Overcoming Barriers in Working With Families

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<ul><li><p>Original Article</p><p>Academic Psychiatry, 30:5, September-October 2006 http://ap.psychiatryonline.org 379</p><p>Overcoming Barriers in Working With Families</p><p>Alison M. Heru, M.D. Laura Drury, M.S.W., L.I.C.S.W.</p><p>Received December 29, 2004; revised January 23, 2006; acceptedFebruary 1, 2006. Dr. Heru and Ms. Drury are afliated with theDepartment of Psychiatry, Butler Hospital, Providence, Rhode Is-land. Address correspondence to Dr. Heru, Department of Psychia-try, Butler Hospital, 345 Blackstone Boulevard, Providence, RI02906; aheru@butler.org (E-mail). Copyright 2006 Academic Psy-chiatry.</p><p>Objective: The Accreditation Council for Graduate MedicalEducation and the Residency Review Committee for psychiatryoutline the expected competencies for residents. These compe-tencies include working with families. This article describes bar-riers that residents face when working with families, and offersways to overcome these barriers.</p><p>Method: In 23 years of combined experience teaching familytherapy to psychiatry residents, the authors have identied typicalbarriers that residents face when beginning to work with families.</p><p>Results: Six clinical vignettes, with the residents concerns, thesupervisors intervention and the residents response, illustratethese barriers.</p><p>Conclusions: In order for residents to become skilled in workingwith families, barriers should be made explicit and ways of over-coming these barriers should be discussed clearly with residents.</p><p>Academic Psychiatry 2006; 30:379384</p><p>The Accreditation Council for Graduate Medical Edu-cations (ACGMEs) description of the core compe-tencies includes the expectation that residents work withfamilies (1). Teaching residents a set of family skills is alsorecommended by the Family Committee of the Group forthe Advancement of Psychiatry (GAP) (2). Adequatefamily skills include conducting a family meeting andintegrating family factors into a biopsychosocial formu-lation and treatment plan. Family skills are to be differ-entiated from family therapy, a psychotherapy that re-quires extended supervision. Although some residencyprograms include family therapy training in their curric-ula, few psychiatry residencies teach family skills, whichcan be taught by supervisors with an interest in this area.This article assists supervisors by identifying the typicalbarriers that residents face when beginning to work withfamilies.</p><p>Rationale for Meeting With Families</p><p>On review of the family research in general medicine,it is clear that families have a powerful inuence onhealth, equal to traditional medical risk factors (3). Mar-ital partners especially have inuential effects on health,with emotional support being the most important type ofsupport provided. However, negative, critical or hostilefamily relationships have a stronger inuence on healththan positive or supportive relationships (3). Familystrengths, such as good parenting, can offset the effectsof family difculties on childrens development (4). Goodfamily functioning, which includes clear, direct commu-nication, collaborative problem solving, strong familystructure, and good emotional relatedness, improves pa-tient outcome (5).</p><p>Family factors also inuence the course of psychiatricillness. Patients with major depression who have signi-cant family dysfunction have a slower rate of recovery (6,7). Conversely, good family functioning is identied asone of ve factors that improves outcome in major de-pression (8). Families that demonstrate high levels ofcriticism, hostility, or emotional overinvolvement are</p></li><li><p>OVERCOMING BARRIERS WITH FAMILIES</p><p>380 http://ap.psychiatryonline.org Academic Psychiatry, 30:5, September-October 2006</p><p>known as high EE (expressed emotion) families (9). HighEE is a signicant and robust predictor of relapse inmany psychiatric illnesses (10), such as schizophrenia(11), depressive disorders (12), acute mania (13), and al-coholism (14). How a family member perceives mentalillness can also play an important role in the patientsrelapse. Critical relatives are more likely to hold patientsresponsible for their actions rather than attribute theirbehavior to the illness (15).</p><p>Family-based interventions reduce relapse rates, im-prove recovery of patients, and improve family well-beingamong participants, as shown by 30 randomized clinicaltrials (16). Family-based interventions are effective for pa-tients with schizophrenia (10), bipolar disorder (17), bor-derline personality disorder (18), and alcoholism (19), andare potentially benecial for bipolar disorder in children(20). In outpatients with major depression, couples ther-apy is as efcacious as medication and is more acceptableto patients (21). Other psychiatric illnesses also showbene-ts from family interventions (22).</p><p>Family involvement in patient care is recommended inthe APAs Practice Guidelines, especially in the Guidelinesfor Schizophrenia (23). The Guidelines recommend estab-lishing a therapeutic alliance with the family, addressingthe familys needs and routine family meetings to exchangeinformation on illness management. The Guidelines forSchizophrenia state, On the basis of the evidence, personswith schizophrenia and their families who have ongoingcontact with each other should be offered a family inter-vention, the key elements of which include a duration ofat least 9 months, illness education, crisis intervention,emotional support and training in how to cope with illnesssymptoms and related problems. The Practice Guidelinesfor Bipolar Disorder (24) and Depression (25) also rec-ommend early family involvement and present the efcacyof family-based interventions. Practice Guidelines forother disorders, such as panic disorder, eating disorders,and substance abuse disorders, similarly recommend earlyfamily involvement and provide evidence of the efcacy ofmarital or family therapy.</p><p>Vignette 1. The Narcissistic Parent</p><p>Thirteen-year-old Alice, who lives with her mother,expresses the desire to live with her father. She is angrywith her mother whom she describes as controlling andselsh. Dr. M tells his supervisor that the mother seemsmore concerned with her own feelings than her adolescentdaughters needs.</p><p>Residents Concerns</p><p>Arent Families to Blame for Lots of Problems?Psychiatry has a history of blaming the family for causingpsychiatric illness and using pejorative labeling, such as theschizophrenogenic mother (26). Dr.Ms desire to be em-pathic toward the patient may unwittingly ostracize familymembers who are often a focus for the patients anger. Itis important to ask residents to put themselves in the shoesof the family. If this were your family member, howwouldyou like to be treated, and what would you need to know?</p><p>Supervisors InterventionThe supervisor asks Dr. M to think about the mothers</p><p>perspective. What might the mother feel? What has tran-spired over the past 13 years? Has the mother been theprimary parent for 13 years and now faces the loss of herdaughter? How can the mother manage her own feelingswhile supporting her daughters wish to live with her fa-ther?</p><p>Residents ResponseDr. M begins to realize how difcult it is for the mother,</p><p>who has been the main support and caregiver for herdaughter, to suddenly relinquish care. Dr. M imagines themother may feel a sense of loss and may need support tohonor Alices wishes. Dr. M wants to help the daughterexpress gratitude to her mother and help the mother un-derstand that this is not a rejection of her but rather anattempt by Alice to develop a closer relationship with herfather. Dr. M is now able to engage with the family in amore empathic way.</p><p>Vignette 2. The Special Boy</p><p>The nursing staff tells Dr. N that Mr. B is a prob-lem. The nurses report that he expects special arrange-ments to be made for his 10-year-old son, Chris. Hewants his son on a special diet, to play basketball in thegym each evening, and to have extended visiting hours.Mr.B presents the nurses with a list of questions about pro-cedures on the unit, such as what happens if one childbullies another.</p><p>Residents Concerns</p><p>I Have No Time to Meet With Families. Meetingwith families improves patient compliance (27, 28),strengthens the alliance between patient and physician(29), sets the stage for future problem solving (30), andhas a positive inuence on patient outcome (31). Statingthat there is no time to meet with the family may be a way</p></li><li><p>HERU AND DRURY</p><p>Academic Psychiatry, 30:5, September-October 2006 http://ap.psychiatryonline.org 381</p><p>of avoiding the family, especially if the family is perceivedas angry or demanding or as expressing high levels ofemotion which can be difcult for the resident to tolerate.</p><p>What Does the Family Want? Family membersusually see themselves as advocates and want to be in-volved with their ill relative (32). Families may express asense of failure as they acknowledge their inability to re-solve family problems and may express guilt or blamethemselves for their relatives illness. In a family meeting,family members may be anxious as they anticipate beingdiscussed, criticized, and confronted. Children may fearbeing punished, getting their parents in trouble, or beingcaught in loyalty conicts. Families state that they do notwant lengthy and intensive interventions but family carethat focuses on building rapport and communication withmental health professionals (33). Families therefore ex-press several needs: to be included in the care of theirrelative, to be understood, and to be respected as con-cerned relatives who are doing the best they can.</p><p>Shouldnt I Wait to Meet With the Family UntilAfter I Know the Diagnosis? Physicians may avoidmeeting with the family if they do not have a denitivediagnosis and treatment plan, as they do not want to beseen as incompetent. Being straightforward with the familyabout the need to gather more information is acceptableto most families. Meeting with the family for a short timeto explain the process will help engage the family and es-tablish a collaborative relationship. The willingness of theresident to reach out to a family is reassuring to the familyand is seen as supportive and caring.</p><p>Supervisors InterventionThe supervisor acknowledges the residents anxiety and</p><p>wish to avoid the hostile or demanding family. The su-pervisor advises that the resident quickly engage the familybecause, if ignored, the family will likely becomemore de-manding. The resident is encouraged to think about whatit must be like for Mr. and Ms. B to have their son hos-pitalized. Do the parents feel responsible and blame them-selves? Do they feel helpless and worried that their sonhas a major mental illness? Is their list of questions anattempt to gain some control and quell their fears? Arethe parents advocating for their son? What do they un-derstand about the process of hospitalization?</p><p>Residents ResponseDr. N arranges a family meeting for that day. In the</p><p>meeting, he acknowledges the parents concerns and</p><p>praises their questions as addressing important aspects ofcare. He then asks, What is it like to have your son hos-pitalized? Mr. B becomes tearful and talks about beingan absent father when his son was young. Dr. N validatesMr. Bs sadness, supports his desire for more involvementwith his son, and collaborates with him on how to spendmore time with his son.</p><p>Vignette 3. The Weeping Chinese Family</p><p>Dr. P is anxious about meeting with the large familyof her patient, a 50-year-old Chinese woman with majordepression. Preparing for the meeting, Dr. P reviews theliterature about Chinese culture and mental health, whichstresses the importance of respecting the reserve and dig-nity of the Chinese family. The patient arrives for the fam-ily session with her elderly father, three adult siblings, andtwo children. Dr. P greets the family and, to her surprise,the family begins to wail and talk non-stop in Mandarin.Dr. P is caught off guard and allows the family to continuecrying and talking among themselves. Eventually she asksthe family to focus on why they are here and speak in En-glish. Dr. P then educates the family with an explanationof major depression, explaining the risks and benets ofantidepressant medication. Dr. P asks if the family has anyquestions. Several family members begin to voice theirconcerns, and Dr. P worries that she will lose control ofthe meeting and prematurely reassures the family thatthings will improve in a few days.</p><p>Residents Concerns</p><p>Im Afraid of Being Outnumbered and Not Under-standing What Is Happening. Residents avoid fam-ilies because they perceive themselves as unskilled. Resi-dents often report feeling anxious in a family meetingbecause there are too many dynamics and emotions yingaround, there is difculty keeping track of the ow ofdialogue, and they feel unable to incorporate the multipleperspectives of the various family members. Providingstructure to a family meeting reduces dynamic interactionsand gives the resident a road map for the meeting (34).</p><p>I Have No Understanding of the Familys Cultureor Background. It is helpful to be knowledgeableabout a particular culture, but sometimes, as in the caseof Dr. P and the Chinese family, cultural descriptions donot t. There is, therefore, benet in presenting oneselfas a nave person, open to learning from the family abouttheir culture and family structure (35). This attitude of re-</p></li><li><p>OVERCOMING BARRIERS WITH FAMILIES</p><p>382 http://ap.psychiatryonline.org Academic Psychiatry, 30:5, September-October 2006</p><p>spect, acceptance, and willingness to learn will help thefamily be more at ease in the interview.</p><p>Supervisors InterventionThe supervisor acknowledges Dr. Ps efforts to educate</p><p>herself about a patients culture and her confusion whenthe Chinese family began to weep; however, the supervisorthinks that Dr. P could have taken control of the meetingmore quickly and recommends beginning a family meetingwith an orientation as to the purpose of the meeting. Theorientation should include the explanation that each per-son will have a limited time to talk, as it is important tohear from everyone. The resident can respectfully explainthat she may need to interrupt to allow everyone time tospeak. As the meeting progresses, the resident can referback to her previous statement that she might have to aska family member to stop talking. This may reduce potentialfeelings of shame or anger. The meeting also should in-clude a discussion of diagnosis, current assessments, andtreatment plan.</p><p>Residents ResponseDr. P recognizes that she lost focus when confronted</p><p>with an unexpected display of emotion. She rehearses thefollowing with her supervisor: I see that everyone is veryupset right now. Would you all like some time togetherbefore we start the meeting? I could come back in a fewminutes and see if you are ready to begin talking. Thesupervisor also suggests that if the family is unable to par-ticipate in a meaningful way, then the meeting can be re-scheduled.</p><p>Vignette 4. Reluctant Husband</p><p>Mrs. D is 45 years old and has major depression. Herhusband, Mr. D, refuses to accompany her to the rstoutpatient m...</p></li></ul>