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Coping with Cancer Interventions for the Family
Cancer & Family continuing education psychology CEUs

Section 23
Developing Resilience Within the Family

CEU Question 23 | CEU Answer Booklet | Table of Contents | Cancer
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

Assess Resilience as a Developmental Pathway
Resilience is sometimes conceptualized as a static characteristic in families. McCubbin and McCubbin (1993), for example, provide a family resilience model that combines a number of characteristics including family type, degree of vulnerability, internal and external resources, and individual and collective perceptions to describe a family's level of resilience at one point in time. From a clinical standpoint, there may be a tendency to primarily assess a family on the basis of how it is functioning at the point it enters therapy, particularly in a market heavily influenced by managed care. Assignment of a DSM-IV diagnosis, for example, is based chiefly on current or recent behavior of one family member, and brief therapies are often concerned with determining a therapeutic goal that is based on changing current problematic behavior with little regard for its development. Even systemic assessments of family functioning, which seek to evaluate the interaction of family members, tend to lack a temporal context. This perspective supports the development of an assessment device that evaluates the level of resilience a family possesses at a given point in time. If family resilience is a static characteristic, then it should be measureable by an instrument.

However, family resilience can also be conceptualized as a pathway a family follows over time in response to a significant stressor or series of stressors. From this perspective, it is important to trace the path a family follows prior to and in response to a stressor, as well as an anticipated route of reorganization. This has the advantage of offering an assessment of family functioning that is contextualized in time. At the point of entering therapy, for example, a family that has experienced a recent major loss may appear to lack resilience. Family members may be reeling, with symptoms such as depression, withdrawal, conflict, and inability to problem solve evident as predominant dynamics. Strengths the family possesses may not be readily apparent as they deal with the immediate effects of their system being thrown off kilter. A long range view, however, may indicate that this snapshot of a family beginning therapy is not representative of their ability to be resilient. An evaluation of family functioning both pre- and postcrisis may suggest they are an adaptive unit that shows an ability to bounce back from adversity. Viewing the family at only one point in time (i.e., their entrance into therapy) fails to reveal this ability.

A theoretical orientation that considers resilience as a developmental pathway calls for therapists to look both backward and forward in time as they assess families. The idea of gathering historical data as families enter therapy is not new, of course. An exhaustive intake procedure that inquires about the individual's and family's past is standard procedure in many therapy modalities. However, many such data-gathering procedures are concerned with symptoms and problem formation, not with evidence that would sup port resilience. Consequently, therapists are tuned to discovering deficits in family functioning rather than strengths and their view of clients tends to focus on inadequacies. Mining for evidence of past successes, however, can provide all members of the therapy system with a different, more hopeful view of clients. Rather than seeing them as victims of their past, this perspective supports a view that recognizes clients as competent people who are in the process of adapting to a setback. An example of this approach is the solution-oriented genogram proposed by Kuehl (1995). This technique calls for constructing a standard genogram with clients, then focusing on patterns in their families of origin that have contributed to current successes in functioning.

Similarly, a forward-looking perspective proposes that all is not "cured" when therapy sessions are complete. As Haley (1973) suggests, therapy can be useful in helping families get back on track after they have been derailed in the developmental process. Successful therapy, however, does not ensure that families will not become derailed again in the future. Hawley and DeHaan (1996) go so far as to suggest that protective factors at one point in time may become risk factors later on. Thus, families may again seek help on later occasions when resources and strategies previously developed in therapy are not as useful as they once were.

This idea may seem to support the notion of long term therapy, a practice that has come under fire in recent years with the advent of managed care and its emphasis on clinical outcomes. However, viewing family resilience as a developmental pathway may not argue for continuous care as much as for repeated care. This perspective assumes that families usually function at adequate levels with periodic forays into distress. Even the most resilient families may face dips in their level of functioning that can be helped by therapy from time to time. Thus, instead of being viewed as dealing with a continuous set of problems that should be addressed in ongoing therapy, families may be viewed as having distinct episodes of disarray that should be treated as they appear. While length of treatment may vary depending on the episode, the emphasis is in helping families get back on track rather than on wholesale renovation.

Search for Commonalties in Diverse Paths of Resilience
Pathways of resilience are idiosyncratic to each family. The various contexts in which a family exist--developmental, historical, cultural, etc.--intersect with its unique dynamics and structure such that no two families are resilient in quite the same way. A one-size-fits-all model of family resilience is not likely to be found. Instead, as Walsh (1996) proposes, therapists need to search for key processes that help individual families address their unique set of stressors.

This notion suggests that developing a stock therapeutic approach for working with resilient families is a fruitless task because of the infinite variety of paths available. However, there may be some value in developing a taxonomy of pathways for purposes of investigating commonalties that families with similar paths may have. For example, Cowan, Cowan, and Schulz (1996) have proposed a theoretical model of six pathways for resilience including:

  1. families that start off well and stay well;
  2. families that start off in distress and stay that way;
  3. families that start off well and develop a disorder;
  4. families that start off in distress but improve their functioning;
  5. families who start and remain in distress but who experience a change in the problem;
  6. families that cycle in and out of distress.

Similarly, Burr and Klein (1994), drawing on retrospective data, derive a typology with five paths while DeHaan et al. (1996) propose a model with six paths based on a small, longitudinal sample.

Collapsing unique pathways of families into categories certainly reduces the variance and overlooks the nuances of each family's story. However, it also offers the possibility of discovering something about common processes that families following similar paths may exhibit that is potentially useful information for clinicians. For example, families living in the same neighbor hood experiencing a natural disaster such as a flood or tornado are likely to experience similar physical consequences while having unique responses to their circumstances. However, suppose we group families by the similarity of response. One group may see little fluctuation in their family functioning and, in fact, may discover that the disaster helps them pull together as a unit. A second set of families could experience an initial drop in their level of family functioning, but over time bounce back to a level they find generally satisfying. A third set of families might also experience a drop in their level of functioning, but instead of recovering as the second set, may continue to function at a less than satisfying level or may even dissolve as a family unit. A number of questions are useful to ask about the experiences of these three types of families. What processes do families within each of these groups share? How do these processes differ between groups? Are there practices found in the families who see little fluctuation or who bounce back that are not present in those that struggle with recovery? Responses to these questions can provide information useful in developing treatment strategies.

In addition, searching for commonalties in developmental pathways has the potential to shape preventive interventions if precrisis differences between groups are identified. Admittedly, this is a difficult task since families generally present for therapy after a crisis has occurred rather than before. Nevertheless, longitudinal research assessing family functioning prior to an anticipated developmental shift and continuing to trace that functioning over time is needed to discover precrisis characteristics that tend to be associated with families that exhibit higher levels of resilience and are often absent among families with lower levels of resilience. Helping families develop these characteristics prior to the advent of crises may help alter their developmental trajectories and enable them rebound more quickly in the lace of adversity.

Developing a Useful Family Schema
The way in which a family defines a crisis has a tremendous impact on how it copes. A key process Walsh (1998) sees as vital for family resilience is belief systems. She cites making meaning of adversity, adopting a positive outlook, and valuing transcendence and spirituality as vital principles in resilient families. Similarly, Boss (1988) indicates that perceptions of stressor events often have greater effects on a family's ability to manage than the richness of available resources or the magnitude of the stressor itself.

Perception is a key element (the C factor) in the ABCX model of family stress, first proposed by Hill (1958). In their most recent expansion on this model, McCubbin and McCubbin (1993) have proposed the concept of family schema, the set of beliefs a family has about itself in relationship to its members and the outside world. Family schema describes the shared values, goals, priorities, and expectations of family members. This concept suggests that family members share a common view of the world and their place in it. Families with healthy schemas tend to emphasize a collective "we" more than "I," generally adopt a relativistic view of life, often show a willingness to accept less than perfect solutions to life's demands, and are usually confident about their ability to overcome difficult circumstances as a family. McCubbin and McCubbin suggest that a strong family schema is a key element of highly resilient families.

A closely related construct to family schema is family sense of coherence, a global concept that assesses the extent to which families feel confident that the outcome of a situation will be favorable for them. This is an extension of Antonovsky's (1987) concept of individual sense of coherence, which is concerned with the degree to which events surrounding a situation make sense to the individual, whether individual perceptions of adequacy are sufficient to meet the demands of a stressor, and the degree to which an individual feels that life makes sense emotionally. Several studies (Anderson, 1994; Antonovsky & Sourani, 1988) have found positive links between higher levels of a family's sense of coherence and a family's perceived quality of life and ability to meet the demands of stressful situations.

Both of these constructs underscore the importance of a shared, positive perception of their family unit among family members dealing with adverse circumstances. The power of viewing adversity in a positive light has long been understood and accepted in family therapy where reframing is a central technique in a host of models. What may be unique in these concepts, however, is their emphasis on a family's collective view. While it might be argued that a family cannot hold a shared view of reality but only a collection of views held by individual members, Wamboldt and Wolin (1989) suggest that both are possible by distinguishing between family myths and family realities. Family myths are the individual perceptions of family reality held by each family member, while family realities describe shared group perceptions held by multiple family members that serve as templates for group behavior and interaction.

Much of the focus in family therapy tends to concern family myths. Therapists are often interested in the differing stories that family members relate about their common experiences. This "news of a difference" (Bateson, 1979) provides families and therapists the opportunity to explore and address misperceptions that exist about these common experiences within the family in hopes of reaching higher levels of congruence in understanding and action. An exploration of family schema or a family's sense of coherence, however, focuses on family realities. It assumes there is or can be a common view of the family that lends strength to individual members. Rather than residing within the family, problems are conceptualized as external forces that are having a detrimental effect on family functioning.

Therapy from a resilience perspective can focus on how this common view of family as a competent entity can be accessed and developed as families seek to overcome external adversity. Fundamentally, this is a question about family identity--who are we, really, when the chips are down and we are lacing difficulties? Although this issue is at the core of how a family functions during challenging times, many families have not talked about it and may find it difficult to discuss without an outsider to facilitate the conversation. Therapists can ask families as a whole to articulate what they see as common values, traditions, beliefs, and experiences that bind them together and can inquire about what these commonly held perceptions say about them as a family. Therapists from a narrative tradition are familiar with the power of meaning questions (Freedman & Combs, 1996) in helping individuals gain a positive perception regarding their abilities to deal with problems. Inquiring about a family's schema and sense of coherence can have much the same effect, but at the collective, rather than individual, level. Discussing what commonalties collectively shared by family members mean about them as a unit can foster trust and loyalty that lends itself to a sense of confidence in times of adversity.

Conclusion
Resilience is not a new idea, but it does appear to be making a resurgence in family therapy. Considerable progress has been made in recent years in evaluating resilience in individual development. Psychotherapists have recognized the power of resilience in aiding therapeutic progress, encouraging clients to identify ways in which they have overcome adverse circumstances, and helping them use their experiences in dealing with stressors. Resilience can also be viewed as a family level construct. Like individuals, family units can show remarkable resilience in dealing with adversity. Family therapists can assist families in discovering these paths of resilience and helping them employ strengths of which they may have been unaware.

However, in order to uncover evidence of resilience in families, therapists must be looking for it. Initial appraisals of families in crisis often point toward the problems that dominate their stories. While these are obviously important, the notion of resilience suggests there is another side to the story. Resiliency-minded therapists may be able to see past the problems by adopting a long-range, strengths-based set of lenses. As they begin to mine the experiences of the family, they may discover a string of successes previously obscured from the family that can help them redefine themselves as a resilient system instead of a bundle of deficits. Encouraging a family to develop a collective view as survivors of distress is not only clinically useful in the present but can equip families for lacing adversity in the future.    

-Hawley, Dale R.; Clinical Implications of Family Resilience; American Journal of Family Therapy; Jun2000; Vol. 28, Issue 2
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #9
The preceding section contained information regarding the development of resilience within the family. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 23
When developing a useful family resilience schema, what is considered to be the most important concept? Record the letter of the correct answer the CEU Answer Booklet.

 
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