GENERALIZED ANXIETY DISORDER - The Basics

GENERALIZED ANXIETY DISORDER What is Generalized Anxiety Disorder? Official Criteria for GAD What Do People with GAD Worry About? Causes of GAD Effective Treaments of .... - Biological Treatments - Psychological Treatments - Combined Treatments Did You Know? Suggested Readings - for Consumers - for Professionals WHAT IS GENERALIZED ANXIETY DISODER (GAD)? GAD is characterized by chronic and excessive worry about a number of different topics. Most of us worry about things from time to time, but people with GAD find themselves worrying most of the time, even when there is little reason to worry. People with GAD also report that their worry feels uncontrollable, so they have trouble pushing it to the back of their minds or doing other things when they are worrying. The worry in GAD often interferes with a person’s day-to-day life, or is bothersome. For example, people with GAD may find themselves having difficulty working, sleeping, socializing, or enjoying themselves as a result of their worries. GAD is also characterized by a number of physical complaints during times of worry such as muscle tension, trouble sleeping, feeling tired, or feeling “keyed up.” People with GAD may also experience symptoms such as dry mouth, nausea, or trouble swallowing. OFFICIAL CRITERIA FOR GAD • Excessive or unrealistic anxiety and worry about a number of events or activities. The anxiety and worry occurs more days than not (i.e., at least every other day) and has lasted at least six months. • The person finds it difficult to control or “turn off” the worry. • The worry is associated with at least three of the following six symptoms. more days than not, for at least six months: 1. feeling restless, keyed up, or on edge 2. feeling tired frequently 3. difficulty concentrating or mind going blank 4. irritability 5. muscle tension 6. difficulty falling or staying asleep • The worry is not exclusively related to another psychological problem (e.g., worry about having a panic attack in panic disorder, worry about being embarrassed in social phobia). If another psychological problem is present, there must be significant worry about things unrelated to the other problem. • If the person also has a mood disorder (e.g., depression) or a psychotic disorder (e.g., schizophrenia), the worry and other GAD symptoms must not occur only during the course of these other problems. For example, if the only time the individual experiences the GAD symptoms is during a period of depression, GAD would not be diagnosed. Instead, the GAD symptoms would be considered to be part of the depression. On the other hand, if the GAD symptoms have been present for six months or more when the individual was not depressed, then both diagnoses may be assigned. •The individual’s worry or anxiety causes significant distress (i.e., it bothers the person that he or she worries too much) or significant interference in the person’s day-to-day life. For example, the worry may make it difficult for the person to perform important tasks at work, interfere with relationships, or get in the way of sleep. •The worry and anxiety are not simply due to a substance (e.g., drinking too much caffeine) or medical condition (e.g., an overactive thyroid). WHAT DO PEOPLE WITH GAD WORRY ABOUT? People with GAD worry about many different things; in fact, some individuals with GAD will report that they worry about “everything.” Studies have shown that GAD worries are similar in content to the types of worries that people without GAD have. However, people with GAD tend to report worrying more frequently, about more topics, and for longer periods of time than do people without GAD. In addition, people with GAD tend to find it more difficult to control their worries, compared to people without GAD. Examples of topics about which people with GAD worry include: • minor matters (e.g., Will I arrive on time? What if I can’t find a parking spot? I will never get all my chores done? What if I get lost while driving?) • health and safety of loved ones • personal health and safety • work or school • money and paying bills • appearance • friendships and relationships • community affairs, politics, the environment • inability to cope CAUSES OF GAD Biological Factors Neurotransmitters – Some studies suggest that neurotransmitters (i.e., chemical messengers that pass information from one nerve cell in the brain to the next) may be important in the experience of generalized anxiety. Specifically, studies have found that anxiety is increased if receptors in the brain for the neurotransmitter gamma aminobutyric acid (GABA) are blocked. So GABA may be important in the chronic anxiety and worry experienced by people with GAD. The neurotransmitter serotonin may also play a role. However, researchers believe that the role of neurotransmitters in the experience of anxiety is complex, and just one of many factors that affect the development and course of GAD. Nervous System Activity – Studies have found that worry is often associated with a less flexible parasympathetic nervous system, the system that is involved in “calming down” or reducing the anxiety or fear response. This inflexibility means that people with GAD experience elevated and chronic signs of anxiety (e.g., an elevated and stable heart rate) whereas other people experience high levels of anxiety in response to stress, then reduced levels of anxiety once the source of stress is gone. This tendency for more stable physical symptoms is reinforcing in the short term because people with GAD do not experience the ups and downs of the anxiety reaction, but it is not helpful in the long run because it does not allow people to respond in a flexible way to their surroundings and to fully experience the physical aspects of fear and anxiety. The ability to experience more variation in heart rate and physical arousal is thought to be associated over time with the ability to distinguish situations that are truly threatening from those that are not. Genetics – There is some evidence that GAD runs in families. When identical and fraternal twins are studied, results suggest that there is a genetic contribution to GAD. However, it seems that what is inherited through genes is the tendency to experience anxiety or depression, in general. In other words, genes only pass on a general tendency for anxiety or depression – they do not pass on GAD specifically. Psychological Factors Biases in Thinking and Reasoning – People with GAD tend to pay more attention to signs of potential threat than others do. For example, people with GAD notice unhappy or critical facial expressions on other people more than they notice neutral facial expressions. By noticing these critical expressions, they may overestimate the degree of threat (e.g., rejection by another person), making it seem is though there is much more to worry about than there is in reality. People with GAD also have a tendency to interpret ambiguous situations as dangerous, even when there is not enough information to support such a judgement. In other words, if they received a phone call late at night, they would be more likely to think this was a phone call with bad news than would people without GAD. People with GAD also rate the possibility of a negative outcome as more likely than others. For example, people with GAD would estimate the likelihood of a car accident involving their loved ones as much more likely that people without GAD. All of these biases in thinking are thought to contribute to the worry seen in GAD. Worry as avoidance – An interesting and perhaps surprising finding regarding excessive worry is that worry may actually reduce people’s physical signs of arousal (e.g., heart rate). Researchers have wondered whether this occurs because worrying often takes the form of thoughts (e.g., “what if” questions), rather than unpleasant images (e.g., the image of your loved one in an accident). It appears to be much less arousing to wonder whether something bad has happened than to actually picture the unwanted event. Scientists believe that one of the functions of worry is to distract the individual from frightening images, thereby actually decreasing symptoms of arousal. Although worry can be an effective way of managing fear in the short term, it can make the problem worse over time. By avoiding the frightening images, worriers never get to fully deal with their fears and realize that the bad things they are worrying about probably will not happen. Beliefs about Worry – Worry may persist because some people believe that worry is helpful to them in some way. For example, some people believe that worry helps them to prepare for things (e.g., “worrying about a test will make me more likely to study”) or to prevent bad things from happening (e.g., “if I worry about my loved ones, they may be less likely to get into trouble”). However, worry does not prevent bad things from happening or increase preparedness. In fact, worry may interfere with a person’s ability to solve problems. Another factor that is associated with worry is the intolerance of uncertainty. People with GAD report being unable to tolerate not knowing what will happen in the future. As a result of this, they may worry in an attempt to predict the future and gain some control. Of course, worry does not actually help people to control the future. Finally, some people with GAD will worry not only about things in their life, but also about the worry itself. For example, some people fear that they are going crazy or will lose control when they are worrying excessively about things. As a result of these concerns, people may try and control or suppress their worry. However, trying to suppress or push away worry may actually make worry more likely to return. EFFECTIVE TREATMENTS FOR GAD Biological Treatments A number of medications have been shown to be useful for treating generalized anxiety disorder, and more medications are currently being studied. Drugs that seem to be useful include antidepressant drugs as well as drugs that are traditionally used for treating anxiety. Examples of medications that are often helpful for generalized anxiety disorder include: Type of Medication Generic Name Brand Name Citalopram Celexa SSRI ANTIDEPRESSANT Fluoxetine Prozac Fluvoxamine Luvox Paroxetine Paxil Sertraline Zoloft OTHER ANTIDEPRESSANTS Venlafaxine Effexor Alprazolam Xanax ANTIANXIETY MEDICATIONS Lorazepam Ativan Buspirone Buspar The decision of whether to take medication for GAD, and which medication to take should be based on the individual’s past treatment history, the individual’s medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and other factors. Studies have suggested that the antianxiety medications often work more on the uncomfortable physical sensations (e.g., muscle tension, difficulty sleeping) while the other medications work more on the experience of feeling tense, anxious or worried. Psychological Treatments The most well studied treatment of generalized anxiety disorder is cognitive behavioral therapy (CBT), though researchers are working on new psychological treatments for GAD to help those people who do not benefit from CBT or medications. CBT involves several strategies: Cognitive Techniques – these include strategies to challenge “anxious” or “worrisome” thoughts that may not necessarily reflect reality. For example, if someone is worried about failing an exam and never being able to get a job as a result of this, it might be helpful to look at the evidence that he or she will fail the exam and to consider possible alternative outcomes (e.g., if the person has written many exams and failed only one, the probability of failing this time may not be as high as he or she thinks). Further, the therapist would work with the person on examining how bad it would really be if he or she did fail the exam (e.g., does this mean that the person will never find a job, or is it more accurately thought of as a minor setback in school). Cognitive techniques may also target beliefs that people have about worry, including beliefs that worry is helpful in preparing people for things and preventing bad things from happening. Evidence for these ideas is examined to figure out whether worry has really helped the person, by preventing negative outcomes, for example. New approaches to cognitive therapy have also included exercises designed specifically to target intolerance of uncertainty, by helping individuals to recognize, accept, and cope with uncertainty in life. Relaxation Training – The most commonly used form of relaxation training is progressive muscle relaxation, in which various muscle groups are progressively tensed, then relaxed. Combined with controlled breathing or pleasant imagery, these exercises can be used to combat the physical tension that often accompanies worry. Practice often starts in nonstressful environments, and is later transferred to more stressful situations. Imaginal Exposure – this technique involves having people expose themselves to the worrisome images that are thought to underlie worry. By repeatedly exposing oneself to images that are feared and avoided, people can begin to habituate or get used to these images. In other words, after repeated exposure these images become less frightening, which, in turn, means that there will be less reason to worry about this topic the next time it arises. In imaginal exposure, fear-provoking images are identified, and then the person begins exposure with a moderately fearful image, gradually working his or her way up to the highly fearful images. For example, if someone worries about the safety of a loved one, they might expose themselves to the image of receiving a phone call about a bad accident involving their loved one. There is still relatively little research on the effectiveness of imaginal exposure for GAD, but studies on this technique are currently ongoing. Exposure and Prevention of Worry Behaviors – This strategy involves exposing oneself to situations or activities that have been avoided as a result of unrealistic worry. For example, if someone has stopped reading the newspaper for fear of worrying about all the bad events in the world, he or she would be encouraged to begin reading the newspaper again. In addition, individuals with GAD are encouraged to stop using the overprotective or safety behaviors that they rely on to protect themselves from imagined danger. These may include behaviors such as phoning loved ones repeatedly to make sure they are okay, or leaving two hours early for an appointment to prevent being late. These kinds of behaviors prevent the individual from learning that their worries are exaggerated. Training in other Skills – Treatment for GAD may involve learning other specific skills. For example, some individuals with GAD appear to benefit from learning new strategies for solving problems, or how to manage their time more effectively. In addition, researchers are now studying the use of mindfulness meditation for reducing worry in GAD. This treatment involves teaching the individual to accept their unwanted thoughts and feelings, rather than fighting these experiences or focusing on the meaning of these thoughts and feelings. Preliminary findings on mindfulness meditation are promising. Combined Treatments Both medication and CBT seem to be effective in treating GAD, though more research is needed to see if they are more effective in combination than on their own. For many people, the combination of medication and CBT does not work any better than either approach alone, although some individuals respond best to combination treatment. Preliminary studies suggest that CBT, which targets symptoms of anxiety and depression, may have a broader effect on symptoms than the antianxiety medications, which target only symptoms of anxiety. In addition, the effects of CBT appear to last longer than the effects of medication, once treatment has stopped. DID YOU KNOW ...? • Generalized Anxiety Disorder affects 2 to 5% of the population and affects more women than men. • Generalized anxiety disorder is one of the most common anxiety disorders in older adults. • Many people with GAD report that they have felt anxious or have worried for all their lives. However, GAD can also start in adolescence or adulthood, and may be linked to stressful life events when it occurs during these time periods. • Worry seems to involve more verbal activity as opposed to images. In other words, when people worry they seem to have fewer pictures or images in their minds than words and thoughts. • People with GAD sometimes experience panic attacks (a rush of fear and physical sensations) when they are worrying. SUGGESTED READINGS Readings for Consumers 1. Antony, M.M., & Swinson, R.P. (1998). When perfect isn’t good enough: Strategies for coping with perfectionism. Oakland, CA: New Harbinger Publications. 2. Burns, D.D. (1999). The feeling good handbook, Revised Edition. New York: Plume. 3. Davis, M., Eshelman, E.R., & McKay, M. (1995). The relaxation and stress reduction workbook, fourth edition. Oakland, CA: New Harbinger Publications. 4. Greenberger, D., & Padesky, C.A. (1995). Mind over mood: A cognitive therapy treatment manual for clients. New York: Guilford Press. 5. McKay, M., Davis, M., & Fanning, P. (1997). Thoughts and feelings: Taking control of your moods and your life, second edition. Oakland, CA: New Harbinger Publications. Readings for Professionals 1. Bernstein, D.A., Borkovec, T.D., & Hazlett-Stevens, H. (2000). New directions in progressive relaxation training: A guidebook for helping professionals. Westport, CT: Praeger. 2. Brown, T.A., O'Leary, T.A., & Barlow, D.H. (2001). Generalized anxiety disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders, third edition. New York: Guilford Press. 3. Davey, G.C.L., & Tallis, F. (Eds.) (1994). Worrying: Perspectives on theory, assessment and treatment. New York: John Wiley & Sons. 4. Dugas, M.J., & Ladouceur, R. (1998). Analysis and treatment of generalized anxiety disorder. In V.E. Caballo (Ed.), International handbook of cognitive and behavioural treatments for psychological disorders. Oxford, UK: Pergamon. 5. Roemer, L., Orsillo, S.M., & Barlow, D. H. (2002). Generalized anxiety disorder. In D.H. Barlow (Ed.), Anxiety and its disorders. New York: Guilford Press. © Laura J. Summerfeldt,PhD and Martin M. Antony, PhD This material is provided courtesy of PsychDirect, a public education website of the Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, CANADA. All material is copyright protected and may be printed for personal use only. Any other use is strictly forbidden without the express written permission of the author. Contact PsychDirect for more information.

Fragmented and Estranged Families: Patterns Reconciliation

Fragmented Families: Patterns of Estrangement and Reconciliation by Ellen B. Sucov, PhD

"Everything has its season, and there is a time for everything under the sun." But how do we understand the "season" for estrangement? When is the time to scatter, to hate, and to cut off from one's own family? Can the fragments ever be restored? Is it possible to heal the wounds, to mend the broken parts? How can a woman reconcile with a brother who has shunned her for forty years? Can we learn to make peace with alienated parents, with children who have banished us from their lives? Will we ever be able to laugh together and embrace them?

Welcome to my Web Site

Fragmented Families: Patterns of Estrangement and Reconciliation expands current knowledge of estrangement and its implications. New insights emerge from the interpretations of family conflict in sacred and secular literature. Narratives of real families present vivid examples of the pain of estrangement and, in some cases, chart the pathway to reconciliation. The process of resolving a prolonged estrangement in the author's own family is documented in detail. The author provides sensible strategies and useful resources for the task of reconciling with alienated family members. By applying suggestions offered in the concluding chapters, readers can discover how to transpose the negative impact of estrangement into a compelling incentive for exploring family dynamics and clarifying their own role in the family.

On this site, you will find excerpts from the book, a brief autobiography, definitions of key terms, a collection of relevant poems and quotes, stories about real families, and suggestions for restoring a fragmented family. I will be glad to respond to questions and comments from readers.

About Ellen B. Sucov, PhD

I am a psychologist, retired from the Faculty of the Department of Psychiatry at the University of Pittsburgh in 1988. I was born in Buffalo, NY in 1931, studied in the Music Department at Carnegie Institute of Technology (1949-51) and earned three degrees from Duquesne University: a B.A. in Music Education and an M.A. and Ph.D. in Psychology (1975).
Since 1989, with my husband Gene, a retired physicist, I have been living six months each year in Jerusalem, Israel and the rest of the year in Pittsburgh, PA. This is a second marriage for each of us. Gene has three sons and eight grandchildren, all living in the USA. I have a daughter, a son, and eight Israeli grandchildren.

My interest in psychology and family systems was sparked by a prolonged estrangement in my own family. After many years of study, preparation, failed efforts, and skilled guidance, the conflict was eventually resolved. Fragmented Families is an outgrowth of that process.

Excerpts from Fragmented Families

"My mother was the youngest child and the only daughter of her aging parents. I am uncertain about the place of her birth. She claimed to have been born in a small town in Pennsylvania, but she had no birth document and I suspect that she was brought to America as a babe in her mother's arms. Her Orthodox Jewish family came from a shtetl (small village) in Lithuania where they had survived more than one pogrom. From fragments of stories my cousins told, I gather that my grandfather was a sober, observant Jew, determined to uphold the laws and commandments of his forefathers. The rest of the family was eager to assimilate, to become Americans. There is one terrifying story, a secret kept hidden, that illustrates their struggle.

One of my mother's brothers, anguished over a failure or transgression, journeyed to the country farmhouse of his elder brother and hung himself on a tree in the front yard. This ultimate expression of cutoff, when the family had not yet gained a foothold in the strange new world, must have been a terrible shock. My mother never discussed this episode, so I am left to wonder how my grandparents, who died before I was born, survived the grief and the shame.

Some years later, frustrated in his efforts to remain an "old world" Jew and appalled at his assimilated family, my grandfather cut himself off from his wife and adult children and moved to an Orthodox old-age home in New York City. He died there, alone and forsaken by the rest of the family. It was on this shaky foundation that my mother set out to find herself and to shape her own identity." (Introduction, page xv)

"Everything has its season, and there is a time for everything under the heaven." But how do we understand the "season" for estrangement? When is the time to scatter, to break, to hate, and to cut off from one's own family? And how can the fragments be restored to wholeness? Is it possible to heal the wounds, to mend the broken parts? How can a woman reconcile with a brother who has shunned her for forty years? Can we learn to make peace with alienated parents, with children who have banished us from their lives? Will we ever be able to laugh together and embrace one another? (page 1)

"Imagine that you could move backward in time, speak with your grandmother's grandmother and gaze at her face as she responds to your questions. What would she tell you about the daily life of her family, the crises they confronted, the rituals for their holiday celebrations, the prayers chanted at her father's funeral? Suppose you could trace the wanderings of each generation in your father's line, going back to the period of the first millennium. Imagine the multitude of places they inhabited before reaching the place you now call home.

Our perceptions and behavior reflect the legacy of our family's past. Remnants of the past adhere to our present actions, as well as to our future aspirations. One family therapist said that we learn five fundamental skills from our family of origin: a pattern of relating to others, a set of rules to live by, a constellation of meanings about life experiences, the ability to handle threats, and the resources to cope with loss, illness, hardships, and calamities.[i]

This basic knowledge is profoundly influenced by the cultural, ethnic, and religious orientation of the family. "Ethnicity," "culture," and "religion" are distinct but overlapping concepts, each referring to a specific claim of affiliation and a common heritage. Like all families, the families described in this book have been shaped by their past, by the historical legacies of their members." (pages 25-6)

[i] W. F. Nerin, Family Reconstruction: Long Day's Journey Into Light (New York: Norton, 1986), 37.

"The act of writing is an ongoing exploration, a continuous learning. As I write about the lives of others, I discover new dimensions of myself. Listening to the stories of estrangement and pondering their meanings, I have come to see the sequence from alienation to reconciliation as a vital opportunity for personal growth and renewal.

Examining an estrangement in one's own family is a journey without a clear destination. The benefits cannot be defined in terms of success or failure. It is not an event, done once and finished. Rather, it emerges as a series of stages that unfold over time, advancing and regressing in alternating progression. Similar to the musical form of a fugue, the process reverberates with themes and counter-themes, harmony and dissonance, sounds and silence.

During the course of confronting, examining, and perhaps resolving a conflict, one must learn to create a sense of connection that has been lost, damaged, or broken. The process includes a renewal of oneself as well as a turning toward others. It can serve as the cutting edge for a new surge of personal growth." (page 242)

"When we reflect on these stories of families who have remained estranged, we can trace the evolution of hostilities. We see how hidden agendas and repressed grievances lie dormant and then flare up in spurts of accusations and retaliations, or remain buried in stubborn silence. What elements distinguish these families from others who have turned away from the anger, who have moved toward repair and renewal? In more fortunate situations, new insights kindle the aspiration for change.

When the protagonists begin to modify their habitual behavior patterns, they are able to see their family in a new light. The occurrence of estrangement then becomes an opportunity for growth; it can actually serve as an incentive to clarify the boundaries of relationships and re-define one's separate identity.

What appeared to be polar opposites - self and others, closeness and distance, right and wrong -- can be re-framed in more flexible, more constructive terms. As old animosities begin to dissolve, new modes of relating become possible. In the midst of this process, family members come to acknowledge a basic paradox of human existence: we know ourselves only in the context of living with others, and we experience relationships only in the effort to differentiate ourselves from others.

The ultimate question is how a person can strengthen his or her individual identity while sustaining meaningful, mutually supportive connections with family members. Those who remain mired in anger are not able to address this question." (pages 197-8)

Strategies for Change

Change is the key to reconciliation. But resistance and rigidity pollute the emotional climate of fragmented families. People find countless reasons not to change. A father asks, "Why should I speak to my daughter when she ignores my most cherished values?" A man insists that he can never forgive his brother's insults. A woman cannot imagine how she could reconcile with her brother after he neglected their dying mother. In the face of such provocations, how can a fragmented family be restored to wholeness? Will the hurt and the anger ever be overcome? How can they begin to move toward forgiveness and healing?

These are legitimate questions, and here is my answer: growth, development, and change are synonymous. There is no growth without change. The alternative to growth is stagnation and rigidity. Estrangements tend to sustain stagnation and rigidity. Efforts to resolve conflict, whether or not they succeed in achieving reconciliation, will promote growth and maturity.

Here are some suggestions for seeking reconciliation with a person who is estranged from you. I will use readers' input to modify and amplify these ideas.

§  Identify your goals but be ready to modify them.
One goal is to resolve the conflict and restore a connection with the estranged person. But don't assume that this is the only goal. Other goals may be just as important and just as useful for your own wellbeing.

§  Don't set deadlines.
For many people, understanding and resolving a family conflict takes a long time; for some it takes a lifetime. Don't expect quick solutions.

§  Recognize that estrangement may have positive value.
Use the estrangement as an incentive to expand your knowledge of your family. Rather than preserving anger or anguish, focus on re-directing some of your energy to the task of clarifying your own role as a family member. Your new insights may or may not lead to reconciliation. In either case, you will become a wiser, more complete person.

§  If the other person won't reciprocate, it doesn't mean you failed.
In many families, only one person wants to resolve the conflict. The others are resistant, indifferent, or simply not ready. If this is the situation in your family, you can still benefit from the new understanding that will come from your efforts. Trying and failing is better than not trying at all.

§  Examine your intentions.
If you intend to evoke guilt, demand an apology, or change the other person's behavior, your efforts will probably be futile.

§  Tone down your expectations.
If you cannot give up your fantasies of a "perfect" relationship, or if you continue to expect the other person to "give in," your efforts will fail.

§  Clarify boundaries.
Be aware of those relationships in which you feel dependent, excessively close, or overly demanding. Try to back up and reduce the intensity of your feelings.

§  Question your habitual reactions.
We often get into ruts and our reactions become repetitive and rigid. Consider alternative ways to behave in situations where you have always done or said the same thing.

§  Accept less than perfect solutions.
When family members become estranged, there is usually a long history of bad feelings that led to the cutoff. If and when reconciliation occurs, remnants of the past will cling to the restored relationship. Don't expect simple or ideal solutions.

§  Appreciate your strengths.
Working to resolve an estrangement can be exhausting and frustrating. Your willingness to begin the task is a sign of strength. Persisting in the face of resistance is another positive sign. Identify your emotional assets and nurture them. They will serve as vital ingredients in the process of reconciling with an estranged relative.

§  Acknowledge the other person's right to be different.
Families are infinitely complex and each individual is unique. The other person is not required to be a mirror image of you. Focus on the positive ways he or she is different from you and work at respecting those differences.

§  Agree to disagree.
Severed family connections are a consequence of significant disagreements over important issues. As you work toward repairing the damage, be aware that some of the friction will remain. Learn to accept the reality of ongoing disagreement as part of the process.

§  Try to achieve a more balanced pattern of closeness and distance.
Conflicts erupt when some family members become excessively involved in another person's life, or when one person is disparaging or indifferent to the other's needs. Be aware of those tendencies that may be stirring up resentment in your family.

§  Recognize estrangement as one aspect of family life.
Many families experience a recurring pattern of alienation and reconciliation. One branch of the family may be relatively calm and peaceful, while another is mired in bitter conflict. Try to perceive these patterns as alternating rhythms in the ongoing life of the family.

§  Monitor your own progress.
Pay attention to the intensity of your feelings and recognize when you are off balance. Notice which of these strategies are most difficult for you to accept. Consider why they are so difficult. The answer may lead you to the crux of your resistance.

§  Obtain professional help.
To guide your efforts, consult a mental health professional who is a family systems specialist. There is no good substitute for skilled professional help.

§  Learn how to express anger without being obnoxious

§  Practice how to apologize and mean it

§  Don't give up

§  Celebrate change

§  Express gratitude

FRAGMENTED FAMILIES contains a spectrum of suggestions for exploring and repairing an alienated family. See especially Chapters 9 and 10.

Family Projection Process - My Notes

Family Projection Process

The family projection process describes the primary way parents transmit their emotional needs/ problems to a child. The projection process can impair the functioning of one or more children and increase their vulnerability to clinical symptoms. Children inherit many types of problems (as well as strengths) through the relationships with their parents, but the problems they inherit that most affect their lives:  are relationship sensitivities such as heightened needs for attention and approval, difficulty dealing with expectations, the tendency to blame oneself or others, feeling responsible for the happiness of others or that others are responsible for one's own happiness, and acting impulsively to relieve the anxiety of the moment rather than tolerating anxiety and acting thoughtfully. If the projection process is fairly intense, the child develops stronger relationship sensitivities than his parents. The sensitivities increase a person's vulnerability to symptoms by fostering behaviors that escalate chronic anxiety in a relationship system.
The projection process follows three steps:

(1) the parent focuses on a child out of fear that something is wrong with the child;
(2) the parent interprets the child's behavior as confirming the fear; and
(3) the parent treats the child as if something is really wrong with the child.

These steps of scanning, diagnosing, and treating begin early in the child's life and continue. The parents' fears and perceptions so shape the child's development and behavior that he grows to embody their fears and perceptions. One reason the projection process is a self-fulfilling prophecy is that parents try to "fix" the problem they have diagnosed in the child; for example, parents perceive their child to have low self-esteem, they repeatedly try to affirm the child, and the child's self-esteem grows dependent on their affirmation.

Parents often feel they have not given enough love, attention, or support to a child manifesting problems, but they have invested more time, energy, and worry in this child than in his siblings. The siblings less involved in the family projection process have a more mature and reality-based relationship with their parents that fosters the siblings developing into less needy, less reactive, and more goal-directed people. Both parents participate equally in the family projection process, but in different ways. The mother is usually the primary caretaker and more prone than the father to excessive emotional involvement with one or more of the children. The father typically occupies the outside position in the parental triangle, except during periods of heightened tension in the mother-child relationship. Both parents are unsure of themselves in relationship to the child, but commonly one parent acts sure of himself or herself and the other parent goes along. The intensity of the projection process is for the most part unrelated to the amount of time parents spend with a child.