsystem of

two parents, who maintain a consider-

ably private relationship with each

other, into which the children do not

have license to intrude. The children

form another subunit, in which they

are given age-appropriate privileges

and responsibilities by the parents.

While enormous variation can exist in

the kinds of family structure that can

effectively function within various

subcultures of a society, some struc-

tures ale universal. For example, ev-

ery family must have some sort of

power hierarchy, and every family

needs an executive subsystem whose

members complement the functioning

of one another.

Families with flexible, balanced

structures are resilient and able to cope

well with the stress of chronic illness,

while families with inappropriate or

excessively rigid structures generate

symptoms in their members. Family

therapy seeks to create structures that

are optimally adaptive for a family

confronted by chronic illness. Four

aspects of family structure are regular-

ly assessed for the planning of ther-

apy: boundaries, hierarchy, alliances

and coalitions, and repetitive behav-

ioral sequences organized around the

symptom .�

I BoundariesA boundary represents a set of stable,

repetitive interpersonal behaviors be-

tween two persons or groups of peo-

ple, and it defines the separateness

between them.4 A family normally has

a boundary between its members and

outside persons, eg, only family

members may ordinarily be invited to

Thanksgiving dinner. There normally

is a clearly defined boundary between

the parental couple and the children.

Inappropriate boundaries in the

family create maladaptive subunits

within it. A rigid, impermeable

boundary around a parent and one of

the children may so distance the two

spouses from each other that effective

parenting is impossible. Boundaries

too permeable do not allow individual

or family subunits to have needed au-

tonomy and privacy, thus creating en-

meshment. At the other extreme,

boundaries too impermeable produce

emotional disengagement among

family members, so that effective

communication does not occur. Each

type of boundary problem is associat-

ed with psychiatric or psychosomatic

symptoms among family members �2

In chronic illness , the need for some

family members to care for the ill per-

son easily gives rise to enmeshment

between the caretakers and the pa-

tient, as in the following vignette.

Case 1A 17-year-old honor student was inhigh school when she sustained a Se-vere closed head injury. She was laterunable to do college work or to be reg-ularly employed. She was still livingwith her parents when the family wasreferred fortherapyfive years after theaccident.

Prior to the accident, the family hadgone on camping vacations and heldcookouts with neighbors. Afterwards

the worried parents so centered their

attention on the injured daughter thatthe vacations stopped and social rela-tionships outside the family withered.The father took an extra job to pay forcontinuing medical bills, and his pres-ence in the home thus diminished. Asthe mother focused her attention oncaring for the daughter, the marital re-lationship became perfunctory forboth spouses.

The family therapist sought first tostrengthen the boundary around theparental couple by arranging for thedaughter to stay with relatives so thatthe two spouses could have dinnerand attend the movies by themselves,and then later go on vacation by them-selves. Relationships were fosteredbetween each family member andpersons outside the family, through

church and community organizations,and at family reunions. The father anddaughter were assigned some struc-tured times on their own in order toweaken the boundary around themother-daughter dyad . Eventually,the daughter moved into a grouphome as she progressed in a rehabili-tation program to part-time employ-ment.

I HierarchyAn inversion ofpower hierarchies that

creates incongruous hierarchies of

powers may be the single most de-

structive force in the structure of fam-

ilies coping with chronic illness. For

example, the parents of a chronically

ill child may be at the top ofthe power

hierarchy in that they control feeding,

clothing, and medical care. However,

the child may find ways to dominate

the parents by strategically producing

symptoms of illness. In some cases, a

hierarchy that functioned for many

years may be disrupted by illness and

the therapist may work with the family

to invert this hierarchy into one that

works better for chronic illness.

Case 2A 60-year-old patient embarked onhemodialysis for end-stage renal dis-ease. She became increasingly un-able to function effectively as wife andmother over nine months of dialysis,abusing sedatives, failing to adhere todietary restrictions, not performinghousework, spending money exces-sively, and exploding in irrational an-ger towards family members.

Neuropsychiatric evaluation foundsevere deficits indicative of a frontallobe syndrome, probably arising fromearly Alzheimer’s disease. This was aparticular problem owing to the struc-ture of her family. The husband was apassive, dependent man who had al-ways deferred to his wife in the mar-riage. His wife had been a strong ma-triarch, dominating the lives of her hus-

204 PSYCHOSOMATICS

Structural family therapy

band and children. Now she ruled thefamily as an irrational tyrant, continu-ing her old roles but no longer compe-tent in them.

Family therapy sessions were de-voted to movingthe husband to the topof the family hierarchy of power byturning to him for decisions while re-straining his wife’s intrusions, pressinghim in sessions to set limits on her be-havior, enlisting support from the chil-dren when his efforts were insufficient,and pointing out when their behaviorencouraged the mother in her undesir-able actions. Although she was infuri-ated by her loss ofcontrol ofthe family,the effects of her erratic behavior di-minished.

I Alliances and coalitionsAlliances consist of two or more fam-

ily members who join together, overt-

ly or covertly, to achieve a positive

goal. Coalitions develop when family

members join together, overtly or co-

vertly, for a negative goal, usually to

oppose the influence of other family

members.2 Secret coalitions that cross

generational boundaries, such as a

grandparent covertly encouraging a

child to resist parental directives, pre-

dictably produce symptoms in one or

more family members.7 In chronic ill-

ness, primary caretakers and the sick

member sometimes bond together in

an intimate relationship through

which they control much of the fami-

ly’s behavior, while other family

members may unite to oppose their

power.

Case3A 37-year-old woman was referred forintractable depression following a se-vere closed head injury ten monthsearlier with major residual deficits in at-tention, memory, and language. Aftera suicide attempt she had failed to re-spond to a variety of antidepressantand antianxiety agents as well as to sixweeks of inpatient psychotherapy.

From a family evaluation it waslearned that her mother had becomebedridden from rheumatic heart dis-ease when the present patient waseight years old. The family had sur-vived by means ofthe five children as-suming full responsibility for thehousehold. The patient bitterly re-membered her childhood as a trau-matic experience. She grew up as anindependent, self-sufficient personwho vowed that she would never placeresponsibility for her well-being andhome upkeep on her children.

Following the head injury, the familysought diligently to support the pa-tient. Her own mother, now recovered,called daily and visited to do house-hold chores. The husband and theirson altered their schedules sothat oneorthe other could be with the patient atall times.

The wife resented her mother’spresence, feeling that “she wasn’t amother when I was growing up, so Idon’t want her to try to be one now.”But she feared hurting her mother’sfeelings and did notaskthat she ceaseher attentive caretaking. The wife feltanger over the loss of her autonomy,guilt that she disrupted the lives of herhusband and teenage son, and worst,despairthat she had betrayed her vownever to be dependent on her childrenfor support. She became progressive-ly more depressed and attempted sui-cide by cutting her wrists. Afterwardsthe husband and son felt compelled towatch her even more closely, whichfurther exacerbated her depression.

In family therapy, the patient’s prob-lems were defined as the “business ofgrownups,” and the son’s attentionwas directed back to his adolescentand school activities with the assur-ance that the therapist and the parentscould handle the family’s problems.After careful prior guidance from theclinician, the wife met alone with hermother and tactfully butfirmly set limitson her overinvolvement. The husbandwas directed to plan brief vacationsand other activities of genuine interestto himself and his son.

The caretaking alliances betweenthe father, son, and the grandmotherwere gradually inactivated, and thepatient’s autonomy and privacy were

reestablished. Her agitation improvedover nine weeks and therapy shifted toa focus on rehabilitation.

I Symptomatic behavioral sequencesEvery family has stable, recurrent Se-

quences of behaviors among its mem-

bers in which the particular behavior

of one member triggers that of another

member in a circular fashion.4’7 For

example, an asthmatic child may pre-

dictably wheeze whenever the parents

start fighting, and then they stop out of

concern for the child.

Case 4

A 1 6-year-old was referred for evalua-tion of an intractable seizure disorder

and family conflicts. He had had sei-zures since infancy, but their frequen-

cy had recently increased to daily, de-

spite trials with several anticonvul-sants. The parents argued about hisillness, with the father angrily asserting

that the son exaggerated his symp-

toms, while the distraught mother be-lieved that he had a serious and made-quately treated neurologic disorder.

Every morning, in the final hours ofsleep, the boy had a seizure. His moth-er would run to his aid from the kitchen,where she could hear his bed shakingas she prepared an early breakfast forher husband. A family evaluation

tracked the steps of the behavioral cy-

cle around the daily seizure. A simple

intervention was prescribed. The fa-

ther would interrupt his breakfast eachmorning to check on the son when thepresumed seizure occurred, while themotherwould remain in the kitchen. No

early morning seizures occurredthereafter.

I Family developmentIn addition to changing the family

structure as observed at the present

APRIL 1987#{149}VOL28NO4 205

time, most family therapists utilize a

developmental perspective to guide

families through predictably difficult

stages of growth.389 Families, like in-

dividuals , move through a sequence

of stages of growth over time . A com-monly used staging offamily develop-

ment is29:

1 . Courtship

2. Marriage and becoming a couple

3 . Childbirth and young children

4. Middle marriage and school-age

children

5 . Children leaving home

6. Retirement and old age

As a general rule, families tend to

show stable behavior within a stage.

However, the transition from one

stage to the next, a change made nec-

essary by time and biology, is stressful

even in normal situations. Stages in

which a new member enters the fam-

ily, or an established one leaves, are

especially difficult to traverse. When

a family stalls and is unable to move to

a new stage of development, psychiat-

ric or psychosomatic symptoms com-

monly arise among its members.9

The appearance of a chronic illness

typically stops development at the

current stage, so that the family con-

tinues to operate with the organization

that existed when the illness first ap-

peared, as if the family has become

“frozen in time. “3.8 The normal pro-

cess of family development is largely

an orderly shifting over time of bound-

aries among family members: the for-

mation of a boundary around the new-

ly married couple that separates them

from families of origin; reopening of

that boundary to include grandparents

when young children arrive; and re-

forming of a boundary around the two

REFERENCES

1. Griffith JL: Multilevel patterns: Family therapywith neuropsychiatric patients. Fam SystemsMed3:151-159, 1985.

2. Minuchin S: Families and Family Therapy.Cambridge, Harvard University Press, 1974.

3. Penn P: Coalitions and binding interactions infamilies with chronic illness.Fam SystemsMed 1:16-25, 1983.

spouses as their grown children begin

to leave home. The next example illu-

minates how chronic illness disrupts

this evolution.

� Case5. A young couple had been married for

onlyfour months when a spinal cord in-� jury in a motor vehicle accident ren-� dered the husband paraplegic. His� parents immediately began to handle� many of his new needs: for transporta-

tion around the City, for recreationavailable to disabled persons inwheelchairs, and for assistance withphysical therapy, in addition to fre-quent visiting to provide companion-ship. The young husband and wife be-gan to argue increasingly often, large-ly as a result of her resentment of hisfamily’s constant presence in theirhome. The pair separated before long.

They had been in the early develop-mental stage of becoming a new cou-pIe. The husband’s injury triggered aregression to the previous stage, inwhich he was an adolescent still in hisparent’s family. The regressionblocked further growth of a boundaryaround the new husband and wife.

Alliances among family members

may be adaptive in many ways, as the

latter seek to minimize stress by join-

ing together to confront the illness.

Likewise, physicians, nurses, and

other health-care providers may form

strong alliances with family members

to help the family cope. If the new alli-

ances powerfully meet personal needs

of the family members or health-care

providers independently from dealing

with the illness, they may persist even

if the situation improves. The impact

of the new alliances, termed “binding

coalitions,’ ‘� on family functioning

4. Umbarger CC: Structural Family Therapy.New York, Grune & Stratton, 1983.

5. Patterson JM, McCubbin HI: Chronic illness:Family stress and coping, in Figley CR,McCubbin HI (eds): Coping with Catastro-

phe. New York, Brunner/Mazel, 1983, pp 21-36.

6. Madanes C: Protection, paradox, and pre-

may become detrimental as they out-

live their usefulness and the family is

unable to resume its previously nor-

mal organization.3

A sense may sometimes exist a-mong relatives that the family can be

stable and safe only if behavior orga-

nized around the illness serves as the

glue that holds the family together.

Helping the family sort out develop-

mental needs and assisting it toward

the next stage often frees it so that

some illness behaviors can be given

up.

I ConclusionFamily-based treatment of the reper-

� cussions of chronic illness opens new

possibilities not available to the clini-

� cian who focuses on the disabled mdi-

: vidual alone. In the best of circum-

� stances, the family can become a pros-

thesis for the ill person, providing life

functions that the patient’s impaired

body may never again furnish.

Cultivation ofa family’s unseen re-

habilitative potential begins with sys-

tematic assessment of family func-

tioning, followed by planned inter-

ventions to create structures in the

family that are flexible to accommo-

date changing needs and that nurture

the well-being and growth of each

member.

An understanding of normal family

development provides an outline for

family growth, so that planning for

predictable crises can occur. When

these tasks are performed effectively

by the clinician, the patient with a

chronic illness can find considerable

improvement in functioning and relief

from suffering, even when no cure is

available for the illness. 0

tending. Fam Process 19:73-85, 1980.7. Haley J: Problem-Solving Therapy. New York,

Harper & Row, 1976,8. Penn P: Feed-forward: Future questions, fu-

ture maps. Fam Process 24:299-310, 1985.9. Haley J: Uncommon Therapy. New York, WW

Norton, 1973.