Families have a powerful influence on health equal to traditional medical risk factors and can be very helpful in identifying the history and precipitants of patient’s problems, as well as potential future obstacles to the management and treatment of psychiatric conditions.
Illness exists in a social context, and a patient’s most important resource is the family.Family interventions have been found to be helpful in managing a wide range of psychiatric disorders including substance abuse, depression, bipolar disorder, schizophrenia, borderline personality disorder, conduct disorder, ADHD, eating disorder and obsessive compulsive disorder.
Problems in the way families deal with an illness may come to the attention of clinicians in a variety of ways. Indicators of family dysfunction include continual noncompliance with treatment, or a lack of improvement despite adherence to treatment recommendations.
Patients may show signs of anxiety and sadness, along with feelings of being alone to deal with their illness, and may report 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 at home when asked.
Family-based risk factors that can adversely influence the onset and course of illness include poor conflict resolution; low relationship satisfaction; high interpersonal conflict; criticism and blame; intrafamilial hostility; lack of congruence in disease beliefs and expectations; poor problem solving; extrafamilial stress, lack of extrafamilial support systems; poor organization; inconsistent family structure; family rigidity; low cohesion and closeness; and the presence of psychopathology in family members.
Conversely, there are many protective relational factors. These include good communication, good problem solving skills, adaptability, clear rolls, achievement of family developmental tasks, mutual support, open expression of appreciation, commitment to the family and strong extrafamilial social connections.
Most patients prefer that physicians involve family members in their care. And there are benefits for clinicians, too.
Family members can provide valuable information about the patient’s functioning at home and can help patients comply with treatment recommendations. They can also help keep track of medication side effects, and prodromal and residual symptoms.
Family members help in sharing responsibilities, lessen the patient’s anxieties, and facilitate and encourage, communication between health care providers.
The essential task in meeting with family members for the first time is to evaluate and assess their functioning in the context of understanding their problem. 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 most important step in meeting with the family for the first time is to establish a connection. 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.
There are three main goals when conducting a family assessment. The first is to orient the family to the interview process and to establish an open and collaborative relationship.
The second is to have family members identify all current problems including those that precipitated the meeting.
The third is to identify the transactional style that appears to be related to the family’s functioning. Dysfunctional transactional patterns are repetitive interactional processes that prevent effective resolution of ongoing interpersonal problems.
Not all families need family therapy, and not all psychiatrists need to become family therapists. However, I’ve found that talking to and meeting with the significant others of patients is a very productive and ultimately timesaving exercise.
There is reasonable empirical evidence that family interventions can act as an adjunct to medical treatment and provide benefits above and beyond what’s available from usual medical treatment.
Family therapies can be broadly divided into two groupings — psycho-educational interventions and relationship-focused interventions. There is no evidence that one type of family therapy is consistently superior to another.
Common goals of effective family therapies include increasing knowledge about the illness, decreasing guilt, redefining problems, increasing adaptive coping mechanisms, and clarifying boundaries.
Family therapy can also help participants improve communication skills, problem solving skills and parenting skills, and decrease conflict. Despite the current emphasis on biological psychiatry, patients continue to experience their illness in very personal ways and within a social context.
The effectiveness of medical treatments in psychiatry continues to be limited for many patients. Awareness of these treatment limitations and the broader psychosocial context in which psychiatric illnesses are embedded is a call to include patients’ families in the treatment process.
Treating the whole family tends to be more effective and less burdensome for the psychiatrist, as well as the patient.
Gabor I. Keitner, MD, is a professor of psychiatry and human behavior at Brown University in Providence, Rhode Island.