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23. Psychological Treatments: The Family
Keywords
Family psychoeducationNAMIFamily-to-family programExpressed emotions (EE)Stress-diathesis modelOpen dialogueEssential Concepts
Family members (often parents or siblings) can be the greatest resource 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, when there is frequent relapse, or when 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.
The expressed emotion model captures the reality that some family environments are more stressful than others for vulnerable patients, leading to relapse. Critical comments may be particularly difficult to manage for those patients sensitive to interpersonal interactions.
Refer families to the National Alliance on Mental Illness (NAMI) which provides family education and support. Their 12-week family-taught family-to-family education program improves coping and family function.
Open dialogue is an intervention that engages a patient’s larger social network at a time of crisis such as a psychotic episode, emphasizing open and honest discussion between all parties affected by the patient’s illness and seeking a mutually agreed upon solution.
“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 [1]
Schizophrenia affects everybody in the family. A narrow, dyadic view of patient and therapist is unhelpful at best 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 many 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. Family homeostasis is disrupted, and families struggle to regain a sense of normal family life. In other areas of medicine, the burden on caregivers is openly acknowledged and addressed. Family members who take care of patients with Alzheimter’s disease, for example are supported, whereas families who have a member with schizophrenia all too often still suffer alone [2]. Psychologically problematic is the fact that a child with schizophrenia might be lost without being dead, leading to protracted grief that does not resolve [3].
Prevent family burnout to avoid abandonment of patients in the long run. All homeless patients had parents and a home at some point.
Decrease isolation of families because of the stigma of mental illness.
Alleviate guilt about having caused the illness.
Provide a realistic assessment of the illness and its prognosis, not too positive, not too negative. Always 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 if the patient lives at home.
Teach skills on how to avoid and handle crises. Do this without being patronizing but do it in a spirit of collaboration. Acknowledge the strengths that families have shown. Assume that solutions are in the family.
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).
Tip
Tom 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, and 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 (assuming you practice in Boston, like me). (I found the Tom Sawyer approach mentioned in Kanter [4].)
As important as it is to help families help their sick relative, you also need to help patients deal with their families (the idea of “managing up,” from the business world). While I always talk with family members who have accompanied the 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. As a rule of thumb, I always include the patient when speaking with the family to model an open approach that cuts through the collusion and the real patient concern that “things are done behind my back.” If families want to use email to communicate with me, I insist that patients are included in order to foster patient-centered care. Most patients readily accept some family involvement if you explain your reasons for it. Make family involvement an official part of treatment by having your patient sign the required paperwork related to patient privacy. Do not forget that families can always let you know if there are concerns (even if a patient has not signed the proverbial “release”).
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, simply being available for questions by phone or the occasional email 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 and at the beginning of treatment. Having had family contact at the beginning of treatment goes a long way in managing a crisis later in treatment. Do not forget to include siblings of patients. Eventually, they may be the ones who have to take over for aging parents. Siblings may also have a less conflicted relationship with the patient compared to parents, particularly if patients resist the often-needed resumption of parental supervision.
Tip
Know who is in the patient’s family. I have found that it works best if you set aside a visit during who literally draw a family tree with the patient. I do this even with patients I have known for years: “Let me go over your family today in a little more detail.” Figure out, “Who lives where? When was the last time you saw your brother? What is your father doing?” For some patients, staff members in group homes or day programs are their family. Find out who is important and trusted.
Red flags for need for intensive family involvement
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