THE NEED FOR FAMILY INVOLVEMENT IN ASSESSMENT AND TREATMENT
Gabor I Keitner M.D.
Professor Department of Psychiatry
Brown University, Providence, RI
There are many reasons why psychiatrists do not assess or treat families. Meeting with families is often perceived as not being cost effective given current reimbursement systems. Equally important is a lack of training for psychiatrists in meeting with families, not only to gather information but also to help them learn how to deal with each other and their loved one’s illness.
Family therapy skills are not part of the “core competency” requirements for residency training programs. Without proper training working with families can be perceived as being more threatening than working with individuals.
Families have a powerful influence on health equal to traditional medical risk factors.(1) Families can be a reliable source of information about a patient’s problems, baseline level of functioning, who the patient is, and how she/he functions in the community. They can provide a longitudinal perspective on the patient’s dealings with others and the world. How a patient interacts with his/her significant others and how they in turn interact with the patient, greatly affects the duration of problems, the likelihood of their resolving or recurring over time.
Problems in the family in dealing with an illness may come to the attention of clinicians in a variety of ways. Patients may be non-adherent with treatment. There may be lack of improvement in spite of following treatment recommendations. Patients may show signs of anxiety and sadness along with feelings of being alone to deal with their illness, not receiving sufficient support or feeling blamed. There may be persistent disagreements and misunderstandings between the patient, family members and treatment providers. Patients may also directly express concern about relationship problems, especially if asked.
FAMILY RISK AND PROTECTIVE FACTORS
There are a large number of family based risk factors that adversely influence the onset and course of illness. These include: poor conflict resolution, low relationship satisfaction, high interpersonal conflict, criticism and blame, intra-familial hostility, lack of congruence in disease beliefs and expectations, poor problem solving, extra familial stress, lack of extra familial support systems, poor organization, inconsistent family structure, family rigidity, low cohesion and closeness, and presence of psychopathology in family members.
Conversely, there are many protective relational factors. These include: good communications, good problem solving skills, adaptability, clear rolls, achievement of family developmental tasks, mutual support, open expression of appreciation, commitment to the family, extra familial social connections. (1)
Most patients prefer that physicians involve their family in their care. Family members can help patients to adhere to treatment recommendations. Families can help to keep track of medication side effects and prodromal and residual symptoms. They can assist in sharing responsibilities, lessen the patient’s anxieties and facilitate as well as encourage communication between providers. (2)
IMPROVED HEALTH OUTCOMES
Family research clearly demonstrates that working with families of patients is an empirically valid practice. Family interventions have been shown to be helpful in managing medical illnesses such as hypertension, low back pain, diabetes, systemic lupus erythematosus, and dementia. Evidence based family interventions have been described for psychiatric illnesses including: alcohol dependence, PTSD, schizophrenia, bipolar disorder, major depression, borderline personality disorder, conduct disorder, ADHD, eating disorders and obsessive-compulsive disorder. (3, 4)
The family assessment is the first step in determining both the need for further interventions and the specific areas of family life that might need to be addressed. Family assessment should focus on adjustments related to the diagnosis of the illness, clarification of treatment options, and collaboration in carrying out the treatment plan. A proper assessment should also identify family strengths. The family needs to feel understood, respected, and validated. They do not want to be blamed for their loved one’s problems or judged for their perceived deficiencies. It is the job of the clinician to put families at ease and to make them feel comfortable enough to participate openly in the assessment process.
It is important to orient the family to the interview process, so that they know what to expect and to establish an open and collaborative relationship with them. The therapist should ask family members to identify all current problems in the family including the problem(s) that precipitated the meeting. The therapist should then assess ways in which families are organized and function and pay attention to family transactional styles that appears to be related to the presenting problem. The McMaster Model of family functioning is one way to conceptualize family functions and a systematic way of collecting and organizing that information. (5,6)
There is reasonable empirical evidence that family interventions, as adjuncts to medical treatment, provide benefits to patients and family members above and beyond what they receive from usual medical treatment. Family interventions can be broadly divided into two groupings, psycho educational and relationship focused.
There is no evidence that one type of family therapy is consistently superior to another. It is advisable to become proficient with at least one approach to assessing and treating families in order to become comfortable with including families in the treatment process. One such approach is the Problem Centered Systems Therapy of the Family. It is practical, clearly articulated and has been tested for efficacy with families of patients with mood disorders. (7)
Some of the common goals of effective family therapies include: increased knowledge about the illness, decreased guilt, redefinition of problems, increased use of adaptive coping mechanisms, improvement of communication skills, problem solving skills and parenting skills, clarification of boundaries, insight regarding current transactions and historical factors, decreased conflict, work on family of origin issues. Family interventions can be implemented successfully at all phases of illness: to prevent disease, to reduce chronicity and to improve functioning in the chronic phase.
Not all families of psychiatric patients are dysfunctional and not all families need family therapy. In fact, many families deal very effectively with recurring, chronic and severe illnesses. Even well-functioning families, however, can benefit from information about the illness, validation of effective ways of coping, and reinforcement of resilience in the face of major stresses. Being clear about what constitutes functional or dysfunctional families and about normal versus pathological ways of dealing with difficult situations is an important base from which to be able to evaluate the functionality of any family.
Meeting with families to assess their ways of dealing with an illness, to provide information, to provide support and to enlist their participation as collaborators in the treatment process should be a routine part of psychiatric care.
1. Campbell, T. L. (2003). The effectiveness of family interventions for physical disorders. J of Martial and Family Therapy, 29(2), 263-281.
2.Fisher L: Research on the family and chronic disease among adults: Major trends and directions. Families, Systems, and Health 2006;24:4:373-380.
3. Hartmann M, Bazner E, Wild B, et al. (2010). Effects of interventions involving the family in the treatment of adult patients with chronic physical diseases: a meta-analysis. Psychother Psychosom 79:136-148.
4. Heru A.M. (2006). Family Psychiatry: From Research to Practice. Am J Psychiatry 163(6):962-968.
5. Ryan CE, Epstein N, Keitner GI, Miller I, Bishop D: Evaluating and Treating Families: The McMaster Approach. New York, Routledge Taylor & Francis Group, 2005.
6. Keitner GI, Ryan CE, Epstein NB (2006). Family assessment. In: Goldbloom D (ed). Psychiatric Clinical Skills. Mosby Elsevier, Maryland Heights, MO pp 327-338.
7. Keitner GI, Heru AM, Glick ID (2010). Family Assessment; Clinical Manual of Couples and Family Therapy. American Psychiatric Publishing, Washington, pp 63-92.