CHAPTER

A Familv SvstemsTreatment for the Impaired Physician BarbarqR. Cunningham

Researchersin the 6eld ofalcobolisrn and addiction havecriticized lhe diseascmodel of treatnreDt,with its Darrow focus on tbc individual iDsteadof the family system (Bowcn, l97U; Kerr & Bowen, 1988;I-awson & La$'son,i998; Morgan, 1981;Wallack, l98l). Such criticisln is especiallyapplicatrlc to thc treatment of impaircd physicians and thcir families. Rcccntrcscarch supports the notion lhrl adultswho havegrorvnup iD farnilieswith addiction hdvc a tendencyto choosecareers in thc hcaltlr'care professions(Mallsky, 1999).Vailldnt, Sobowale,and McArthur (1972)rcportcd that physician vulnerabil ity to addiction corrclatcswitlr unmet personalneeds. According to their prospective study,doctorc werc morc likcly to cxperienceproblenrs with drugs and alcohol,require psychotherapy,and havcmarital problernstlran werenratched non-health profcssional coDtrols.ln fact,Vailla'rt ct al. notcd that son1edocto$ choosea medicalcarcer to help themseh,esby helping othcrs. Vtrillant et al. concludedthat thesedoctors, doggcd by their perfectionisnr,were dcdicatcd in the extrerneto the well being oftheir paticnts,to their own detrinrent aud often that of thcir fnnrilies. Gabbardand Menninger (1989)furthcr €oncludedthat plrysicianstelrd to be less happy in their marriagesthan those in mrny othcr professions.Physicians'long hours arc not thc 6drseof their nrarital problems,thcsc rcscarchersfbulrd, but rather, doc tors'cxcessirework rvasoften a resllt ol their dcsirc to run arvayfrorn facing marital tcnsions.Emotional renrotenessanci withholding of angcr are two ofseven attributes of physiciansidcnti6ed by Ellisand lnbody(1988), ln nn carlystudy, Martin and Bird (1959)chardcterizcd thc troubled nredicaLmarriage as Lhe"lovc-sick wile" and "cold sick" husband.l hc notion that relatitxrshipdifficulties !lnderlie chcmicaldependency in physiciansis additionally sopported by the finclingsof Angres, Mccovern, Rawal, and shaw (2002),rvho fbund the pcrcentageofphysicians from comorbid psy chiatric disordersor marital discordto be 60.370.

30t 302 c Lrnrn,3 -

Ir his fcvie$'of thc psych{rso.ialf'rcl{rfs conlril)LLtirlg lo phvsi.i.rnrclcliction, CooDlbs( 1996)l;und I h.rtphysicitlns x'erc gcncrally ignomnt ol lhc delcloPnrentalaD(t intcrpersonald1'namics of addiction.I\'lore scYcre Drrlital dilllculties huvr rlso bcfr) l;Lrn(lLo bc highlycorrclrted with physicirnxddictn'rr (NIcCovcrn, An$rcs, & Leon, 1998).IioL)b (1998) norc{l that mcdical schools lypicilly do not i|rclLrdelf.rining in alco- holisn ard rddictior.It isalarDring that physiciaDs .fc nol trainrdto recoS|iz€ or tfcnl signsandsynr on1sin lheirp:rti.rrtsorinthclnselvcs. 'fhis chirpterprcscnts a tanrilys,vst€ns lfcatment li)r lhc inrPrircdPhysicial1 bitscd upon Bowcn Famil,vSysterrs Thcory (BlrSl).Corrccptualizing lrcatnlenl ofthe inr pailcdphysiciaD fro .rperspecl ivc that iDljlrdes thc PurLncrshilis the focLrsflorr Lhc in(lividualpcfspeclivc churacterit ccl by thc diserscnxxlel of tfrrtnlent lo x sysl.n\r focUslhat l(lclrcsseslhc llrultiplcvurirbles withir lhc physiciinliimily rhul can con tributcto addictionand keepil irlive.Addiclion is secrnot asrrr illrljvidurrldcficierlcl' (\v.,llack,l98l), but rs the resulrot ntult\nc influencc's.Larvson and l..rNson(1998) conctLrrvith thc needto conceptLralizeaddictir)o .rs x prcblen in relationshiPsyst.'rns. 'fhr)' citcl\4organ (1981), !\,llo lhcorires th.rl lhc diseascntodel "pxrvidcs r n out lor so' .ictl' in deilingu'ith sfrioussoci.rl proLrlcurs b,v crerlir)g a ileed1o treirl thc indiYiduirl irodtherebv lcgitimizcs thc problemas b.rscd !n th€ indi!iduall.l(h€r thil'r in thelaf$cr systclnol sociil rclations(the flnrily, the schoolsystcm, thc church,the conrlnunit),)' 1t. 360). l hus,irr licuo1 r rcductionisticlircus,lrc.tlrrrcnl shoul(l iclcntif,v lhc syslenri. .rndmalad.rptiYe fan)il)'pnltcrns that are lrnnslnillcd througlt urrltip{e Scncrations. A brorrdcr,fanil,v-oricnted lpproach is cspeciallyirrrPortrrll lor inrpaircdphysi ciirnsbecdusc th€y LcntlLo hav,-'ilctached intcrp€rsonrl slylcs (Sotile & S('lile.2000), au)idanceol intensccnroliolrs (l\4cvcrs, 1994), a slrcssfulpra.ticc (lalboll & liallegos, 1990),an(l cnsy a.c.s\ to rlirr.oti.s.Cllini.itlns rre encourrgedto conccPtullizccherrri- crl dcpendrrrccas a likclyfellcction ol scriousrclationslrip issucs in thecloclols noclcrf rnd cxtcldcil l:rnlilies,l)chreellind wiLlrirrgcncr.rtiorrs (Bowen, 1978). {lorrverscl), Lrs- ing rn indivnlnl tLe.]rnrcnt appt on(h Nith rbeinpaitcd phvsieianis likc' lhrow;ng hi,rr or lrrr out ol .r\\41ite\\,irter currcnt, res s.itirlirlghirn ('r hef,ind thenlhr(,wing hinr of hcr rightbi(jl( into thc lorrenlirlwaters. 'lb underlincthc vfracit\'ol this nrcl.rpho,f,tlboll (1987)JirLrnd in artanal|sis ol i(X)phlsi.irns, foll(xvf(l tirf 4 !crfs subscqLrcnt!o tl(irtIncnt.th.rl the reln|scrate $'as (lrarraticallybighcr vrhcr th€ spolrs€(,,rs Lrnilvolvctl ard Lrntfr.rtccl.Sirrrilrrlv, r tc cfnt studyol'.rdLrll opirrlc users irrclicate(l bctt€r oulcornes lbr lhoscrecci!ing fanrily I rcatlnentthnn for thosc rccei\ ing l\,o indi!idurllI birscdinlcrycnliors, prrl jcularl!li)r rhoseLivins rvith r prrlncr (Yin(loli,Eislef, Itobbins, \'lullei dy. & I)ar€,l(X).]). Lr ln.r, inrf.rireclphvsici.rns and thcif rrmilies,lilic rny olhcr lJnril)'sLrlliring rvith chenical dcpcndencc,crnrot bc treilcdelllclively wilhout a lhofoughtrs\tssnlcnt trrr(i lreatncnl ol dystirn.rion"ldyn:rnrics $ithin (hc ranrilt.A parailigmshilt ho indiyi(lualtrerr nrcntstypilicd b,v thc diseaseunxlel Lo .r tlnrillr systerrrs tfealrrrcnt xs lyfilicd b,vltfs I ollcrsanopl)o|tuDilyloflasli,rgchrngcth,rlSocstlecpcrthanplacing,tllrtnclAiclonLr gapingwound. IiFST,wit h its!rt ol interloching principles, prrrvidcs a roarlrllap for sr-\temjc tfctrl lrc l. Tr€rlrrrcntshills lrun licusingon thc paticntlo clisco\'cricsfegar (ling whrrl 1)rrfL c,rchl.rnrillrrrcmbelpl,rvsinnrnintairlirgrllcproL)lcrn(l)rpen),1990).ThffatieDlhcl|s k' (reitc r hnrill dirgr':Lmcorcring thrcc or nlorcScnciation\ rs l,n|t cil.r cognilivclr A F^Mtrysysrdt Tr(^rMrN' toR u. tMprrRrDPHysrcr^N ! JU5

lbrrscdcllbrt to viewthc l.rIn il)'s cnlotional pr(,ccss rcross time (Kerr& lnNcrr,1988 ). Altcr.rnorgarized efforl ri) (t)llcct ftrcts and idcDtilyp.rttenrs of familytunctioninS, the clicnt(or clicnts)in tretlrnrentis irsked to idenlilyand rrke responsibilirylbr hisor her. plrt in thc mairtenanceol thc synrpton. An inrportantpart oflrcotrnc l invoh.€sbridSirrglhc distrnce betlveen l.rnrill'rr)cnl 'ticrrnrcDr bersrml Icpairing thc cnn)ti(nrnlcutofIbetweeD Scncroti(nrs (Bo\{en, 1978). involvesactive efforts by thc timily (o discoverhow rchrionshipsfincriouerl in prcvi ors gcncrllins, in ordcrto understandhorv prst relrtionshipsinflue|cc cLrrrenr rcla tionships.l)rticular;ttorli(n) is prid lo identifyingthc ovcrfunctiolingolone n)cnbcr in lclatiorrto the undcrfunctioningofanother (l)(^t,cn, 1978; Cilbert, 199,1). wilh rhc lrtnrilydiagrrm asa blucprintt(' 8uidefurthcr tliscovery, rhcrapy is crnrccprunlircdas thebcgir)ning ofa lifelor8journey bward incrcirscdnrv.rreness ol how c'nmtion,rl tbrccs nnd r\icly aretransmi[ed rcross geDeratioDs (Kc & lJowen,1988).

The Promiseof BowenFamily Systems Therapy ln thc lrie 1950s,l)r. J\'lurravllowcn obscrvcd rhrr secnringlvcurt'd schizcryhrcnic pa ticntsrchpsed upon rclunriDghonle lo thcir tli|lrilirs5oon.llicr the,v rvere dischalgcd lrnn iopnlrenttrealmcDt pr1)!ir.rnrs (Uoit'cn, l97lt). AItcr obscryingtlris phcnontcnon, I)r. lJolcn

Underlying Philosophy and Theoretical Concepts ttowcn(1978) char.rcfurized chcmical dcpcndencc .rs one of the moreprevalcnt hurnan dyslunctions.Like all clysfunclionrlpatlerns in .r filnily,one c nnot conceItralizethis behaviorrvithout vicwing it in !hc brcaderco|tcxt ol an inrbrhncc in funclioningir the{'holc liInil.r'syslcDr (Borferl, 1978). TreatmcDt is ainrcd .ri riising cach irnill mem- bcr'sarvarencss ofthe prrt heor shepln,vs in miinttlining lhc syrnptom-Thc trcatmcnt is initiatedwiLh the fanrily member rvho has the grcrtestnrotivltion aDd ability to modifl" his or her lirnctioningin the syslcnr.Ofter lhis is the lirmilyllenbcr rvhooverfirnc- lions and is in the grertcstpaiD (llowen,1978). thrl is not so ovcrwhelnjngns to paralvzeclTorts to nrovc forwaxl bu that plovides enough discomlort that famil), A faM ry sysrEMsrRr^rMrNr roi rHElMpaRED rl

menbers wclcom€th€ ider ofchangc rnayrurD olrt to l)c tb€ gater.ayto rcs

Chronic VersusAcute Anxiety

uolvclr(1978) noled !hirthLrnuo beings share Dn'c sinrilariticsthar dillcrcnccswith olhcr lbfnrsof life.I'erhcps thc nrostsalient $irfcd featureis that the orliirnism&'i11 l€l]cl dclc'nsivel.vto a real or inugined thrc.l 1()sun,ival. This survir,.rl rcirctioD n1it,v bc phvsicrl,cnrotional, ol a conrbinationofboth.'lhc clinicial will obscrvc'thatin some people,.rnxict,v is so continLl('uslypresent thnl lh is hcightenedreactivity nccd not nec essarilybc stimulatedby |ealor irnaginedthrctrt (Cilt)eft, 1992). lnstcird, the nnxieti is chronic,an anxietythat hLrslil

Whcrc.schronic arxiety slrxins or exceedspeoplc s nbilityto adap1, acLrlc anriiet,v is a responseto a rcalthreat.Thc rclclionto a realthre l isof limiteddurrlil)n, aDd peopl€ can usunll),adjLrst. Acute aDxicl,vis rooted in ol what is, wlriie chlonic rnxiety is rootedin fearofrvhat ,/tglrr r( (Kcrr& Bowen,1988). Peoplcrvho exhitrit high lcvels ol cmotionalreactivitl in resporselo nrinoror €ven imagincdstresses tcnd to actrnd reactrvithout thiuking. One goal ir BlrSl is to more familicst{ru,ard decrcnsing thcif re.ctivityto one0uother whilc increasing lhcir ability lo rcsporrdnrore thorighlfuliy (lkx{en, 1978). Blrs'lfocr.rses on the cnlolionirlsyste 'sstru8gle with two opposi|girrstinclual lifc fo'.cs: lhos€forces that kccpirrnrily mentrcrs.oDrccted nnd 1hcco trrr),forcesthat cotnpc'lpcople torvard indn,ittuality (tlowcn, 1978).One [orce is oriente(l loilard to- gelhcrncss,and the other l;rcc isoriented to\\,ard scprrrateness. |rom thc pcnpectiveol BIiSI:lhc trvo\€ctors $'ithirt thc familialenvironnrcnt thnt inllucncc.hronicanxietr ale peoplclrrcactivity to lhcif pcrsonalspace bcing intrud€dupon rtnd thcir conrple ment.rrynccd for connection(l(cff & Bowen,1988). l hc clich6"Can'l li!c \\'iththen, car't livcwiLhort them" descril)csthis connnondilcmnra. Patterrs ol cmolionalfurc tioDingrrcallrclatedtother! ysr famil,vdeals wit h its membersinpinging uponone another or, in rcaction to in4,irrgcmcnt,diseDg:rging lionr one another (Kcn & Borven, 1988). lVhen xnxietycscalrtes in a systcm,the forceslbr togethernessincrcasc. One can rccallhorv pe0ple canrc' together in the UnitedStrtcs ir Ilcr 9/ ll. Overtinre, thc togeth cfncsslir|ces lhrerten gfolrp nlenrbers' scnsc of iudividoality.Family rolcs rncl family rulc'sbccome inllexiblc, and nonrrrrldcvclopmentll li{e cyclc changes alc pcrccivcdas upsetting.A delensivcmeasur€ in the faceof such ir perccivcdenrotioDirl lhrcat is to distancconeselffrom thc fircc! oflogcthcrncss ir orrlel to achievesoDrc scprftrtcress antl avoid "swallo$,cd up nhole." In farnilieswith a high dcgreeol'lusion, thcre is dn incrcasedrisk that onc of nlore membersrvill cr.rtoff fron thcir pirfcrltsin a movc 306 I cuerrra13 to preservewhat little is lefl of"self" This reactiveculoffis no[ he]pftrland can lead to symptomssuch as substance abuse (Bowen, 1978).

TwoOpposing Life Forces: Can't Live With Them and Cant Live Without Them l tnpsychicfusionaes.ribes a lack of differertiation and clarity betweencognitive ard affectivefurctionirg. Bowen (1978)explatus, "The capacityto differentiate bet\/een thoughts ard allo$,ssome choice ovel beiDgdirected by one's'head' or b1 onei'gut"' (P.62). He notes that what setshumans apart from other speciesis their ability to think and their ability to be alvareofthe differencebetween their thoughts and emotions.Ho'\.ever, if the human organism becomesovenvhelmed rvith anxietl, cognitive ability may becomecompromised or may cvcn shut dorvn. If tbc cogniti\-c ability shrts down, thc human spcciesoper.rtes just as r-eactivell'and instinctually as other speciesthat do not havethe advantageofa highly cvolvedintcllcct. Interpersonalfllsio describesa lack ofdilTcrentiation bctwccn oncsclfand othcrs. It manifestsitsclf in a \\'ay that disallowsa pcrson l'rom knowirrg where he/shestops and another begirrs.When lusio|r is inlense,lanily memben seemto haveno sepamte ideotities.lntense lusion resultsin family nlembe].snaking "we" rather than "I" state ments. Husbandsand $,iveswho complain that they carrot li\-e with their spouseor withoLrt lhem are desclibirg an inability to manageeffectively the universalconflict ot theseopposing li1€ forces. It hasbeer suggestedthat a diso nirg of the needfor family ties may be a motil.at ing iictor fbr sone peoplervho choosea medical career(Twerski, 1982). The int€nsity of the hospital ervirorment aDd long rvork hours may fulfill a person\ wisb to lcc neededalld emotional]yconnected while at the sametinre safelydistanccd frorn his or her inportant family r€lationships.It may be true, as thc convcntionrl r{isdom goes, that the hallmark ofaddiction is denialj vet if we look beneaththc surfacc,1vccnn see that it is withiD the denial of needingothers t hat chem ical dcpcndcncyth rives. l hus, the problem ofaddiction may be viewedas an outcomc ofavoiding the taskofresolvinb attachmert issuesin the r€lationshipslstcm. The smoothestperiod bctwccnpartners is driring courtship (Kerr & Borver, 1988) Predictabll',howevcr, rclntionship tension mav escalateto problematicproportions over time. Typically,rvhen t$.o pcoplcnlirry, !he emolioDalpalterns that firstattracted then- to one anoiher m,ry intcnsifl As the relaliorship developsand as day to day stressors remind them ofthcir hcigbtenederrotionaJ inlerdeperdence upon oDeanother eacl- partner miry bccomcrcacti\'e and evendisgusled by tlre personalitycharacteistics that initially irttracled them to ore another.McKright (1998)obseNed that "the morc ir- tcnsclya personseeks to fill the elrotioral delicitsofth€ other or to haveanothcr shorc up his or hel liL, the more fused the rnarriagerelationship becomei' (p. 272). Whcr pcoplcrvith high levelsofDeed for togetherDessmarry, eachpartner in\rsts hcightening lcvclso1"1e11"'in the other. This fusion becornesmor€ binding as thc sharing ofdaill l;ving dulies heightenstheir needfor one another. Uriike during courtship, when they experiencedmorc frccdom to be themselves. lhe spousesbegin to assumethat they can read thc mind of the olher and begiD to A F^MtrysysrrMs TREATMTNT foRrNr MpAR.DPHyscaNt 3O7

bchaveas ifthey know how lhe other rvill rcacr.lhe couplebecomcs likc lrvo cells that havemerged trnd now hnveone nuclens.NciLher indivictual can ch.rrt inclependent goals.One spousefccls swallowed up ir the rclatbnship rvhilethe othcr spoLrscbecomes drained from being hypcrviSihnt lest he or shc bc abandoned,A heightcncdsense of dependenceon anothc'rcan ririseanxiet)' lcvcls. Hcighlened arxiety nrayrcsult in in- creosedeffbrts to copeby cre tjDg distance.l)rinking irrrd/or drlLgabuse is one rvayto rchicvcthis dislaDceill the shorttcrm, bul in the longterrn, the heightenledNDxiety thit thc abusecauses ir the individualswho dependon thc dbusercreates iocrcasingly conrplcxproblems in the frrrily systcn. Thc rclationsh4rsystem in cach spousei family oi origin inlluencesthe dcgfcc of the dcsircfbr e otionalcbscncss ;n the arriage.If inclividualshave e otionallycut thcnrsc'lvesoff frunr their rcspcctivefanrilies oforigin, thcre is enormousprcssurc upon thc nuclearfamily to bc cvcrylhing to one aDoihcr. l he high degreeof invcslnlent in thcir spousesard childlcn is basedin a rsish to compcDsatefor the emotional delicits lionr their own familics. l)isirppointirgly, thc prcsslrrchas a deleteriouscllict on the urrion,ulld anxiety riscs $,ilhin such a context. I'coplemay find that lhcymaLried someonc with a similardegrec of nccdiness.As Lhe(lisappointmcnt, depressicm, and lonelincssr11ouuts, these peoplc cxpericnce con fLictwith thcir spousesand nlaylook to their chil(lrcnto 6ll the void of counection with thcirspouses. The pircntsthcn pro;ect their irrability to dcalnith relatioualclosc- ness/distancemanagenrent in thcmsclvesorto theirchildrcn, and thechiltiren bccomc caughi iD thc crossfireofunrcsolvcd cnloljoDalattrchn)crt. Bol{,co(1978) noted that whcn "two pseudoselves'fusc'into the enotioual 'wc- ress'of marriage,lthere is ilsol n highpotertial fof impiiring the functi(nringof onc spousc"(p. 263).Th€ discorrifbfl ol this fr.rsionmay bc handledin various wiys. How cvcf, almosi all fused marriagcsinvolre adaptivccilbrts lo createsome dcgrccol emo tionrl disiancebetlvccn pnrlnels. lt is a reacti\,cmovc trased ir the survivalinsrinci io

One way emotioDrl distance is increasedis thrrrugh nrarital conflict. l)uri'rg the rraking-rrpphase, thc couplcmay experiencc thc togcthernessthat thcymisscd during rhc !list:rncingperiod. Altcr tiring ofholdingorrlo onc\ owr positionand not "givil1g i ," partler may move brck toward thc othcr. And so it goes,in a continuing cycleof tensk)nbuildirg, conflict, and rnaking!Lp. Bowcn (1978)believed thirt thc most con1lnonplttcrn for dealiDg ennxionrl 'vith fusiollis.rn underfunctioningl)vcrfirnctioning rec4rfocity- Onc spouseassunres r dom- inint rolc and the other spooscrssumes an adaptivefolc. Thc adaptivespouse bccomcs "rvircd" to support the morc dom;nant, decision nlakinS spoLrse.ln most respccts,thc adaptivcspousebecomes a funclionil "noself" (Bolvcn,1978). lhe ore $'hoirccorrmo dalcslhc Dost gi\.esup thc most selfto the other. This .rdaptiveperson is morc vulner ablclo sonletype ofchronic dysfuDction. lnnven(1978) belicvcd dyslirnctions expressing systcmic chronic anxicty nright in cluclcone or more ofsevcrrl prtlerns. tleightened chronic rxiety in the family systenl nraycmerge in an individualas physical illness, cnrotional illness, or a socialdysfunc tion,slrch as alcohoLism or clrugaddiction. Thc othcrcomlrlon pattern is one in which plrcDtsproject thc;r imnralurityoDto one or moreol theirchildren. A conrbinationof all oftbese pattcrnsma,v be present. 3O8 curerrn,3 -

Bowen(197u) noted that when things arc caln !vithini family,thesc iclaptive pat- t!) rrsfunclion tu maiDtrinhomcostasis in thc systemwithout serious sylnpto srrising in a fimily membcr.lloweve'; rvhen anxiely escal.rtcs, thc adapti\€pattcrlls losc llex- ibiliq--The patternsrigidify until synrpto s erup!.Because pallcrils arc multigcnerr- tiorally transmitled, they are progrnnrmedinto the nucte.rffalnily fro the respectilc tdmilicsof origin. I hismenns that the familyhas ro corlsciouschoice !rbout thc selec liolr ol .rdaplivcpattcrns. tsoweD (1978) emphasized lhat rhcre is grcaterllcxibililv irl rl lamilywith a spectnLrnofsllch transmittcd paltcfns than in r fami'yusing only one of

Thc quality alrd dcgreeto lvhich eachspouse is in enDtional cortact u'ith his ol hcr fa ily oI ofigtu is the otherkcy variablein assessingthc adlptabilityin a lamily system.'lbeSeographical dislnnce L)ctween then aDdthe qr.ralit),oftheirrclati(mship intcractionscan detefnrine enrotional distunce or cbsencssto thc firn1ilyoforigin. It is .rssumedthat thc greltcrthe dcgreeofemolioral crtofff(nn thc falnilyo1'origirr, thc' nlorelikcly it is thatihc nuclearfanily will bc s,vnlptomatic(Boeicn, 1978).

Differentiationof Self

Differcntiationolselfis inversel)r relxlcd to chroniclcvels ol anxietyand nraybe concep tralizcdns emotional nlirturity (Kcrr & Bowen,1988). The conceptofdiflirentiation ol sclfiscofe !o BFS'll.rn(l \/orking to incrcascdifferontiaticnr ofsell is:rlililol1g process (Pipcro, 1990).Thc.ibility to choosebetl!'ee1r thinking and fcelnrg,along lvith thc abil it)'to clifferentiateoocsell frorn another person (i.e., kno}ing rvhercone stops.rnd the otherbcgins) rfe thc bisic characterislicsol the €urotioDrll)'malure or difTerentiated indiv uat(rlowen, 1978). It is crroncolrsto cqualediffercntiation with inclivi(luati(nr,or in(lepen- ^utoiomy, dcnce. KcIr and Borven(1988) en4trasize lhat diitreDliirtion dcscribcsthe pr,rr-rsrlx rvhich inclividuality and togcthernessale nrirnagcclwithio a rel.ttiolship systcln.C)nc's lcvelol differentiationofsell is delcrlninedby lhrcc flctors:thc lclel ofclilferentiatior of one'sparents, the qualityol relationshipone has r{ith onei parcnts,rnd lhc nlanncr in whichone handles Lrnresolvcd atlrch entto pcrcntsi1r adullhood (l]owen, 1978). Levclsof diffcrentiation nray vrl,v bel\\,censiblings .tnd bctween geDer.tli(nrs.A siblingwho receivcsnrcrc of thc pnrcnts'nrrxious lbcus wilt be lcssfrec to grow ancl devclop,because this indir,idu;rlis molc fuscd rvith one or both parcrts. lironl lh is evo l(ltionarypcrspccti\€, (rnc can Lrnderstand how it is thatsiblings lurn oul sodillirently. Siblingv.rriabilit), accounis for onelinc rrlovingslightly Lrpt'ard with e.rchsuccceding geieration and rnothcf line nroving slightly dorvnwardwith erch succccdinggcnela tiolr (Kcrr,2008). Gilbert (1992)poirts out that viriatior in the tc'ndencytoward fusion €xists iD othern)lllllmrlian spccies as well,.iting Jrre Goodirll'.sobservations ofchimpanzccs at (lonbc, wlrerccoodNll saw N widc fnngeof(lifl'crelrliation. Gilberl (1992) providcs ihe oianrplcofonc chimp,Flint, and his rothe.,Flo. I hc)'w€rcso cnrotion.rllr,attached that Flint'sinfuncy wils prolonged.FIe woulcl always st.ry close to his mother, neverv€n- turingver,vlirra!va\'. As Gilbcrt explains, "\{hen hisnodrcrbccame old anddied, Flint, .rhhoughhe w.\seight and a halfvcirrsold (an agcofinclcpendcnce for nlostchimpt, PtsY9C]AN JUY ' fcll into a statcofgriefand .Hc died three and a halfrveeksafiel her dcdth in (pp. the samespot 'hereshe had died" 19 20). Thc intcnsity of fusion rviih the p:rrentswill replicatein rhe marital relationship. Undillircntiatcd spousestcnd to hrvc an cxternal locus ofcontrol nnd meas re thcir worth through lhe eyesoI others. lnside of lheir 'Ve ness,"there is lil!]e solid seli. Instead,two pseridoseh,esnariy and havefew prirciples that cannot be co opted by a pressureto conforn to the needsard rvishesofthe other. The higher the level of fusion rvithin the maital coupl€,the greaterthe risk for impairment ir one or both spouses.The lo\\,erthe level ofthe differentiation,the more eachspouse operates withil a reactive,Geling stateard the lesseach spouse is able to call upon coglitir.e functions or adaptsmoothlyto change.Insteadofthinking through responsesto stress,the p€rson with a lorv level of differentiation or immatrrity will blameothers for hisor herrnhappiness. Additionally, at ibe lowcrlevcls ofdiftcrcntia- tion, a pcrsonwill look ro fusc into an cmotional symbiosiswith anothcr or, in rcaction to the symbiosis,c!L! off, nuch as he or shenrerged with and/or crLtofffrorn his or her parcnts.Rclational lifc takcs on the q[ality of being rcactiverathcr than rctlectivc or proactive.Individmls with lorv differentiation havelittle irbiliiy to be selvesindepen- dcnLof their reactionsto what others say,do, or denaud. "No selves"ale del'inedby others ind haveno internal colrpass with which to navigatea]org their life joumeys (Bowen,1978 ) . Bo$,enbelieved that people\\'ith similar levelsof d ifferentiatior marry

In assessingthe ability ofan impaired farnily to tolerntedifference amoDg its mem bers, Gilbert (1992)suggests questioning along the foilorving lires: In $,hat ways can individuals become freer to live their own lives, $,ithout instinctil'ely repeating the €motional processesof past generations?Can peoplethink in oppositesand tol€rate ambivalencearising liom internal conflicts?Can pcopletbink clearlyeven amidst the roiling cmotional forccsthat affact thc corc oftheir bcing?Cnn pcoplc renct lcssauto- matic.tlly and more thoughtfiLllyinside of their nitnchmcnts?Can they tolcratc bcing separatepcoplc yet remain conncctedto other family members,or do thq, to cut themselvesoff from uncomlbrtable rel.tionships?Do irdividuals havethe ability to be an "1" whell the g1oupis screaming[o be a "We"? The differeltiated personhas alr abidinlix$,arenessthat no perso[ can chanliean other (Kerr & Bower, 1988).One camot regulateanother persont life. Takhg respon sibility for selfnrerrnsthat onelearns to defineself, der.elops a serseofonet boundaries, ard has a clear idea of orei core beliefsand values.Differentiated people realize that charting a coursefor responsiblefunctioling in a family requiresa lifetime of work, tiil and error, and trouble shoothg (Kerr & Bowen, 1988).One cannot signihcantlv raise one'sler.el of differentiation in a f€w therapeuticsessions, or er-enwithin a ferv years.Ho'\,ever, one can be helpedto embracethe courseof stlch a journey and learn to rnakc one\ own lifc a researchprojcct. By bcing rcsponsiblcfor self,the cntire family, ofwhich the difTcrentintingmen'rbcr is a part, is affcctcd in a positivcway. Diffcrcntiat- ing membersmodel thcir efforts to de\-elopin $.aysthcy may not ha1'cthought possible prior to trcatmcnt. Whcn one docs not cxpcricncca scnscofsclfand a sep.rratciclcntit)' of onc'.sown, defensemecl,anisms aimed at sLrrvilal will energe. Peoplen,ray cot oil emotionally 510 a cNAprm13

lroln lhosewho thfextcnthcif scnscol inclividualiry.Subsrancc :Lbuse is onervay thar lhfe.rtenedpeople €nrorion.rlly crLt oll lr)rn inrporllnt ollrcfs,ind it is a patterrthat is InLrlligcrerrtionlly lftlnsmiitccl. Ir BliSl: thedilferentirting jou rncv irrvolvcs llnding ways to honorone! orvl sep .rfilenessin intens€rclntionships irrd to bcconrclr'ccr ol rutonlllic reactiorsto others. t'uradoxicall,v,the extcnLto which onc can llrnor one'.so$n sepirateDessis alsothc extentto $,hichonc.irrr rcrn0i viirl)lycorrircclcd to lhc othersin the fimil)..Io.rccom- plishtbis gorl,thc clirricil n guitlcs lirnrily mcnrbcrs to bccomcmorc cognizant of thcir r€nctidrsto thc 1:lrrily.li |rnrily nrcnrbcris const.rntlyrcsp ldiDgto othcfs'nccds, thisperson is difcclcdto look t inlcrn l lnxiclv noLbeiDg lddressed and to considcr lhe overhelpiuln!'ssirs ir fc(l lltlg.It is irnporlll]l lirr hnrily nrenrber.sto unclcrstanclLhc systemjcconccpl lhirl onc pcrson nr.ry cirrry lbc nDxict,vfor thc systcm,and lhal persof- i. r',o,tr.r r',r ,l l( r,' ,lf\ flut ins ,) n.fl,,rrr.. r\dullsiuc (lifcclcdlo l{r{)l{lt plllcfns ind tri.rnglcsin which lhc)-rre c ught so th.rtthc) crn dc\cloPr phn 1oincrcilsc dilli'rcrrlintiorr. I hc thcrrpislcoiches.lients to retlrfn1() thcir lamilicsoforigin in i qr.rcslto ealhrr nc\\,ll.ls lboul lanily rolesand tunctiorrirlg.lhcclicDl nDdrheripisl nriy brninstornr.rlist ol q!cstiolrstoask fn]nil,y nrcnrl)crs.Clionls.rrc coaclrcd to cngrrgcin onc o|l-orrcc()nvcrsnlions to gair conr€x Lurl licls aboul e ch p.rrent'slrrnrill ol:origin cxpcricnc€s.lher rre educatedabout dctriangling noves rrd dircclcdto l(x)l(li)f kc),rriirngles through the gereritions.Ad ditionnlly,.rss€rtn'cr)csstr.rining. pl?.liro rrrrliing"l" stntenleDts,emptl cbaif \\,ork, and mailedor unnuilcd lcllcrs\{rilcn lrl tIc dililre,rti.rtingrnenrbers (cspcciall,v ro t rcnls)m.r,v be hebful. 1'hecnrphisis is upon tllling responsibilir),fornroling dil' lerentlyin one'ske1,tri.r|glcs. lnl(inS lhf k,crs ofianothel aDdkccpine thc licus on oneselfrequircs incn'.rsinq dii!iplinf rs x)r\iclL iscs. The eflrrt n) dc'llnea scll is lirll (n l\!isrs,tur ns, ancl dctours. As , fcrson iearrs De\j\\,avs to rrrrnigcin cDx)tionlllv intcnscrrlrtionships, a strongcrsense of identitl en)ergcsthrl rlk\!s lirr clcrrerlilc tlircctiorr.-li)incrc.rsc oncs lirncrionrllevel ofdif lerentiltioD,thc rlork rnusll)c (k'n. \\,ithilln pcrson\own l.rrDilv,whelher one suffers trom .hcnric.lldcpcn(lcncy of :rny('lhcr cnt(.golv of hunranclillicullics. The thfosrof BFSTis b l)cconrccl.nrel about one's prrt in a linrilv sysrcnrr cl(henlo learnnerv r..aYs .\"r'; r' r(. r'ror.r|l' rl..rr.r,.u|rt inirc .rrrglrn.'lnrk',Lot \(lr r('t\, ^l 'i.,rlir!. 'l hegoal ol becomingruorc ol)jcctiv. !vhcn ('trscrving on€ s pnft in familvdynam icsmav h.rvepnrti.LrLrf.rppcirl to thc s.i(ntisl,phvsiciirn.UFST mighr bc clc6ncdas a ''Lhinkingperson's thcfipy" thil is not so r)rLrchli,r lhose\\4ro are "brokcn" as it is lbr thoscrvho uish to be.onlcnrorc rvhoh. (llirrrts nre tuullhr s,vstemic idciN,:rnd, Iike llo{en lrxincdthclnpists, t.rkc o lhc }x)sl fr (,1fcs€.rrchers in thcir orvofinrilics. the therrpyrequifes €xpfricnti.rl work outsidcol session,in thit clicntsarc cillcd uporllo applynew .on.cpts .rs lhcy cx plofc I hcif liniil)' systcnrs. Bou€n(1978J l)clicvc(l lhlt it ispossiL)lc to nxrvcknvrr.l n scicnccol hLrnanbehav ior andhis positi!isL vi.w clcilrlyrclleclc(l his.rssUmption thrr ll rc.rlworld exists that is illdepeldcntofan obscfv('rjssuL)jccli!c pefccptions ofir (Papcrr,1990). tLis worklvierv may be xttractivcto thc physici,rn,rvho is tr.rincdto l)c objccrivcrnd clelachedfrom eDotionalpftrccsscs. Hou,rvcr, il is inrpoftr[rtk) rcnrcmbcrthat wi(hin lhe effort to incrc.rsconcs ot)jcctiviL),by collcctingficts offanrily lirncrioning,ol1e also is increas- iDgoncls irhilily Lo bc in lnxious cnrotionalilclds uithour losingth€ abiliryro think A FaMry sysrEMsTREATMENT FoR rHE lMra,REDPtsys c,AN a 3ll

and nake gooddecisions. ll is in mnnaginBdris balancc ofdistancc rnd togcthcrrcss lbr oneselfwhile a! the sdne tine honoring a signiiicant other'.qdilfering closeness,' distanceneecls that one achievesa heightencdlcvcl ol dillircntiation ofscll

Solid Self Versus Pseudo-self

The solid selfcorsists ofa personf core,non negotiable,clearlv defined values and be liefs. Theseare formed gradually and are not easilycoerced or changedtiorn outside forces(Kerr & Bow€n,1988). Building or developinga solid selfis an hportart soal ir- BFST.Ir cortrast, the pseudo selfcan be deined as a "pretend" or falseselfthat is ac quired byenotional pressureand that can alsobe changedby ernotionalpressure (Kerr & Bowcn,1988). It is mrdc rp of random,discrepant bclief-i and principles,acquire. bccauscthcsc idcas wcre considcrcd "righi' by thc group.Thc pscudo'sclfis a sclfr,'ith an cxtcrnallocus olcontrol lhnt conforn,sto the cnvironrncntin ordcrto fccla scnsc olbclonSing.

CodependencyVersus Fusion

Durirg the 1980s,the field of chenical dependercyextended its focus to irclude the family membersofchemically dependentpersons, Senerrtiry r separatebody ofclini cal theory and treatment for codependency.As La!\,sonand Lawson (1998) explai11, "With the broadeningofth€ contextofund€rstandnrg ofalcoholism from the alcoholic to the alcoholictamily, many ronsystemicid€as became popular ir the field" (p. 317). GierymslriandWilliams (1986)noted ihat th€ terrn cadepcndcncy originally desiglated the spouseof thc alcoholic,brt that it cameto be generalizeclto all fbmily memben and thc chcrrical dcpcnclcnt'sclosc social ncrworlt. Pathologizing labcls such as eznbli,l codepettdent,nnd rr./coroli. blamed farnily rrenrbers for rhc alcoholic'.sor adclict's problcrns(l.alrson & t-alvson,1998). lhc poplLlnrlitcraturc on .oclcpcndcncyoflirs a plcthorirofclclinitions, ranging liom "a cliscasc"to "immaturit)"'io "toxicbrain syn' drone" (l.ar6on& ld$,son,1998). Iherewereevenellbrlsintheche icnldependence lield to n ke codeperdencya didgnoslicenlitr_, even lhough lhe corrceptwds rrol sup ported empirically (Babco.k& McKa.v,1995). The codependencymovenent has been viel,€d by mrny, especial\' femhists, as an attempt to stigmatizerDd p.rthologiz€$'om€n (Babcock& NIcKiy, l99s). F€ninists hive charact€riz€dthe codepeDdeDcymovement as daDg€roush that it revictimizes victinx (Larvson&Larvsor, 1998).Babcock and NIcKayallowedthat \a'ornenlivilgwith alcoholicsdid, irl fact, suffer and that they often engagedin self blame, but thesere searcherstooh issnewith the notion that thcir behaviol constinrteda disease(Lawson & I-.r$'son,1998). Lawson and l.a$'sondcscribc thc codependcncymovcment as onc ofh),stcria,noting that thc myriaddcfinitions flo.rting around in populrr culturculti- lnatclyrcndcrcd thc tcnn mcaninglcss."lhcy cmph.tsizc thrr bhmc and pathologizing labclsarc not congrucnt$'ith s,vstcnrsthcory. Marry in the coclcpenclcncynroycrncnt bclic\,'c thrt nariial thcrrp,v m.t)' ihrcatcn thc recovcryof lhe chernicallyd€pcndcnt pcrson. Brown (1985) lbund maritalthcrap), to be contrairdicated 1orthe alcohoiicill earlylecoler,v, a rebulous lin1eperiod, while Slantor ard colleagues(1982) corsidered the uif€ to be secordarr"in inporlance lo lhe 312 I currrn13

family of origin for the addict\ tlcitnreot. such pracljccsmav well hrvc been thc death kncll fbr rnany mariages il1 which thc synrptoDrwas a]lcviated. Unforluna!ely, for the addictaDd bis spouse,these practiccs did not addressthc avoid:rnceoflhe rcl.rtionship (cnsiongiviDg rise to thesynlptom. Mafriageslnay becomcunbalancecl and brcak apart rvhcnthchonreostaticbalanceolthcfarnilyhasbeendisturbcdbyasignilicantchange in thc lirnctioningofthe alcoholic. Codependcncyis often collfusedrvith fusion, a centml conccpt usedin BFSI F-u- sion is consistentwith a systemicview. It is a conceptthat doesnot assignblame. :lhe sylnploln is not viewed as the "problcm," brt rather is viewedas nn attempt at adapla- tior to relationshiptensioDs. h thc closcnessofan intenserelationship, the emolional selvesot cach individual blend or firsclogether ir a comrnon scltl a kiud of "we ness" (Papero,1990). Fusion refersto eachpirlrncr trying to deal \\,ith lhc intensity ofthis comnxn) selfby using mechairisDlssimilar to those he or she used irr rclationshipto his or her parents (Papero,1990). CoDverse\', those in the codeperrdcncymovement l)clic'vcthat the "probleni' is rooted in the personor in the substaDce.I his is not a sys tcmic conceptualizat;on.From dre perspectjveof BFST,the problem is not iD drepe6on or dyacl,but in the multigcncratiorlnlsystem, each generation of rvhich has passedon rvaysto beha\€ ir relationshipivith regard to closencssand distance,'l hc difflrence lrctwccncodependency and fusion is very important. lb rcitcrate,alcohol or drrrgsare not vi$vcd as "the problern,"l'ronr a systeoricperspeclive. instcad, rLc(:hol or drugs arc viewcclas one ofrnany possibleways to bird aDxietyin responscto tensionin the rela- lionshipsystem (Bower, 1978).

Triangles

The tr iirngleis a basicunit ofanalysisin BFST.It refercto a three-conrcrcdreiatiolship system.Bowen ( I 978) observed t ha vhcn tcnsiona r isesH'ith i n aD unstablc two person rclntionship system(thc dyad), tlrere is a tendcncyto recruit a third pcrson into the system in order to reducetensiorr ancl Lo rccstablishstabilit),. To .lcrid,ry/. to 'neans redirect the energyof thc triangte back to the dyad that rvasoriginally involvcd in th€ conflict or tension. Functional trinngles are composedof persor-b-pcrson relation shipsamong cll peopleinvolvcd in the triingle. lnterlocking triarlglesrelar !o a slstem consistingof four or nore pcoplc who shire lnor'ethan orc triaDlile (Ken & Borvcn, rgrlrJ). Somechildren nay occupyi positiorliD a parerlaltriangle u'herein lhe youngstcr is pivotalto the stabilityoi thc pircnts'relatioDship.l hjs rray lunctionas a kind ol diplonraticmessenger or ncgoliator for the disagreementsbctu'een the parents.l.lach p.rcnt dependsor the child 1()nranige the tension expericnccdwith the other par eDr.l:or cxample,a child rnay align rvith a parent rvho is suffcring from the €ffectsof thc othcr parcntt substaDceabuse or dcpcDdence.The other pArcnt is shovedto the outsidcposition and teels alone and isolatcd.The persorin theoLrtsidc position ofthe trianglcma), experience ircreased !rnxicty as a resultoffeeling "lclt oLrt"and discon neclcclliom important others. lrlr111ilysystcms theory positsthal thc triangleis the basisol all lclationships.There ilre nrilrlyLrianglcs wiibin a giveDfarrily. As tcnsionescalaies in ir lamilp predictable A t^Mtry SysrEMsTRrarMENr roR rsr IMFAmEDPIye.r^N ! 313

patterns cnlerge.Anxicty in il parental dyad, for cxaDple, may be rerouted through one or nrofe childr€n. To nranageanxiety il a dyicl, ()nepafiner may lurD to substance abusednd of dependencc.ln a physician\ family, lfi.rnglescan includc felationshipsiD themedical workplace as a Lhird legin a triaDgle.Arrxicty is spread arronS three insteao ofbeing managedbetwccn two, decreasingthe intcnsitv and making it nrcrc tolemble For this reasor, trianglesirc morc stablethan dyatlsand thc basicbuilding Lrlocksof rclationship systems(Bowen, 1978).Tianglcs are used to managecbscncss/distance forccs.When tension is bigh cDoughin a trian8lc, the outsjdeposition nlay be more favorablcas the bondsbetwecn two becomeovcrrfheliniDg (Ken & Bowcn, 1988). Mcclicalcouplcs have u feady-n]adediversion lioln $,orl(irg out thcir relationship problcns (Meyers,1994). Wofl( pfessurescan both causerelationship distress and si- multaneouslyoftlr escapefrom tircingup to being I sclf in the contcxr ol the relarion sh4r distress.F-xcessive involvement in (,ork is one rviryto avoid resolvingmarital con flicts, !vith rvoidancebeing a nrultigelerationallytrtiDsmitted pattcrn ol functioning in closercliltionships. N'ork rclationshipdemaDtls thus bccoDrea convenicDtthird leg of a triirngle.Hortever, as aDxicly iD the systen increrscs,fonnerly adaplivc patterns\^/ill bcconc |raladaplive. It is at lhis point that a person who avoidsmalital colflict ma1 rbuse.nd conle to depcnclupon substancesas I rn,rltdiptive way lo work out teDsior in the rcldlionship.In the words ofone phliician, "1 really think lhe reasonI lvorkedso hard at nry practice,rvorkirlg rc l)c specialand mceded,lr,as so that I felt I $,asn'talone" (Gerbcr,1983).

The Family Projection Process

Thc ltrntily ptajectionpt?.crs rcllrs to the tcndencyof parcntsto defuscslfcss or aoxiely by pfojectiogtheir own problcmsonto thcir childrcn.lhe child nroslirrtrchcd ro rhe prrents lvill havethe lo$'cst level of self differcnti.rtion and havc rhe ulost diiicultv scp.rrirtingfrom the parents. l he greaterthe leveloi rhc parcnts'undilTerenri,rtion (de fincd is iDrn)atLrrity),the nrorc the)'will rely on thc projectionproccss lo stabilizetheil rclalionshipwith ore aDothcrrnd within the s,vsrcnr(Kerr & Bo$'cn,1988).

Multigenerational TransrnissionProcess

FromInNvens(1978)perspectivc,peoplehavcnr!rchlcsscmotionalautonomyrhanrhe), tlrirrkthcy

devck4rvarying levelsof d i lfcrenti.rtior, trnd the child rcceivioll the gre0tcstdcgree ol anxiouslbcus from lhc parcDtsr{ill be mostvulnerablc to s,vnptoms(Kerr, 2008). ln fact, the mulrigcner.rtionaltransnlission process progranN the !va),sin which peoplc intcracl $'ith othersirnd faclofs irlo the lcvel of"self" ao irdividual nlny de1.elop. Flssential\,,the nrultig€nerationaltransmission prcccss includes two criticai con- cepts.Firsl, pcopletcl,Id to selectspouses who hLrvca similar lcvel ()1'differentiition s their o$'r (Bolver, I 978).Second, th rough t hc dynam icsol the fanr ily pmjectior proccss, theretcnds to be a lbcuson the child who is thc most vulncrableor the niost enmtionally conDccted1() the pireDts(Bo$e , 1978).1hus, through the familyprojection proccss, .ertain childrcn rvill haveslightly lolverlevcls ofdilfercDliatior ( o(hersin their sib- ling group.Over several gcueralious, signiilcamt dysfunclion will unfold.Onc possible outcorrc,for cxamplc,rnight bese!'cr€ problems w ith cher)rical dcpcnden cy emcrging i n onc generationand bccomingincrcasilgly intenscin futufe gcner.rtions. The therapist'slbcus on helpinSthe clierl to identily a d inLcrrupt multigenelr- lional patternsof dysfunction should bc balanccdwith a focus on the idenlilicatidr andbuilding upol ol rnultigcnerationaIrcsiliercics or srfcngths.1n tbis wry,thc therr- pist scrlToldslhe clicnt coning fronr an intelse systen, so th.rt he or shedoes not fecl doo red to repeatthe scverityofdysfunction discoverecllvithin nuny prev;olrsgenerr- tions(Cunringhanr, 2006). Both individu.rl resilic'ncies .tnd fanrilv pt ocess rcsiliencics may be iderrtified (seeurolin & Wol;n, 1991,for a list of nrdn idual rcsilicrcies and \\',l.rr. lqoR.li'r u l st.rl .'nri..r..:l (rfi'\ .

Sibling Position

Rowen(1978) believcd that the firnily tlirth ordcr, rcferrcd to as s/r/rrr3positirrrr, con tribulcs sigDilicantlyto thc developmenlof personility. Ilec^useof this pherrornelon, he paid closeattention to eachparclt! sibling position. Boivcr'.\lhcory wasexpanded on ir rcsearchcomplcted by Toman(1993). Tom.r n concludedthat childfen rake on dil- lareDrcharnclcristics, in part bec.ruseol Lheirsiblirg posilion in terlnsof Lrirlhordcr. Clendcrhas innuencc as well. He noted th.rt children rvho grervup to n).rrry pcq)lc \\41o rverccorrpatiblc wilh tbe rank anclgendcr they cxpericnced irr their ftrnilicsol origin had a lrttcr chanceat slcccssin their marriage.lbr exantple,an oldeslsister ofbrothcrs wouldbe mostconrPtllible wjth : yorngerbrother who hadol(lcf sislers. Both parlncrs woulclfeel co fortableWith farrili.rr roles- Tornln (1993)descfibed characlcfistics ol each birth positior. trirst-born children, lor ex:rmple,nright bccomc lenders,acconl plishcd,ancl highly responsible mclnbers ofsocicty. Al lhe olhc'rerhcnle, lhcy lnip,ht beconlesuch perlccliorriststhat thcy 6nd it impossiblelo meetlheir olen expcctatior)s. As slrch,a llfst born lnaybeconc a11 ovcffuncti(rrer in il rcciprocnlrelationship rvith a subslnncedcperdent parlncr.

Emotional Cutoff

Eflotio aI cutolhelLtstothc proccssofrunrling iway or clenyingthe cnxrljon.rllics to lhc farnilyoforigin (Bo!ven,1978). ElnotioD.rl culoil and distaDcingcan L)econlused wilh actionsofdiflercnti!lion. Instead,cmotioral culolFbehrviors arelllerclypscuclo nroves thatdo not changethc intensityol cmotionrlalllchmenls. lD lcct,onc Inayassumc thlt A FaMry slsrEMs TRrarMENrroa rHE lMpa,ffiDPtsyec,aN I 315

lo lheextent thatonc trics to cutoffistheextcnt to lvhich heor sheis fusedinto hisor her tamilysystem.Emotionalcutoffisa fear-basedresponse oran apprchensionlhat one has lostselfin the faceofintense lusior- The clinic;an needsto assessfbr the exte tofcuroff, asrhis pattern is highly .rssocinted$'ith sevcrcsympl(nnoloSy (Kerr & tso'fen, 1988).

The Role of the Therapist in Bowen Farnily Systems

BFSl is ulique in its emphasisupol the self'dcvclopDeDlofthe iherapist.lhcnpists rnusl coDtirually do thcir orln lvork on increasinSlhcir separationfiorn their' farli- licsof origh whilestlll r.ctaininggood emotional conncclions with theircxlcnded rrd nuclcarfamily systems. Ificdmiln (1991)points out that"Bowen has consistenlly l11rin- taincdthatitishardibrthep lientto maturcbcyond the marurity le1'cl o f !he ther pist, no nratterhow goodhis or her techniqre"(p. 138).In fact,as Friedmanexplains, "ln Bowentheory, thc differentiirtioDofthc therapistis the tcchnique" (p. 138).ln ordcr to mrintnir a non-anxious prescncein the preselce of thc anxicty of a family suffcr'ing with atr i'npaired physician,onc rnusthave personal boundrries slrong enoughto rcsist fusing into thc interse eDrotiolralenvironment. Bowen(1978) salv hinlselfas nn objectiveresearchcr who helpedhis clierts L)cconre researchersinto their ou/n lvnysof futctioning. A goal of this tl'rerapyis to bclp lhe clicut make a researchprojcct out ol a life as lived within a nultigenerational lamily systcnr.lhe focusis on lcarningnore aboutthc family nther than fixing Lhel.rln- ily problem. Therapistswho becone ioo eagerto "fix it" ref'lecttheir orvn reactivity rncl undifferentiation,As a coach,th€ therapistasks questions that facilit:rtethe clienti thinking process.Therapy scssionsare controllcd and cerebral.Familv mcmbcr$ talk through lhe therapist,and direct confrontationsaIe avoicledto rninimize lensioDilnd cmotioDal reactil.ity. Throughout treatment, thc !horapist maintains an emoli(Dally ncutrrl Dosition. The thernpist genenlly worL

Useof the Family Diagram as a Major Tool of Assessment the useol the firmilydiagrilm, a graphicrepresenlrtion ofthc functioningputterns of ntledst thrce gencralioDs, isused iu the beginningsessious oflrcatment (l(crr & Bowcn, 1988;Papero, 1990). It is a tool that hclpsthe clinicianwork \Litha clicntto idenliq' multigcnelatiolralpattcrns tbat ma,vl)c plrying out in the currcDtslstcn. -Additiu- al1,v,thc l.rrnilydiagram functions to catmpc(rplc. Knowing trcts, identifying pitttcfns of multigencrati(al cmotioDalprocess, aDd ackno\vlcdliig the univcfsalityol tl)cse nrechanisnrsle.rtts to nrore objectivity rbolrt onelsfamily. lhe se.rfchfor palterns in cludeslooking fol trianglesthal block gro\vth, enrotionil cuk)ff, llsion, overlilncti(m ing/underfunctioning rcciplocity, rubstanccabusc, divorce, nnd other rvaysto avoid manirgingthe sell in regardto cll)soress/djsl.rncenceds. The cljllicianlrics lo cstat)lish i broideningconlext lo clarifydet.rils of the tirnctioningof Lhenucleaf and cxtended fa ily s,ystcs. lrquiries rs to thc qraliry ofmaniagesduring tincs oftr.rnquilitvand timcsof.listress ire uselul-OccupatioD.rl chrnges and gcographic.rlmovcs may be un dersk)odir thc contcxtofwhat clscwirs going on in thc fanrilvat the lime. A clicnti perccptioosoI fnnily ind illdividurlstfenglhs oray bc notc(]. Assessnlen{is ongoing ard is a pllt of treatnrent(Kerr & Bo\\,en,1988). I'he rig- orousand nethodicalsearch for palLcrnsnrny rcsorrfc with thc iInpaifedphysiciin- patient,r\4ro h.rsalso been traincd to searchfor ulderlyilg causcs.llbress nrnv bc iln cxprcssionofnrcrcased e otion.rlintensityoccurfingin thesystenr and mayl>caripple cffect,fol cxan4rlc,ol the dcath ol an inrpoltant f.inrily nlenrl)er.Sucir evcnts are \.icwed asnodal events, often malking a turning point in lhefimilv (Papero,1990). lvla iiges, births, deaths,

togethcrncss;n the nucleir f.rm;l!,.Cutting offa relationshipby physicalor cmotional distanccdoes not end a fuscd cnotional pr-ocess.To lhc'coitrar,v,it inteDsi6csil. Therapistsexplore the context into rvhich eachchild is born. What u'as going on (luriDg the pregnancy,.s wcll as immediatel),before conccption and after birth? What is thc rclativeposition ofcach child in relationto cdch pdreDt?Th€ overarchingconcept bchindlamily diagram conslruction is that events and changes in a familydo not occur in a vacuurn(Papero, 1990). 1t is important to lcnrn rbour the fr€qltcncyand u:ture of contactthat the nu.lear fanrily hasrvith the extcndcdfamily (Papero,1990). 'l he cliniciant effort in collaborativel),crcating the family diagram is to embody thc'dttiludeofa u'arrn,rcspcctful, and obtectivcrcscarcher (Papero, 1990).'l he point ol crcaliDgthe diagramis nol to "do something"rvith any bit of infbrmatidr.lnstead, cach fact leadsto furthel inquiry and a clearerview of how eachperson fits into thc prtlerns and cvcntsof lhe fnnrjly. The goal is mlt to find iuswcrs, but to keep nsl(ing qLrestidrsthat invileother qLrestions (Papero, 1990). lrl thc creationof the fanrilydiN gr0m,the clinician mo(leLs an attitudcofcuriosity. Togethcr thc ciientand theripist plrt logetheran ever-broadeningpicture ofhow the fan1ilyhns cvolved over time. Clicnts are holored as expertson theif own family s,vstems,and thc cmphasisis upon asking w/ro, ulhat, wherc,hlhen, and /rowqucstions.'fhereisan avoidanceof ,rryquestions,ns such qucstionsimplyblame. For examplesoffarnily diagrumsu'ith the appropriutesynbols explaincd,scc 1.'rrr ily F,'toluotioll(Kett &Bowcn, 1988,pp.307312).RcadersmiyalsoperLLscfanrilydia you li|.llns ol lamous people i1 Cdn Go Hotne A'l,in (Vlccoldrick, 1995) lo increase thcir Lrndeistandingofhorv lo properlyuse this l,alurblc assessmenttool.

Broadnessof Perspectivein Bowen Family SystemsTheory: Universalist Concepts

It is Dotpossible lo exphin thc multiL.ryeredcomplcxitics of Bowentheory rvilhin the f|anrcworko1'an ertire volornc,let alonea singlcchnpler (Friedman, 1991). l)iverse populdtionsall shnrethe rcr!lity o[ nu]tigenerationil ctuolional processcsthat involve tbc strlLggleto managethc lbrcesoftogetherness and separateness.Thus, wh.rtcverthe difftrcnces among culturcs, divcrsepopulations nray tt colsidered as diffcrcnr spices in thc soup of life. Bowen cnlphasizedthe idea that humaDsare rnorc like lh.rn uD- likc nonhurnanlife forrns(t:r'icdrran, 1991). Othcr rbeoriestend to focusupon dif fcrcnccs.A perspectivehigblighting differenccs,according to Bowen (1978),decreases objcclivity about, and cvcn increasesdenial of, what rcally drives human behivior irnd

liower theory is rootcd in th€ assumptionth;r! lhe hulrranspccics is part ofa stream ol-cvolutionary emotional processesthat can be lraceclback to the beginning of lifc. \{hen a clinician vicws a lamily, he or shc must considerthe lact that the opposiog lbrcesfor togetherncssand separatenessrcflect the rlegreeof rcactivity in the evolving systeln.Thc more reactir,ea fanrily is to forcesofcloscncss and sepamteness,thc nrore likelythat sympronsrvill appcarin one or morejr)dividuals in the systen.AIso, oDe 318 crarrrr,3 -

ay assunlcthal tr fanily that hasa high deglccofenlotionnl cutotl is most vulnerable lo scrioiis problenrssuch as chcnricalclcperdcnce. lrinally, il it is ssune(l that cmo tioral proccss;s cvolulionary, fi|nil;es that contair high dcgreesol ernotional crrtofl may be flLfther ilorg in an enotiondl regressionth t is gencrationsdeep-a regrcs sior causcclbl rcaction to irtolcfable dcgreesoffusion or togctherncsspassc'd or liom prcvious gcnerations.1hc rvork in the differentiation processis to hclp clicnts become moreobjcctive in ar elibrt to gcl a bil moreoutside lhc emotionallbrces domin0ling thc family. lncreascddiflcrentiation, as cxplaincclearlier, involves bcing ableto rcmain cornecled as mlLchas il involvesbeirg "rseparatc self. Borvco(1978) once srid,

'l hercis nothing iD schizophrcnia thdl is Dot ilso prescrrl iD il1 ofus. Scbizophrcnia ir nadc up ofth. cssen..ofhunrtln e\pcricnce rrany tiDrcsdisrillcd. \irith our iDcapn(- ity to look ai ourselves,$/e ha\c muchto learnlbout orrselvestiom strdling th€lclst ttlaturcofus.(p.89)

'fhis comment cpitonizcs Bowen'sconsistcnt elJort to n1ike conLinuouswhal other theories tend to dichotumize (Friedman, l99l). llorven'siclea that the fnmily is the preferrcd uni! of treatrncnt pldceselnphasis upon thc emolional lbr-cesshared by all families.Sinrilarly, it siSnificantlydecrcases thc focus on rvhich fanril,vmcrlbcr is thc synrptombearer. Friednin expl.rined,"The unity of pcrspecliveturns the therapeutic endcavorof proDoting differcntiation iDto r broad-spectrumantibiotic lhat miry bc apltiedto dnytanril). no matterrvhat its natureor rhenaturc ofthe 'dis-case"'(p. 137). Thus, frorr Llo\\'cn'.sperspectivc, .l sking what uDit oflrcatment a cliDicianis treatirrghas no meaning.Similarl),, r{hether one secscouplcs, ir(livid als, or farnilics asirrelcvaDt. 1 hc focus is ah'ays on universal,systenric facrcrs rathcr lhao on spccilicproblems. The clinician's apploach is inlbrmeri lcssby his or lrer formal tcchrique than it is b,vthe r igor with which the cliniciar consistentlyrvorks on increasinghis or hel or.n levcl of diftcreDlidlionovc'r the lilc coursc.

Common Patternsin Families With an Impaired Physician

Physiciarswho expericncechcnrical dcpendericy likcly hanclledthc emotirnal ittach rrent to their parents,and especi:rllyto Lheirlllothers, bv a der)ialofthe attichDent and by a pscudoindcpendence or lllse bravac{o(Borven, 1978). This childrvoold insist that he did not necd the parcnt. "1 cnDdo il mysell,"might bc tlris youngster'srallying crl,. During thc adolescentycars, fol exanple, such chilclren would bc norc delianl thair chilcircn lessflLscd with the pdfents (Borv€n,1978). In nrcre diffir€ntiatcd fan1ilies, parentsaD(l teenagels arc €almcr ns the rdolesccntswork toward scpalalior).Ir lirct, i]r the lnorc differentiatedlirmily, there is grertef llexillility and ndxptatioDto chnnsc as met)rberspass lhrough lhe variousdevelopmenlal strfies in the individualand farnily A FAMrysysrEMsTREArMENr foRrNE MpAREDPHyecaN a 319

life cycles(Bolven, 1978). Families on the higher end ofdifferentiatior may tolerateaDo evenhonor differencesir individual members. Bow€nposited that all peopleha\€ a fairly irtense level ofattachment to their par- ents.It is not the lel€l ofintensity that is salienttu the caseofimpairmenl. Instead,it is the mannerin whi.6 rhc attachmentis handl€dthat is important. The posture ofphysicianswho spcnd a lot oftheir life energydenying this attach mentto lheir parenls(andlaterto thejr spouses)maybe ableto flrnction quite well fora long tine. Suchdoctors' functional lercl ofdiffcrentiation may appearto be quite high, as theyexcelin medicalschoolaod later ;n thci r profession. Thesephysicians are overly responsibleto others and, in nanyrespects,have such high standardsthat theyare im possibleto maintain o\er time. They continue to asslrmethe pse[do-independentpos ture in their nuclearfamilies. Spouses,children, and societyparlicipate in reinforcing this postur€by d€1€lopingthe expectationthat the physiciar upon whom they depena $.illcontinue to function at an impossiblyhigh level.Sadl)., unrealistic self expeclations and an extremesense ofresponsibility seriouslycompromise the overftinctioning doc tor's quality oflife. In den)'ingtheir needfor oihers ard keephg up a pseudo indepen dentposture,theybecome increasingly isolated from their family. The children and $e spouscplay a p.rt jn maintaining the physician'sdistance in the family system.As the physlciaDfeels jnc(easingly burdened, thc lonclincssand intensify.k is at this point that serchindiriduals nTaybecome most vlrlncrablc to developinga relationship *,ith alcohol or drugs, especiallyil'this pattern has beenprevalcnt in past generations- A! the oppositeend olthe spectrun ofattachment partemsare the physicianswho are symbioticallyattached to their parcnts,and especiallyto thcir mothcrs.These indi- viduals areso mergedwith their pareDlsthat they arc unableto function indcpcndentl)- in the world. In their emotionalfusion with motherswho had a low leveloldilferentia tion of self,these doctors were de selfed.They usedthe defenseof denial to avoid Iacing the deprh oftheir ne€dfor ihe mother. Tlis intensityofdenial ofneed replicatesir the subsequentmarriag€(s). As Bowen (1978)explained, this type of irdividual "collapses into drinking earlyin lilb, while loudly aflinning his nrdeperdenceald his coltinuing 'I can do it myself'postrre" (p.26s). Bo$.enidentified theseindividuals as haviry the poorestprognosis for permancntrecovery from srbstanceabuse. He characterizedther as socialoulcasts whose need for emotionalcloseness is so ovcrpoweringthat they musl go to extrenes to derryit, rellrring to them as "dysfunctional rcfugeesfrom the family rclationshipsystem" (p. 265). Becausethey riin lron thejr lamiljes oforigin, tbey wil continueto rrin frcm lheir spouses.:l he spouses,rvho aresimilar to thc impaired mem- ber in their levelof dif1lrentiation, can prcdictablybe expectedto play a reciprocalrole il1 the alcoho]ic or drug addicteddysfunction. As noted earlier,Bowen (1978)postulated that people mairy people wilh similar levelsofdifferentiation ofselt While eachpartner may presentas havirg opposite!!ays of dealing with stress,each maintains the stability of the relationshipby playiDgoul both sidesofthe coin oftogeth€rness/distanceforces. Conflict, ovedunctionirg/urder fuctioning reciprocity,and a degreeofproj€cting their problems onto their childrer- arepatterns us[allyrlsed in somecombination bythe medical couplewho is threatened with attachmentfears. The pattern of one partner adapting or giving in to the other spor,rseis the saljent pattcrn in problcms lvith alcohol or drug dependence(Bowen, 1978).Both spousesusually belic've that thcy arethe oncslvho arc giving in to the other 32O carerrnr3 - the nnxt. Rut it is !hc oDewho is, in fact,most accommodatinlithat losesan incrensilli levcl of selfaud thcrr becomesmost vulncrable ro the devclopDrentof a problerr rvith chcmical dcpendencc.ln lhe recovcryprocess, lhc d€ scltbdsponse will regain more llncti()ning self. It is importan{ firl the clinician to alert the family to the probability of iDcreasiDg anxiety in thc faceoi changc.As the accornmodatingmember realizesthat in "th;nk- ing alike," thcy havelelilquished thcir ability to thjnk for lhen)selvcs,therc will bc r signillcant anlount of intensity in the family system'sadjustmcnt to thc impaired fam ily mctlber's shift ir percepLion.There will bc pressurefronr other lanrily mcntbersto "changcback" as the irnpaircd fanrily melrber progressesin treatnrent.The whole of rr family systeD is gfeatcrthan the sum of its parts. 'l his meansthat thc ferocity of sys temic folceswill challengethe individual to maintain thc positive change.Thc Bo$,eD therapistwill predictthis challengc to clicntsand coach them to j(st "hold on."

A Family SystemsTherapy Approach With the ImpairedPhysician Family

BFSl' ofTenthc imp ifed physicianfamily I sct ofprinciples for urdcrstardirg the un- derl)'ing connectionsamong peoplc that crcateprcdictable patterns of iDtcraction in the firnlily'scmotional proccss.BFS I' pushcsthe clistressedmedical family to broadcn itslensfro sceirgonly a paticulaI syrnptonsuch as alcoholism.lnstead, thc fanily is called upon to view the s/n4)tom in lhe context of mukigenerational1)roblenls lvithin the widcr relationships).steD'r and i11lhc contextofthe nrtural world ol emolional pal- ternsofwhich humansare ir part. From the pcrspectivcofthis theory,no mattcr {.ha! symptornappenrs in ihc family systen, the trcatmeDlis alw0ysthe salnc.The family is directc{ to look at ihc $'aysin rvhich tcnsion in relationshipshas beenavoided Ard coAchedto begiDto corliont thc tcnsion.The lirrily learnsthat i1'nvoidancc ofrelationsbip pressurc colllinues across th€ generirtions,the.iskind scvcrityol symplomsinlcnsilies n'ith eachgeDeratiorl lo coDre. l hc emphasisis upon pfoc'eJsratlrcr than rpon .onrdlrror the natrre of Lhcsymptonr Frcnr thc perspcctiveof BFS], alcoholism and addiction ale viewed as I humar- condition thnt is an outconle of lamily rclationship proccssesacross gencrations- Ir-- lhjssense, thc drinkingor drugproblen is not vicwcdas a diselsercsi(ling in the indi- vidunl who is inrpaircd,or in his ovcrtuDclioninspartner. lnstead,the nnxicty-bindiu!. necltrnis of chenical depcndenccis explored lbr horv it functions ir a nrisguidcc attenlpt to managerclatioDship tension. The therapy,in fact, becomcsa tnotivationu force that calls upon family membersto tescirch tbc cnot;onal systcm from which they clnerged.When the symptorrro1'alcoholisnr or drug addiction is seenrs one o rnanyrvavs in rvhich peoplebind arrxiety,the focus upou one pcbon and the tcndency to blanredininish. l hc arxietyof thc syst€mis boundin the synplom, and coaching peoplc to le18() ofrhc slmplom pushestheD to redircct the anxiety where it belolgs: inside the relationshipsystem. lfonly onc person ir thc systenlfunctions dilIcrentlv, the enl;re svslemcan be renrrangcd.Thc flmily is coachcdto clcvelopgreater strenglh A FAMtrySysrtMsTREArMrNr FoRrNt Mp^REoPHytcaN a 321

in their collective"emotional muscle."Clients' work ofgoing homc again may be com- paredwith achievinggreater litn€ss ftom a workoot in a gym, whererfreisis definedas toleranceto staythe coursein relatiorrshipswithout rushing to cut off or dcny the fact ofonet own interdependence.It is also definedas the ability to be a selfwith a core set ofnon-negotiableprinciples, cven in thc faceofpressure from a lovcd ore to conform. Likc all families, families with ar iDrpairedphysician struggle wit)r underlyiDgre- lationship issues.The problem is not the substance,but rather how severetensions go unaddressed.Whcn family membersrelate ihrough drinking or through drug abuse, they arc attemptiog to regulateemotionllity and attachmentto ilnportant others in tlre fanrily. The medical family's handling ofDeedinessthrough depcndencyand care taking, through cyclesofdistance and closeness,and/or through overinvestmentin the needsofothers, such as childrell, needto be exploredin treatment.Alternative waysof handling interdependencyneeds should be identified and coDsidered.

Information Is Power: SuggestedQuestions for the ImpairedPhysician Family

Calling upon irnpaired physiciansand theh families to think about the relationship systen Ether than the de6nedproblem ofchemical dependenceopeDs up the possibil- ity ofincrcasedfreedom to explorethe conplexity and richnessofa fanrilyi emotional process(McKnight, 1998).'l'reatment should posequest;ons for family membersto ex- plore on their ow[ betlveensessions. McKnight (1998)suggests questioning along the following lines:

Canthe fanily shiftfrom viewingthe alcoholord.ug impai.menl.rsan individnal problcmto licwingthe inpairmerl asafamily problem? Canthe famiiycometo vicwtheinrpairment as adisgtriscd opporluDityto allow membento uDderstandtheir relationship systcm rather than as rdiscaseto bc curedin an irrdi\-idual? Horvdo peoplein the fanrily holdon to their personalbouDdaries? Howdo familynrembcrs managc lo stayconnected? Horvdo peoplcplayout underfunctioning and overfunctkrning reciprocal positions in lhc family? wbat is the maturitylelclofeach pcrson? ofthe systcm? Whatncw directions might people tlke in an ttttemptto makenorc thoughtful.1Dd lessreaclive decisions in a fa jly? What pattcrnscan each member ofthe maritalunit ide'rtifyas coming from thcjr rcspectn€families oforigin, andhort' do theythink aboutthese pattcrnsi How nrethcscfamily-of-ofig prttens beingreplicated or rcactedto in the nuclcar family? ln whatother w ysdo pcoplein thc familysystembind nnxiety,in additionto sub- 222 cu*rtt t3 -

' How do peoplethink.rbout thcir siblingroles .rnd position iD their t)rimnrylri.rnSl( with their parentsiD lheir fi|nilies oforigin,.rnd hoE Jrc theserolcs rehtcd r0 thoughts,bcliefs, and behdviorsin thc nucledrftmily?

Mccoidrick (1995)also suggests nryriad qucstions that mayaid thc clienl-rclic.rrchcr (seehcr YouCan Go Hone Agai : Iktonnectitjl With Yo r [antily, \!hi.h contains use- ful listsofsuch queslions it lhc cndol cachchrpter). l hc ideais to leurowhercvcf ilod r/hnlcver ).ou can, becauseit mry becomeappircnt that a cerlain pieccof inlin-lnation will hclp you conDectpicces of thc jigsawpuzzlc in a way that crcatcsa clcarcr pi.ture. Openingup the lan)ilyi conrmunicationsystem strcngthens thc family (&xven, 1978;Walsh, 1998). Cuiding clicntsin their clTortsto gither colhlcral inlorn)ntion fron various famil,vmc'nbers builds an iDdividualk identity \rithin the s),stenr.Also, it reclucespohrizations, climin.rting the notioDthat peoplemust bc assigncdlabcls of "s:rint" or "sinner-" In f.rmily systc'rlsthinking, thcre are no saintsor sinncrs; instcad, thcrcilre rccipro.nl falnily processcs th,rt scrvc a functionLo maintain the sl.rbililyof

Conclusion

In otherthcoretical oricnlrlions, chenr ica I deF'ndenceis typically clclirrcd is l problen-, that residesin the indivklual.In placeolthe disc.rselrodcl ofalcoholisrrarrd rtldiction a broadercontcxtual intcfprct,tti(D ol this pltlcrn ofbinding anxictyis offcrcrlhere A sigDificanlnunlber ol studiesh.ivc lcstcd the validity oI BFSTand provittc cn4rirical supportfor the relationshipbetwccn diflcrcntiarion ofselfand chronic anxict,v, nrarital difliculties,and psrrholt,gicaldistrcss (Nlillcr, AndcrsoD, & Keala,2004). In tr€atingthe nrcdi€alf:rnrily srrllcring from substrncerelarcd ilrpairnrcnt, thc Bowen-trainedcliniciun coaches thc n(xivaiedlarnily mcmbers ttr cxplorethcil lole: and muttigeneratiollalltimily p.ittcrnsrrther lhrn keepingthe prinrnrYli)cus upol) clrangingthe alcoholicor .rddict.'l hc l]l:Sl clinicianrealizes that n pushto .hlnge thc inprircd physicianmry cxacerbatcthc problcnrnnd dcnythe firmilyu rcorrfkrblcop porlunit,v to grow and (lcvclopirr a nrorefunctiorral rvair 'lhcrap,vbasctl on tht'set ol intcrlockingconccpts ind prirciplcsdevclrl)(t bI Dowcn(1978) Suicles the hmily with arrirrpirired physiciin to nx)vcinto in.reisincly aDxir)usenvironments, lrying to.rssuulegrc.rtcr resporsibilitl, arcl nrrkc nxr|enrcirn ingful conrectionswhilc rt the $rnrctinr hol(lingo k) individuility in thlj |rce oi- group prcssurerc confornr. lly embarkingupoD thisjourney.r.rcss tinrc, impairccl physicirns rr(l thcil lanilic.s r:.rntliurnph irr thc faceol lragedy. l hcy can bcgin to dclirrea responsibledircctiorr in thcir li\,csas rhcy learn t(' th;ok diflcfcntl,vnbout humrn relationships(cill)crt, 1992). Suchan cfTortinsures lhit ifpeoplcstruggling with adversityremrin true lo thc coursc ofexploration;rnd fact-lintling, thcy c.rn replircc shanre rvith "survivor\ priclc (Wolin & Wolin, 1993). A F^MrLvSysrrMs rREArMrNr FoRrrr MpaR.DPHyscAN t 323

I,tedicalstudenls should l)c lLrughtfroln the very begir11ingoflhcil crrccN that they haveas much responsibililyli)r rhcif owD DeDtalhealth and physicalu'cll bcing as tlrey do fol thoseoftheil prticnls. l hcy nrustrealize that it is crucjal to pay attcntion to their connectiolswith theil own lrrnrilicscven as they atteDd to theirpa!;entr. Fulfillirg their farnily responsibilitiesand nurlurinS thcir orvn relatiorshipsnot only helpsphydici,Urs to morc successfull,vDaviglatc tlrc cvcr'-prcscntstruggle betlveen the forcesol conncct edncssand those of indivicluality,btrt also protccts the public from lapsesir medic.rl judgmcnt. Thc devekrprlerltol a sound,systcmic vicw oftheir owlr lives as doctols and family mcmbcrscannot heb but to enhanceovcrall firnctioning,both at horneand in thc rlorkpl.rcc.Iiclinicians look for p.tlerns insLcrdoicauses, see solutions arxl problemsas being incxtricrbly codetermined, lnd devclopthc abiliq' to thhk and apply "syslems, nledicxl doctorsand thcif tanliliesnlry cone lo appreciatcthc abidingwisdon underly ing the injuDction,"Physicinn, hcal thyself"

References

,\nsrcs,D. H., M.Gover., N1. l'.,Ilrwrl,l)., & sh!{, M. (2002).Psy.hi.lLiccoDorbdit.rind fh)'\i.ian\ wirh $,tJnrr( uscdlnnlcrs: Olinicrl rhrr..(crislics, ueitnerr experlenccs,rnd postLrcdonurl lofct ofif8. r,1,/n1n1/)ii,losdrtl th.n lit'ri,rrt, tt.1),8998. hbcock,M., & NlcKiy,(r. (l:ds.). (lee5). (:rdl/dr!tAdr/ctotd(r)': Fdri ntdiri1ft'.lbUrro: UDirersill olT.0rto Prcss, Bo(ef, Nr.(re78). a,,it'ioI) i, tliriil 1,'111t\'.Jo hulc, Nl: la$n A,onson. Aroun,5. (r98i). tldrr'.( r,ctholbli: l tlnllottn tnl,,odclot,c.r,r,r.\cwYorl: wiley. Coon,b.,R.l! ( I9t6). ,\ddr.lcd hc.rll h lldissionr ls..iorrxal ot.szrndtr.. ,\riirra I, 187 19.1. Cunningbnnr,B. R. (2006).,1r\i/ir1rr-rd!?, rnnor tr,tilr,'t.'I; dpproftltto tturtn{ d jil,/n'l !,an?' ofhonti.itlt:t\.d.t'ttrlt tti.ror.l discrhrion, AllianrIntc.narionalLinirersirr'., S.tr DicE ,(;\. EUis,J- J., & Inbodt,l). lt. {11)lis)l)svchorhcripr $.ith ph.\siciin!finilies: When.|lribuics iD nr.di.nl prr.ri..b.on.liibililiLs i,' li ilylitu.t,n'nn,/d!'xlo-lPsyttothcnt.v,.t),)atttaa. Fridnrao,E- il. (191)l).rnnv.D rh.ory rnd rhLriD:ln n. S.GunD.n & D.P Knisk.n ([d\.),In,r/i,.dt 4 lt tlr,tht .l,t\\'1.2,tt. tJ4 170).Ncw York 8runner/Nl.zel. Gablird,G. O., & Nl.rn r8cr,lt.W (1rf9).lhc psydrologlolposrponernent in dr. mcdi.alnunirit.. Jt\trnl.l lP At|t^1rt l,1rlli{!/lJlriirfidt, 16l,2lt8 ll8l. Gerber,L A. (resj). ttrri.tl to th.it ntk\r!: httill tliltlrr!,r tr do.r(,i h,.J \clv \nrk: livisro.k. GierInNki,T.,&\\riLlinnrs,l.1Le86).(i(rl.p.ricrct..lortrnlolP5ych.dtN.Dtryr,t8,7 13. GilLr.ft,R.NI.(1992).hru"llnrn)alrt\,r:lttp.:At\,trtd),tothinkah.uthn"tnitrd./ntlr.NNYork:

(iilb0rt, R.M. (1994).r\ddictior Lofrcscr hcd ncili.itnns. /i'ntli,s^rc,rj n /.r/rdlol N'rrrrr/Sl,it.rrj 't hntkiryiI t\)\'lIiiIry rtrlt1r s, i,rr..J,/.57 66. Harpcr,J., & (irrdcvili,C. (l9el)). (irlcfcfdcn.y:4., itnrtc.loti,al oJPsfthDd.tir. /)/,.qJ,::,2ts 292. Kcrr M. L 12008).why dosibl r8s lL r l oul dilfiicnrlliIn A. li)scl,!. J.Kntg, & S.Shinkcr (|d\.), rJt nlindtr.1.tItrtiitlht2t!tnnlut)':\tisiairt) rrsJio,r{5rr'frs J.i.r rijrs (u).206 215).Nc{ Yorlt:Crf rbridS.tJf i!$siL! l,(ss. Keft,iU.1., & Do\r r, i\I.{ e88)./irrill olrlrdltd,.N.wYork:Norron. LNNsof,A. uJ.,& I arvv)n,(1. W. (1e98)./1/or.il!, ir,1 th,lilrlit: A {uidr t. ttrrintnt rnl t,ntu"tit,t (ld cd,).,\unin, lXr Plt()-lil). 324 a

l\'hnr, (i. r\. (Le9ll. llirtor,vrid rhror,rof l.erl.rerl lar dtug rad nlcoho!.dd(lnD, h N. s. Millcr ll:d.),(:1,rp^li(r:ittl)[email protected],(pp ll0l lllz).NclLYodt:Ma,.l i! rnslir, P.A. (reef)) Issu.sir Lhc,crovdy ofthysi.ian\ Itom rd(li.tncilln.s\cs. P.r.hnttti. Q!tuhl). 74, tn7-t22. sirl Ni|!rnddic ddsick hlsbtrnl. Psr.ltidtq,2), ^rilrin,P,\,&Bird.Ir-$.{195e).Ihc115 2.19. NI(Gotllrj.k, M. (r99.1).)l)r e go hnrt ds.ir: Rl\,rr\rtr.q trrlfo/,rJir,,it. N{v \nr!t: No,Lou. U(co\..n, NI.l'.,.\n8,N, lt. fI.,.\ I (on, s. (let8). Diffrr.riiil rhonfc!tics ii(l tl)einrfaircd rhysiriai: r'ari.nrtrc.,tni.nt ni.n.hing bI sp..ili.ilv .,trd; cn\it\. of f. l)'r..nJ, r2(2), ldn1,11 '\lhtti 93 107. NJrKnigbL,A.S(1998).!i$ilrsystcnlNitlrr!.oholirn:l\.ascsru(ll.tdPlirctn n {td.), C/t,n1r/r/' t.lilta,istrlltrr\nfnrtiltstndrs//id)rr,(p|.26r.?9f).NewYorklls(rlhI'.e$. N{er'c6,I1.1:.{19e4). Da rr,'f,rirrn'X.r. London:l,l.nuN l,rcss. Nlillc,li lJ, Ardes(D, S, & Krih,l).l(. {100,11.lsllow.l rl€.ry !alft? A rc\l$! ofbrsic rek'Nr.h././r tdl olnhtitdl nhtl 1:dntl) tfu?/,11 r/),.151-166 i\lorglr, r,. (r9$rl. nLdl,.l, ,li,inh&itit , ant tlanrnnlia : A rn".tt,trrl r')rl.r\i: lhpo'tLetnrerl .r the (irnl.ri r.c on nl.oholin(lDisinhibirn'r, ulilcsi$ ol(;lilorrin, Bcrkclcy. Nynrrf, l). 1.,& Co.dres,l. (l9r)ll. (i. di.tnrn: lrcntdcnr of rhr frntily nrcnrbo. ln N. S. N1ill.. (f(].), (irrpnf.rii{ l',.,/took ojtnttd dltahrldldidid, ( r.877 rJss).NLs Yoiki \1i..cl

P,,l)(m,D. \r.119!0).lldrdrrDirt,l^rdra 1i,.o,rlLr,\1,).: Allrn & lrr.on. R.bb,N.{r9e8).r'.i.hingoDrddklioDjs$cshcl(iisiortr(iicrl\.ho.l,sp..i.lisrsr(nl.ttrldrl n )\,kni .dl.1:e,.ntLn r lttt, , la8,64i 641. sorile,w\1.,&s.1il.,r!.o.(a't)o). 1tu n\dit.1"rL)id!.:st!riltilElr\lttD rlrtk Jri/,J/i, trlri.irrrJ drilrl,d, /i,,,ili,J.(.hi.igo:,\m.ri.an rlclicil A\\o.i,tion srirloh, D. NJ..lbd{1,'r.,& r\$o.i.rci ile8l). 77rcln,rtr.tlt.m ol11,rrdhw rntl nrlrln./r,r NsvYorkl GuilLo|tl!\.s. 'rirh01L,(i D. {re87i. r'hellntnird physi.!rr: Ihe rolc.irhe \lll)ure in tu.o\ctt. toLL"l.J tht itl4litrl .lsqJ//t,,tl;d4iJ, 76,190 192. 'lall)ort, {;. l).,& Gtrll.8os,(. \'. (19s0,Sfpt$rber). Ir1$vcfrnm wjrlr hcrlrlrI d$sionals.Il,/n r,n,,a,,l t..,ktl; pp. l:|-irr. -llrlborl,(j. D.,* Ilnrrir, C. l. {1986,l].t.urrr. Tr.alinij ir4rriBl phvsi.iifs: Irourrccfh,vs ro nr...s l'tEi,, ir ,\,Ii //,11,lr.J, e5 9e. lbNrn, w (l e9ll. ftali/1,tur jr, lhln ,. No, rhr.lc, Nl: JtrnD,\nftoD. 'l\!crsL(i,,\. l. (19112).i/ /|V,trrrj'ri r/o.1orr,rrD. Ccnlcr Cirf, ItN: Ilrz.ld.n. !rilhnl, C. L.,Sob.\r!c. N. (l , { NJ.Anhur,C. (1972).SoNe psl.hol,)gi..lruhcr.rbililies ofphrsi.iris. Ntr t 1tllti trl lt,| ) Ml o.lMctli.i r., 2s7,l7 2 ti (re8l,,At.il).'11t. wn/h.f, L. Il ttul'l( nn 01t\'rr rtnS-. tr)ltf,J. r,.l,e(p,csulrd ar d,c(:onLrcf.r otr l)evcloPlnijP..r(rlioD frogr.D{, Nebrrsh L)irisnnrolllloholi$ .nd DLug ]\busc,I in.. f,

\\rlslr, r. (199u).srd/!rltrtritt ldtrn) n:tli.t.t Ncw \biL: cuillnrd l),css. \l,rlif, s. I., & \\inin, s. (re<)3).I h. tltilitnt \'lt: ttdr :uftot:.I raftljl ttn)jl\.' ja\ rl,rq i!(titr. \ewYort: \rilld . Y. LL{nr.I)., hisler,L, ltohbins,(1., \lLLllc.d}, c., & ltuc, a. (:0(J2i.A .otrrFral^.c ntrdy of t.Dih Lhcrrrl in Lhr I e.Lnrcnro o|i c usrr\ io i Londo. ahb. (|ni.. i!,n.l ol rnnib Ttltn\., lr,,10l 4:1.