Alison Heru, MD
Professor and interim chair, Department of Psychiatry, University of Colorado School of Medicine.
Dr. Heru has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
You are treating Mr. A for a depressive disorder, and you ask if he can bring his wife to his next appointment. When the couple arrives, you say to Mrs. A, “Welcome, and thank you for coming with your husband today. You’ve known him longer than I have, and I’m sure you’ll have some important observations. You can also ask your husband whether he’d like you to help him manage his illness.” You then tell Mrs. A to feel free to take notes, ask questions, and be part of the decision-making.
Involving families is a very important part of treating your patients. When the family or spouse is included with the patient in the assessment, decision-making, and treatment planning, the patient’s adherence to treatment improves regardless of diagnosis (Wolff JL et al, Health Expect 2015;18:188–198).
Family members can tell you about patients’ level of functioning, and how they spend the day. They can confirm sleeping and eating schedules. Family members can raise questions about cultural beliefs and values that you may not have time to assess in a first interview. Family inclusion does not require specific training, and it should be a routine component of your overall care plan.
The family meeting process Start by asking the following questions to get a high-level understanding of how a family is dealing with a patient’s diagnosis:
Do you all agree on when your family member has symptoms?
Do you all agree on how to manage the symptoms?
Is there a treatment plan, and do you know what it is?
After that, continue with the following assessments:
Assess global family functioning. The illness affects the patient, who then affects family members, who then further impact the patient. In order to avoid any suggestions of blame, externalize the illness. Ask family members, “How are you coping with the illness? How is the illness affecting you as a family? How is the illness interfering with your ability to live your lives? How is the illness interfering with retirement, schooling, etc? Are there unresolved issues/feelings that you as a family have about the illness?”
Assess caregiver burden. Patients’ families can be overwhelmed with physical, emotional, or financial demands—which can impact caregivers’ health and mental well-being. With this in mind, ask the family caregivers how they are coping with providing care for the patient (Heru AM, J Psychiatr Pract 2015; 21(5):381–388).
Assess educational needs. Ask family members, “Would you like more education about the illness? Would you like someone to consult with your family about the emotional side of dealing with the disease?” Providing written information about referrals also helps normalize the process. Family psychoeducation means providing illness education, as well as giving family members the opportunity to express their feelings and discuss their difficulties managing the illness.
Assess the family’s ability to identify problems. Ask, “How do you generally solve family problems? Who has the final say? Which problems are easy to resolve, and which ones are difficult?” Family members typically need to address practical problems, such as helping the patient get medications from the pharmacy, making time to attend appointments, and arranging day care for children.
Ask about other family problems. In addition to common practical and emotion problems, you should try to learn about additional issues by asking, “Are there other family problems that you are coping with at this time? Do other people in the family have illnesses or problems they are struggling with?” If family problems predate the illness, then recommend family therapy.
Advice for keeping the family meeting on track Many times, family meetings can become contentious and difficult, thereby diminishing their utility as part of the treatment plan. Here are a few tips on how to keep the meetings headed in the right direction:
Listen to the family story. A family story or narrative about an illness is a window into the family’s general sense of confidence and efficacy in managing chronic illness (Heru AM (Ed.), Working With Families in Medical Settings. New York, NY: Routledge; 2013). The presence of a coherent story indicates a low-risk family. High-risk families appear disorganized and/or traumatized, and have no coherent illness management plan.
Ask: “How will you manage an emergency, such as a relapse or an acute attack?”
Watch the family interactions. The way in which family members interact during a routine interview helps determine family needs. If the family shows significant conflict, overtly disagrees about how to manage the illness, or admits to family problems that were present before the illness, consider a referral to a family therapist.
Ask: “Would you like some additional help to talk through the issues that are getting in the way of managing this illness?”
Control the interview: If a family member is talking too much and does not respond to 2 escalating requests to give the patient time to talk, ask that person to step out of the room. Say that you will bring the family member back in at the end, but that you need time alone with the patient. If the patient is verbally attacking the family member, this is also a time to ask that family member to step out. Patients’ or families’ inability to make use of a family interview is a clear sign that additional intervention is needed.
Ask: “Would you like some additional help to talk through the issues that are getting in the way of managing this illness?” Or more forcefully: “I want to refer you to my colleague, Dr. X, for help with managing family conflict.” As an example, family therapists practice a specific type of family treatment called family systems therapy (FST), which aims to change dysfunctional family transactions. FST is effective in improving outcomes for patients with many psychiatric illnesses (Von Sydow K et al, Fam Process 2010;49(4):457–485).
TCPR Verdict: Involving families in the overall care plan of your patient can be critical to effective treatment outcomes. But for family meetings to be successful, you need to prepare yourself to be able to ask the right questions and adequately control the meeting environment.