Death and Chronic Illness in the Family

Bowen Family Systems Theory Perspectives

Peter Titelman, Sydney K. Reed, Peter Titelman, Sydney K. Reed

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315515038
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

What does it mean to be 'present and accounted for' when a family member is facing chronic illness or death? How does one define a self in relation to the ill or dying member and the family? Rooted in Murray Bowen's family systems theory, this edited volume provides conceptual ideas and applications useful to clinicians who work with families facing chronic illness or the death of a member.

The text is divided into four parts: Part I provides a detailed overview of Bowen's theory perspectives on chronic illness and death and includes Murray Bowen's seminal essay "Family Reaction to Death." In Parts II and III, chapter authors draw upon Bowen theory to intimately explore their families' reactions to and experiences with death and chronic illness. The final part uses case studies from contributors' clinical practices to aid therapists in using Bowen systems perspectives in their work with clients.

The chapters in this volume provide a rich and broad range of clinical application and personal experience by professionals who have substantial knowledge of and training in Bowen theory. Death and Chronic Illness in the Family is an essential resource for those interested in understanding the impact of death and loss in their professional work and in their personal lives.

I
Bowen Theory Perspectives on Death in the Family

1
Family Reaction to Death¹

Murray Bowen

Direct thinking about death, or indirect thinking about staying alive and avoiding death, occupies more of man’s time than any other subject. Man is an instinctual animal with the same instinctual awareness of death as the lower forms of life. He follows the same predictable instinctual life pattern of all living things. He is born, he grows to maturity, he reproduces, his life force runs out, and he dies. In addition, he is a thinking animal with a brain that enables him to reason, reflect, and think abstractly. With his intellect he has devised philosophies and beliefs about the meaning of life and death that tend to deny his place in nature’s plan. Each individual has to define his own place in the total scheme and accept the fact that he will die and be replaced by succeeding generations. His difficulty in finding a life plan for himself is complicated by the fact that his life is intimately interwoven with the lives about him. This presentation is directed to death as a part of the total family in which he lives.

There are no simple ways to describe man as part of the relationship around him. Elsewhere (Bowen, 1978, p.2), I have presented my own way of conceiving of the human as an individual and, also, as part of the emotional-social amalgam in which he lives. According to my theory, a high percentage of human relationship behavior is directed more by automatic instinctual emotional forces than by intellect. Much intellectual activity goes to explain away and justify behavior being directed by the instinctual-emotion-feeling complex. Death is a biological event that terminates a life. No life event can stir more emotional directed thinking in the individual and more emotional reactiveness in those about him. I have chosen the concept of “open” and “closed” relationship systems as an effective way to describe death as a family phenomenon.

An “open” relationship system is one in which an individual is free to communicate a high percentage of inner thoughts, feelings, and fantasies to another who can reciprocate. No one ever has a completely open relationship with another, but it is a healthy state when a person can have one relationship in which a reasonable degree of openness is possible. A fair percentage of children have a reasonable version of this with a parent. The most open relationship most people have in their adult lives is in a courtship. After marriage, in the emotional interdependence of living together, each spouse becomes sensitive to subjects that upset the other. They instinctively avoid the sensitive subjects, and the relationship shifts toward a more “closed” system. The closed communication system is an automatic emotional reflex to protect self from the anxiety in the other person, though most people say they avoid the taboo subjects to keep from upsetting the other person. If people could follow intellectual knowledge instead of the automatic reflex and gain some control over their own reactiveness to anxiety in the other, they would be able to talk about taboo subjects in spite of the anxiety, and the relationship would move toward a more healthy openness. But people are human, the emotional reactiveness operates like a reflex, and by the time the average person recognizes the problem it can be impossible for two spouses to reverse the process themselves. This is the point at which a trained professional can function as a third person to work the magic of family therapy toward opening a closed relationship.

Chief among all taboo subjects is death. A high percentage of people die alone, locked into their own thoughts, which they cannot communicate to others. There are at least two processes in operation. One is the intrapsychic process in self [that] always involves some denial of death. The other is the closed relationship system: People cannot communicate the thoughts they do have, lest they upset the family or others. There are usually at least three closed systems operating around the terminally ill person. One operates with the patient. From experience, every terminally ill patient has some awareness of impending death and a high percentage have an extensive amount of private knowledge they do not communicate to anyone. Another closed system is the family. The family gets its basic information from the physician, which is supplemented by bits of information from other sources and is then amplified, distorted, and reinterpreted in conversations at home. The family has its own carefully planned and edited medical communiqué for the patient. It is based on the family interpretation of the reports and modified to avoid the patient’s reactiveness to anxiety. Other versions of the communiqué are whispered within the hearing of the patient when the family thinks the patient is sleeping or unconscious. Patients are often alert to whispered communications. The physician and the medical staff have another closed system of communication, supposedly based on medical facts, which is influenced by emotional reactivity to the family and within the staff. Physicians attempt to do factual reports to the family, which are distorted by the medical emotionality and the effort to put the correct emphasis on the “bad news” or “good news.” The more reactive the physician, the more likely he is to put in medical jargon [what] the family does not hear or to become too simplistic in his efforts to communicate in lay language. The more anxious the physician, the more likely he is to do too much speechmaking and too little listening, and to end up with a vague and distorted message and little awareness of the family misperception of his message. The more anxious the physician, the more the family asks for specific details the physician cannot answer. Physicians commonly reply to specific questions with overgeneralizations that miss the point. The physician has another level of communication to the patient. Even the physician who agrees with the principle of telling the patient “facts” can communicate them with so much anxiety that the patient is responding to the physician instead of the content of what is being said. Problems occur when the closed communication system of medicine meets the age-old closed system between the patient and the family, and anxiety is heightened by the threat of terminal illness.

My clinical experience with death goes back some 30 years to detailed discussions about death with suicidal patients. They were eager to talk to an unbiased listener who did not have to correct their way of thinking. Then I discovered that all seriously ill people, and even those who are not sick, are grateful for an opportunity to talk about death. Over the years I have tried to do such discussions with seriously ill people in my practice, with friends and people I have known socially, and with members of my extended families. I have never seen a terminally ill person who was not strengthened by such a talk. This contradicts former beliefs about the ego being too fragile for this in certain situations. I have even done this with a spectrum of comatose patients. Terminally ill people often permit themselves to slip into coma. A fair percentage can pull themselves out of the coma for important communications. I have had such people come out long enough to talk and express their thanks for the help and immediately slip back. Until the mid-1960s, a majority of physicians were opposed to telling patients they had a terminal illness. In the past decade the prevailing medical dictum about this has changed a great deal, but medical practice has not kept pace with the changed attitude. The poor communications between the physician and the patient, between the physician and the family, and between the family and the patient are still very much as they were before. The basic problem is an emotional one, and a change in rules does not automatically change the emotional reactivity. The physician can believe he gave factual information to the patient, but in the emotion of the moment, the abruptness and vagueness in the communication, and the emotional process in the patient, the patient failed to “hear.” The patient and the family can pretend they have dealt clearly with each other without either being heard through the emotionality. In my family therapy practice within a medical center, I am frequently in contact with both the patient and the family, and to a lesser extent with the physicians. The closed system between the patient and the family is great enough, at best. I believe the poor communication between the physician and the family and between the physician and the patient is the greatest problem. There have been repeated situations in which the physicians thought they were communicating clearly, but the family either misperceived or distorted the messages, and the family thinking would be working itself toward malpractice anger at the physician. In all of these, the surgical and medical procedures were adequate, and the family was reacting to terse, brief speeches by the physician who thought he was communicating adequately. In these, it is fairly easy to do simple interpretations of the physician’s statements and avert the malpractice thinking. I believe the trend toward telling patients about incurable illness is one of the healthy changes in medicine, but closed systems do not become open when the surgeon hurriedly blurts out tense speeches about the situation. Experience indicates that physicians and surgeons have either to learn the fundamentals of closed system emotionality in the physician-family-patient triangle, or they might avail themselves of professional expertise in family therapy if they lack the time and motivation to master this for themselves. A clinical example of closed system emotionality will be presented later.

Family Emotional Equilibrium and the Emotional Shock Wave

This section will deal with an order of events within the family that is not directly related to open and closed system communications. Death, or threatened death, is only one of many events that can disturb a family. A family unit is in functional equilibrium when it is calm and each member is functioning at reasonable efficiency for that period. The equilibrium of the unit is disturbed by either the addition of a new member or the loss of a member. The intensity of the emotional reaction is governed by the functioning level of emotional integration in the family at the time or by the functional importance of the one who is added to the family or lost to the family. For instance, the birth of a child can disturb the emotional balance until family members can realign themselves around the child. A grandparent who comes for a visit may shift family emotional forces briefly, but a grandparent who comes to live in a home can change the family emotional balance for a long period. Losses that can disturb the family equilibrium are physical losses, such as a child who goes away to college or an adult child who marries and leaves home. There are functional losses, such as a key family member who becomes incapacitated with a long-term illness or injury which prevents his doing the work on which the family depends. There are emotional losses, such as the absence of a lighthearted person who can lighten the mood in a family. A group that changes from lighthearted laughter to seriousness becomes a different kind of organism. The length of time required for the family to establish a new emotional equilibrium depends on the emotional integration in the family and the intensity of the disturbance. A well-integrated family may show more overt reactiveness at the moment of change but adapt to it rather quickly. A less integrated family may show little reaction at the time and respond later with symptoms of physical illness, emotional illness, or social misbehavior. An attempt to get the family to express feelings at the moment of change does not necessarily increase the level of emotional integration.

The “Emotional Shock Wave” is a network of underground “aftershocks” of serious life events that can occur anywhere in the extended family system in the months or years following serious emotional events in a family. It occurs most often after the death or the threatened death of a significant family member, but it can occur following losses of other types. It is not directly related to the usual grief or mourning reactions of people close to the one who died. It operates on an underground network of emotional dependence of family members on each other. The emotional dependence is denied, the serious life events appear to be unrelated, the family attempts to camouflage any connectedness between the events, and there is a vigorous emotional denial reaction when anyone attempts to relate the events to each other. It occurs most often in families with a significant degree of denied emotional “fusion” in which the families have been able to maintain a fair degree of asymptomatic emotional balance in the family system. The basic family process has been described elsewhere (Bowen, 1978).

The “Emotional Shock Wave” was first encountered in the author’s family research in the late 1950s. It has been mentioned in papers and lectures, but it has not been adequately described in the literature. It was first noticed in the course of multigenerational family research with the discovery that a series of major life events occurred in multiple, separate members of the extended family in the time interval after the serious illness and death of a significant family member. At first, this appeared to be coincidence. Then it was discovered that some version of this phenomenon appeared in a sufficiently high percentage of all families, and now a check for the “shock wave” is done routinely in all family histories. The symptoms in a shock wave can be any human problem. Symptoms can include the entire spectrum of physical illness from an increased incidence of colds and respiratory infections to the first appearance of chronic conditions, such as diabetes or allergies, to acute medical and surgical illnesses. It is as if the shock wave is the stimulus that can trigger the physical process into activity. The symptoms can also include the full range of emotional symptoms from mild depression, to phobias, to psychotic episodes. The social dysfunctions can include drinking, failures in school or business, abortions, and illegitimate births. An increase in presence of the shock wave provides the physician or therapist with vital knowledge in treatment. Without such knowledge, the sequence of events is treated as separate, unrelated events.

Some examples of the shock wave will illustrate the process. It occurs most often after the death of a significant family member, but it can be almost as severe after a threatened death. An example was a grandmother in her early sixties who had a radical mastectomy for cancer. Within the following two years, there was a chain of serious reactions in her children and their families. One son began drinking for the first time in his life, the wife of another son had a serious depression, a daughter’s husband failed in business, and another daughter’s children became involved in automobile accidents and delinquency. Some symptoms were continuing five years later when the grandmother’s cancer was pronounced cured. A more common example of the shock wave follows the death of an important grandparent, with symptoms appearing in a spectrum of children and grandchildren. The grandchild is often one who had little direct emotional attachment to the grandparents. An example: After the death of a grandmother, a daughter appeared to have no more than the usual grief reaction to the death but reacted in some deep way, transmitting her disturbance to a son who had never been close to the grandmother but who reacted to the mother with delinquent behavior. The family so camouflages the connectedness of these events that family members will further camouflage the sequence of events if they become aware the therapist is seeking some connectedness. Families are extremely reactive to any effort to approach the denial directly. There was a son in his mid-thirties who made a plane trip to see his mother who had h...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Preface
• Acknowledgements
• About the Editors
• Contributors
• Part I Bowen Theory Perspectives on Death in the Family
• Part II Death in the Therapist’s Own Family
• Part III Chronic Illness in the Therapist’s Own Family
• Part IV Death in Clinical Practice
• Appendix I
• Appendix II
• Index