Psychologic Treatments—The Family
Essential Concepts
Family members (often parents or siblings) can be the greatest resources your patient has. Help family members understand the illness, and let them help you take care of their child or sibling.
Families need more help when there is violence or the police are involved, or when there is frequent relapse or the need for reassurance is high.
Use the stress-diathesis model to explain the role of stressful environments (which can be the family environment) on the patient without assigning blame.
“Never tell people how to do things. Tell them what to do and they will surprise you with their ingenuity.”
—George S. Patton, US Army General, 1885-1945
Schizophrenia affects everybody in the family. The dyadic view of patient and therapist is inappropriate and at times dangerous; you need eyes and ears in the community, and the family is your natural ally. Today, family work is more pragmatic and less theory driven than decades ago. In this chapter, I provide some suggestions on how to work with the family of your patient with schizophrenia, for everybody’s benefit.
REASONS FOR FAMILY INVOLVEMENT
Families often play a crucial role in aiding treatment and recovery simply because most patients are still living with their families or have returned to the family home after a crisis or a hospitalization. Having a child or sibling with any illness is stressful for parents and siblings; having a child or sibling with psychosis is even more stressful. The concept of relational trauma might be useful: Even if family members do not suffer from overt symptoms, the illness nevertheless
disrupts family function. In other areas of medicine, the burden on caregivers is openly acknowledged and addressed. Whereas family members who take care of patients with Alzheimer’s disease are supported, families who have a member with schizophrenia all too often still suffer alone. Psychologically problematic is the fact that a child might be lost without being dead, leading to protracted grief that does not resolve.
disrupts family function. In other areas of medicine, the burden on caregivers is openly acknowledged and addressed. Whereas family members who take care of patients with Alzheimer’s disease are supported, families who have a member with schizophrenia all too often still suffer alone. Psychologically problematic is the fact that a child might be lost without being dead, leading to protracted grief that does not resolve.
Think of these as the goals of family involvement and interventions:
Prevent family burnout to avoid abandonment of patients in the long run.
Decrease isolation of families because of the stigma of mental illness.
Alleviate guilt about having caused the illness.
Provide realistic assessment of the illness and prognosis, not too positive, not too negative. Give hope that a good life is still possible.
Teach families how to supervise medication adherence gently, without power struggles. Give the parent permission to be in charge of the medicine.
Teach skills how to avoid and handle crises. Do this without being patronizing. Acknowledge the strengths that families have shown.
Help reconnect patients with family members from whom they have been estranged, if this is desired.
Reduce relapse rates by reducing stressful interactions among family members (see below, under Expressed Emotions).
Make it clear that you not only understand that families have concerns but that you value their involvement. A good working relationship with families goes a long way, as Tom Sawyer (and General Patton) recognized.
TIPTom Sawyer understood how to motivate people to get a job done. Apply the Tom Sawyer approach to problem solving: Identify what needs to be done, then delegate appropriately (i.e., know the limits of family responsibilities). There is no reason that a family member cannot try to get a discharge summary from a hospitalization that happened in Alaska. (I found the Tom Sawyer approach mentioned in Kanter, 1996.)
As important as it is to help families help their sick relative, you also need to help patients deal with their families. While I always talk with family members who have accompanied a patient to the appointment, I also always talk to the patient alone as well to address concerns that the patient has about his or her family.
SELECTION OF FAMILIES
All families that want to be involved in the treatment of their child or sibling should be involved in it, but the degree and type of involvement vary. For many families, you simply being available for questions by phone or e-mail is sufficient. Even in those “low-maintenance cases,” I ask all my patients to bring one family member to one of the appointments “to touch base” at least once a year.
TIP
