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Five Questions With Evan Imber-Black, PhD

Posted By Matthew P. Martin, Tuesday, March 4, 2014

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. 

4) You've written extensively about family rituals. What role do rituals play for couples struggling with illness and/or disability?

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. 

 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. 


Evan Imber-Black, 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 Academyrecipient 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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