The way people react to illness and behave in the face of illness-caused vulnerability is influenced by many factors, among them their own family dynamics. Many people, including both those we visit and the bikkur holim volunteers themselves, may be tempted to unconsciously replay dynamics from their families of origin in other family-like systems, such as synagogue communities.

Even in the healthiest family system, feelings of anxiety might be heightened during an illness. Any challenging dynamics that already exist in the family system are likely to be more pronounced than ever. A volunteer may react strongly to certain behaviors of some congregants. A volunteer may also feel greater excitement or reluctance about visiting some congregants as opposed to others. This may be because they remind you of some of your own family dynamics.

By introducing you to the basics of family systems theory, this unit will help you be aware of how family relationships might be affecting the people you visit, the way you react to what you encounter, and how these might influence your role as a bikkur holim visitor.

Image of a pad and pencilBefore we review some of the basics of family systems theory, take a few moments to think about congregants you have visited.

  1. Which congregants have you felt most and least excited about visiting?
  2. Which visits do you enjoy the most?
  3. Which visits do you feel neutral about?
  4. Now consider how the visits and people that come to mind may reflect some key dynamics from your family of origin. This self-awareness will help you be a better bikkur holim volunteer.

Basics of Family Systems Theory for Volunteers

The focus of family systems theory is on the entire system (including the bikkur holim committee and the congregation), rather than on individuals and their behavior. When things aren’t going as we would like, many of us have a tendency to want to find the root of the problem and fix it. We may feel compelled to find the person who is “causing the trouble” and try to fix their “disruptive” or “difficult” behavior. It is important to be aware of this impulse, because we may unwittingly bring it to our bikkur holim work, which can distract us from being the support and neutral presence that we hope to be in this work.

A family system is very much like an ecosystem. Equilibrium is a primary goal of any ecosystem. Family systems theory teaches us that this is the case in families as well: they have a natural tendency to stay in balance and resist change. And when change inevitably comes, like a major illness or crisis, the entire family system will be impacted and will need to adjust in search of new equilibrium.

Family systems theory teaches that the behavior of individuals within the system may actually be “symptoms” of long-standing patterns in the family unit that have been replayed over long periods, rather than just emanating from the individual or crisis at hand. In fact, unaddressed patterns do not dissolve with time and distance.

It can be easy to jump to seeing this as a flaw in the person or make assumptions about this behavior.

Image of a nut (hardware not legume)Here are some tips to help you stay neutral in your role as a bikkur holim volunteer:

  1. Notice any thoughts or feelings about the behavior. Do you feel annoyed? Are you puzzled?
  2. Refocus your thinking on the whole system, rather than the individual.
  3. Consider what else might be going on. Ask yourself: What purpose does this behavior serve, even if it seems self-destructive? Why might this behavior surface at this time?
  4. If you feel comfortable doing so, use your natural curiosity to gently ask the person you are visiting about what else is going on for the person. Perhaps a big procedure or test is coming up. Or maybe the person is coming up on the anniversary of some painful event, such as the death of a loved one.

Self-Differentiation vs. Fusion                     

Family systems theory teaches that self-differentiation is an important goal for all adults. This is especially true for individuals in helping capacities, like bikkur holim volunteers. Because we want so much to help others, it can be easy at times to get caught up with other people’s needs and feel overly responsible for them. Self-differentiation is a person’s ability to simultaneously be emotionally connected to a significant relationship system and function autonomously by making her or her own choices.[i] The opposite—fusion, lack of differentiation, or enmeshment—occurs when a person sets aside individual choices in the service of achieving harmony within the system.

Image of a nut (hardware not legume)Here are some tips to help you practice self-differentiation:

  • Be clear about your own goals, feelings, commitments, and values, and state these, despite pressure from the family system.
  • Be patient with yourself. No one is ever fully self-differentiated; it takes a lifetime of work! Also remember that self-differentiation tends to be more difficult when there is more anxiety present, such as with an illness or other crisis.
  • Consider what behaviors in relationships make the most sense to you and who you are. Call upon your creativity, rather than pleasing others.
  • Remember that a key point to self-differentiation is being clear about who you are and what you need and staying connected to the system at the same time. Saying or thinking something like “I’m just going to do what I need to do (or quit) because this system is a mess” is actually a kind of fusion.

“The Bridge”: A Fable

Edwin Friedman, a rabbi and family therapist, wrote a fable about self-differentiation versus fusion, titled “The Bridge.” It tells of a man who is racing to finally achieve his life’s goal when, on a bridge, he encounters another person—who has a rope tied around his waist. Before the first man can figure out what’s happening, the person with the rope thrusts one end into the man’s hand and dives off the bridge. The man holds the rope and keeps the jumper from falling to his death, but finds himself unable to pull the person back up, leading to a discussion between them over what the right course of action is. You might want to read the story yourself in Friedman’s Fables.[ii]

Role-Playing Your Bikkur Holim Encounters

Image of a pad and pencilThe following role plays illustrate some scenarios and possible interactions between the volunteer and the person visited. After the presentation of the initial scenarios, you have a choice among different ways for this interaction to continue. Click on the link of the response you choose to see how it directs the unfolding of the interaction. Then, using what you have learned about family systems theory, discuss which choice you think was most effective and why.

Role Play 1


The man in the red sweater is a bikkur holim volunteer from the synagogue. He is visiting a long-time synagogue member who has a serious illness and feels she has been “forgotten” by the community.

Setting the Stage

You now have three choices of how to proceed:

Choice 1: You join with the patient and complain about how much the synagogue community and rabbi have dropped the ball.

Choice 2: You make promises to do more for her and to mobilize the community in ways that you are not sure are actually in your power.

Choice 3: You acknowledge and empathize with the congregant about her feeling separated from the community, especially after having been so active.

Role Play 2


The man in the red sweater is a bikkur holim volunteer who is visiting with a congregant. The congregant is waiting for test results to determine whether she has a serious illness.

Setting the Stage

You now have three choices of how to proceed:

Choice 1: You try to reassure the congregant and tell her everything is going to be fine.

Choice 2: You try to take the congregant’s mind off of the waiting and change the subject.

Choice 3: You name how agonizing it is to wait for this news and empathize with the congregant’s feelings of fear and uncertainty.

Image of a head with a question mark inside. Critique the different approaches and explain what kind of impact they had on the interaction.

[i] Michael E. Kerr and Murray Bowen, Family Evaluation: An Approach Based on Bowen Theory. (New York: W. W. Norton, 1988).

[ii] Edwin H. Friedman, “The Bridge.” In Friedman’s Fables, 9–13 (New York: Guilford Press, 2014).

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