ARTICLE:

Patterns of Family Caring:
Help that Helps – Help that Hurts

Loren Crabtree, MD
Medical Director and Co-founder, Project Transition

Over the past twenty-three years, Project Transition’s apartment-based therapeutic communities have helped many individuals with complex and persistent psychiatric problems, including coexisting drug/alcohol problems. The recovery accomplishments of each person reflect numerous strengths, including the support and guidance of family members. But…

Helping can be a Problem?

Families are essential sources of acceptance, insight, compassion, and love. Mental illness confronts families with challenges that are enduring and saturated with stress. When a family member has persistent, serious psychiatric problems, everyone in the family soon learns that there are no quick fixes, no magic pills. As the weight of responsibilities and concerns fall on the family, it can feel overwhelming.

When a family member is in pain, our natural response is to help. Helping a person with psychiatric difficulties, however, can lead to patterns of caring that quietly foster an exclusive reliance on the family. When the impact of well-intentioned help unwittingly fosters dependence, we call it Help that Hurts. For the person with mental illness, exclusive dependence has a negative effect on self-esteem, maturation as an adult, and -- in some instances -- psychiatric symptoms. It also promotes lifestyle impairment: loneliness and withdrawal, the erosion of will, and a withering of motivation. These problems inhibit getting on with one’s life.

The Good News

A better way to help is within reach. The first step is to recognize the two distinct patterns of helping. Understanding the first pattern of helping, Help that Hurts, is a natural place to start since we know it well. It’s so easy to do – and that’s the rub! Not only is it easy, but also it is intuitively correct. Consider the essence of our intentions: we want to reduce suffering – we want the pain or problem to go away. So we swoop in with solutions that work. It’s a “doing for” approach that simply feels right: it’s efficient, it reduces tension and stress, and it restores predictability. This unfolds in a way that is consistent with our roles as loving family members – when we make things better, it validates that we care and are responsive, whether or not our efforts are appreciated. Both the “doing for” and its family member exclusivity shrink the window of experiences that are essential to growth and limit the development of relationships beyond the family circle. That’s the “hurt”.

The second pattern of caring is Help that Helps. Rather than “doing for”, this helping response steers the ownership of problem solving back to the person needing the help. It’s a supportive, mindful way of “throwing the ball back”. Help that Helps is a cornerstone of personal restoration and recovery because it promotes:

• greater personal effectiveness and self-sufficiency through the practice (and gradual mastery) of skills related to coping and problem solving
• self-management of the ups and downs of psychiatric problems and of life’s challenges
• the cultivation of relationships – within and beyond the family – that reflect mutual support (interdependence) rather than exclusive reliance (dependence) on the family.

An Example

Jack is 23 years old. He has psychiatric problems and has been hospitalized several times. Jack had been planning on going to a hockey game tomorrow night with a friend, who just informed Jack that he couldn’t make it. So Jack calls Mom and he sounds depressed…

Jack: Dave can’t go to the hockey game.

HELP THAT HURTS:

This example conveys two of the primary goals of Help that Helps. First, by throwing the ball back to Jack, Mom is seeking to transform his existing dependency on her to interdependency – she is encouraging him to consider solutions that involve individuals other than family members. In doing so, a second goal emerges: the learning and practicing of the required skills. Mom is figuratively on the sideline, rather than rescuing. She is respectfully advocating for and supporting Jack in exercising a number of valued competencies: anticipating ups and downs, problem solving, coping, relating, having fun, and learning from a setback.

Core Concepts of Help that Helps

Interdependence: an essential component of adult development is the balance between self-sufficiency and the capacity to use other resources (including relationships) to cope with need. Some level of dependence is essential to the welfare and happiness of a person with persistent psychiatric problems. In the Help that Hurts scenario, a parent meets that need rather exclusively. We like the term “interdependence” because it combines the meaning of independence with the need for relationships outside of the family that help with problem solving – a form of mutual, “give and take” support rather than exclusive reliance on the family. While interdependence acknowledges the role of parental guidance and love, it also calls for the need to establish a network of support beyond family: friends, peers in the mental health system, acquaintances, professionals, coworkers, programs, and the like. As these relationships mature, they foster a sense of self-worth, social acceptability, and greater security.

Problem Solving and Constructive Thinking: the hallmark characteristic of Help that Hurts, exclusive dependency on family, is characterized by caring family members who are continually “doing for”. While such actions serve to protect a person who is vulnerable, they also diminish his or her ownership and participation in problem solving. Help that Helps, on the other hand, emphasizes the learning (and coaching) of competencies related to self-management, responsibility, and maturity.

Allowing for Change, Growth, and Challenge: while engaged in Help that Hurts, parents tend to resist change because it threatens a familiar (though frustrating) way of life. Skepticism may lead family members to believe that their adult child’s emotional growth has reached its limit. At Project Transition, many instances have shown us that
Help that Helps releases capabilities that were otherwise dormant or undetectable. Given the choice and expectation, we believe that persons with serious psychiatric problems tend to actively pursue ownership of their lives, want to better navigate change and challenges, and seek to broaden their connections with others in a climate of essential support, encouragement, and hope.

Four Facets of Doubt

As family members learn more about Help that Helps, critical questions emerge. These concerns are both natural and adaptive, and the staff of Project Transition strongly identifies with them.

Facet 1: Many Roots, One Tree

As family caregivers, it’s hard not to focus on the origins of our loved one’s psychiatric problems. The causes of a problem intuitively shape our response to it. As family members mobilize around the concept of Help that Helps, a natural question occurs: is it the right approach if the cause of the behavior is… a symptom of mental illness?

• an expression of a physical health problem?
• a function of lifestyle impairment?
• or a combination of the above?”

…and what about situations when we don’t know what’s driving the behavior – does Help that Helps still make sense?

Our view is that Help that Helps is an effective response to all of these situations since they share common desired outcomes: self-sufficiency, relationships beyond the family, and more satisfying growth and development.

Facet 2: Individual Inexperience

It can be overwhelming for any person to be faced with a host of new expectations. Simply withdrawing family support is not Help that
Helps! It is important for family members (and whoever else can help) to find and cultivate external sources of support before pulling back their own support. Project Transition acknowledges this need: as a stress-buffering transitional community, extensive supports promote self-sufficiency, relationships, treatment, and recovery - moving on with one’s life.

Facet 3: Family Inexperience

Changing ingrained patterns of caring can be daunting. Fortunately,
the themes of these challenges can be predicted. Over the years, family members have told us that there is a supportive value in forecasting the discomfort and growing pains associated with the practice of Help that Helps. This reminds us of the adage “forewarned is forearmed”.

Change is, by nature, disruptive. In response to new forms of helping, family tensions are bound to increase. When Help that Helps is practiced, the parent’s (or sibling’s) role as caregiver is displaced by the family member’s shaky first attempts at self-reliance. The parent also tends to feel shaky. In response to ‘pulling back’, questioning may kick in: “Am I fulfilling my parental duties?” Sometimes the concern is self-critical: “This feels like detachment… are my actions communicating a lack of love and caring?”

Throughout the beginning phases of Help that Helps, it is important to know that some role shifting will be occurring. For the person with psychiatric problems, making decisions for the first time may elicit fear, apprehension, and a tendency to lash out. In the long run, the new pattern of care will improve the lives of all the family members.
In the short run, however, it can cause friction. A family member’s feelings of insecurity or vulnerability may invite back the familiar pattern of Help that Hurts, since it is known and comfortable.

Facet 4: “Why Fix What Ain’t Broke?”

While exclusive dependency is a predictably detrimental outcome of Help that Hurts, the specific caring behaviors associated with it are experienced as favorable expressions of compassion and thoughtfulness. “Doing for” is incredibly efficient at minimizing unpleasant surprises, reinforcing safety and predictability, and conveying concern. Maintaining “doing for” is really tempting, especially when confronted by the anxiety of these facets of doubt. Reverting to Help that Hurts can feel like the short-term relief of an escape hatch.

This sets the stage for another question: “Why go through the turmoil of such change when it can be avoided by keeping things the same?” If keeping things the same is the solution, there is little need for outside support or help. We have noticed that, over the long haul, resentment and bitterness can creep into the family, often followed by guilt. Watching a family member slip further into isolation invites hopelessness and despair. For the person with the psychiatric difficulties, this rut is etched with feelings of defectiveness and deficiency. It becomes increasingly difficult for the person to feel capable when faced with interrelated challenges and competencies associated with establishment and nourishment of friendships, work, independent living, and personal growth.

When the Rubber Hits the Road

Shifting from a pattern of Help that Hurts to one of Help that Helps is no picnic. While over the long term, the transition yields major benefits, the initial experience of change can be destabilizing. Since the old pattern of caring was good at relieving tensions, a newer pattern of response is likely to increase those tensions simply because
of its unfamiliar nature.

Detachment and dispassionate caring are vital to the success of the transition, but it often makes parents uncomfortable because they equate it with aloofness, unresponsiveness, and lack of caring. Additionally, the person with psychiatric problems may initially feel abandoned and react by lashing out or threatening harm. As the nature of these relationships is redefined, a potential third challenge relates
to the void that can occur as the prior (and familiar) care giving behaviors fade. Learning to fill this ‘space’ can be unsettling. We have found that it takes some time for family members to give themselves permission to focus more on their own needs, growth, and relationships rather than the storms and struggles of the person with mental illness. An ironic benefit from crossing this bridge is that the person often feels more capable as a parent, spouse, and individual. The person with the psychiatric problems also benefits.

Guiding the Way

Many family members have told us that their involvement with Project Transition has led to positive changes for the family, as well as for
their loved one. Our work with families is supportive and practical. We begin with a personal orientation to our approach, including frank discussion about predictable ups, downs, and impasses. In addition to ongoing dialog and progress meetings, we sponsor monthly support groups. These are forums for family members to connect with one another through shared experiences, collaborative problem solving, and mutual support. On a quarterly basis, we also have special educational seminars, the focus of which is treatment, recovery, and the unique challenges and dilemmas of family members. One of the most popular presentations explores the nuances of practicing Help that Helps.

Extensive treatment, coaching, and skill development activities are components of Project Transition. Alone, each is potent, yet insufficient without the context of the therapeutic community to which we belong. Its core intentions emphasize relationships and positive action: trust, mutual peer support, a sense of belonging and social responsibility, and healing. Project Transition members become roommates, neighbors, and friends who work together in support of
one another’s recovery and reintegration in to the broader community. In many situations, the effects of peer support are more powerful and favorable than the interventions of mental health professionals.

Through collective participation, patience, and perseverance, we practice Help that Helps. As a concept of mindful guidance and
support, it remains a fundamental aspect of our work with families.

Project Transition
200 Highpoint Drive, Suite 213
Chalfont, PA 18914
(215) 997-9959
www.projecttransition.com