The following article was written in the year 2020, during which Jo Vanderkloot’s patient, Sam, had begun therapy with her. We have provided an update in the Postscript. All names and some other family details have been changed to protect the patient’s and his family’s privacy.
Staying Power
A third bout of cancer
Sam had beaten cancer twice before using alternative treatments, but when he was diagnosed with stage 4 melanoma late in 2018, disrupting everything in his life, he knew this bout was much more serious. So this time, in addition to working with alternative medical practitioners, he chose to begin therapy early in 2020 to help his family handle the interpersonal problems this new cancer was causing.
Sam’s important relationships had been thrown into turmoil by his illness: he was having problems with his wife, his children, and even his business partner. It was his good fortune to happen upon Jo Vanderkloot, a therapist who had been exploring the relationship between family issues and chronic illness for decades. Prior to therapy, Sam had had no idea an illness could be connected to family issues. It was in working with Jo that he learned this was true—that those problems can both help to cause chronic illness and prolong it. This new knowledge was critically important. If Sam’s goal had been merely to help him and his wife improve their communication and decision-making skills, his disease might have cut his life short within a couple of years.
At the first therapy session, Sam and his wife, Rose, described to Jo the way this case of melanoma was threatening his job (and therefore their financial wellbeing), their daughter’s college education, and all their family relationships. Through therapy Sam and Rose would heal the interpersonal family problems: they would make decisions together and learn to communicate better. But far more importantly, they would also discover patterns running through the past several generations of their families that were making Sam vulnerable to disease, both consciously and unconsciously, and that would impede the effectiveness of any treatments he used, no matter what they were. While the medical profession focuses on physical treatments for physical illness, Jo had found early in her career that chronic illness is more than its physical manifestations.
Before we begin to explore how Sam’s family issues were affecting his health, we want to be clear that this article is in no way suggesting that a person causes their illnesses. Often people with serious illness blame themselves and feel as if they are letting their loved ones down. No one is in conscious control of their unconscious processes. This article is based on many years of experience in family therapy and describes observations of the inter-relationship between physical and mental illnesses and family history and dynamics. The primary take-away is that understanding all the factors involved in causing and lengthening an illness can be helpful in its healing.
A chronic illness patient is someone either living with a disease over time with no cure in sight or someone who succumbs frequently to acute illnesses. Chronic illnesses such as heart disease, diabetes, auto-immune diseases and some cancers can hang on for years and years without killing their host. In contrast, less complicated illnesses, like the common cold or a fractured bone, can typically be treated successfully in a predictable amount of time. However, duration itself is not the only difference. From Jo’s experience working with chronic illness patients and their families, she has seen that these illnesses can owe their staying power to the fact that emotional issues often add to the disease’s complexity, although this is not widely recognized. Eventually most patients who are experiencing an illness that just won’t quit seek medical attention. Doctors will typically try to ameliorate the symptoms and help the patient live with the condition by prescribing chemical and physical treatments. The narrowness of a focus on the physical neglects other major factors that influence health and ignores the fact that a person’s mind and body are constantly interacting. Everything in a person’s life helps determine the state of their health.
This article explores the complexities that allow illnesses to become chronic and presents Sam’s situation as a case study to illustrate how expanding the scope of treatment options can advance healing. It sheds light on the question, “Why did Sam get sick when he did and what in him is resisting his healing?”
To understand an illness’s complexity, we have to expand our frame of exploration. Using a holistic view, we look at the patient’s emotional health and history and the nature of their relationships with family members, friends, and co-workers as well as their physical symptoms. Their emotional history takes us into the traumas they’ve experienced since birth and how they’ve been affected by past and present family problems. The investigation deepens when we also consider thoughts and beliefs residing in both the conscious and unconscious parts of their mind.
A holistic approach such as we are describing is systemic, with a focus on family systems. The family of a chronically ill person is typically riddled with malfunctions of various magnitudes. Functioning is not smooth and straightforward in these families. We call them “Type 3” families. (Type 1’s have few problems, Type 2’s have difficulties such as drug abuse, divorce, and depression, but in spite of these problems exhibit cohesion and some degree of mutual support, while Type 3’s face a history of escalating problems through recent generations including alcohol and drug abuse, chronic physical and mental illness, verbal and physical abuse, death of children, depression and serious mental illness.) Progression from Type 1 to Type 3 is marked by an increase in complexity. Challenges in Type 3 families include communication problems such as lying, keeping secrets, and sharing incorrect or incomplete information; self-absorption; aberrant and anti-social behaviors; win-lose attitudes and many failures in health, business and marriage. Overall, Type 3 systems are fraught, and individuals who are part of them experience more tension and challenge than they would if the group dynamics were easier. Family therapy assumes that overwhelming trauma in previous generations leads family members to adopt problematic coping skills that result in the challenges faced by members in succeeding generations. Chronic illness is one manifestation of a family’s high level of complexity. For more information on complexity, see our website, chaosinstitute.org.
Relationships
Relationships, often ignored, are critical
We‘ve been taught to solve problems by looking at each contributing factor separately. This approach unfortunately jettisons consideration of relationships. This prevalent approach is why our medical profession often limits its attention to the physical when treating a chronic illness. When doctors focus primarily on the illness, consideration of the patient is secondary. In contrast, an expanded focus requires that we pay attention to the patient’s entire situation, including relationships of all kinds, as Sam began to find out in therapy.
Sam begins therapy
Sam’s struggle to defeat his third bout of cancer demonstrates that when patients become aware of their family’s interpersonal dynamics and history of trauma over generations, their ability to heal from a serious physical disease is greatly enhanced. Sam’s case study is unusual in his extraordinary ability to look deeply inside himself for what is making him sick, but a therapist can help many patients achieve this goal. The stakes were high, and he chose a path of self-cure, both physically and mentally.
Sam began family therapy with an urgent set of problems. He had just been diagnosed with aggressive melanoma, his third bout of cancer. Greatly upset by this diagnosis, he had abruptly decided to quit his job, throwing his marriage into a tailspin. His wife, Rose, not currently employed, foresaw financial disaster if he were to do that, but Sam feared that if he continued working he would die. Sam and Rose had two children: Stephanie, a freshman in college, and Zander, ten years old. Sam had decided that Stephanie would have to transfer to a state university when he quit his job; this decision caused even more family turbulence.
All Sam’s problems were urgent (and interconnected), but his medical condition demanded the most immediate focus. The melanoma was presenting with an enlarged lymph node under his left arm, as well as one on the right side of his neck. Sam’s illness was throwing his whole life, as well as his body, into turmoil. He didn’t know which way to turn. His therapy began with an intensive series of sessions with Jo; meanwhile, he also continued working with a team of practitioners who could help him strengthen his immune system by employing alternative medical approaches, as he had done with his previous illnesses.
Patients can reach an impasse of ambivalence about their disease, unsure whether to keep fighting or just surrender to it. This ambivalence can stop the healing process, undermine their strength and allow the disease to escalate. However, this healing slowdown can in turn re-energize them in their determination to heal and force them to work harder than they ever believed they could, with the result that their struggle takes them into places they could not have imagined before.
Sam was having such an experience. He had been able to manage the two prior incidents of cancer, but this more advanced case was an escalation of the disease, and he at times lost his sense of confidence that he could win the battle this time. His reflexive reaction was to quit work suddenly and spend almost all his time exhaustively searching for an effective treatment. He was working harder than he could have imagined, but there was the possibility that what he would learn would take him to places he hadn’t conceived of before.
Jo’s extensive experience with similar patients led her to question whether any medical approaches to healing Sam’s newest cancer could be effective if he did not gain access to two types of information currently hiding in his unconscious mind and bring them into consciousness. First, he would need to recall earlier traumas he had experienced from childhood into adulthood that could be contributing to the current situation, and second, he would need to pull together information about patterns relating to disease and death running through the recent generations of his family. As long as this information remained out of his conscious reach, it would continue to throttle his immune system and ultimately might lead to death.
As we go through our daily lives, we mostly live in the present in the conscious, cognitive world where logic generally prevails. At the same time, our deeper consciousness, which we call the unconscious, is storing memories of highly emotional, meaningful and sometimes traumatic experiences that we repress. Traumatic experiences stored in the unconscious exert uncontrolled influence on us; when memory of them can be apprehended consciously, we can use other knowledge we possess to defuse their toxicity and move on. If we cannot access these memories, they remain powerful hidden shadows.
The unconscious uses repressed memories of highly emotional experiences to create guidelines or suggested pathways for our present and future behavior and experience. When we follow those guidelines or pathways, we create behavioral patterns that connect the past with the present and may predict the future. However, because our conscious and unconscious minds are linked in subtle ways, clues to the repressed knowledge of these experiences can reside in our conscious mind.
For example, if a faucet is dripping in the background when a person experiences an assault, in the future that sound of dripping water may cause them to feel uneasy without realizing why. When someone experiences a severely disturbing event, their mind may separate aspects of their memory of it, with the fact that it happened remaining in their conscious mind, and the remembrance of their emotional experience being pushed into their unconscious mind. A fifty-year-old man might be able to discuss the fire that killed his parents and burned his family’s house down when he was five years old without displaying much affect, but the emotional distress he experienced at the time, which is what is most meaningful to him, will still be alive in his unconscious mind and could be causing unnamed stress. Therapy can help patients gain access to traumatic memories that are currently affecting their lives and their health.
Therapists have ways of helping patients access their unconscious memories. During sessions Jo notices any behaviors that are anomalous for the patient. Any changes in tone or unusual words, gestures, patterns of speech and non-verbal behaviors are the royal road to unconscious processing. As people delve deeper inside to discover what has been happening to them, they generally go into a light trance, an internal focus of attention. In a therapy session earlier in her career when three other therapists were present, the patient began to use phrases such as, “it hit me that..,” “it struck me that..,” and “it hit me upside the head.” Jo asked her who had abused her. The patient was then able to access her unconscious memory, and she began to talk about it. The other three therapists asked Jo how she knew to ask that question: it was the unusual speech pattern the patient suddenly used. Therapists look for many types of patterns when working with their patients.
Sam’s family history
When a practitioner expands their view of a patient’s situation to include a focus on relationships, they find themselves facing a picture complicated by myriad details. To avoid being overwhelmed by this logjam, they must step back and look for patterns. Jo helped Sam see the important patterns in his family’s history. Patterns, with their repetition and variations on a theme, show important information that can help solve the mysteries surrounding the patient’s illness.
In Sam’s initial intensive therapy sessions, he and Jo began to dig. Jo was looking for patterns, for example, in the ages of family members when significant medical events took place, in similar types of illnesses in the family across generations, and in similar types of relationships or structures. She was also looking for mechanisms by which those patterns had become imprinted so deeply and out of conscious awareness that Sam presented with a life-threatening illness.
Sam began to pull up from his unconscious mind salient aspects of his family’s history hoping to unearth the patterns that related to his illnesses with the intention of making them conscious and easier to deal with.
Some patterns manifest in intergenerational structures. In Sam’s case, structural patterns are found in similarities linking Sam with his mother, Ilana. In both generations there were adopted children along with one natural child. Ilana was the only natural child of her parents, as was Sam. Furthermore, there are patterns of strong attachment between one of the parents in these generations and the natural child. Ilana had been closely attached to her father and was especially close to Sam. Later, Sam developed the same type of relationship with his daughter. Remarkably, aspects of such special relationships in complex families can determine the time some of these family members will die as a result of illness, and this was the case in Sam’s family. Understanding this phenomenon enables one to predict and often disrupt future disease and death that are likely if dysfunctional relationships and losses are not healed.
Disease and death patterns in a patient’s family are extremely significant when that patient is threatened with a very serious illness. It is important to note the ages of family members when illness or death strike and also to pay attention to the length of related time spans. Sam’s father was nine years old when he lost his mother to sepsis following a hysterectomy. Sam’s mother died six months after Sam married. His maternal grandmother had a stroke about a year later and then died the day before the anniversary of her husband’s death. When Sam’s wife, Rose, was initially pregnant with Stephanie, Sam was diagnosed with testicular cancer. He learned of the diagnosis, in fact, hours after Rose found out she was pregnant. The relationship patterns expressed by these events include the loss of a parent by a young child and death and disease occurring close to the time of a significant or celebratory family occasion.
In any family with many cases of illness and early death over generations, what happens is that these events and their timing burn deep impressions in the unconscious minds of younger family members and sometimes function almost as an unconscious pull to replicate them at the same age. Ages when events happen and time durations between important events become emotional markers for younger family members.
In Sam’s case there are other additional and even more important events to consider. When he was twelve years old, his father, who was fifty, committed suicide by drowning. When Sam himself turned fifty, he was diagnosed with melanoma, but with the help of alternative treatments it went into remission for three years. At age fifty-three, six months after Stephanie left for college, the melanoma returned with a vengeance. At that time, Zander was ten years old: here, the pattern predicts the possibility that Sam would die two years later when Zander was twelve, the age he himself had been when his father committed suicide. Furthermore, in Sam’s family there is a pattern of the father dying when his children are still young.
Patterns relating to work are also present. Sam’s father had been in and out of work before he committed suicide. When Stephanie left for college, Sam told his business partner he couldn’t work any longer: he believed he would die from the stress if he continued in his job. He then told Stephanie he wouldn’t be able to keep her in the college she was attending, and he told Rose the family would need to move. This threat of financial collapse and the need to move had been present in Sam’s childhood in the years preceding his father’s suicide.
Before Sam’s father killed himself, he had begun to cry incessantly and had called his best friend to ask for help. His friend told him to go to a therapist, but he refused. Recently Sam had been crying a lot, and Rose told him he needed to seek more aggressive cancer treatment, but Sam refused because he had been successful in healing from cancer twice before by using alternative treatments. In expressing his despair through tears and in rejecting the advice to seek help, he was following his father’s pattern. Sam’s father had held his mother hostage by saying if she left him, he would kill himself. Sam held Rose hostage with his serious illness.
Sam’s process of knowing
During the initial therapy sessions, Sam began talking intensely about his family and their traumas, which were creating great anxiety for him.
As he began to talk about his parents, Sam would unconsciously point to parts of his body that represented disease and the loss of his mother and father. When he talked of his mother having a mild heart attack, his hand went to a point just below his heart precisely where his first melanoma was discovered. In doing so he was also registering her lung cancer five years following her heart attack. (His mother had had three rounds of disease before she died, and Sam was now on his third.)
Sam’s touching of relevant parts of his body while remembering the painful losses he experienced were an anomaly that caught Jo’s attention. Patients don’t usually do that. These unconscious expressions are individual and not generic. But patients often find ways to show their therapist what they don’t know consciously.
The nodule on the right side of Sam’s neck represented his father. Unconsciously touching this spot called up the last night he had spent with his dad. They had been sitting on the sofa watching TV. His dad had had his arm around Sam and was cradling him as he fell asleep. His dad’s arm was touching the spot where the nodule had recently appeared. While he was describing this memory, Sam began to cry uncontrollably, saying that was the last time he saw his dad before he disappeared, and it was the only time his dad had ever hugged him. Following this session the nodule was smaller and pliable, rather than hard and hot as it had been at the start of the session. An interesting piece that was to come up over and over throughout this therapeutic process is how the nodules moved in relation to Sam’s discharging difficult memories. The nodules seemed to respond like blood pressure in a heart patient. When Sam’s stress went up, the nodules expanded in the way blood pressure rises in cardiac events.
Sam’s father killed himself Christmas Eve, but his body was not found for three weeks. The family had no idea what had happened to him. It’s hard to imagine the stress they experienced. His car was found crashed into a tree, but he was not there. Three weeks later his body was discovered floating in the Hudson River.
Sam’s second nodule was not quite under his left arm pit. He said it hurt as he was talking, and then he talked about his Dad’s funeral. He remembered crying hysterically and feeling as if he were in the coffin too. He said that at Jewish funerals it is customary to place a ripped cloth on a part of one’s body in remembrance. Sam had placed the torn cloth on the spot where the nodule later appeared under his armpit.
Another pattern Sam was able to discern was that the months for disease and death in his family were October to January. His testicular tumor was found in November; the first melanoma in October; and the tumor in his neck in November. In addition, December was the month his mother died and his father left (different years, but same month). His mother had been sick during the preceding fall. Sam said that the memories of these illnesses and deaths ruined every New Year: the family could never celebrate.
With each step of his therapeutic journey, Sam cried nonstop, which was highly unusual for him. He was surprised that he was following in his father’s path. “I always said I’m not going to be like my father,” he would say. It was important for him to understand that the unconscious does not register negative statements. Statements such as “I don’t want to be like my father” were registered as “I want to be like my father.”
In summary, Sam had been imprinted with what turned into an eighteen-year march toward death. When Rose became pregnant with Stephanie, he began this march with testicular cancer. The illness brought about a period of financial and housing instability: Sam quit his job and had to live with a friend separate from Rose because they were evicted for non-payment of rent, while Rose and baby Stephanie went to live with Rose’s brother. Sam then began driving a wheatgrass truck because he wanted to be in alignment with his values of health while he put together his own alternative cancer treatment. Over the next ten years, until age fifty, when the second instance of cancer hit, Sam was reasonably healthy. This time it was melanoma, and he stopped working again. Sam used natural cures for the illness and seemed to be healthy for three years. At age fifty-three, in November 2018, he was again diagnosed with melanoma, but it was more advanced. Sam’s son, Zander, was ten years old at this time, which indicated that Sam might die in two years since he was following his father’s pattern. If Sam ended this march in two years, he would be leaving his 12-year-old son without a father, just as his father had left him at that age. Fortunately, he was seeking a path toward mental and physical health, hoping to interrupt the family pattern of disease and loss over the generations.
We are all imprinted by our experiences of traumatic and earth-shattering events. The experiences make impressions on both our minds and physical bodies, like fingerprints. The more intense or traumatic experiences are impressed more deeply, as if the fingers are pushing harder. Those imprints are permanent, and they shape our growth and the way we experience future events. They change the lenses through which we encounter everything as we go forward into our lives.
People tend to encounter and assimilate experiences either physically or mentally. If our families and others close to us deal with experiences through the mind, we may be primed to have unresolved trauma lead to mental illness. On the other hand, if those around us when we are developing are especially tuned into their physicality, we may tend to express unresolved trauma as chronic physical illness.
Disarming Chronic Illness by Understanding Family Dynamics
Bringing memories from the unconscious into the conscious mind
When Sam became consciously aware of the patterns relating to disease and death in his family’s intergenerational dynamics, he felt as if his mind had been blown open. He finally understood that those dynamics were compelling him to follow patterns of behavior which could well lead to his death in two years. For all of us, it is as if there is an unwritten rule imprinted in our unconscious mind that we must follow the family traditions (e.g. patterns). We are being told what to do. Sam’s unconscious mind was aware that he was being compelled to follow his family pathway into tragedy, even while his conscious mind was frantically trying to find solutions to his problems.
When the unconscious mind is pushing us in one direction and the conscious mind is pulling us in the opposite direction, we can experience extreme confusion, stress and anxiety. These emotional states themselves can also inhibit our immune system. Unconscious knowledge derives its power of compulsion from its hidden nature: what we don’t know (consciously) can really hurt us. But when that knowledge is brought into the light of consciousness, exposure diminishes its power. When knowledge resides in the conscious mind, we can interact with it, negotiate with it, appreciate it, and make peace with it until it no longer holds sway over us.
For Sam, knowing and feeling how the excruciating physical memories related to the sites of his melanoma nodules allowed him to consciously express the grief embodied in those sites for the first time, draining away emotional toxins. His intensive crying spells were washing them out of his mind. That opened the way for his body to use the alternative medical treatments to drain away the physical toxins which had been locked in by the emotional barricades.
The roles of chronic illness
Ongoing illness can take on various roles in a family. It can bestow a kind of power on the patient, mediate relationships in the family, shut down conflict so as to protect the patient, and control emotions. The power given to the patient by the illness, which is often experienced at the unconscious level, can exert a form of resistance to healing because the patient may want to be the focus of attention to avoid the destabilization of the family.
In each family in which someone is chronically ill, the illness can help to maintain the family’s homeostatic balance. This is one of its most important roles. Homeostatic balance is a biological term that refers to the functional, stable internal environment the body is continually trying to maintain. In this article the term is used in relation to balanced, harmonious, and mutually supportive interrelationships for an individual and within a family. A chronic illness can help keep a family together around a central focus—the illness itself. Family members orchestrate their schedules, their activities, and even their emotions, to accommodate it. It gives everyone a common purpose, which further unifies them. Their petty annoyances with each other fade into the background because the illness is so much more important. Conflict retreats. It’s as though an illness can become not just another member of the family, but the central member responsible for keeping the family functioning effectively. But there’s always a price.
Jo Vanderkloot first became aware of this most important function of chronic illness in a family in her early career as the coordinator of the crisis unit at the Morissania Neighborhood Family Care Center in the South Bronx, NY. She and two other mental health practitioners were working with three families: each family had a chronically physically ill member and one with a presenting problem in mental health. In these families, when the mental health issues went into remission, the three chronically physically ill members dropped dead. Jo and her colleagues were so struck by these incidents that they asked themselves a question that isn’t usually asked in mental health practice: “Are these mental and physical conditions in different family members related?” The answer was yes—absolutely yes.
When this happened, Jo went to talk to doctors on the medical side of the hospital to see if they would be interested in forming a team with the three mental health colleagues to explore the mind/body connection with their chronically ill patients. Three of the doctors were very excited at this prospect. They described their patients as walking time bombs who were non-compliant with taking their medications and with treatment. A week later the three doctors met with the mental health team and were very disheartened: they couldn’t get anyone to participate in the project. So Jo asked them, “What were you saying to these patients?” They replied, “We were telling them that we’re working with a team to help cure their illness.” Jo and her colleagues told them, “You can’t say that! You have to tell them that you’re working with a team to help them manage the illness better.” When the doctors did that, they got all the patients they could handle. The patients were unconsciously concerned about maintaining the homeostatic balance their illness was creating; they were afraid to disrupt it.
One of those cases that was particularly striking involved a mother and her five children. The mother’s father had died five years earlier of an asthma attack. The mother’s youngest child, seven years old at the time, had been in the Westchester Children’s Hospital for a year with intractable asthma. During a meeting the doctor was having with the family in the clinic, he began conversing with the oldest child, the patient’s fifteen-year-old brother. The brother told the doctor, “I have to take care of the other four children and my mother (she insisted he be home immediately after school), and all I want is to be able to spend one or two hours a couple days a week with my friends after school.” At this his mother visibly tightened up and the asthmatic child began to wheeze. Jo remembers: “It was as if we were watching an orchestra conductor, and the family members were the musicians.” If practitioners can determine the function of the chronic illness, they can often predict what the outcome might be. Here the function-related question was, “How was this child’s asthma controlling the interrelationships among all the family members?”
The child’s chronic asthma stifled conflict quickly and effectively. Everyone’s attention (including the team’s) turned toward the wheezing child, and his older brother’s wishes for a more normal life, wishes that threatened the mother, were immediately ignored. The mother’s anxiety had triggered an asthmatic reaction in the young patient, allowing the illness to suppress the conflict without a word being spoken.
As mentioned, a price is paid when an illness creates a needed balance in a family. Illnesses’ roles can have a purpose, a useful purpose, but it is always precarious. When chronic illness maintains the homeostatic balance in a family, it often does so by preventing conflict: it silences differing opinions. It also causes family members to repress their negative feelings, stuffing them into their unconscious minds (where they can wreak havoc). This type of suppression stifles emotional growth and development, especially in younger family members, and It paves the way for some members to become chronically ill in the future, replicating itself. Additionally it guarantees that future family members will be afflicted with increasingly more serious problems with each succeeding generation because poor coping skills lead to compounding problems over time. This is one process by which Type 3 families develop.
As you can see, chronic illness brings with it a mixed bag of side effects, some positive, some negative.
One of the outcomes of Sam’s recurrent battles with cancer was that he derived a certain kind of power in his family. His illness was a major consideration in the family’s decision-making. “I’m ill; therefore I must leave my job. I’m ill; therefore we must move. I’m ill; therefore my daughter must transfer to a less expensive college closer to home. I’m ill; therefore I must use almost all my time in researching cures.” And everyone gave full consideration to what he was saying, not always agreeing, but being careful about how they disagreed. Furthermore, the illness suppressed conflict between Sam and Rose, which could be seen as a positive outcome, but it meant that they could not resolve some of their long-standing disagreements, which was clearly a negative. On a more truly positive note, Sam had always been seeking a stronger connection with his father; the melanoma, with its nodules at sites on his body related to his father’s death and funeral, was unconsciously drawing him closer to his dad, strengthening and clarifying that relationship even though Sam’s father was dead.
Expanding the Approach to Healing Chronic Illness
Bringing together two different treatment modalities
Chronic illness can indicate that the patient probably comes from a Type 3 family. As you will recall, these are families in which serious problems of all types have been occurring over the past several generations, including but not limited to mental and physical illnesses, addictions, the deaths of children and of adults in their prime of life, divorce, criminal behavior and physical/verbal abuse. Why is this context important? Why is it helpful to know what problems have beset the family of a chronic illness patient over generations? What does that information have to do with this patient’s illness?
These intergenerational patterns indicate that the patient has probably been taught subliminally during their entire lifetime that conflict is to be avoided at all costs. When loss and other traumas overwhelm people who lack the wherewithal to cope with their devastation, they can shut down emotionally and unconsciously pass down to future generations this unhealthy response to such situations in the form of unspoken rules of conduct. “Shut down and repress negative, disturbing emotions, such as anger and fear. Don’t feel. Don’t resolve things. Hide and stuff things.” It’s a “protective” pattern that leads everyone to be closed off. The repressed emotions then express themselves as either mental or physical illnesses. When a patient begins to understand how these patterns have been limiting their life and controlling their thoughts and behavior, it’s as though doors are flung open and layers are thrown off. It’s a time of great unburdening, which can stimulate the immune system to rev up and battle the disease. But if the patient remains unaware of this family background, the internalized response patterns may defeat all medical treatments.
When practitioners (both mental and physical) understand the importance of a patient’s family context, one of the first steps they will take when treating a serious illness is to try to determine if the patient’s family is highly complex—a Type 3 family. If there are only a couple of issues in the past few generations, both the patient and their family will tend to be more flexible and amenable to making changes in behavior to aid the healing process. But if there are multiple layers of complexity, the patient and their family will no doubt be more rigid and resistant to change.
Discovering whether a patient comes from a Type 3 family is helpful in another important way. If the practitioners are aware that when dealing with complexity, all behavior makes sense in the context in which it occurs, they can steer the patient and other family members away from blame and into an understanding of the various motivations for their behavior. Blame becomes yet another obstacle to healing; understanding motivations invites compassion and other therapeutic emotions into the process.
Guidelines for treatment
When practitioners are working with chronic illness families, whether the illness is physical or mental, it is helpful to consider these questions: “If the illness is healed, what will be the implications for other members of the family? Who will be affected and in what way?” And, “How ready is the patient and their family to deal with the issues?” Figuring all this out paves the way to address these additional questions: “When the illness has been maintaining the homeostatic balance in the family, albeit by negative means, how can healing take place without sending the family into chaos? What healthy mechanisms can be introduced into the family that will be able to take over the role of maintaining that balance?” Answering these questions will lead to an understanding of the family’s core problems, and the practitioners will be able to intervene at both levels without destabilizing the family’s balance. Practitioners who can accomplish this will be effective in their professional roles and will provide families with an optimum opportunity for healing. Furthermore, when practitioners understand these dynamics in families, they will be less likely to burn out.
In the second case mentioned above, to treat the child’s asthma in isolation from the family context would not provide any long-term solution to the problem. What the family needed in coordination with the medical treatment was helping the members develop different coping skills to deal with honest issues of conflict in constructive ways. For chronic illness patients from Type 3 families, a treatment plan that encompasses both physical and emotional approaches is necessary for success. The inability to deal with conflict in healthy ways is at the core of complex family systems burdened by many difficult problems.
A most important point to remember is that in working with chaotic family systems, it is critically important to help the family maintain its homeostatic balance: if the balance between the individual, the immune system and the family is disrupted, a “runaway” in one of those systems will result. In the situation mentioned previously, when Jo and her colleagues were working with mentally ill patients at Morissania who had chronically physically ill family members, the therapists improved the mental stability of their patients too quickly for the physically ill family members to adjust to the changes: the resulting homeostatic imbalance brought on the death of those physically ill family members. In highly complex and rigid families in particular, an escalation in the illness is a red flag for the practitioner to take all actions with intense care. Patient/family rigidity, as well as illness escalations, indicate that a team of both mental and physical practitioners will have a greater chance at success in healing the illness than only one type of practitioner working alone.
As the complexity increases in a family, so does its rigidity. Very complex families are resistant to change. In these Type 3 families (but typically not in those exhibiting less complexity), a therapist will usually be able to discover a specific pattern of dysfunctional behavior running through the generations. That behavior is deeply and emotionally imprinted on members of the younger generation as their elders engage in it, and those individuals tend to replicate it at a similar age. Rigidity is a response to the need to hold the family together through ongoing tough times, regardless of the dysfunction of the behaviors in question. The rigidity helps keep the family from falling apart. To cite an extreme example, when a parent commits suicide, children can almost seem to feel a compulsion to do the same at the approximate age the parent was when that happened.
In the family with the asthmatic child, complexity was at a high level, and the pattern across several generations in that family was the role of the illness in controlling conflict.
Unsurprisingly, because it is often the case in complex families, both Sam and Rose came from such backgrounds. We are all attracted to others who have grown up in similar levels of difficulty. The patterns in both family systems played a role in Sam’s chronic illness situation, and so it was important during therapy to identify the patterns in Rose’s family as well as those in Sam’s and see how they interacted with and reinforced each other. Each family unit in all the recent generations in Rose’s family had had a chronic illness. In this article, however, we have highlighted only Sam’s family’s contributions to his illness because they exemplify so well the way family patterns can relate to a patient’s chronic illness.
Family members confronting serious, life-threatening illnesses are usually so confused and caught up in an emotional whirlwind they are unable on their own to identify their underlying problems, especially since important information is unconscious. Their attention is on what’s happening on the surface: they might say, for example, that they have a communication problem or different lifestyles or that their lives are going in different directions.
In therapy sessions with Sam and Rose, each would describe their own experiences and perspectives, but even working together in therapy they had no idea how to think about the larger issues affecting them both, and they were unable to identify the underlying problems. That inability is the norm in such cases. Sam dealt with difficult situations by shutting down and “people pleasing,” thereby stuffing every angry thought and feeling into his unconscious mind, and he had been doing this over the course of his life. All this anger and fear erupted as cancer. And Rose’s approach was to push against him when he encroached too much on her needs, and to unconsciously experience a bit of resentment when Sam’s illness took center stage.
Another important consideration for practitioners is the pace of treatment. On the physical level, if, for example, a cancer is treated too aggressively, the patient’s body cannot accommodate the rapid accumulation of dead cells and may be overcome even to the extent that the patient dies. The immune system must be re-stimulated in such treatments but not overwhelmed. Similarly, in chaotic family systems, the pace of psychotherapy must be geared to the patient’s ability to assimilate new understandings into their conscious frameworks for there to be a positive effect. Too rapid a pace may overwhelm the patient and their immune system and potentially destabilize the family’s homeostatic balance. Treatment must be in balance with the patient’s optimal pace for healing and the family’s ability to accommodate change.
Another type of balance is also important. When a person is healthy, their immune system is in balance with their family system. If either experiences a crisis that negatively impacts its functioning, the other will be affected. Thus, when a healthy person suddenly experiences a crisis, they may get sick. And a serious disease that overwhelms the immune system can cause disruptions among the patient’s family relationships.
We have been talking about systems, about the way chronic illness plays a role in family systems. Some grounding in systems thinking is extremely helpful in undertaking to heal chronic illness, whether the starting point is in the mental or physical arena. Traditional medical and mental health approaches grew out of older, linear, non-systemic ways of understanding the world, ways that promoted the use of mental silos to enhance understanding. These approaches are ineffective in dealing with complexity. We can continue to use what we find helpful from them, but if we are to succeed in healing the problems we face in all areas in our complex world, it is imperative that we advance into non-linear, systemic approaches in our problem-solving. This means we must pay attention to the context surrounding a problem, and because doing so increases the scope of our explorations, we must also become more collaborative.
The ideal structure to maximize treatment of chronic illness would be teams of medical and mental health practitioners looking at both parts of the dilemma. In today’s climate no individual professional has the time to do all the interventions that have gone into Sam’s case study. But even with such collaboration and a commitment to systemic approaches on the part of both medical and mental health practitioners, there is no guarantee of success. In some situations, the chronically ill patient will have come to the point in their life when death will happen no matter what. But while there is no guarantee of success, there is a much greater chance for it.
During two and a half months of intensive therapy, Sam confronted the agony he had experienced as a child when his father died but also felt the excitement of new insights, while at the same time he experienced a rise and fall of his physical melanoma symptoms. Then he came to a clear crossroad, and Jo told him that there was a war being waged in his armpit: it was a battle between life and death.
When Sam had been first diagnosed with this case of melanoma, he had feared for his life, and he felt as if the business he co-owned with a partner represented death. That’s why he told his partner and Rose that he had to stop working or he would die. When he realized the nature of the battle being fought in his body, he had an epiphany.
He was finding new energy from this discovery process, and he felt a rush of ideas forming. He texted Jo that “The illness was created to move me forward in work and in my relationships. Now I’m moving, moving, moving! Things are moving and flowing, and I can now connect with the flow and move with life like healthy people do.”
One night, as ideas about how to restructure his business ventures began to flood into Sam’s mind, he noticed that there was a huge swelling in the lymph node under his left armpit accompanied by a rash and pain. Rose thought it could be a blood clot. Over that night and after meditating, he realized, as he told Jo, that “I am choosing life, and the hold of parent-deaths is letting go. It’s draining out of me, because I don’t need it anymore as a motivation. As I choose life, it’s almost as if death is dying.”
The following morning Sam noted that while it was still hard and swollen under the arm, draining had been happening, and “things moved so much in twenty-four hours.” He said, “My body did all the work with no outside intervention. The armpit is repairing and rebuilding the lymph system. So much goes on out of conscious awareness. The logical brain is so limited! And it all happened at Passover!”
That morning Sam told Rose how grateful he was for all her love and understanding, and for her staying by him through all the years. Now he felt that they could get through this and have the fun they both wanted. Thirty minutes later, Rose’s ear, which had been blocked for eight weeks, started to clear. As Jo put it, “She was finally hearing what she wanted to hear, and she needs a little more of that.”
Moving toward the future
Throughout his life Sam never felt quite right, always a little bit off. Jo believes that was because his unconscious mind knew he was going to die early. Sam has lived his life in an illness bubble that didn’t allow him to fully connect outside it. The people closest to him learned to accept that and not to expect more. It is typical of chronically ill people to begin to disconnect from the living, especially when their illness is severe and life-threatening. Now Sam reports that he is moving more out of this bubble and is connecting to people very differently.
Sam’s therapy and medical treatments are continuing. He chose to undergo treatments at Issels Immuno-Oncology Center in Santa Barbara, CA. He and Rose went together. Often patients at the center are treated on an out-patient basis in Santa Barbara and then spend some time at the Tijuana Mexico Inpatient Hospital. Sam’s progress was so rapid and thorough that his doctors in Santa Barbara decided he did not need to go to the Tijuana hospital. He and Rose returned home, and in the following weeks, Sam saw his tumors drain away. He believes that without the family therapy he experienced and all his new understandings, the outcome might well have been different. While at the Issels Center, Sam noticed another patient who had come with his wife. That patient was defensive and demanding, and his wife just swallowed it and gave him leeway because he was sick. He died while Sam was there. In contrast, Sam had a positive outlook and Rose was there to support him: they had worked through their tensions and problems.
The collaborative, two-pronged approach we are suggesting is intensive for all involved. Some critics will claim that it’s too expensive, but in fact, it is actually cost effective. When mental and physical conditions are healed in a family and its members learn how to handle relationship problems effectively, their transformation has a multiplier effect across the extended family and future generations. Medical problems, both mental and physical, that would have resulted from the patterns of dysfunction in the family will have been prevented: treatment of those potential problems would have cost much more than the cost of treating the initial family using our approach.
We currently live in a time when medical practices are to a certain extent held prisoner by the financial systems supporting health care. These financial systems reflect the older linear, silo mentality. But much can be done without butting heads with the insurance industry. Medical and mental health practitioners can find ways to collaborate in the care of individual patients and families dealing with difficult, systemic problems. We are seeing this happen with the establishment of some types of wellness centers. Medical advances are increasingly moving in the direction of systemic approaches, as in the burgeoning field of immunotherapy. (An excellent book, Back to Balance: The Art, Science, and Business of Medicine by Dr. Halee Fischer-Wright (2017), describes the way the business aspect of medicine has taken over at the expense of its art and science aspects. It’s well worth reading, and, like the tenets of this article, suggests a current too-narrow focus in medicine and notes that the consideration of relationships has for too long been neglected in this field.) Fortunately, we are advancing away from more linear thinking patterns and moving toward more holistic approaches: doing so will greatly increase our effectiveness in healing chronic illness going forward.
Postscript (2022)
At the time the above article was written, we didn’t have the final outcome of Sam’s battle with this aggressive melanoma, but we were sure that much emotional, psychological healing had taken place which seemed at the time to be having a positive effect on his body’s ability to fight the disease. We had strong hope that a complete physical healing would follow the excellent results of his hard work in therapy.
But even though Sam had done well with the Issels Immuno-Oncology Center’s program and had begun to feel as if his life was opening up in completely new directions, his illness soon regained the upper hand, and he entered the hospital. He and his family understood that he was dying. He told Jo that he knew he was on the right path, but he hadn’t been able to trust western medicine enough to try recent new approaches such as immunotherapy, which were being touted as effective against melanoma. Therapy had helped him become free enough of his old phobias that he was ready to try these treatments, but he acknowledged that it was now too late. Sam died in October of 2020 with his family at his side.
What gave rise to his fears of western medicine? Two sets of experiences. After his father’s death, his mother had had to work hard to keep the family together, and at the age of 12, Sam was largely on his own. He felt that because the usual support system for young adolescents wasn’t available to him, he had to trust and rely on himself alone. He had had to assume adult responsibilities all of a sudden. For example, a week after he got his drivers’ license, his mother had him drive her to New York City.
As he matured, this attitude prevented him from taking advantage of many resources outside himself. And throughout his life, Sam seemed in one way stuck in that period of 12-year-old adolescence: his medical research was always scattered, much the way a 12-year-old without any guidance would go about it. In fact, he had a scattershot approach to life in general. Second, his cousin had had melanoma and had been treated in the western medical system: the treatments were painful, left him seriously disfigured, and he died anyway. His cousin’s experience amplified Sam’s already built-in distrust of the American medical system, and he had rigidly limited his search for help to alternative practices.
Please understand that this article is in no way implying that alternative medical practices are in any way ineffective. In some situations, they are the only remedy that works. Many patients seek them and find success after all their Western allopathic treatments have failed. But when a patient is in as threatening a situation as Sam found himself in, they need to be open to trying appropriate and promising treatments from both schools of medicine. Sometimes it is a combination of naturopathic or homeopathic and allopathic treatments that brings relief.
As Sam persevered through therapy with Jo, his ability to understand how his life experiences and family behavior patterns related to the progression of his illness brought hope that he would be able to defeat the cancer. But the disease had become well established, and time had run out. He told Jo that he had started this work with her too late. Was all his hard work in therapy in vain? Rose gave Jo the answer to that question.
Rose was in frequent contact with Jo during those last days of Sam’s life and for a while afterwards. Her words in a text message sum up the value of Sam’s hard work. (Text message edited to protect identity.)
“Good morning, Jo. Were you able to Zoom the funeral? If not, I can send a recording.
How are you?
We’re hanging in there. Very sad. We are crying and walking around without focus and forgetting to eat, etc. Friends and local family are there for us. Sam’s out of town family members left yesterday.
Kids and I are crying and talking every day. I’m so focused on their well-being and processing the whole thing—want to avoid what happened to Sam. Stephanie is extra sad because [her boyfriend] flew back to school (he’s really a special guy!)…Zander comes out with amazing comments and insights daily…so far we’re in decent shape.
I think I’d like to keep talking to you as we go along.
Even though we lost Sam, you gave our family a year and a half of much-improved relationships and were instrumental in Sam’s being able to sign a DNR in the end and leave us all with loving connection.
I hope Sam is feeling the impact he made and the inspiration he provided—I think he would’ve been surprised.”
Date of Revision: 3/4/22
