Family Sacrifice: Models, Research and Interventions

While anxiety and depression are the most prevalent diagnostic categories seen in therapy, the presenting problems are variable and often reflect the cultural, political and economic stressors of the time [1]. The early twenty first century has been characterized by enormous economic hardships, reduced employment opportunities for the young and an increasingly fractured family system. Not surprisingly, today’s presenting problems have less to do with self-actualization and prioritizing opportunities and more to do with gaining the strength to help others in the family and learning to maintain a sense of optimism. Thus, the cases that have inspired this article will be familiar to most family therapists.

their own life course and dreams. The social rewards in some cases were significant (the casting director could not stop praising his wife and clearly it had strengthened their bond) but more often, there was more complicated feedback (resentment and further self-loathing in the case of the depressed daughter, anger and rage in the demented wife, and no visible understanding of the sacrifice in the case of the autistic son).
All of these families would have loved to outsource the caring, if they could afford it and could find an appropriate person. They were not enjoying their chosen course of action, nor were they acting out of pure altruism. But like most of us, the family was the only one that could supply what was needed on a regular and reliable basis. Their motives were mixed, including duty, guilt, empathy, expectation, and fear. Sacrificing families enter therapy searching for a way to cope in a context that accepts their burden as a reasonable and perhaps unavoidable life event. Trying to deny the burden or shift the burden isn't realistic. They need help recasting dreams and goals so that they match the new reality. As one ponders how to help these sacrificing families, the following three questions become essential for theory and research endeavors.
"What is a useful operational definition of family sacrifice?" "How does research inform what types of sacrifice are dysfunctional and what is worthy and noble?" "What intervention model and intervention strategies can help sacrificing families become more resilient?" The goal of this paper is to incorporate "family sacrifice" into our theories and models of family normalcy and life course dynamics.

More specifically, the paper aims to
A. Provide clinicians and researchers with an operational definition of family sacrifice.
B. Review the research available on factors affecting family sacrifice.
C. Succinctly propose a new conceptual model for family sacrifice.
D. Begin a discussion of how therapists can help sacrificing families reduces their stress and optimize total family functioning.

Defining Family Sacrifice
One of the most documented phenomena in family psychology involves the critical role of social support in maintaining family resilience [2,3]. Whether it is helping someone recover from depression, PTSD, difficult life transitions, or health crises, family members are called upon to provide informational support, emotional support, tangible aid, and network support (help maintaining social integration) (Cutrona & Russell, 1990). However, in order to provide the needed social support, individuals as well as the family system are often required to make sacrifices that alter the life course of the family and the other family members. On a personal level, one must often sacrifice time, resources, values, goals and self-care. On a systemic level, family productivity, family adaptability, family rituals, and even family cohesion can be severely compromised.
The literature on social support is increasingly realizing the costs of social support. Most often, it is studied under the rubrics of "caregiver stress" [4]. And "compassion fatigue" [5]. Caregiver stress has been associated with multiple negative outcomes, including poorer perceived health, increased health-risk behaviors, and increased anxiety and depression [6]. The current paper expands on that model by stressing how essential it is to examine and address the stress and costs of social support on family members who are outside the focus dyad (the person-in-need and the caregiver/sacrificer).
The current model is a triangular model that proposes it is equally important to assess and address how a pattern of family sacrifice affects a) the person-in-need (PIN), b) the sacrificer, and c) the rest of the family system. As individuals, we aspire to help others without enabling them. We also try to stretch our own humanity and empathy without unduly neglecting our own care. And finally, we strive to be aware that there are multiple loved ones in every support system and that what aids one person might have a negative impact on the other. These three aspirational goals can be seen as familial see-saws, of a kind, that need to be constantly rebalanced for optimum health.
Finding an optimum operational definition of family sacrifice is beyond the scope of any one paper, but to begin the discussion, the following 6 conditions are proposed as necessary before an individual is labeled as engaging in a "family sacrifice". Note that the emphasis on the collateral costs of care giving.
A. One or more individuals in a family relinquish a highly valued resource, goal, or activity in order to B. Provide another family member with the opportunity to reduce the discrepancy between their actual situation and the situation they and/or others in the family reasonably expect for that individual.
C. The relinquished resources, values, goals or activities impact more than one person in the family unit and D. Act as a stressor on changing family structure and/ or dynamics.
E. The duration or repetitive nature of the giving decreases the likelihood of the family member ever recapturing the relinquished resource, goal or activity.
F. There is no expectation of reciprocity from the designated family member.
Such a definition would help differentiate family sacrifice from the often co-occurring construct of altruism. Both altruism and sacrifice are non-reciprocal forms of pro-social behavior. That is to say, they both refer to actions that benefit others, without any expectation of the effort or benefits being returned. However, there are important theoretical differences between altruism and sacrifice [7]. Although altruism is well studied in psychology, and sacrifice barely studied, it is proposed that the two behavioral/cognitive processes be differentiated in six important ways: 1) Altruism is motivated by devotion to the welfare of other; often due to empathy. Sacrifice can be motivated by duty/obligation, guilt, and/or empathy.
2) Altruism is often a win-win situation, the benefits outweigh the costs. Sacrifice is often a win-lose situation.
3) Altruism most often strengthens general family functioning. Sacrifice most often stresses general family functioning.

4)
Altruism can occur for short term or long term goals. Sacrifice more often occurs in relation to long term goals.

5)
Altruism is most often appreciated by the recipient. Sacrifice can be appreciated or not appreciated by the recipient.
6) Sacrifice often decreases family cohesion and increases flexibility. Altruism often increases family cohesion and decreases flexibility.
Research will have to be conducted to test if these distinctions are valid; they are being proposed as a model which is in need of testing and verification. It is possible that many family situations begin with altruism and, over time, morph into sacrifice, suggesting an impact continuum. It is also important to bear in mind that the utility of the altruism-sacrifice distinction may be confined to systemic models that examine how to change complex interactions and life narratives.

Factors that moderate the effect of sacrifice on family resiliency
There are a number of overlapping factors, that we can glean from the empirical literature, that are likely to influence one or more of the family narratives about sacrifice: Not all of these factors have equal empirical validation nor will all be equally salient for everyone's narrative but it is the important for the therapist to be aware of all these factors to best tease out which ones are relevant to any one family's life situation (See Table I for guided interview questions to help elicit relevant factors from family members).

Emotional Fusion
The more a person professes that they feel one and the same with another individual, the more likely they are to act in a sacrificial manner [8]. To protect or further the other's goals are indistinguishable from protecting or furthering one's own goals. And most often, if the other is younger, more valued, or a group (the children vs. the one parent), the need to sacrifice is greater than the need for self-care. Indeed [9]. Found that Hispanic adolescents often place their suicide attempts in the context of not wanting to burden their families and they see the sacrifice of their life as a way to make things better for their families. All clients need to tell textured stories that include the factors that influence the emotional impact of family sacrifice. While creating each narrative, the client would benefit from thinking about the following questions:

a)
How emotionally connected are you and your person-in-need? Are you able to separate your emotions from their emotions or are they all mixed into one pot?

b)
Do you believe that it is each person's responsibility to take care of themselves or do you feel that the family is responsible for taking care of each member? Maybe you think the government is responsible for taking care of family members who cannot be independent. What is your philosophy on how dependent or interdependent family members should be?

d)
After making a list of the sacrifices, the client needs to evaluate who, besides themselves, could make a contribution in each area. e) Do you feel that you have already given or taken more than your fair due from each family member? How does that affect the current sacrifices you are making? i) Are you sacrificing more because you have a positive goal you are hoping to achieve or is it more that you are trying to stave off a number of negative consequences? Please describe this in detail.

j)
How is your sacrifice impacting the rest of the family? Who is most affected? Who is least affected? How has the family functioning and activities changed as a function of your sacrifice?
Whether you are a member of the family, the person-in-need (PIN), or the sacrificer, the more emotionally fused individuals are with one another, the less able they are to refrain from sacrificing. One has to have a sense of self, emotionally independent of the other, in order to refrain from over-benefitting the PIN and under-benefitting oneself and others in the family. This is the basis of many Al-ANON sessions -that each person must be responsible for themselves and if you take responsibility for the other, in the end you are enabling their behavior and not helping them. If fusion is desired, culturally or existentially, then the cost of sacrifice is greatly reduced. If differentiation is a desired goal and there is resentment over the degree of fusion, the cost of the sacrifice is increased.

Interpersonal Orientation
Related but independent of fusion, is the cultural / interpersonal orientation of each person. Those who are individualistic in orientation don't want to receive and/or acknowledge the sacrifice and resent or are burdened with having to act contrary to one's own interest or be a member of the family that is bearing the costs of the sacrifice. On the other hand, those that are more collectivist will find it easier to acknowledge that they need the help of others. Both the person providing the services and other family members will find it easier and more rewarding to endure the sacrifices required if they have the collectivist orientation [10]. Using a laboratory analogy, found that when sent a mail request to donate 0 to 10 hours for a worthy cause, cooperators contributed significantly more of their time to the cause than did individualists and competitors [11]. Demonstrated this effect with fire emergency workers. Those that had a more pro social orientation expressed less anger toward their partner and reported more relationship satisfaction.
Of course, culture probably affects interpersonal orientation as much, if not more, than any individual differences. One of the most distinguishing features between cultures concerns how they vary from independence to cooperation and their willingness to accept support when it is offered [12].

Commitment
Commitment is one of the strongest predictors of continued efforts to put the partner's needs above one's own and whether one chooses to stay or leave a sacrificing heavy relationship [13]. An excellent model put forth and tested by [14]. Asserts that commitment is but the second step on the path to sacrificial behavior. The first step is the dependency which exists in any intimate relationship where there are multiple overt and covert dependent interactions that inhibit self-initiative and foster inter-dependence. It may be as simple as knowing that I don't eat dinner when I am hungry but rather that dinnertime depends upon my partner coming home. It may be as complex as needing your partner's co-operation to pay the bills, get to work, and avoid pregnancy. From this enforced dependency arises commitment -a feeling, a vow, an expectation -that these many patterns of dependency are going to continue into the future. In this model, family sacrifice is rooted in the historical and anticipated future of the relationship. When one engages in a sacrifice and it is acknowledged, the dependency in the relationship is reinforced and the entire cycle gets strengthened [15]. Provide additional empirical support for the link between dependency and sacrifice in intimate relationships. Unfortunately, these two studies are isolated in the landscape of sacrifice research and have not been built upon for the past 15 years. (This could be due to the fact that the commitment research field has become entirely devoted to organizational commitment).
Unfortunately, [14] were only modeling dyadic interactions. Working from our model of "family sacrifice" it is interesting to posit that perhaps many of the negative consequences to the other family members arise because of the emotional dependency patterns between the PIN and the sacrificer. Families are networks of interdependencies and when any dyadic subsystem is locked into a dependency cycle, the others can get locked out of any gratifying interdependencies and become isolated or overly involved with the remaining subsystems.
Together, satisfaction experienced in the relationship, the history of investments in the other, and available network alternatives (discussed below under "networks"), combine to explain approximately 60% of the variance in commitment to interpersonal relationships [16].
Satisfaction in a relationship varies depending on one's expectations for that relationship. As long as the relationship expectations are met or exceeded, one is likely to continuing acting in a sacrificial manner. If the relationship expectations are not being met, the sacrificer will be more open to rearranging his/her priorities. Relationship satisfaction is a very important concept to explore with families because when it can be increased, stress is greatly reduced and the rewards of sacrifice greatly enhanced; when it cannot be increased, the therapist can be a supportive agent in changing the structure and nature of the family system. For example, if I truly enjoy my relationship with my autistic son, the sacrifices I make in my personal life to take care of him and be with him are not particularly stressful. My sacrifices can be acknowledged and minimize the stress relative to the joy I get from our relationship. His sister, if she also has a good relationship with him, will not be adversely affected by the loss of mother-daughter time. She may miss not having more time, but she will not feel that the sacrifice is being made without consideration of her if she has a truly satisfying relationship with her brother. However, if the relationship is nothing but a hardship, changes need to be made to unburden me and ways of enriching the child-parent bond need to be explored.
Commitment is also intimately intertwined with the past investments one has made in a relationship. These investments can be both tangible (e.g., material possessions, money, friends) and intangible (e.g., time, identity, future plans) [17]. Assert that the more one person has invested doing things for another and being committed to the other's well-being, the more likely they are to continuing sacrificing for that person. The immigrant mother from Central America who has left her children behind and succeeds in having them all graduate high school may continue her work exile so that one of the children can become a nurse or another a lawyer. Past sacrifices reinforce the desire for future sacrifice in order to insure that one's previous efforts were not in vain and that gains achieved are not lost. We all want to create a story in which our actions had purpose, our goals were fulfilled, and our effort justified. The more we have invested in a person, the greater the need to create such a story, reinforcing the tendency to continue sacrificing.

Community support
As we perform our part of the family drama, we want our role to be acknowledged and valued. The veteran trying to walk on prosthetics needs a community that reinforces his bravery and steadfastness but so also does the wife who is working and raising the children during his rehab. The children also need to feel that their loss is acknowledged and that they are doing their part by keeping the family together and functioning. The community of neighbors, teachers, church members and extended kin are all essential in reducing the negative costs of family sacrifice and maximizing the positive virtues inherent in such behaviors [18,19].
The size of the social network appears to be important but there are still lots of questions about what makes a successful social network (e.g. number, amount of help, felt support, etc.) [20]. found a weak but significant relationship between the size of one's social support network and psychological symptoms and morale, although social support or the size of the network did not correlate with any of the physical health indicators. This makes intuitive sense. There is a certain critical mass of others needed, but after that, more doesn't necessarily equal better. When networks are of sufficient size, the over utilization of one sacrificer may even be detrimental to the PIN as well as the sacrificer and other family members. If there are many people that can take a child to his tennis coach, but the father chooses to quit his job to be the chauffeur/overseer, the sacrifice is unlikely to be appreciated, acknowledged or reap the benefits the father so desires. Similarly, the father may feel more suffering over his sacrifice and less fulfilled if he acknowledges that there many other relatives, carpools, and public transportation options that could safely get his son to the many coaching sessions. The siblings will resent that their father is not there for their games and their transportation needs. When there are no other sources of help, everyone is much more likely both to value the sacrifice and to feel the benefits of the sacrifice as worthwhile.

Desire of recipient for help
One of the most important factors influencing whether or not social support and family sacrifice is beneficial to a loved one is whether or not the person-in-need is desirous of this help. When the assistance is forced on an adult, it rarely helps and most often enables self-defeating behaviors for the person-in-need [21]. When the loved one is requesting the help and acknowledges the sacrifice, they are much more likely to benefit and use the aid to its maximum potential. This can be seen in hundreds of daily examples: the parent who sacrifices to send his/her child to an expensive college when the child has no interest in studying and would be happy to attend a community college is likely to be disappointed compared to a parent who sacrifices because the child has begged and pleaded to help make their dream of attending a specific program of study a reality. Similarly, the daughter who takes a second job so that her wheelchair bound mother can have an aide take her out to the museums and lunch once a week will be permanently frustrated if the mother simply does not want such outings and protests each week. The daughter whose mother has asked for help to keep involved in her outings will be truly helping in a very fulfilling way. Of course, there are times when assistance is rejected, and the sacrifice will still help -especially in the case of children and adolescents, those chronically unable to ask for help, and those too incapacitated to ask for help. But even in these cases, the amount of push back and oppositional behavior needs to acknowledged, weighed and analyzed for how it is likely to affect the desired end goal.

Pride
Sometimes one sacrifices because the motivating goal is judged so worthy that the gain in personal pride is enough to override any other personal losses associated with the sacrifice [22,23]. For example, found that female Thai masseuses who felt that their sacrifice would lead to a happy and protected family at home had pride in their work. The sacrifice was infused with positive emotional experiences that gave them a sense of dignity and importance. While this sense of pride can arise from a personal philosophical system, more often it occurs nested in a strong cultural background of sacrificial expectation and life purpose (e.g. one always takes care of their elders, no matter what).
This, of course, is not far from the patriotism felt among the armed service men and women, whose willingness to die for one's country is a major source of pride.

Approach and Avoidance Motivations
The literature finds ample support for the proposition that putting your partner's needs in the forefront, and forgoing your own desires, can yield many positive effects on the relationship. Willingness to sacrifice has been associated with increased marital adjustment and satisfaction in both cross sectional studies as well as longitudinal studies Van Lang, Agnew, et al. [15]. and among unmarried college students has predicted relationship continuity [14]. However, common sense and life experience confirms that equally profound negative outcomes can be associated with sacrifice. Perhaps as research expands to include the wide range of outcome variables associated with sacrifice, more of the negative outcomes will be empirically demonstrated.
One important study in this direction has been made by [24]. Who assessed the impact of the motivational system of the sacrificer on relationship satisfaction, personal wellbeing and relationship continuity among college students. They employed approach and avoidance models that have been studied extensively for decades. Individuals motivated by genuine concern for the other and or because they seek to strengthen the relationship (approach motivations), are likely to feel very fulfilled from sacrifice. On the other hand, people who sacrifice in order to avoid conflict avert community disapproval, or to stop annoying requests (avoidance motivations), end up feeling resentment and unhappiness and indeed these avoidance motivations can actually weaken a relationship. [24]. found that the laboratory findings on approach and avoidance motives held up in the real world. While the sacrifices were minimal (e.g. I missed going to the movie I wanted to see), the effects were significant. Those who missed a movie because they wanted to support their partner by attending a basketball game felt good about themselves and the relationship. Those who missed the movie because their partner would be resentful and bad mouth her for missing the event felt the relationship was weakened by the sacrifice.
Families need to discuss the plethora of motivations they have for their sacrificing behavior with the therapist. Then the therapist must assess if they are resilient enough to continue sacrificing or if their avoidance motivations are so strongly rooted, that seeking divestment strategies is a more prudent than trying techniques that change the narrative of the sacrifice.

Four clinical intervention strategies to help the sacrificing family
Narrative Therapy: Re-creating the sacrifice narrative Narrative therapists are increasingly recognizing the value of identifying the multiple storylines that get intertwined to create complex family narratives [25]. Often the best way to help a client re-author the family sacrifice story is by creating a flexible narrative that balances three interlocking storylines common to family sacrifice.
One storyline, the Recipient Storyline, investigates how likely different types of sacrifice will affect the personin-need (PIN). Therapy is focused on helping the family unravel what is actually helping the PIN and what is enabling destructive behavior. Is driving a son to school every day because he sleeps past the scheduled bus pick up, helping him graduate or simply enabling poor sleep habits? For some adolescents, such behavior is a useful sacrifice, but for others it is the epitome of enabling behavior. Three characteristics that distinguish helping behaviors from enabling behaviors are 1) lack of appreciation by the PIN for the sacrifice, 2) unwillingness by the PIN to try strategies that would increase independent behavior, and 3) lack of concern about the consequences of their dependency. If the therapist gets detailed examples of the family interactions, it will help flesh out this storyline and give ideas of possible alternatives.
The second storyline, The Sacrificer Storyline, investigates the emotional and behavioral costs and benefits of the sacrifice. Is the person offering help neglecting his/ her own mental or physical health? Are they balancing their own momentum towards goals and pleasures with helping the loved one achieve their goals? Often, our sacrifices are well worth it for the PIN but they are causing so much personal distress that the see-saw is not balanced. When one is sacrificing their own long term health or happiness, they need to acknowledge the probability of self-harm and existentially decide if such sacrifice is desired and if so, for how long and at what cost. If self-preservation is valued as much as preservation of the other, options can be more openly explored. This is, of course, the situation facing many elderly partners who find that keeping their loved one at home is no longer feasible because it is so negatively impacting their own well-being. A new narrative that includes out-placement as the help most needed by the PIN can alleviate the spouse's guilt. It can sometimes even provide a relief narrative where instead of taking on all the care responsibilities and not being able to deliver on it, they are making sure the spouse has the needed care.
The third storyline, the Systems Storyline, investigates how the family system and other subsystems are affected by different levels and kinds of sacrifice. Is helping one family member causing severe angst or problems for others in the family?
After the client or family has fleshed out the three storylines with the therapist, each narrative is deconstructed and/or reframed with the goal of exploring what changes in attitude, behavior, or interactions would lead to an overall more satisfying "next chapter".
It is often helpful to use character roles that are familiar to the families when reconstructing the three storylines. Sacrificers are oftentimes playing the role of muse, caretaker, coach, tutor, therapist, sidekick, or financial backer. The person-in-need is often playing the role of veteran, elder, patient, child, depressed person, loser, or addict. The other family members may get caught in a Satire type triangle and play the role of blamer, super-reasonable one, irrelevant or appeaser [26]. Modifying these roles is easier if the new roles are given new names.
When building the 3 storylines, it is also important to explore the aforementioned moderators that are known to influence the impact of sacrificial behaviors. Clinicians can help clients explore the moderators affecting each of the storylines by keeping in mind relevant research and best practices. When helping clients re-author new narratives, clients should be able to identify the existential tensions within each of the storylines that are a universal part of life's journey. The goal is to have clients re-establishing balance rather than trying to perfectly fulfill any one pole of any of the storylines.
Other interventions for sacrificing families comes from the caregiver stress literature that repeatedly has shown that there are three factors that can help mitigate the negative consequences of family sacrifice and increase the positive consequences. These are cognitive appraisals (discussed in this paper in terms of narrative), coping responses and social support [27].

Coping Skills Therapy
Despite one's initial energy, resources, and desires, all three can be depleted over time by the grind of family sacrifice. There is no one who has these characteristics go untouched by time and effort. Helping an ADD child with homework each night may become routine over the years, but the ability of the parent to sustain this activity depends on how well they have developed coping responses that limit the seepage of energy, resources and motivation. What coping skills are most important for the family to have in their toolbox? While every family will find different tools effective, best practices suggests the top 10 coping responses for those without much time and with limited financial resources often includes: routine exercise/walking, music, prayer/contemplation, humor, bibliotherapy and cinematherapy, online or invivo support groups, nature, daily schedules, self-rewards, and a commitment to try something totally new every month (this can be anything from trying a new route to get to the doctor, to asking someone for relief time, to deciding to save for a new sofa). While some of these coping skills can be part of the new narratives, others are simply great tools for the toolbox. Helping clients find effective coping skills is as much an art as a science. You have to find the right coping skills for the right person in the right situation at the right time at the right level of complexity. Humor may be a great coping response when you have to cancel a long awaited dinner out because your mother is having a crisis with her dinner mates at the nursing home but is not the right response when she is going into surgery!

Social Support Interventions
We will almost all be in positions of dependency at multiple points in our life. We will need someone to sacrifice their own desires in order to help us. While our loved ones will hopefully rise to the occasion and be our social support, the helpers also need social support. Indeed the helper needs assistance often as much as the person receiving the assistance.
It takes a village for any one of us to thrive in the position of primary helper. Maybe all your neighbor can muster is to drop off a carton of milk, but that act can go a long way to make one feel that they are appreciated, that they have one less thing on the "to do" list. When clients say "There is no one else to help", they are often looking at who can take over their role. Most often, they are correct and there isn't anyone else likely to become the primary helper. However, if the question is rephrased and instead of discussing who can replace the primary helper, one asks who can assist or support the primary helper, many more possibilities become apparent.

Acceptance and Commitment Therapy (ACT)
ACT helps people become resilient by teaching them to accept the inevitable negative thoughts and feelings about their sacrifice instead of trying to reframe them or deny their existence. If someone is feeling that life is unfair, the goal is to observe and experience that feeling and its associated thoughts without judgment. Then one draws upon their core values to decide how to proceed. For example, the spouse of the veteran who has had three deployments and lived as a single parent for many years, may indeed feel cheated, lonely and overwhelmed. But if one of their core values is serving country, they can be buffered, in part, by the fact that they are living their core values.
ACT asserts that many of our problems are due to fusing our behavior with our negative thoughts, constantly evaluating our experience, avoiding the negative feelings whenever possible and trying to rationalize our behavior (FEAR is the acronym). By practicing non-judgmental mindfulness and letting our behavior be guided by our loftiest values, we are reflected in a more dignified and noble mirror that enriches our life rather than drains it. There are now dozens of studies attesting to the effectiveness of ACT in reducing depression and anxiety [28]. ACT is classified as an evidence based treatment by the American Psychological Association, with the status of "Modest Research Support" in depression (APA, 2014).