In the late 1950’s, Dr. Murray Bowen (1978) observed that seemingly cured schizophrenic patients relapsed upon returning home to their families soon after they were discharged from inpatient treatment programs. After observing this phenomenon, Dr. Bowen decided to try hospitalizing the schizophrenic along with his/her entire family, and he obtained more favorable results. Out of this clinical discovery, Bowen (1978) came to conclude that the family, rather than the individual, was the proper unit of treatment. His unique new approach assumed that all families operated from a highly emotionally interdependent position. Furthermore, the more interdependent the members of the family were, the more highly fused each individual was with the other. Finally, the more highly fused the family system was, the more vulnerable the family would be to developing symptoms that often were carried by one family member for the whole system. As such, he labeled the family unit an “undifferentiated ego mass.” Families could increase the level of their collective health by increasing the level of individuality of each member, an individuality that could choose when to be separate and when to remain connected.
If family members are viewed as highly interdependent, it must also be assumed that linear models of causality cannot account for, nor effectively treat, their substance abuse and dependence, for such models ascribe to “fixing” an identified patient. It is not a big leap of logic to move from the notion that one family member needs to be “fixed” to the notion that the person in need of “fixing” should be blamed. The substance and/or the individual become labeled as “the problem.” However, Bowen’s theory assumed that, identifying multiple variables to account for symptoms present in the system would be more likely to affect real change, with the therapy aimed at interrupting multigenerational patterns of transmission within the family system.
When a treatment protocol aims to change the structure of a system instead of aiming to change the behaviors of an individual, treatment outcome has achieved second order change, as opposed to first order change (which merely decreases individual symptomology and is likely short term). Second order change is long term and means that the game itself has been changed rather than only the rules (Harper & Capdevila, 1990). Within the worldview of Bowen family systems theory, therapists are offered a distinctly different approach to treating emotional problems such as chemical abuse and dependence. Such an approach thus represents a paradigm shift in the field of chemical dependence. Bowen (1978) posits that “Therapists with the motivation and discipline to work towards systems thinking can reasonably expect a different order of therapeutic results as they are more successful in shifting to systems thinking” (p. 262).
Bowen family systems theory offers a worldview that is functionalist. Symptoms serve a function in the system. No matter what the symptom, whether alcoholism, addiction, or other symptoms, it reflects the system’s attempt to adapt to relationship pressures.
From the perspective of Bowen family systems, symptomic patterns evolve and are passed on through the generations (Bowen, 1978). It is of little use to treat a symptom as if it resides solely in the individual. Symptoms are part of the fabric of the family system as it moves through time.
Research conducted by Nyman and Cocores (1991) corroborates Bowen’s (1978) theoretical assumptions. They found that addicts whose families participate in treatment have better outcomes than those addicts who are treated alone. Similarly, Mann (1991) asserts that treating the patient as an isolated entity almost guarantees a poor outcome. Without considering the family as the unit of treatment, achieving more than symptom relief may not be possible.
In many treatment programs for the impaired physician, his/her family members are virtually ignored, or at best, viewed as support systems cheering on the patient from the sidelines. Family members are not really treated, but instead are provided with psychoeducation to aid them in supporting the recovery of the impaired physician, who is the identified patient. Rehabilitation facilities that direct family members to attend Al-Anon and/or psychoeducational support groups frequently, but erroneously label such rehabilitation efforts as family-centered treatment. However, to ignore a systemic treatment of the family is akin to taking the impaired physician out of a whitewater current, resuscitating him, and then throwing him right back into the torrential waters. To underline the veracity of this metaphor, Talbott (1987) found in an analysis of 500 physicians followed for four years subsequent to treatment that the relapse rate was higher when the spouse was uninvolved and untreated.
The need for a systems approach to treating the impaired physician and his/her family is supported in the research. Gabbard and Menninger (1989), for example, concluded that physicians tend to be less happy in their marriages than many other professions. In fact, the researchers emphasize that physicians’ long hours are not the cause of their marital problems. Instead, it became apparent that doctors’ excessive work often resulted from their desire to run away from facing marital tensions. Thus, members of the medical profession may be self-selected as people looking to compensate for past wounds and/or looking to gain other-validation from society, instead of as people who are capable of self-validation and who have the maturity to tend to their most intimate relationships in a genuine and courageous way.
It therefore also seems possible that the same intimacy-avoiding factors leading people to choose a career in medicine may also predispose them to a preoccupation with excessive work, troubled intimate relationships, emotional struggle, minimal self-care, and vulnerability to substance abuse and depression. Sotile and Sotile (2000) agree that many physicians may choose their career to soothe early family-of-origin wounds.
Johnson (1991) notes that several separate studies have concluded that a disportionate percentage of doctors experienced childhoods deficient in nurturing attention. For example, Vaillant, Sobowale, and McArthur (1972) reported on the psychological vulnerability of physicians. According to their prospective study, doctors were more likely to experience problems with drugs and alcohol, require psychotherapy, and have marital problems then were other matched non-health professional controls. These researchers believed that physician vulnerability correlated with unmet personal needs. In fact, Vaillant et al. noted that some doctors choose a medical career to help themselves by helping others. The research concluded that these doctors were unusually dedicated in the extreme to the well being of their patients, to their own detriment and often that of their families.
Following from the above-cited research, it can be argued that people in fields such as medicine overfunction for others as a way to avoid healing early unresolved attachment issues. Such avoidance of resolution of attachment dogs them throughout their life course, contributing to ever-increasing chronic levels of anxiety and resulting in problematic adult/family relationships. In the avoidance of dealing with relational issues within and between the generations, the immaturity of the nuclear family system contributes to escalating emotional regression from generation to generation (Kerr & Bowen, 1988).
One way that this emotional regression may express itself is substance abuse. The substance abuse may likely be an avoidant way to deal with stress learned from previous generations and becomes rigidified into the family system over time. Without interrupting the cycle of relationship anxiety bound up in substance abuse, addictive behavior continues to be a legacy for future generations.
By the time alcoholics or addicts face the upward climb toward recovery, they have grown to recognize that they have areas of growth and maturity that are intact and other areas which have not been addressed. Their coping skills are like a piece of Swiss cheese, with solid areas representing age appropriate coping skills, and the holes representing coping skills which have not been developed through learning and creativity. This partial vacuum represents a maturity deficit, and a good part of this lack of maturity is likely due to the avoidance of facing one’s uncomfortable feelings. If these feelings are avoided through learned family patterns, it may lead to binding the resultant anxiety with addictive behaviors. In the face of this pattern, existing levels of maturity within one generation may regress to even more immature levels in subsequent generations.
Isomorphic to addicted or alcoholic people’s frequent avoidance of facing discomfort is the unfortunate lack of in-depth training in medical school curriculums to help training physicians recognize and treat substance-related disorders in themselves or in others (Robb, 1998).
Many physicians do not understand that in order for them to “first, heal themselves,” they must first gain awareness of the anxiety driving many in their number when they are called upon to heal others. For example, in a study of addiction to prescribed medications, Gilbert (1994) concluded that part of the problem in treatment is rooted in a relationship problem between the prescribing physician and the patient. Gilbert used the theoretical framework of Bowen family systems theory to explain the relationship problem as an overfunctioning/underfunctioning reciprocity. Because of a physician’s anxiously-based need to “fix” a distressed patient, he/she assumes an overfunctioning posture in his/her relationship with the patient. Such anxiety on the part of the treating professional may result in over-prescribing medication, an outcome likely based in the doctor’s unawareness of relationship reciprocity. The anxiety in the physician may be interpreted as a lack of faith in the patient’s potential to resolve his problems without medication. Thus, the doctor’s lack of work on learning to recognize his/her own triggers to anxiety may contribute to a patient’s development of an addiction.
While physicians may not deliberately overfunction, they may be acting out their own family-of-origin patterns, unaware that their interventions are playing a part in the problem. If physicians become anxious enough about whether they can “fix” discomfort in another, they will go into their “automatic.” The reversion to automatic functioning is a red flag that anxiety is present in the treating professional, in that he/she has an exaggerated need to rescue the patient. It is likely that the physician’s patterns originated and were kept alive in his own family emotional system. The need to save others may be a distraction from facing the doctor’s own demons and may result in a doctor who ignores principles of good practice and prescribes inordinately high doses of medication.
By hiding behind postures of omnipotence, invulnerability, and self-importance, physicians may also assume dysfunctional leadership in their respective families. The leader of the family sets the tone and tempo for members’ management of their own emotions within the system. The anxiety of the leader of a system determines the overall level of anxiety of its members (Friedman, 1991). If physicians overfunction for others, anxiously distance from dealing with their familial relationships, and use their work as yet another place where they can reinforce self-concepts of omnipotence and self-importance, the family system is in trouble. Indeed, important research concludes that impaired medical families run from facing their emotional wounds (Sotile & Sotile, 2000).
Members of the medical family system may come to depend upon the strong validation they receive from a society that holds them in the highest esteem. This social affirmation substitutes for the self-validation upon which genuine mental health is based. Whether physician, spouse, or child, society’s applause for the medical family provides opportunity to receive care and attention that may not have been provided in the respective partner’s families-of-origin. Spouses of physicians in highly fused families, for example, may experience a vicarious sense of grandiosity. The spouse idealizes and identifies with the medical profession in their role as doctor’s spouse. Thus, they “borrow self” from their partner, maintaining a pseudoself that creates a fragile sense of identity that may be easily shattered when normal and abnormal stressors mount.
Many impaired physicians protect their ability to maintain a future practice by participating in State Diversion Programs. Such programs, such as the Diversion Program in the state of California, are based on the disease model of alcoholism and addiction. Participants are taught that their abuse and dependence is a “disease” that is incurable but manageable. Such labeling may relieve some impaired physicians of the shame associated with their impairment. To others, however, such labeling is a ready opportunity to absolve themselves of taking responsibility for their recovery. Diversion programs usually require physicians to participate in AA programs, and such 12-step programs are also based in the disease model. To label oneself as an addict or alcoholic publicly and to ascribe to the notion that one’s relationship to abuse and dependence is lifelong may stigmatize and disempower some physicians and their families. Furthermore, to require physicians, spouses, and children to respectively attend AA, Alanon, or Alateen if they do not believe in God or a higher power, is, at best, disrespectful, and at worst, alienates them from other aspects of treatment that may be useful to them.
With the focus of treatment remaining on one individual rather on than his/her family system, the disease concept minimizes the multiple variables accounting for symptoms and maintaining the problem. Lawson and Lawson (1998) underline this problem with existing treatments, emphasizing that treatment and prevention must take a multicausal approach if one is to interrupt multigenerational patterns of abuse and dependence. In fact, they cite Morgan (1981), who suggests that the disease model lets society off the hook for taking responsibility for its part in the etiology and maintenance of social problems when individual treatment is emphasized.
A treatment and relapse prevention protocol for impaired physicians and their families informed by Bowen Family Systems Theory, a family systems model, offers great promise for achieving long-term, positive results. Impairment cannot be understood apart from the multigenerational context in which it occurs. In a groundbreaking article he published regarding alcoholism and the family, Bowen (1978) offers a roadmap to treatment providers who wish to utilize a non-linear systemic treatment when working with the impaired physician family. Broad application of Dr. Bowen’s ideas regarding this symptom and how to effect treatment will be outlined in future blogs. For more information about Dr. Cunningham's practice in marriage and family therapy, visit her at http://www.Cunninghamtherapy.com.
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