Internal Family Systems and Marital Therapy

 

As most of my readers know, I believe in a family systems view of the way patients who are repetitively self-destructive or self-sabotaging are acting. I do not think it’s “all in their heads,” but that it serves some sort of purpose for the members of their families as a whole. 

Furthermore, this is ongoing and continues to take place in the present, not only when they may have been initially traumatized as children. The family continues to interact over the trauma, because most people continue to have relationships with their parents. If they don’t seem to, it’s often because they are communicating through third parties. In this and the following post, I’m going to illustrate how the field does not take this into account, even when they look at systems issues.

I have also been writing about how the psychotherapy profession has seemingly given up on family systems theory, except for some masters level family therapists, because of a variety of social factors. Some readers may argue with me about that because of the growing popularity of Richard Schwartz’s Internal Family Systems Therapy. I really had not read much about it because I always wondered why he was dealing with internal models of the family system and not the actual living family members. Sort of like Schema Therapy or working on one’s “inner child.”

I finally got around to reading a book he wrote for lay readers in 2008 called You Are the One You’ve Been Waiting For. Although I think the kind of treatment described therein can indeed be helpful in many situations in which interactions with one’s parents are not too complicated, I do not think it would have helped most of my patients with severe personality disorders.

And even in cases in which it does work, IMO it would be even more effective if it paid attention to some other factors which the author seems completely unaware of, as illustrated by an extensive case example he wrote concerning a narcissistic doctor he names “Kevin” and his wife “Helen,” who was described as a bright woman with a career of her own. I will talk about this case in a moment.

One thing about the IFS model that I’m not enamored with is his descriptions of peoples’ personality “parts” — protectors, controllers, exiles, critics and tor-mentors. I would like to believe he is speaking metaphorically, but he seems to be following along with the tradition (in my opinion inaccurate) of dividing up a personality into little beings running around inside someone’s head with thoughts, desires, and feelings all their own – not unlike the animated characters inside a girl’s head in the Inside Out movies. Just like the psychoanalysts used to refer to id, ego, and superego as if they were parts of the brain. I find the concept of a “false self” to be much more useful.

A bigger problem is that he sees the problematic behavior of people as trying to protect themselves from reliving past hurts. He says they scan the environment looking for threats and run away at the slightest hint of one. 

That wasn’t at all what I saw in my patients. 

People who couple off with people in a dysfunctional relationship were not only not looking for red flags, they were actively ignoring them! If anything, they seem to be attracted to certain dangers, like a woman from an alcoholic family who marries one alcoholic after another.

I see them as protecting their parents and the ongoing systems dynamics, not themselves per se. I fail to see how being self-destructive can be selfish, unless someone is unbelievably unintelligent. I will give a possible explanation of Kevin’s and Helen’s behavior in that case, consistent with this idea, so back to that.

According to the author, for thirty years Helen had put up with Kevin’s “carping about her taste in clothes, her child rearing, her political opinions, her education, her intelligence, and her logic.” He frequently dissed her in public. She also was said to hate his long work hours and felt neglected. And now she suddenly said if he didn’t straighten up and fly right, she was outta there.

Wait…she put up with this behavior for thirty years before the ultimatum? Why so long? And how did Kevin interpret her staying despite the fact that he must have repeatedly heard many of her complaints during that period. The author attributes Helen’s sudden attack of courage to their youngest child graduating high school, but many people with kids still at home get divorced. 

Furthermore, the book does not mention any ongoing interactions during the marriage with parents and in-laws, despite the fact that he attributes Keven’s behavior to his parent’s behavior towards him when he was a kid. Did the parents just evaporate? Did Helen possibly get brave because they - or her own parents -  died? We don’t know.

According to the book, Kevin’s father left his mother when he was seven, after a fight between them in which the dad hit his mom. The Dad remarried and never saw Kevin again. Mom then went on to have a series of problematic relationships. Sometimes, she seemed to not want to have Kevin around. Kevin handled this by throwing himself into academic and professional success and becoming fiercely independent. I believe this was meant to demonstrate to his mother that he did not “need” her or anyone else. 

After some individual and couples counseling with the very empathic Doctor Schwartz, and when he is starting to get in better touch with himself, Kevin remembers blaming his mother for his dad’s leaving and making her cry just after the breakup when he was seven. He says the “little boy” inside him would rather die than upset her again.”  That sounds like, in his mind at least, he is protecting her - not himself - and feels guilty about what he did.

What I would hypothesize is that the mother indeed felt very guilty about the Dad leaving her and how it affected Kevin, and was blaming herself. This is why she became uncomfortable when he was around and seemed to prefer he be gone and be independent of her “bad” (in her view) influence on him. So he tried to make her feel less guilty by being successful without any need of her. And later maybe displaced the anger he felt towards his mother onto Helen (while displacing his anger at his abandoning father onto his co-workers). 

So perhaps Helen’s “job” was to stabilize him by allowing him to do this displacing. Her initial attraction to him was probably due to something similar to this dynamic going on in her own family.

When he got better, he was able to be more empathic with his mother’s behavior because he realized she felt she did not really deserve any love. I agree that understanding a parent’s problematic behavior helps people feel better about themselves – and about the parents. But of course this aspect of her mother’s behavior just kicks the question of the reason for all this back another generation. Why was she like that?

Schwartz comes quite close to understanding of the dialectical way dysfunctional couples interact, with each enabling the false self of the other and punishing any evidence of each's own true self. Each denies that they need this help themselves even as they give it to the other. They have motives for doing so that have to do with stabilizing their parents, but they also hate that they have to be like this. They are ambivalent. So they also complain about it. Mixed messages!

Schwartz gets away from these ideas by instead thinking that "vicious circles" of interactions are present- just as systems therapists also suppose. But then he also calls it a dance. In a dance one member of the couple may be leading, but simultaneously, the other is closely following. If either fails to do their part, there is no dance.

Once a couple gets in touch with these patterns, however they do it, this means that there is another issue (apart from ongoing interactions with living parents) that arises that may further greatly complicate making changes. Even if, say, the wife is ambivalent about her role, she has thought all along that her husband wanted and needed her to perform it. So if he suddenly says he no longer wants this without acknowledging his ambivalence, at first she won’t believe him. 

But if he somehow convinces her he is sincere, the wife is still prone to think to herself, “Hey wait. I have been sacrificing for him for all this time, and only now he tells me that he did not want me to! And he no longer wants to enable me?” She feels betrayed. This of course also comes out as a double message as her true self really wants the change too. Schwartz talks about members of the couple being triggered by the other, but misses this very important reason why.

 

Dr. Allen's Second Book Back in Print

My second book, Deciphering Motivation in Psychotherapy (which was originally going to be titled Ulterior Motives) is now available in paperback at a reasonable price on Amazon for the first time. It is actually my favorite of the ones I've written, but by far the least read.

It was out of print for a time, and then back out but at a ridiculous price. (A different publisher had bought out the original publisher, then re-published the book without even letting me know!)

It was meant for therapists but is written so lay people can understand it.

This book explains some basics about the theory behind Unified Therapy, including the core concept of dialectic causality.

The main topic is the use of language in dysfunctional family interactions, and how the true intentions and meanings of individuals who are being ambiguous or misleading can be discovered. If you want to see things that have been said to you repeatedly by difficult relatives in a whole new and surprising light, this is the book for you!

Borderline Personality Disorder: Children Burdening Parents, Or Parents Burdening Children?

I had a telling experience while trying to get a paper published about how the parents of offspring with borderline personality disorder (BPD) give their adult children a lot of double messages (The instrument I used and the results of the study are described in a previous post). The experience indicated that the peer review process by which other practitioners review an article for scientific merit and accuracy may sometimes be more political than scientific.

At the time, I belonged to, and was the treasurer for, a research group in psychiatry in the field of personality disorders that had editorial control of a journal, the Journal of Personality Disorders (JPD).

For the purposes of gaining more financial support for their organization and its research, this group of researchers had been cultivating very close relationships with two "support groups" for the parents of people diagnosed with BPD - Treatment and Research Advances National Association for Personality Disorders (TARA), and the National Education Alliance Borderline Personality Disorder (NEA-BPD). 

As readers of this blog must know by now, my take is that the disorder is produced and maintained by certain ongoing repetitive dysfunctional interpersonal interactions with patients' families-of-origin members, particularly with primary attachment figures like parents. My paper showed that adults with the disorder reported frequent ongoing double messages from their parents and other attachment figures. The results proved to be highly, highly significant: BPD patients reported significantly more contradictory responses than did both patients with other psychiatric disorders (p=.004) and "normals" (p=.003). And this was with a small sample size that makes the results even more impressive. 

Nonetheless, the JPD turned down it down. Flat out rejected it. That the article had merit was evidenced by the fact that it was subsequently accepted for publication by a mainstream psychiatry journal, Comprehensive Psychiatry, with a broader readership. 

I cannot prove it, of course, but I suspect that the reason the paper was rejected was because the group was cultivating the relationship with the parent support groups and did not want to take any chances on alienating them.

Further evidence for my suspicion took place a short time later, when I was one of the peer reviewers for a paper for the JPD by some other authors. This paper detailed what was said when the authors interviewed the members of the parent support groups about their "burdens" in having to deal with an adult child with the disorder - as if the parents had nothing to do with the child's problems in the first place.

Research has consistently shown that a history of severe physical and/or sexual child abuse is one of the most frequently-seen risk factors for the disorder - although not all such parents of people with BPD had been physically or sexually abusive. A significant minority of them in fact exhibit a rather virulent version of highly over-involved, so called "helicopter" parenting.

Not only are these parents over-involved with their offspring, but they also feel they are burdened by them. And according to this study, by their own admission! This is the source of a borderline-ogenic double message, "I'm obsessed with you, but I feel that you are big burden." If children believe that their parents need their children to be burdensome, then that is what the children will become. Far be it for a child to deprive a parent of a cherished role.

After a while, it becomes difficult to tell who is doing what to whom to cause burdens, because the adult children and the parents feed into one another's dysfunctional behavior simultaneously. I refer to this phenomenon as dialectic causality.

My review of this other paper pointed out that the members of the support group who had been interviewed most likely fell into the over-involved rather than the abusive category of borderline-ogenic parents. After all, parents who had, for example, sexually abused their children were highly unlikely to join a parent support group (except perhaps the False Memory Syndrome Foundation, which would support them in their denial). 

Therefore, I recommended that the authors should mention that the sample they interviewed was highly likely to be a somewhat biased sample.

The paper was eventually accepted and published with almost no mention of this irony at all!

Changing the Rules of A Game That Will Not End

You can check out any time you like

But you can never leave

    -----The Eagles

Why is it so damn difficult for family members to stop engaging in repetitive behavior that is clearly driving them all nuts?  Back in baby boom lore, we used to refer to a big question like that as the $64,000 question, in reference to a TV quiz show.  But hey, there's been inflation, so now if we want to refer to a TV game show question, we have to call it the million dollar question.

One reason it is so hard to change was described way back in 1967 by Watzlawick, Beavin, and Jackson in a book called Pragmatics of Human Communication. It was the first book to look at the linguistics of family dysfunction.  That subject later became the main theme of a book that I wrote called Deciphering Motivation in Psychotherapy.  One of the most interesting and curious concepts introduced in the Watzlawick book was called the game without end.  The book describes what happens when someone in a family steps out of a role that they had, up to that point, always been playing in their family system, and tries to get everyone else to change the rules by which the whole family operates. 

What often happens is that no one else in the family is certain that said individual really wants the change he or she is requesting, because he or she had compulsively played the role all the time up to that point.  Leopards do not change their spots, after all.  They all suspect that the request is, in reality, just another maneuver in the same old game that had been going on up to that point. Therefore, no one else takes the request seriously.  This happens even when everyone else covertly would actually be happy with the changes.

The example Watzlawick et. al. used to illustrate what they were talking about was cute, but I did not quite understand exactly what it would mean for a real family.  They imagined a family where the rule was that everything anyone said really meant the exact opposite of what it seemed to mean.  How would anyone in this family go about trying to change this rule? 

If someone said, "Let's change the rule," this would naturally be taken by everyone else to mean its opposite, "Let's not change the rule." Therefore, the rule would stay the same.

Aha, you say.  Why couldn't the person requesting the rule change just say, "Let's not change that rule."  By the original rules of the game, this statement should be interpreted as a request to change the rule.  Not so fast! Remember, everything said under the old rules is supposed to mean the opposite of what it seems to mean.  The request not to change the rule would in fact seem to be a request to change it.  Therefore, under the old rule, it would be interpreted to mean the opposite of that, namely, "Let's not change the rule."

No matter what anyone said about the rules, it could therefore be interpreted to mean a request to go on playing the game with the original rules.  Every move to change the rules of the game could be interpreted as a strategic move to make them continue.

Clever, but what family would ever operate by such a bizarre rule?  It took me a while to truly understand the game without end, but let me see if I can explain it to readers. To understand it, let me describe some actual rules under which real families do operate, and how they can be devilishly difficult to change.  

I will start with a very typical example that you might just recognize.  Let's say a middle aged couple had always operated under traditional gender rules and roles, so that the man had always been the breadwinner and the woman had always taken care of the house and the kids.  After the kids leave, one of them, say the wife, decides that she is really bored being just a housewife and decides to get a job.  Her husband is actually really happy that he no longer has to be the only one responsible for making money, since that had been a real burden for him, even though he had guarded the breadwinner role rather jealously.

The wife tells the husband that, since they are now both working, she wants him to start to help with the laundry, the dishes, and maybe the housework.  He says he agrees, since it's only fair.

We know what typically happens next.  He never starts doing the housework that he promised to do unless she specifically asks him to each and every time.  Never shows any initiative.  She finally gets frustrated having to constantly nag him about the housework, gives up, and angrilly starts to again do the housework all by herself.   The husband is a typical male chauvinist pig, right?

Wrong.  What happened when he first started doing, say,  the dishes?  What happened was that she kept telling him he was not doing it right!  He was putting them in the wrong cupboard, he was missing a spot or two, he was using the wrong detergent, whatever.  The husband starts to think that maybe she really wants to continue to be in charge of the kitchen, like she always has been, and does not really want him there in spite of her request.

He will not tell her of this belief, because he knows she will get angry with him and deny it.  Unbeknownst to him, she is secretly feeling vaguely guilty about making him do the housework, because she was raised in her own family of origin to believe that doing so was the woman's job, and she is guilty of derilection of duty.  She will not admit this to her husband, because she really does want him to help with the housework, despite her overall ambivalence about it.

From her perspective, he keeps doing a poor job in order to get her to take over the tasks again because of his own selfish wish to avoid housework, not because he might think she really wants to keep doing it herself.  After all, she thinks, he actually does know what soap to use, where they keep the dishes, and that he is doing a poor job.  He just acts like he does not.  In actual fact he does indeed act that way - but only because he thinks she's just looking for an excuse to nitpick so she can take over.  When she does nitpick, that convinces him even more that the real reason she nitpicks is because she wants to remain in charge of the house.  Still with me?

This situation is all the more complicated because all these events, mixed signals, thinking about the motives of the other person in the relationship, etc. go on simultaneously.  They do not follow sequentially one after the other.  Understanding this aspect of human interaction was one of the most difficult problems I faced when I created my treatment paradigm, which I call Unified Therapy.  We are all used to thinking sequentially rather than seeing everything as simultaneous.  Systems theorists call this linear thinking.  A leads to B which leads to C, etc.

Systems theorists, on the other hand, see what's going on as a feedback loop - like a vicious circle - but that is not accurate either. The events in the feedback loop are thought of by systems people as sequential even as each even feeds back to the next.  A leads to B which leads to A1 which leads to B1, etc. The mutual (two-way) and simultaneous nature of human interactions is better accounted for by something called dialectical thinking, which I will not go into here.

But why do the people in this situation follow the "new" rules in such a half-assed, irritating manner, when they know doing so will almost certainly elicit criticism by the partner?  They do so because they already think they know what the other person really wants, so they are just providing him or her with an excuse to do what he or she seems to want to do anyway.  They allow the other person to blame them for what is actually a shared problem.  So very thoughtful.

Here are some more examples of the game without end from Deciphering:

1. A wife had been encouraging her husband to be more honest about his true feelings. Consequently, he began to express himself, but in a loud, abrasive, and embarrassing fashion - and in front of her boss.   (Not in the book: he's thinking about the girls he knew in high school.  Which type of guy got to go out with the most popular girls - the sensitive, touchy-feely guys or the macho football players?  Does she really want him to act like the former?)

2. A mother finally got her twenty-five-year-old son to get out of the house and find a job; he opted for a low-paying job at a fast food
when he had been offered a high-paying apprenticeship.

3. The same mother got the boy to fill out his own tax return; he then claimed himself as a dependent so she could not claim him, even though she was still supporting him.

4. A husband had been encouraging his wife to pursue her long-repressed desire to have a career. When she finally got a job, she chose one in which she had to work a different shift than he did. As a result, the couple never had any time to spend together. When he complained, she told him that he never really did want her to be more than a housewife.

5. A young couple encouraged the wife's mother to learn to drive after the death of the wife's father so mom could be more independent.  The mother indeed learned to drive.  However, she would never drive to visit the couple because, she said, they lived too far away. However, the mother would regularly drive a similar distance in another direction.  (She secretly believed that the only reason the couple wanted her to drive was so they could use her as a baby sitter).

There is relatively simple way for game players to end the game without end, but I will save that for a later post.