The arguments for including families in the process of any mental health procedure range from strictly practical to more theoretical. Practically speaking, families take care of their family members. They usually report the emergency, accompany the patient to the emergency department, and assume responsibility for caring for the patient throughout the course of the emergency response and ongoing treatment. Family members provide important information about the patient as well as information about the circumstances leading to the crisis. Recognizing this fact, mental health professionals can identify the family as a significant resource. A complete assessment of the strengths of the family as a resource will critically influence decision making about interventions. Not taking the family into account risks alienating the family from the mental health providers and, more problematically, possibly alienating the family from the patient. Frequently, when the family is ignored, the patient’s condition is “medicalized” and the family’s sense of expertise about the patient is undermined. The family’s ability to care for the patient is then diminished.

When families are involved in patient care, benefits occur both for the patient and the family. A Denver-based crisis intervention project demonstrated that patients sent home from the emergency department with a treatment intervention in the home had a speedier recovery, decreased morbidity (manifested by shorter time away from daily activities), and decreased relapse rate compared with patients who were hospitalized (2). The patients receiving the home-based intervention were randomly selected from patients presenting to the emergency department whose condition was deemed serious enough to warrant hospitalization. Those treated in their homes with family involvement had decreased overall morbidity, a shorter time before returning to premorbid functioning, and decreased relapse rate. However, these findings, although well publicized, did not significantly influence practices of engaging families in treating psychiatric crises. This is consistent with the general preeminence of a medical model for psychiatric illnesses that locates disease within the individual and relies on medical treatment for psychiatric illness.

Many randomized clinical trials have demonstrated that family-based interventions reduce relapse rates, improve recovery of patients, and improve family well-being among participants (3). Successful family intervention reduces
rates of relapse and improves quality of life for patients with schizophrenia (4), bipolar disorder (5), major depression (6), borderline personality disorder (7), and alcoholism (8). Two detailed reviews of family research over the past 10 years have been completed for both child and adolescent psychiatry (9) and adult psychiatry (10).

The benefits of family interventions extend beyond the patient to the family itself. Seventy percent of family members who have recently had a family member hospitalized reported depressive symptoms as well as impaired social, family, physical, and emotional functioning (11,12). If families attend psychoeducational programs, they report less displeasure and worry about their ill family member; feel more empowered in the community, in their family, and with the service system (13); have greater knowledge and self-efficacy; and are more satisfied with the patient’s treatment than those who do not participate (14).

The perspectives of children of parents with a psychiatric illness clearly indicate a need for more support and educational information (15). In the United Kingdom, children and young adults who have parents or siblings with psychiatric illness utilize their own website (www.youngcarers.net) and participate regularly in community-based activities. In the United States, literature is also available for helping teens cope with parental illness (16). It is strongly recommended that all family members be given literature and information about community resources to help them cope when a family member with chronic mental illness presents with an emergency.

Certain children are at risk themselves of developing psychiatric illness. In a large study of health care use patterns among children and adults, the influence of parental illness was evident (17). Teenagers of depressed parents had fewer well-child-care visits but more visits to emergency departments and specialty clinics, and infants of depressed parents had 14% more sick visits than children of nondepressed parents. It is therefore worth screening family members for the presence of psychiatric illness, especially depression.

Involving families in assessment and treatment can also substantially improve risk management. During the initial assessment, listening to a patient’s family members and recognizing them as valuable sources of information about the patient is an important and easy way to reduce risk in psychiatric practice. Families can provide information that increases the likelihood of an accurate diagnosis or early detection of harmful behaviors such as substance abuse and self-injurious behavior. Family members usually want to be helpful; they often appreciate guidance to lessen the likelihood of harm to their loved ones. Listening to the family, taking their fears and concerns seriously, and teaching them how to help keep their loved one safe are important first steps to providing optimal family-oriented patient care. It is important to document the steps taken to ensure the safety of the patient and others. These statements may be subject to discovery or search warrant in court proceedings. Courts may interpret a failure to document as evidence that care has fallen below an acceptable standard. Good documentation and good rapport with family members perform a protective function against adverse incidents (18).

Finally, to be more effective in caring for our patients, we need to support and encourage the practice of assessing the patient from a biopsychosocial perspective. This means attention to the family environment as the primary social milieu within which the patient lives. This is especially important in the emergency situation, where the synthesis of collateral information enriches the clinician’s understanding of the patient’s presentation and informs the necessary elements of the treatment plan (19).

Every professional who responds to psychiatric emergencies should have adequate family skills to interview, assess, and support family members as part of a comprehensive assessment and disposition in the emergency situation. Good family skills include displaying an attitude of interest and warmth and having an appreciation of the multiple points of view of all family members. The professional should be comfortable sitting with families, and familiar with the typical concerns of family members. The professional should have an appreciation of the impact of illness across generations, because effects can be felt by the parents, spouse, and children of the identified
patient. Extended family members and close friends can also be invited to join a family meeting if they are closely connected to the patient.