Gabor I. Keitner, MD
Director, Family Therapy program at Rhode Island Hospital. Professor, Department of Psychiatry, Brown University.
Dr. Keitner has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: Why is it important for psychiatrists to meet with families of patients?
Dr. Keitner: If you want to comprehensively understand your patients and modify variables that might impact treatment and outcome, it’s important to understand families. There has been a lot of research showing that the family environment can have a significant influence on the course of an illness, either in a protective or risk-inducing way (Weihs K et al, Health and Behavior 2002;20:7–46).
TCPR: But often clinicians don’t meet with families.
Dr. Keitner: That’s true, and there are many reasons why. I think the main reason is that a lot of families are anxious about psychiatric illness and worry that the meeting will get out of control, or that it will just take too long.
TCPR: So, how would you suggest we approach family meetings?
Dr. Keitner: I work mainly in the inpatient setting, so most of my patients are acutely ill with depression, bipolar disorder, schizophrenia, substance abuse, and so forth. I meet with the families of about 70% of my patients as a way of trying to understand their problems. I explain that this is part of the routine, which normalizes the process and reduces their apprehension. Most of the time, the patients are grateful and are interested in having a meeting. In addition, the notion that the meeting will take too long is based mostly on worries about being able to conduct the meeting effectively and efficiently. Once you acquire the skill, it doesn’t take any longer to meet with families than it does to meet with patients. In the long run, it actually saves a lot of time if you get the family to cooperate with you to effectively and comprehensively understand the problem.
TCPR: Whom do you invite for a family meeting?
Dr. Keitner: I like to ask people to bring in whomever is important to them, and it doesn’t have to be an immediate family member. It could be a best friend, somebody at work, or anyone whom patients identify as closely familiar and supportive.
TCPR: And how do you begin the meeting? What do you say?
Dr. Keitner: The most important part is orienting the group to the purpose of the meeting. I start by welcoming everybody in, then introducing myself and the people who are with me, such as trainees or a social worker. I thank them for coming in and explain to them that the goal of the meeting is to provide an environment where everyone can describe what their concerns are without being blamed, criticized, or invalidated. I tell everybody that they’ll have a chance to tell me how they see the problems and that they’ll have a chance to ask me questions—which is important because they always have questions. Finally, I say that I’ll try to present my understanding of the problem, and then together we’ll make some decisions about what we should do. I find that when we orient the families that way and they know what to expect, they really settle down and are much more likely to take turns and participate in a constructive way because they know they’re going to be heard.
TCPR: After an initial family orientation, what are the first questions you ask?
Dr. Keitner: I ask, “What are the problems?” And then I say, “Who wants to go first?” Usually, I tell patients that they’re going to go last because I’ve already heard from them, and I want to hear from the others. I do this also because I want the others in the meeting to see that I’m not there just as an advocate for the patient, and that I’m trying to understand everyone’s concerns. I also tell the group that I’d like to hear from just one person at a time; when people start interrupting and arguing, that’s usually how these meetings get off track. I let people know that I’m not a judge and the idea is not to find out who’s right or wrong, but to be able to hear everyone’s perspective. That way, we can all appreciate how everyone’s looking at the situation.
TCPR: What sorts of issues tend to come up in a family meeting?
Dr. Keitner: The problems that family members identify invariably relate to why the patient is in the hospital. And in the process of that, I’ll get a much more comprehensive history of the set of events that—at least from the family’s perspective—landed the person in the hospital. I’ll usually follow up with questions I still have about the onset and the course of the illness. Then, I’ll ask the family members in turn to give their viewpoint on the nature of the problem. My experience is that most groups end up concentrating on only 3, 4, or 5 issues, and that they either agree or disagree with each other, but they get a clarification of the situation. And in the process of getting each other’s perspective, they are better able to fine-tune their own thinking about it.
TCPR: One of my experiences in working in inpatient units is that meetings with patients often revolve around the fact that they want to leave the hospital as soon as possible. How should we deal with this?
Dr. Keitner: It’s true that a lot of patients don’t want to be in the hospital, and I often tell them that the fastest way to get out of the hospital is to have a meeting with the family so that we can get a better understanding of what happened and be reassured about their safety once they leave. This often incentivizes them to participate in a meeting. Sometimes patients are reluctant to have family meetings because they’re afraid that nobody’s going to show up; they’re afraid it’s going to validate their worst fear that nobody cares. But that rarely happens. In fact, most often they’re pleasantly surprised by how many people are concerned and come in to support them. And, finally, I think they’re worried that the family is going to say things that are opposite to what they’ve been telling us, and that maybe they’re going to look worse than they would like to present themselves. But if you run the meeting in a collaborative way, these things won’t happen.
TCPR: Can you give us an example of a meeting where some issues were resolved?
Dr. Keitner: Sure; here’s a story of a patient in trauma therapy. The therapist had started going over the patient’s history of physical abuse. The patient wrote a trauma journal, and in the process she got progressively worse, until she became suicidal and required admission. Nobody in the outpatient team had called the family. So, we had a family meeting with her husband, her parents, and her daughter. I asked all of them what they thought the problems were, and they all felt that she tried to take too much pressure off everybody else and place it all on herself; that she didn’t tell anybody what was burdening her.
TCPR: How did the patient respond?
Dr. Keitner: She was able to explain that the reason she didn’t talk about her worries was that she had been so traumatized that she was conditioned to avoid displeasing anybody. She was afraid that, if she talked about the trauma, they would abandon her. She was able to talk to her husband about their financial difficulties, and she talked about not wanting to upset her daughter by opening up about how abusive her former husband had been. The feedback from the family was that her in-laws were ready to support her, and that her daughter was supportive. I discharged her after the meeting. We finally understood where the patient’s trauma was coming from—what was forbidden and hidden before, and that it was potentially toxic in her mind. She had a here-and-now experience of realizing that that wasn’t the case, and the husband reassured her that he loved her, would never leave her, and wasn’t blaming her for anything.
TCPR: This worked out well. What are you trying to accomplish, in general, with these meetings?
Dr. Keitner: I get everybody to tell me what their problems are. I validate everybody’s perspective. I get them to talk about the issues with each other. I try to formulate for them what I heard from what they’ve told me to see if they agree with it and if it makes sense to them. I then ask the group what they want to do about it and how I can help them. And, I would say that most of the time, something constructive comes out of it. They come up with a plan that makes sense for them or validates what their perceptions are.
TCPR: What should we do in situations where the meeting becomes argumentative or heated between different family members? I think, because we don’t know how to handle that, a lot of us are a little scared of family meetings.
Dr. Keitner: Yes. I think that’s a very common problem. So, one of the key issues in meeting with couples and families—and this is sort of a subtle point—is that the therapist must be in control of the process. The therapist is not in control of the content, so it’s not for me to determine what people should and shouldn’t say. But it’s my job to provide a safe environment for people to be able to express themselves without being attacked or criticized or hurt. People should agree to only have one person speak at a time, and to disagree in a respectful way. If they don’t do that, I terminate the meeting.
TCPR: How do you terminate the meeting? What do you say?
Dr. Keitner: If the family members become argumentative, I say to them, “Is this what happens when you try to talk about problems at home?” And, of course, it is. And then I say to them, “Look, if you want help, then you must try to do things differently. If you’re going to keep doing the same thing that you were doing at home, then there is no reason for us to meet.” Or I might say, “The meeting is over. This is not helpful. You aren’t ready to work on this in a constructive way, so I think this is a waste of time. When you’re ready to work together, let me know, but until then, this is all I can do to be helpful.” So, I put the responsibility back on them to control themselves.
TCPR: What about family meetings in the outpatient setting? How do they work?
Dr. Keitner: When I see outpatients for the first time, I like to meet with their significant other or family member at least once as part of the assessment. This does not mean family treatment. Not every family needs family therapy. I would say that—in at least 60% to 70% of the cases—the families are functioning well (Friedmann MS et al, Fam Process 1997;36:357–367). I just reinforce that and support them to continue to do that. Even with high-functioning families, it’s good to give them the opportunity to ask questions and to be more active in understanding what’s going on.
TCPR: How do these meetings inform your treatment and your understanding of the patient?
Dr. Keitner: In general, I find that family meetings are like a shortcut to understanding the patient. Because they are embarrassed or anxious, there are things that patients may not tell you for months in individual therapy. Then, when you bring in significant others, they just tell you. I find that meeting with a significant other always enhances my understanding of what’s happening with the patient, and it gets to the point much quicker. It’s an opportunity for both the patient and the family to identify in a safe setting the things that are causing concern. So, my job really is not to be an interrogator. My job is to create an environment where people feel comfortable talking about the things that they are worried about.
TCPR: That’s good advice. I also want to ask you about logistics. I’ve had families come in during a time when I was doing 20- or 30-minute medication sessions, and found that it usually wasn’t enough time. How much time should we budget for these family meetings?
Dr. Keitner: Before I answer the question, I don’t want to give the impression that family treatment is the end-all and be-all. It’s just one part of a comprehensive treatment plan. It works in combination with biological treatments and psychotherapy as needed. Now, in terms of time with the initial family assessment, it depends on how comfortable you are and how well you can do it. But the initial assessment, depending on how complicated the problem is, can take between an hour and 90 minutes. Subsequent follow-up meetings can take as long as an hour or be as short as 15 to 20 minutes.
TCPR: How many meetings with family is enough?
Dr. Keitner: Well, I would say that with many family meetings, 1 is enough. If a family is functioning pretty well and they have an opportunity to address their problems together, listen to each other, and pay attention, then they’ll carry on from there after 1 meeting with you. So, I would say that most of the time, if there are no significant family issues, a single meeting is enough. For some families, you may need to meet 3 or 4 times until they feel that they have a better handle on how they’re going to work on their problematic issues. So, I think it really depends on the severity of the problem and on the family’s level of problem solving skills.