FAMILY THERAPY
(see Communication Problems, Talking with Families)

Some current concepts of family therapy are very helpful when working alongside families in crisis. In simple terms any attempt to help a family adjust to problems could be called family therapy. In fact, family therapy is evolving as a specialized and effective form of counseling which enables families to adjust in healthy ways to problems and difficulties, often long-term ones.

The knowledge and skills of a family therapist are applicable to helping families in crisis. More work is needed to define useful interventions in terms of family counseling around the time of a death. Some basic concepts from family therapy are outlined here.

There are many different types of families, each with particular problems and needs, including single parent, divorced, separated by distance, extended, fostered, communal, step-families and others. Although all families have certain characteristics in common, it is important not to assume that one family is like another, or like our own family.

When talking to families and when helping them to communicate together it is helpful to remember the characteristics of a family, which are:

1. An interdependent system

2. A life-cycle of development

3. A common history

4. A future together

1. A family is an interdependent system. Changes in one person affect all the family members. It can be very helpful to say to a family "This problem is affecting all of you", or "This cancer is really here in the middle of you all." It can be important to know who is part of the system, and to ask "Who is missing from this family?" For example, grandparents often wish to be included (even once) in a family meeting and can bring vital new understanding.

Communication within a family often follows a pattern. Disputes tend to be settled in similar ways. As a family develops it must be able to change these patterns from time to time – by open communication and willingness to change. Failure to adapt results in conflict. Pathological ways of coping with conflict usually involve blaming other family members, either by labeling one member (usually a child) as “sick”, or by creating coalitions (the basis of prolonged family feuds which commonly date from a major crisis such as a death). These pathological patterns can be prevented around the time of a crisis by encouraging a family to share their feelings and to witness each other’s distress. (“Can you tell us all what it has been like for you to be a daughter with a very ill mother?”) The family counselor must avoid singling out individuals for responsibility or blame. Problems belong to the whole family.

2. A family has a life cycle. A normal family develops and changes. Periods of transition occur (a new school or new job, adolescence, marriage, new in-laws, a new baby, retirement) when a family must negotiate new roles and new boundaries. A major crisis such as a terminal illness in the family may occur during an already stressful transitional phase. For example, a particular conflict occurs for adolescent children with a seriously ill parent. The normal role of adolescents is to move away from the family, but the illness will tend to draw them back. This can result in powerful feelings of confusion and resentment.

Another difficult situation occurs when parents return to help nurse a married child, become possessive, and exclude the spouse. Parents will normally have stepped back years before to allow the independent couple to make their own decisions. Yet now they may also feel powerfully drawn to nurse their sick child. The counselor needs to ask “What are the pressures and priorities for this family apart from the obvious major crisis?”

3. A family has a history. Attitudes and feelings within a family are partly inherited from the past. An impending loss will re-awaken memories of previous losses. Responses to a loss are more easily understood when previous losses are explored. Drawing a family tree can be a good way of starting a useful discussion. (see Family Tree)

Family myths and beliefs may be difficult to challenge. Myths and secrets in a family are intended to be protective, but can also put considerable pressure on individuals to behave in certain ways. A family can be helped to re-experience the past and feel less burdened by it. Unresolved grief is the cause of many long-standing family problems. A death of another family member is an opportunity to re-explore these events from the past.

A delinquent boy (and his family) were seen at the time of the death of his grandfather. The family was asked about previous experiences of loss. The boy’s father recounted how his own brother had died in an accident at the age of 11. He felt blamed for the accident and a poor substitute for his dead brother (“who was so clever”). The father retold the story for the first time in the presence of his family. Witnessing this grief helped to release his own son from the family myth that the “boys in our family are dumb”.

4. A family has a future. Even though one member is dying, the family will live on. A crisis is also an opportunity. “We are not only dealing with present problems  . . . we are modeling a way of coping with future living.” (Elisabeth Earnshaw-Smith)

One reason why a cancer death is usually less traumatic to a family than a sudden death is because there is time for anticipatory grief work. The events around the time of a death will powerfully affect the future of individual family members. It is mutually strengthening when a family (including the dying member) can be helped to discuss the future. The dying person can retain some control, for example, by discussing the future care of the children, or by teaching a spouse to take over roles and skills.

Anticipatory grief work is often sad, but it can be rewarding. The patient’s common worry is “How will they cope without me?” Discussion helps to reduce the isolation of the dying person and is of considerable benefit to the rest of the family in their future adjustment and grief.

Mrs. L.T., 12 months after her husband had died from cancer, said “We were very close. For a long time we didn’t talk about it. We wanted to protect each other. Then the doctor talked to both of us. I felt angry at the time, but my daughter said, ‘It’s not the doctor, Mom. It’s the fact that Dad's ill.’ But by the end he came to accept it. Before he died he said to me ‘I have to leave you now and I want you to let me go.’ Those words are a great comfort to me now.”

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.