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In the fall of 2012 I had the great opportunity of attending a workshop given by Dr. Evan Imber-Black entitled "Will talking make it worse?" During her presentation, Dr. Imber-Black persuasively made the point that many couples are paralyzed with the uncertainty and fear that naturally comes with serious illness. Recently I was fortunate enough to convince Dr. Imber-Black to share some of her thoughts with the CFHA community. Here are five questions and answers as a result of my conversation with her.
1) What have you
learned from working with couples facing illness and/or disability?
When people come in
with a medical illness, they are never just dealing with a medical illness.
Never. There are finances, decision making, spiritual needs, planning for the
future, all the histories, all the anger, and many other problems they’ve faced
through the years. When people are coming to see us they walk in with much more
than just an illness. You are addressing things at multiple levels including
the illness. So just start with where they are. Then you are faced at every
moment with therapeutic choice points. Where do I go? Do I go here or there?
Then watch very closely for their responses. I tell my students that the only
mistake is to do the same thing over and over again when a couple is telling
you “Don’t do that. We don’t want to go there”.
2) Are there ever
times that denial, despair, secrecy, and other so-called "negative"
reactions to illness may be functional or beneficial for couples? If so, when?
I would say it’s all about timing. In terms of secrets, unless the
secret is dangerous like someone planning to kill themselves, you have time on
your side. You don’t have to open up the secret this instant. You have time to
talk it over, about the risks and benefits of opening up the secrets, about who
and when. In my experience, people have thought about all of the risks, but
have seldom thought about the benefits of greater openness. Asking a couple to
imagine the impact of speaking - the advantages and disadvantages – on every
person and every relationship is usually a whole new experience. Most often
people will shift toward openness.
In regard to despair,
it seems like a lot of people when they are facing the end of life or when they
are going through God-awful treatments are going to feel despair. Are there
going to be moments of despair? I think so. It’s reasonable to expect that
someone experiencing pain, suffering, terrible treatments, a rocky medical
system, costly payments, of course they are going to feel despair. That’s OK.
You just don’t want people to get mired there. But there also has to be a point
where people can talk about that and experience it and hopefully help not just
their therapist but their partner to witness and walk along side. And the
partner might feel despair too because it’s pretty awful seeing someone you
care about suffer. So I am very much not a believer in the idea, “Oh let’s be
positive all the time”. I want to create an environment of authenticity. If I
can do that then I trust some good things are going to happen.
|Illness can be
unpredictable. Therapy can become a place where you make choices about what to
talk about, what to express, how to show yourself to your partner or therapist.
One wife at the end of our work said to her husband “Here in this room you are
more open in this place than any other place in your life”. He replied “Well,
we need to find more rooms like this”. He died a month later. Did that give
them a sense of control over the illness? I don’t know. But that leads back to
the medical system and what patients are told. Toward the end of his life, this
husband was repeatedly approached by the surgeon who would say “Here is one
more thing we can try”. But they were all hopeless attempts and would keep the
couple out of sync because he would say “Oh yes, brain surgery. Let’s do it!”
She would think “Oh my God. I cannot stand this and go through one more thing”.
And then a day later they would switch. He would say “I don’t want to do this.
They are saying I need to gain weight and I can’t” and she would say “Eat, eat!
You need to gain weight!” That is very typical toward the end of life and most
often no one tells couples that they can get out of sync with each other and
then shut down, afraid to tell the other person what they are thinking. Couples
should know that that is a natural and expected experience. ||Most often no one tells couples that they can get out of sync with each other |
3) There is so much
emotional "work" that goes into helping couples facing illness and/or
disability. How can providers balance the need to explore and process emotions
with the need to change patterns of behavior?
I don’t think it’s an
either/or proposition. I think it is both/and. They inform one another. When
you are working with a couple and they are doing the emotional work, it changes
their interactional pattern, their proximity and distance from one another. The
mere fact of being in a room with one another and talking about vulnerability,
potential loss, and physical pain with a couple that never has had vulnerable
conversations. What I have noticed is that when couples come to therapy, not
only do they talk about coping with the illness but they talk about parts of
the relationship that have gone missing. One couple told me “cancer saved our
marriage”. It sounds bizarre and I’m not recommending that couples seek out
cancer to save their marriage.
One couple came in, 18
year marriage, very rocky marriage. He had stage four colon cancer that had
already spread to his brain and liver. They did not talk about the cancer. They
said “We are here to work on our marriage”. It would have been a mistake if I
had not honored their request because I know that we will eventually get to the
other issues. Over the course of therapy, the cancer proved to be a crucible
for their relationship and enabled them to really talk in therapy with each
other about all kinds of things including cancer. Their marriage had been in
shambles for a long time. You have to deal with that first before dealing with
what the illness is doing to them. They both came from families where they each
had fathers who both died from cancer around the same time as the husband. The lesson
growing up they learned was “The less we talk about the cancer the better”.
They were both Irish Americans, so there was a cultural piece. There were many
things pulling at them and they didn’t have yet a strong enough “basket” to
hold the enormity of what was happening to them together. So instead they would
go off and talk to friends. One friend told the wife to go get a book about
hospice. She ordered it secretly and he found her reading it and crying. They
brought this story to therapy and that was my entry point.
You have to watch and
wait and stay a tiny step ahead in therapy. Go too fast, too far, look back and
they are gone. I trusted the process to know that we would get there
eventually. Any good therapy, whether or not we are talking about medical
illness, requires that circular process between you and the couple. With this
case, I had a team behind the mirror and after sessions they would reflect with
me, give me a hug which was great because we knew he was dying. Little by
little, each week, it was like peeling an onion, talking about what was really
in their midst, how we spend our time knowing that we don’t have the luxury of
time. The therapy room became a place where they could really reveal to one
another what each was thinking silently. Our strategy was simple - “talk about
it, talk about it, talk about it”. She had held a secret that she thought it
was her fault that the cancer was in the final phase because she had referred
him to the doctor that missed the diagnosis. He never knew that she thought
that until our work together. Over time as people develop trust they can begin
to tell each other these things. Well, going back to
the couple where the husband had stage four colon cancer, the wife made an
amazing surprise party for him and gathered all his friends. She told him “put
on your tuxedo, we’re going out” and then they walked into a room with 200
people. He said to me in therapy “You know, I think that gave me a few more
months of life”. In terms of what a ritual can do, I’m not sure if it did or
didn’t but there is a sense that maybe it did.
4) You've written extensively about family
rituals. What role do rituals play for couples struggling with illness and/or
| The interplay I see
over and over again is that when people engage in meaningful rituals they are
able to talk about the hard stuff. That feeling of being connected to others
who care about you and you care about them enables good conversation and more
open conversation. With this particular couple, their son knew that dad had
cancer but in the midst of the therapy work he developed a crisis. It turned
out he had some serious surgical adhesions in his colon and they had to do a
colostomy. Later they overheard their son say to a friend “My dad doesn’t have
cancer anymore”. This dad came home feeling better, and so they didn’t correct
their son’s idea that dad was all better nor had they told the son about the
colostomy. Meanwhile, there are people in and out of the apartment like the visiting
nurse and others. They went to a beautiful Thanksgiving with all of their
extended family which they thought about skipping. They told me “We know that
this is going to be his last Thanksgiving” and on the way home they decided to
talk with their son about Dad’s medical condition. His response? – “well I knew
that – I was just waiting for you to tell me”! It’s very hard to keep secrets
from kids – they are heat-seeking missiles when there is missing information.||That feeling of being connected ... enables good, open connection |
In another example
where the wife had cancer, the parents instituted a ritual of Friday movie
night with popcorn. They have fun and laugh and that has been a terrific
container for when they also need to have serious talks with their little girl.
“Yes we are going to have a movie but we are also going to talk about mom’s double
mastectomy”. Those kinds of things that provide the ability to create a sense
of connection that repeats and you can count on it. I think this reliability is
extremely important especially for families facing a lot of uncertainty.
5) What role can physicians
play in working with such couples?
They can say “let me
refer my patient and their family for family therapy”. Some physicians don’t
think that part of their responsibility here is for everyone’s wellbeing and to
send them to a competent family therapist. Another important role for
physicians is to encourage patients to bring in a spouse, a family member, or
someone that they trust. A lot of physicians don’t like it when another family
member comes. They haven’t been trained how to talk to people in those
circumstances. The outer culture around medical problems encourages more of
this individual, doctor-patient sanctity in the room. Doctors can say “you
know, I think it might be helpful for you to talk with someone on a more
regular basis” and then give them a good referral.
Ph.D., is the Director of the Center for Families and Health and a Senior Faculty Member
at the Ackerman Institute for the Family in New York City. The Center for Families and Health delivers training,
consultation and systemic therapy for families who have one or more members
with a chronic or life-threatening illness. In 2007, Dr. Imber-Black became a visiting professor at
Mercy College, Marriage and Family Therapy Program, and in 2008, she became the
Director of the MFT Program. Dr. Imber-Black maintains a private practice in Couple
and Family Therapy in New York City and Westchester County. Dr. Imber-Black is a past president of the American Family
Therapy Academy; recipient of the 1990 American Family Therapy Academy Award
for Distinguished Contribution to Family Therapy Theory and Practice; and the
1999 recipient of the American Association for Marriage and Family Therapy
Cumulative Contribution to Marriage and Family Therapy. Throughout her internationally recognized career, Evan Imber-Black has made major contributions in
thematic areas that cut across different models of practice, including Families
and Larger Systems, Family Rituals and Family Secrets. She is the author of
over 50 original papers, and several books, including The Secret Life of Families (1998), Secrets in Families and Family Therapy (1993), Rituals for Our Times (1998; co-authored with Janine Roberts); Rituals in Families and Family Therapy (1988; Second edition, 2003; co-edited
with Janine Roberts and Richard Whiting) and Families and Larger Systems (1988). Married to Lascelles Black, MSW, LMFT, Evan is most proud to be the grandmother
of Josie, 15; Lois, 12; and Zane, 10, who have helped her to
know that generativity is the core value she wishes to bring forth in her work
and in her relationships.
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