The Family

and Jeffrey R. Strawn2



(1)
Department of Psychiatry and Child Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

(2)
Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA

 



Abstract

An integrated approach, recognizing that a family system depends on all its members to find a degree of stable balance, is crucial for improved treatment outcomes. In order to provide a sense of hopefulness and purpose, the consultant must work toward understanding the fears and expectations of each family member.

Perhaps the most challenging aspect for treatment teams working with difficult families is understanding and tolerating their anxieties, even if they are exhibited in the form of negative interactions. Families that experience anxiety and helplessness when their loved one is seriously ill may unconsciously resort to negative behaviors—triangulation , scapegoating, misuse of boundaries—in an effort to regain a sense of control over their environment. Treatment teams will benefit from seeking a psychiatric consultation to tease out how to best intervene and help the family participate in the treatment planning for their relative.


There is no doubt that it is around the family and the home that all the greatest virtues, the most dominating virtues of human society, are created, strengthened, and maintained

—Winston Churchill (1874–1965)



4.1 Dancing Together


The way that family members come to function as a unit can be likened to learning to dance. When families have learned to successfully dance with each other, there will be spoken and unspoken customs , rules, and patterns of behavior that are unique to them and yet serve the common goal of maintaining cohesion and stability of the family system . For some families, however, the dance reflects recurring patterns of conflict that provide a degree of cohesion but are still dysfunctional. In this chapter, we will describe a practical approach to common family systems conflicts and present some useful family-based and family-informed concepts that may be used in difficult psychiatric consultations. We will also review the importance that family system s theory has in consultation-liaison work. First, however, we will touch upon the early influence of family systems theory on psychiatry and child psychiatry.


4.2 Family Systems Theory


Family systems theory views families as being part of a dynamic and interactive system that changes over time. The main function of a family system is to support and nurture its members, and to promote their role as part of a larger collective community. The ways a particular family system supports and nurtures—that is, learns to dance with—each other develops over time according to the different temperaments, attachment styles, and personalities of each member. A family system is in essence the microcosm of a larger community and cultural system. Winnicott (1966) stated that a baby cannot exist alone, but is essentially part of a relationship. Bowlby (1999) also recognized in his work that an infant cannot exist without a set of loving persons, preferably a larger family system that functions collaboratively to care for them. He further emphasized that a person’s existence depends on the family system that has a past (before the person arrives) and a present (which includes the new member) and is part of a larger group, the community. The family system that functions well and is stable will intuitively know when a member needs support. It may be that a child with learning disabilities will require extra attention and time to complete their homework, or that an adult member with diabetes will need help following their diet.

It was during the early 1960s that general systems theory began to gain prominence in the scientific community, spearheaded by the work of the biologist Lvon (1950). He described systems as complex interactions between elements and used mathematical equations to indicate when systems were closed (if the elements did not have contact with the environment) and open (if they did). Family therapists excluded Bertalanffy’s mathematical approach but took hold of the concept of open and closed systems. These systems seek “homeostasis,” understood as the process by which a group of humans maintains a stable mode for survival. When the family system remains stable and balanced, then homeostasis is maintained and survival is assured. McConville and Delgado state that, earlier, “systemic approaches to family therapy were based on general systems theory, including the concept of cybernetics, which held that families tend to maintain equilibrium: a tension always exists between homeostasis and change, balancing stability and self-preservation with change and adaptation” (2006). The shift toward working with family systems had its origins in the social-work movement of the mid-1960s, when scholars and clinicians were dissatisfied with Freudian psychoanalytic theories. Ackerman, Minuchin, and Bowen—among the early family theorists who were analytically trained—found that general systems theory had many useful clinical applications to families and other social systems, and a number of distinct schools of family therapy began to emerge (Barker 1992; Hoffman 1981; Minuchin 1974; Minuchin and Fishman 1981). McConville and Delgado (2006) point out that “strategic and structural family therapies arose from this theory and focused on the observable as well as the reported family behavior” which is to say that several models of family therapy with different theoretical bases were developed, and though they had different theoretical bases, they shared an understanding of a family system’s problem as evolving from the interplay of its members. Although a family may see a specific member as the “identified patient,” the family therapist understands the problem as resting within the larger relational context of the family system as a whole. Therefore, in family systems theory, the diagnosis as such was not a central focus but rather the many unstable observable patterns of interaction seen in a family system.

Recognizing “unstable observable patterns of interaction” among family members is important during difficult psychiatric consultations. Not surprisingly, the work with families in such consultations can be quite challenging. It is essential to be familiar with family systems theory principles in order to address these issues and improve the outcome of the patient’s treatment. When working with families of patients in difficult psychiatric consultations, the clinician should identify the strengths and weaknesses that existed in the family system before the diagnosis . Taking the time to understand the stable state a family may have had prior to the medical or psychiatric condition is extremely valuable in identifying how to best intervene and guide the family toward reestablishing their state of relative equilibrium. In reviewing with the patient and family their behaviors, rules, and styles of communication, the consultant can use this information to outline interventions that are respectful of the family’s beliefs and customs . There will be significant changes in how a family system functions when coping with the inherent complexities of a medically or psychiatrically ill family member, and as such there will inevitably will be a recognizable “before and after the diagnosis” schism. In general, the psychiatric consultant’s role is to help the treatment team provide resources that help the patient and family move as close as possible toward a known equilibrium to promote a shared common goal: the best outcome for the patient.

When the treatment team , patient, and family are engaged in conflict , the psychiatric consultant should keep in mind that the conflicts are multilayered and are influenced by the different expectations all parties have of each other. Helping these parties involves readjusting their energies to work toward a shared purpose—that of delivering the best care for the patient. When a patient has a serious medical or psychiatric illness, their known healthy historical self is set off balance, and consequently the family’s stable historical collective self is also set off balance, as they are unable to tolerate the feelings of uncertainty and unpredictability the illness elicits in all. Once a stable system experiences the significant effects of the loss of predictability, it will promptly seek to regain it. How this change in the family system is displayed in the hospital or academic setting will be influenced by the interplay of all the family members’ adaptive roles.

In designing interventions based his or her understanding of family systems concepts as well as his or her knowledge of the particular family involved, the psychiatric consultant helps the family “readjust” their priorities to allow for mature decisions with a minimal amount of conflict and to support their medically ill loved one.

When viewed through the family systems lens, the complicating factors that arise due to a patient’s medical or psychiatric illness will move naturally, though perhaps with initial difficulty, toward homeostasis. Though subspecialty treatment teams are accustomed to treating people with illnesses that are similar, the patients’ families all present with different configurations of bio-psycho-social complexities, which necessarily influence the outcome. There is no one solution to any set of family problems. The psychiatric consultant’s role will be to explain to patient, family, and treatment team the impact that the medical or psychiatric condition has had on the emotional, relational, and cognitive strengths previously present. In more general terms, the usual family dance that existed before has now shifted. By understanding the patterns and identifying the patient’s and family’s unique needs, the psychiatric consultant can help treatment teams tailor their approach when delivering treatment plans, providing the patient and family with more informed expectations and a renewed level of encouragement.

Being diagnosed with a serious medical or psychiatric illness is frightening. When the condition is acute and known to respond to treatment, the family, although anxious, can reassure each other if there is a positive sense of predictability and certainty about the outcome. For example, knowing that the symptoms and changes in behavior of their loved one are the consequence of a viral upper respiratory tract infection is reassuring to the family, who understand that the condition will be short lived and that there is a high probability of a recovery. Furthermore, there is a sense of predictability and certainty about the treatment intervention, in this case with fluids and analgesics. The course and outcome are known factors, and balance is maintained. When the medical or psychiatric condition is acute but the course of treatment is unknown and complex, the homeostasis of the family is threatened, and issues of uncertainty and unpredictability arise. The reaction of a family system when one of its members is diagnosed with a serious medical or psychiatric illness is influenced by the unique and personal characteristics of each individual within the system. The reaction is further affected by the patient’s personality style and ability to empathize of the medical providers who have completed the medical or psychiatric work-up, and the setting in which the diagnosis is delivered. When the diagnosis is delivered in the emergency room or on the medical unit, for instance, the loss of the family homeostasis is palpable. The response by the family members is also dependent on whether the quality of life of their loved one is likely to change.

Uncertainty and unpredictability are, of course, states that most would prefer not to experience. They may easily reawaken regressive patterns of behavior commonly used when under duress. The psychological threat created by the diagnosis of a serious illness can interfere with the welfare and cohesion of the family system . With the loss of homeostasis comes a new set of dilemmas about how this crisis should be handled among its members. The illness will elicit a completely different way of organizing relationships within the context of the family, with likely new polarities. Some families are resilient and adapt to change quite well, while others hang on to unrealistic wishes, struggling to accept that there has been a significant threat to their system. They may deny that their spouse, child, parent, or sibling is seriously ill and psychologically believe that soon everything will be “just fine, the way it was before.”


Family Systems Theory in Difficult Consultations


The psychiatric consultant’s goal in working with families should be to provide concise and practical recommendations to all members that can improve their role in supporting their loved one during the many difficult aspects of their illness. These recommendations should be determined according to what can be expected of the family system , which is intrinsically related to their collective functioning. If a treatment team is unable to help the patient and families manage feelings of anxiety and distress in the treatment planning meetings, the patient and family will be less able to participate in the decision-making process necessary for the implementation and delivery of optimal care. The psychiatric consultant can help by suggesting the treatment team assign one of its members to address the family’s anxieties and explaining complex medical information. We have seen many cases in which the lead team member wants to “outsource” reassuring the family to a psychiatric consultant, believing it will take too much of his/her time. Despite this, the consultant with experience in family systems will facilitate the “dance” between patient, family, and team members, imbuing them with a sense of collective purpose. Of course, the consultant has limitations; he or she cannot make an angry and despondent family with temperamentally difficult/feisty members and with a disorganized attachment style become an easy/flexible family with a secure attachment style. Nevertheless, with the use of family systems concepts described later in this chapter, the consultant can help an angry family with a history of a disorganized attachment style learn to give priority to helping their family member, the patient, by allowing the treatment team to deliver and monitor the best-practice treatment needed, instead of engaging them in conflicted and unproductive interactions.

At the center of many requests for psychiatric consultation are family stressors not frequently recognized by the treatment team . When these stressors are not addressed early and with sensitivity, they can escalate rather quickly and lead to conflicts between family and treatment-team members. We have found that the most common family stressors, which are experienced as overwhelming, typically resolve after sensible interventions that can be implemented by the treatment teams (Josephson 2008). Unfortunately, families that are feeling overwhelmed do not often share their distress with treatment team, either from a sense of shame or the fear that they will receive lesser care if seen as “difficult.” Among the common unrecognized family stressors are: (1) when the distance from home to the treatment facility is significant; (2) when the family has a history of prior losses due to complications from medical conditions; (3) when there is financial concern about the treatment needed (medications, follow-up visits, hospitalization). We suggest that the psychiatric consultant ask several simple questions to help identify the conflict triggers between the family and treatment team. The responses will guide the psychiatric consultant in formulating practical interventions that allow the parties involved to create a partnership with an agreement that their end goal is to provide the patient the best evidence-based treatment possible (Table 4.1).


Table 4.1
Questions about family stressors













• Is the distance from the patient’s home to the treatment facility significant?

• Is there a history of losses in the immediate or extended family due to medical conditions?

• Do any members of the family have negative attitudes toward the medical field? If so, why?

• Do financial difficulties have a role in the family’s daily life?


If so, financially, what aspects will be most affected by the hospitalization?

We have seen difficult situations in which a family system is so distraught about caring for their loved one; they attempt to avoid participating in his or her care. When this happens, the treatment team may lose sight of the fact that there may be many psychological reasons that are overwhelming and affecting one or more of the family members expected to care for the patient. Upon observing that the family is not being attentive to their loved one, or not following the treatment recommendations, the team members may feel upset, perceiving that the family is either failing the patient or doesn’t have his or her best interest in mind. To avoid this situation, the psychiatric consultant should encourage the team to learn about family members’ ability to participate in their loved one’s care. Currently, there is scant reference to assessing how the family system can participate within the context of a seriously ill child. There is still less attention given to the evaluation of the spouse, significant other, or family of adult patients. What references exist are found in literature regarding organ transplants , which emphasize the need to routinely perform a psychiatric-psychological evaluation of the patient prior to surgery “to help determine the capacity to consent, the presence of psychiatric disorders, the suicidality, and the potential for self-care” (Mamah et al. 2004). In addressing the case of children who need organ transplants, the importance is placed on the evaluation of parents (Afifi et al. 2006; Guadagnoli et al. 1999). We hope to see more research about the role family members have in the length of time needed for recovery when a member is diagnosed with a chronic serious illness. We recognize the importance of family systems and suggest that more attention be given to how family members, including siblings, function as a unit.


4.3 Family Systems Concepts


As in Chap. 2, in which we cherry-picked psychodynamic concepts relevant to consultation-liaison work, we have selected what we consider useful and practical concepts about family systems theory in understanding families. The following are terms commonly used in family systems theory to describe the dynamics when a stable state (homeostasis) is lost and conflict among members ensues, as often occurs in complex consultations (Table 4.2): joining , reframing , triangulation , scapegoating, generational boundaries , permeable boundaries, and family mapping or genogram .


Table 4.2
Common terms from family systems theory

















• Joining: technique used to build rapport with family

• Reframing: giving new meaning to a behavior or set of interactions

• Triangulation: two family members, in conflict , attempt to enlist the support of a third ally

• Scapegoating: family projects problems on a particular member of their system

• Generational Boundaries: a family’s age-related hierarchy on how to psychologically relate to each other

• Permeable Boundaries: boundaries susceptible to change due to patterns of closeness between family members


Family Mapping/Genogram : a visual display of a person’s family tree


Joining


This term is used to describe the rapport -building process necessary to allow the family therapist to make comments that facilitate communication among the family members with the therapist. Several rapport-building techniques that a therapist might use are: taking a one-down position (i.e., the consultant avoids the role of “expert” and empowers patient/family) without challenging the family’s views, particularly when members have problems with authority figures; identifying common experiences, such as sports, cultural, or social events; matching the vocabulary used by the family. In difficult psychiatric consultations, joining with patient and family is essential for the consultant to be seen as someone who can broker the impasse that exists with the treatment team .


Reframing


“Reframing” refers to therapeutic approach in which the psychiatric consultant relabels the interactions between family members, providing a different perspective that increases awareness about the fact that a situation can have several “truths.” This broadening of perspective gives the provider the space needed to change a negative pattern of interaction for a new one without feeling a loss of control over decisions.


The Pediatric Patient and Family Who Frustrate the Treatment Team


Melissa, an 11-year-old girl, is transferred from a community hospital to a large academic medical center after being diagnosed with an autoimmune encephalopathy . At the community hospital, in the context of her encephalopathy, Melissa’s right arm was initially flailing uncontrollably, and she was yelling out words and was tremulous. Moreover, she appeared to be responding to internal stimuli and actively experiencing visual hallucinations. Upon her arrival at the academic medical center, her care is assumed by the neurology service, and plasmapheresis is initiated to treat her encephalopathy. A parenteral antipsychotic, olanzapine, is begun to treat the patient’s delirium, but over 2 days, the neurologists find that olanzapine only minimally improves her delirium. At that time, a psychiatric consultation is requested.

Initially, the attending neurologist had informed Melissa’s parents, with empathy and honesty, that their daughter’s autoimmune encephalopathy could be fatal or might leave her with a chronic mental disability that would prevent her return to a functional state. Melissa’s parents began to cry and said that they wanted their daughter to be medicated to keep her from “knocking things over and screaming out.” The neurologist agreed, though also expressed that it was best not to overmedicate Melissa because they would not be able to assess whether her mental status and neurologic condition were improving or worsening.

During the same conversation the neurologist shared with the parents a desire to involve social services, who would make arrangements for them to temporarily stay at a local hospital-affiliated facility where they could have some reprieve from the hospital, would be able to change clothes, shower, etc. Melissa’s parents became irritated and told the team, “No, we don’t need a social worker,” and thereafter refused to speak with any of the neurology team members. Fortunately, they felt understood by the nursing staff, which relayed their questions, observations, and requests to the neurology team.

The psychiatric consultant reviewed the information available, met with neurology team, and met with Melissa’s parents (Table 4.3). The consultation-liaison team, after introducing their members—attending psychiatrist, resident, and fellow—and explaining why the neurologist had requested the consult, shared with Melissa’s parents that they believed quetiapine could be helpful in managing their daughter’s agitation (Turkel et al. 2012). Shortly after this discussion, the parents had a “meltdown” in the intensive care unit where Melissa was receiving plasmapheresis, and they “cussed out” the neurology team, blaming their daughter’s agitation on the new medication, although the behavioral chart indicated it had actually lessened. At that point, the neurology team became frustrated with the psychiatric consultants, saying, “You need to tell the parents that they cannot behave like this,” adding, “If they are not going to allow us to treat their daughter how we think is best, we might have to transfer her to another hospital.” The psychiatric consultant, in an effort to use this as a teachable moment, spoke with the neurology team about the difficulty that Melissa’s parents had had: they were being asked to cooperate with complete strangers when in fact their daughter could die at any minute. The key member of the neurology team replied, “Well, the parents are really going through a lot, and they must be angry that are going to lose their healthy daughter. They actually are doing their best. I will go later and speak with them about all of the options and the importance treating her delirium appropriately.”


Table 4.3
The pediatric patient and family who frustrate the treatment team

























































 
Patient before diagnosis

Patient after diagnosis

Family before diagnosis

Family after diagnosis

Treatment team members

Suggested consultant’s intervention

Observed cognition

Good

Impaired

Good

Limited/good

Inflexible

• Helps the treatment team members recognize their own fear in having to deliver potentially devastating news to caring, although overwhelmed parents has led them to take a rather inflexible approach to the case.

• Reminds the treatment team of parents strengths, prior to daughter’s illness.

Observed temperament

Easy/flexible

Difficult/feisty

Easy/flexible

Difficult/feisty

Slow to warm up

• Facilitates parents, and treatment team members, recognition of common goals and the need to develop a collaborative partnership.

Observed defense mechanisms

Mature

Self-injurious behaviors

Mature

Immature

Neurotic

• Encourages the treatment team to provide ample time for questions when explaining to parents the seriousness of daughter’s condition.

• Shares and discusses experience in other similar cases to reassure parents of their approach to the condition.

Observed attachment style

Secure

Insecure

Secure

Anxious

Anxious

• Helps parents discuss fears.

• Provides the psychological space for the patient’s parents to feel safe and to share their frustrations with the treatment team and gradually help them reflect that some of their frustrations relate to their own fear of vulnerability.

Family

Scapegoat

Stabilizer (under crisis)

Scapegoat

• Helps parents identify factors that led them to retreat from their typical stabilizing roles.


The table may be used to succinctly identify and assess the areas that require action by the psychiatric consultant in complex psychiatric consultation. It permits a careful and practical multidimensional assessment of the patient, his or her family, and the treatment team and will facilitate interventions that will allow the consultant to collaborative with all parties, with the best interests of the patient in mind. In the table, we have used italics to indicate relevant changes (e.g., pre-diagnosis and post-diagnosis), which may be the focus of clinical attention

Later that day, the consulting psychiatrist spoke with Melissa’s parents at length and observed, “It seems there’s something about using this particular medication that really frightens you.” They replied that Melissa’s mother had worked in a nursing home and felt that the nursing home staff “would just keep the patients sedated all day long with that antipsychotic, and they looked like zombies.” The consultant was able to join with Melissa’s parents in feeling powerless and reframed the need for the medication as something that would help the patient with her discomfort and agitation, rather than sedate her. Also, the consultant used a “one-down position ” in which he asked Melissa’s parents, “Would you consider allowing us to use quetiapine, just a few more doses, to help with Melissa’s agitation?”

Using a family systems approach, joining , the consulting team asked Melissa’s parents what their daughter’s summer had been like and how had she’d done at school before the illness. In tears, Melissa’s parents told the team that the summer had been fun, adding that Melissa enjoyed swimming, that she was a “straight A student,” and had been eagerly looking forward to sixth grade. They had clearly begun the mourning process of their high-achieving daughter and were struggling with the feeling any psychologically healthy parent would have, not wanting to accept such a sad reality.


Diagnostic Formulation and Interventions for Melissa (Table 4.3)

The Patient. Melissa exhibits psychological and cognitive changes consistent with her autoimmune encephalopathy , which requires pharmacological interventions to address secondary agitation. In this case, the shift in observed temperament , defense mechanisms , and attachment style after being diagnosed with autoimmune encephalopathy are clearly not amenable to psychological intervention by the consulting psychiatry team.

Intervention by Psychiatric Consultant. The psychiatry team makes pharmacological recommendations to decrease the patient’s agitation.

The Family. Melissa’s parents manage their anxieties, fears, and anger about their daughter’s serious condition by projecting onto the treatment-team members, and they perceive the treatment team as not being supportive, believing members act in a negative way toward their daughter: “They just want to medicate her so she can be like a zombie.” The healthy and stable system that allowed Melissa to be a high-achieving adolescent prior to her illness was abruptly disrupted by the autoimmune encephalopathy . The acute onset of the illness led the usually high-functioning parents to suddenly transition to observed difficult/feisty temperaments, limitations in cognitive and affective flexibility, and the use of immature defense mechanisms .

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Dec 3, 2016 | Posted by in PSYCHOLOGY | Comments Off on The Family

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