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Original Article

Academic Psychiatry, 30:5, September-October 2006 http://ap.psychiatryonline.org 379

Overcoming Barriers in Working With Families

Alison M. Heru, M.D. Laura Drury, M.S.W., L.I.C.S.W.

Received December 29, 2004; revised January 23, 2006; acceptedFebruary 1, 2006. Dr. Heru and Ms. Drury are affiliated 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; [email protected] (E-mail). Copyright � 2006 Academic Psy-chiatry.

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.

Method: In 23 years of combined experience teaching familytherapy to psychiatry residents, the authors have identified typicalbarriers that residents face when beginning to work with families.

Results: Six clinical vignettes, with the resident’s concerns, thesupervisor’s intervention and the resident’s response, illustratethese barriers.

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.

Academic Psychiatry 2006; 30:379–384

The Accreditation Council for Graduate Medical Edu-cation’s (ACGME’s) 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.

Rationale for Meeting With Families

On review of the family research in general medicine,it is clear that families have a powerful influence onhealth, equal to traditional medical risk factors (3). Mar-ital partners especially have influential effects on health,with emotional support being the most important type ofsupport provided. However, negative, critical or hostilefamily relationships have a stronger influence on healththan positive or supportive relationships (3). Familystrengths, such as good parenting, can offset the effectsof family difficulties on children’s development (4). Goodfamily functioning, which includes clear, direct commu-nication, collaborative problem solving, strong familystructure, and good emotional relatedness, improves pa-tient outcome (5).

Family factors also influence the course of psychiatricillness. Patients with major depression who have signifi-cant family dysfunction have a slower rate of recovery (6,7). Conversely, good family functioning is identified asone of five factors that improves outcome in major de-pression (8). Families that demonstrate high levels ofcriticism, hostility, or emotional overinvolvement are

OVERCOMING BARRIERS WITH FAMILIES

380 http://ap.psychiatryonline.org Academic Psychiatry, 30:5, September-October 2006

known as high EE (expressed emotion) families (9). HighEE is a “significant 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 patient’srelapse. Critical relatives are more likely to hold patientsresponsible for their actions rather than attribute theirbehavior to the illness (15).

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 beneficial for bipolar disorder in children(20). In outpatients with major depression, couples ther-apy is as efficacious as medication and is more acceptableto patients (21). Other psychiatric illnesses also show bene-fits from family interventions (22).

Family involvement in patient care is recommended inthe APA’s Practice Guidelines, especially in the Guidelinesfor Schizophrenia (23). The Guidelines recommend estab-lishing a therapeutic alliance with the family, addressingthe family’s 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 efficacyof 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 efficacy ofmarital or family therapy.

Vignette 1. The Narcissistic Parent

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 andselfish. “Dr. M” tells his supervisor that the mother seemsmore concerned with her own feelings than her adolescentdaughter’s needs.

Resident’s Concerns

“Aren’t Families to Blame for Lots of Problems?”Psychiatry has a history of blaming the family for causingpsychiatric illness and using pejorative labeling, such as the“schizophrenogenic” mother (26). Dr. M’s desire to be em-pathic toward the patient may unwittingly ostracize familymembers who are often a focus for the patient’s anger. Itis important to ask residents to put themselves in the shoesof the family. “If this were your family member, how wouldyou like to be treated, and what would you need to know?”

Supervisor’s InterventionThe supervisor asks Dr. M to think about the mother’s

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 daughter’s wish to live with her fa-ther?

Resident’s ResponseDr. M begins to realize how difficult it is for the mother,

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 Alice’s 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.

Vignette 2. The Special Boy

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.


“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 influence on patient outcome (31). Statingthat there is no time to meet with the family may be a way

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of avoiding the family, especially if the family is perceivedas “angry” or “demanding” or as expressing high levels ofemotion which can be difficult for the resident to tolerate.

“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 relative’s 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 conflicts. 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.

“Shouldn’t I Wait to Meet With the Family UntilAfter I Know the Diagnosis?” Physicians may avoidmeeting with the family if they do not have a definitivediagnosis 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.

Supervisor’s InterventionThe supervisor acknowledges the resident’s anxiety and

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 become more “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?

Resident’s ResponseDr. N arranges a family meeting for that day. In the

meeting, he acknowledges the parents’ concerns and

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. B’s sadness, supports his desire for more involvementwith his son, and collaborates with him on how to spendmore time with his son.

Vignette 3. The Weeping Chinese Family

“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 benefits 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.


“I’m 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 flyingaround,” there is “difficulty keeping track” of the flow 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).

“I Have No Understanding of the Family’s 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 “fit.” There is, therefore, benefit in presenting oneselfas a naıve person, open to learning from the family abouttheir culture and family structure (35). This attitude of re-



spect, acceptance, and willingness to learn will help thefamily be more at ease in the interview.

Supervisor’s InterventionThe supervisor acknowledges Dr. P’s efforts to educate

herself about a patient’s 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.

Resident’s ResponseDr. P recognizes that she lost focus when confronted

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.

Vignette 4. Reluctant Husband

“Mrs. D” is 45 years old and has major depression. Herhusband, “Mr. D,” refuses to accompany her to the firstoutpatient meeting. “Dr. Q” calls the husband to invitehim in but is intimidated by the husband, who dismissesmany of his wife’s complaints, although he does emphasizethat their sexual relationship has become “a problem.”


“No One Expects Residents to See Families.” Theresident may perceive the social worker or the marriageand family therapist as the person to meet with the family.Medical family therapists are becoming part of the teamin many different specialties because they are cheaper,more attentive to patients and families, and because man-aged care increasingly wants to use them to bridge the gapbetween the medical profession and the family’s needs (36,

37). However, family medicine encourages all residents tomeet with families on a routine basis (38), and psychiatryhas traditionally valued family involvement. However,when asked, residents who have graduated state that theskills most needed after graduation and the skills leasttaught are family skills (39).

Supervisor’s InterventionThe supervisor points out that an assessment of the cou-

ple’s relationship is an important part of a comprehensiveassessment, although the husband is reluctant to partici-pate. The supervisor encourages Dr. Q to persist in herattempts to bring the husband in for an assessment.

Resident’s ResponseDr. Q agrees and calls the husband again. She explains

to him that each patient receives a full assessment in theclinic and that an assessment of the family is an importantpart of the routine workup. After the assessment, the cou-ple decides for themselves if they wish to enter couplestreatment. The husband agrees, expressing relief that it istime-limited.

Vignette 5. Mr. and Mrs. F

“Dr. R” is the therapist for “Mr. F,” a 48-year-old ex-ecutive who presented with depressive symptoms and in-creased job stress. As individual therapy progresses, Mr. Fbegins to focus on marital issues. He is concerned that“Mrs. F,” his wife of 20 years, is pulling away from him anddrinking heavily. Mr. F is anxious that his wife is involvedwith a co-worker and explains that when he tries to talkwith his wife, she becomes upset and refuses to talk. Mr.F discloses that 2 years ago he had an affair with his sec-retary, which was devastating to his wife. Mr. and Mrs. Fseparated for several months at that time but then recon-ciled. According to Mr. F, they never sought any counselingand did not discuss the issue further. Dr. R recognizes thatMr. F and his wife would benefit from couples counselingbut is uncertain if she should treat the couple or refer thecouple to another therapist.


“Should I See the Patient and the Family To-gether?” Dr. R is unsure whether she should meet withMr. F and his wife. Is she too aligned with Mr. F? Wouldanother therapist be more objective? Would Mrs. F acceptDr. R as an impartial therapist? Dr. R would like to treatthe couple.

HERU AND DRURY


Supervisor’s InterventionThe supervisor encourages Dr. R to talk with Mr. F

about bringing his wife into the office to participate in anassessment. This would provide Dr. R with the opportunityto assess Mrs. F’s use of alcohol and evaluate her recep-tivity to completing a couples assessment. Whether or notDr. R will treat the couple can be deferred until Dr. R hascompleted the couples assessment. After the assessment,as part of the negotiation for treatment, Dr. R can offertreatment or refer the couple to another therapist. In de-ciding how to proceed, Dr. R can explain to Mr. F thatcouples work is very different from individual therapy. Mr.F would need to understand their individual work focusesexclusively on Mr. F’s concerns and that in couples ther-apy, Dr. R would also be focusing on Mrs. F’s concernsand sometimes endorse her point of view. On the otherhand, Mrs. F might feel that Dr. R could never be fair toher, in which case another therapist would be preferable.Fairness has been identified as one of five preconditionsfor change in couples therapy (40). If the psychiatrist isunable to establish an atmosphere of fairness, then work-ing with the couple will be ineffective. The supervisor alsodiscusses the use of family treatment in alcoholism (41) incase Mrs. F does need specific alcohol treatment. One suchmodel, behavioral couples therapy for alcohol abuse or de-pendence, consists of weekly sessions over 5 to 6 monthsand the use of a daily sobriety contract (42).

Resident’s ResponseDr. R asks Mr. F to bring his wife into the next meeting

for a couples assessment. Mrs. F is pleased to come in andreadily agrees. Dr. R finds out that Mrs. F believes herhusband also drinks excessively. Both want Dr. R to com-plete the assessment and treatment. Using a sobriety con-tract, Dr. R incorporates abstinence from alcohol into thetreatment. Mrs. F assures Mr. F that she is not involvedwith a co-worker. The couple agrees to stop blaming eachother for infidelities and to work on increasing trust anddeveloping mutually acceptable hobbies and interests. Af-ter the couple’s treatment is completed, Dr. R continuesto see Mr. F for a short while to work on managing stressat work.

Vignette 6. Children in the Middle

“Harriet,” 9 years old, is admitted to the children’s unitfor behavioral dyscontrol, bed-wetting, and weight loss.Her parents, who have separated, are embroiled in a cus-tody fight over her and her 12-year-old brother, “John.”Harriet and John both live with their mother and visit on

weekends with their father. “Dr. S,” a child fellow, hasspoken at length with both parents separately. Both par-ents want to be actively involved in Harriet’s treatment.

Child Fellow’s Concerns

“Should I See the Patient and the Parents To-gether?” Because of the acrimony between the parents,Dr. S wonders if he should meet with the parents sepa-rately or together. Should Harriet be in the meetings?Should her brother, John, come to the family meeting? Dr.S is afraid of being involved in the parents’ legal battle overthe children.

Supervisor’s InterventionThe supervisor suggests that Dr. S meet with each par-

ent alone to discuss their concerns for Harriet. In the sepa-rate meetings, Dr. S is to assess whether the parents couldsuccessfully meet together with him to discuss Harriet’sproblems. If the parents are able to put aside their differ-ences and focus on what is best for their child, a joint ses-sion would be invaluable. If the joint session is successful,then Harriet and her brother can be included in the nextmeeting. An important part of working with this family isto help the parents appreciate their conjoint role as par-ents and that continued fighting hurts their children.

Child Fellow’s ResponseDr. S meets with Harriet and each parent separately. It

is clear at these meetings that the legal and emotional bat-tle between these parents is intense and that a family meet-ing together with both parents would not accomplish any-thing. This illustrates a realistic barrier to working with thewhole family. There are also similar situations in adult psy-chiatry, for example, where the patient is a victim of do-mestic violence and is afraid of her or his partner. How-ever, the standard of care should be to meet with thefamily, and only under exceptional circumstances shouldcare be delivered in isolation from the family.

Conclusions

The reasons to meet with families are clearly articulatedin the substantial body of research. Residents who masterfamily skills and meet with families of their patients on aregular basis express disbelief that assessment and treat-ment of patients can occur without the families being in-volved. The barriers to working with families need to bemade explicit and seen as part of the normal developmentof the psychiatric resident.



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