11: Families

Our experience of health, illness, and health care, as patients and as practitioners, occurs in a social context. The “family” is at the heart of that context. Making the patient’s social context an explicit part of medical care affects every step of the clinical process, from basic assumptions about who the patient is to the conceptual framework for the database, theories of causality, and the implementation of treatment. Consider the following vignettes:

1. Despite wondering whether she could have done something more for Joe, the doctor is gratified and reassured by the family’s overwhelming thanks for the “wonderful care” she provided for the past 10 years, and in particular during the time preceding the patient’s death. The family is grateful for her help in family discussions about end-of-life care.

2. Eric is a 40-year-old man with diabetes who has extraordinary difficulty following a reasonable diet. His partner has been unwilling to change his expectations about their meal plans and he has been unable to negotiate a change with him.

3. Mary, 50 years old and previously without complaints, presents with headaches that have been ongoing for 2 months. She is afraid she has a tumor or “something bad.” A brief discussion about her family reveals that her 60-year-old husband has been depressed and forgetful for at least 6 months. Two months ago he got lost on his way home from the hardware store. After her doctor listens to her story, she agrees that she too is depressed and very concerned about her husband. She is upset that he has refused to see a doctor. She accepts her doctor’s offer to help her get him evaluated, but she is still worried that her headache is something bad.

4. Eva, who is 27 years old, has multiple somatic complaints and panic disorder. She was raised by her grandmother after her mother died, and when her grandmother died 4 years later, by an aunt 20 years her elder. She and her aunt became very close, “almost like sisters, we did everything together.” After completing college she returned to live with her aunt, who had recently begun the first serious relationship of her life. Eva does not understand why her aunt needs a boyfriend, and reports that her panic attacks often interrupt her aunt’s plans to spend time alone with her fiancé.

In every case, the family context is critical to understanding the situation. In the case of Joe, the doctor has attended to both patient and family and the family is a partner in care and grief. Family function has become a significant barrier to critical self-care for Eric. Mary is having a psychophysiologic reaction to family stress. Eva is a vulnerable young woman whose panic disorders are not only partially a response to her aunt’s perceived abandonment but also a high-cost and inadequate “solution.”

All health care providers have an intuitive understanding about “the family” and how families work and develop. However, lack of clinically useful tools for making the family an explicit part of care may prevent successful application of this knowledge. Caring for the patient in the context of the family goes beyond involving some families in the management of care. Two case illustrations are presented throughout the chapter that will illustrate the conceptual foundation and basic skills of family assessment and intervention.

The family is the primary social context of experience, including that of health and illness. The individual’s awareness and perception of health and disease are shaped by the family, as are decisions about whether, how, and from whom to seek help. Use of health care services and acceptance of and adherence to medical treatments are all influenced by the family.

Reciprocal Relationships

There is a reciprocal relationship between healthy family systems and the physical and mental health of its members. Physical symptoms and illness can significantly influence the family’s emotional state and behavior, often causing dysfunction in family relationships; and dysfunction in the family system can generate stress and lead to physical illness. Dysfunctional family systems can incorporate a physical illness and symptoms into the family’s behavioral patterns, thereby reinforcing the sick role for one or more members and sustaining or exacerbating illness and symptoms. In these “somatizing” families, the presence and persistence of the symptom or illness cannot be understood without examining its meaning in the context of the family.

What Is a Family?

Our understanding of family is based on our experience with our own family and experiences with the families of others. The variety of groups that make up a family is enormous: two-parent nuclear families, single-parent families, foster parents with children from different biological families, families of divorcees blended through remarriage, families with gay or lesbian couples as parents, and married or cohabiting couples without any children. In some cultures, the “family” may be other members of the clan who are not related by blood or marriage. Isolated elderly individuals may think of their home health attendants as family, and for other solitary individuals the only family they may know is their pets.

All of these groups can be experienced as families. They share similarities in the structure of the relationships between their members and the role that the family group plays for the individuals and for the society in which the group exists. So, rather than define the family in terms of its members, we describe it as a system having certain functional roles.

The Role of the Family

Family relationships are described more by their roles than by the labels traditionally applied to individuals. For example, in one family an elderly woman may obtain companionship and emotional support from a home health attendant, a friend at the local senior citizen’s center, and a daughter, whereas a woman in another family may find these needs met by her marital partner. In one society, the primary education and socialization of children may be accomplished in the household of the child’s parent(s) and in community schools. In another, parent collective or unrelated individuals may accomplish these educational tasks, and play a more prominent, family-like role in children’s lives. Hence, for health care practitioners, the patient’s family context must be understood as the individuals in the social system, who are involved in the roles and tasks that are of central importance to the patient (Table 11-1).

The Family as a System

Families as systems are characterized by:

1. External and internal boundaries;

2. An internal hierarchy;

3. Self-regulation through feedback;

4. Change with time, specifically family life cycle changes.

The qualities of these four system characteristics in a particular family help shape the family’s internal milieu and functioning.

Boundaries

The family is partially separated from the outside world by a set of behaviors and norms that are embedded in specific cultural systems. Family boundaries are created by norms that determine who interacts with whom, in what way, and around what activities. For example, teaching children “not to talk to strangers” creates a boundary around the family. Different parts of the family system (i.e., subsystems), such as “the parents” and “the children,” or each “individual,” are separated from one another by boundaries. Internal boundaries work in the same way: children who speak back to a parent may be told that they “don’t know their place”; they have crossed a boundary that defines their role. Healthy boundaries balance the individual identity of family subsystems with the openness required for interaction and communication across boundaries.

Internal Hierarchy

Subsystems of the family relate to one another hierarchically: parents have authority over the children, the older children over the younger children, and so on. A healthy hierarchy is clear and flexible enough to evolve with the needs of the family, and localizes power and control in those who are the most competent. Hierarchies may become dysfunctional for a number of reasons; for example, when they are unable to adapt to change, when the allocation of power or authority is not consistent with the location of expertise or competence in the family, or when the lines of authority are blurred and effective decisions cannot be made.

Self-Regulation Through Feedback

Relationships within the boundaries of the family system and its subsystems are regulated by “feedback.” All behaviors in the family set a series of actions in motion that in turn influence the original actor.

Feedback maintains the integrity of the family system as a unit, establishes and maintains hierarchies, and regulates the function of boundaries in accordance with the individual family’s norms and style. This tendency toward maintaining “homeostasis” is critical. All family systems must learn to balance the desire for stability with the inevitable need to evolve and change.

Change and the Family Life Cycle

The family must continually adapt as its members evolve both biologically and socially (Table 11-2). For example, the family with young children must protect them within the boundaries of the family (or that of specific delegates, such as the schools). Adolescents need to achieve a degree of independence and the ability to function without immediate adult supervision. To facilitate this, the family must develop new norms of behavior and relax the boundary between the child and the world and redraw the boundaries between parent and child (e.g., provide more areas of autonomy and privacy). Each stage of the family life cycle presents new challenges, and healthy families are able to modify their hierarchic relationships and boundaries. Families whose boundaries, hierarchies, and self-regulatory feedback are dysfunctional have difficulties at each transition.

Health and Illness in Families: The “Sick Role”

Behavior in social settings can be understood in terms of “roles” that are shaped by shared expectations, rules, and beliefs. All roles have prerequisites, obligations, and benefits or dispensations. One such role is the “sick role,” which is temporarily and conditionally granted to individuals when they have an illness perceived to be beyond their control, seek professional help and adhere to treatment, and accept the social stigma associated with being sick. Individuals in the sick role are exempt from many of their usual obligations and entitled to special attention and resources. The sick role therefore has a profound effect on relationships within the family.

The exemption from obligations that is part of the sick role is critical to recovery from illness and adaptation to disability. The obligations and stigmatization of the sick role are important to protect others from abuse. Physicians play a critical role in establishing the legitimacy of the sick role by certifying the prerequisite illness or disability, and attesting to adequate adherence to treatment. Because the sick role has such a profound effect on the family of the sick individual, physicians’ obligate role in establishing the sick role makes them a powerful actor in the patient’s family system, and makes the family system an intrinsic part of the doctor–patient relationship, whether the physician is aware of these ramifications or not.

The Doctor–Patient–Family Relationship & the Compensatory Alliance

A positive relationship with an active and concerned family can be one of the physician’s most powerful tools and rewarding clinical experiences. In these circumstances, working with the family seems quite natural and the complexities of the doctor–patient–family relationship are not apparent. On the other hand, when significant family problems exist, the doctor–patient relationship can become entangled in the family system’s dysfunction.

When one or more members have assumed the sick role in response to family problems, the task of providing appropriate care for the patient may be subverted and subsumed by family dysfunction. Some families can achieve internal stability and meet the needs of their members only when one or more individuals are perceived as being sick.

The physician’s role in determining that the patient is entitled to the special prerogatives and dispensations of the “sick role” makes the physician a central and powerful member of these family systems. The authority to prescribe changes in role function for the patient further involves the physician in the life of the entire family. In effect, the physician and patient develop an alliance that compensates for the dysfunction and deficit at home. Hahn, Feiner, and Bellin have termed this a compensatory alliance.

When the physician is unaware of underlying family dysfunction, the compensatory alliance can become dysfunctional and contribute to somatization and noncompliance, and support the ultimately inadequate coping mechanism afforded by the sick role.

General Considerations

Treating the patient in the context of the family requires a practical method that can be learned and used by health care providers in real world practice and training. The large number of tasks that occupy the provider places limits on the complexity of and time available for family assessment and intervention. A family assessment and intervention method must be focused, time efficient, and consistent with the general scope of care.

All patients should receive a “basic” family assessment that allows the doctor to understand how the family milieu will influence the basic tasks of care, and that identifies family problems requiring intervention (Table 11-3). Basic family assessment consists of two processes: (1) conducting a genogram-based interview and identifying the relevant family life cycle stages, and (2) screening for family problems that are associated with family life cycle stage tasks, or the patient’s medical problems. A subset of patients with problems rooted in serious family dysfunction will then require the four-step family intervention described below.

Treating the patient in the context of the family does not necessarily mean bringing the family into the examining room and in adult medicine usually does not. Family assessment and intervention can be accomplished by meeting exclusively with the patient, though meeting with other family members is very often desirable, sometimes necessary, and almost always enhances the care. Using a family systems orientation without meeting directly with other family members requires the ability to explore the life of the family and bring the family into the room through the patient’s narrative.

The genogram-based interview, described below, is a powerful technique for accomplishing this goal. However, the task of understanding the patient’s family system in this way can be complicated by the fact that patients often give a distorted and incomplete presentation of family life. Such distortion may be conscious, unknowing, or some of both. Therefore, clinicians need to learn to infer what is going on at home—to “see the family over the patient’s shoulder”—by imagining how members of the patient’s family might be reacting or behaving in ways that the patient does not understand or would not report.

Constructing a Genogram

The first step to treating the patient in the context of the family is to create a picture of the family by conducting a “genogram-based interview.” A genogram is a graphic representation of the members of a family. It uses the iconography of the genetic pedigree (Figures 11-1 and 11-2) and can be used to record data ranging from family medical history to life events and employment, as well as family issues. The overall objective of the genogram interview is to help the patient tell the family’s story.

Conducting a Genogram Interview

Begin with a blank page, or a designated section of the patient’s chart. Place the genogram where the patient can see it and draw a family tree with the patient’s help. Note important dates such as marriages, divorces, and deaths, and the general location of individuals in other households. Family systems data can be recorded using lines to enclose household boundaries, double lines between individuals to indicate strong relationships or coalitions, jagged lines to indicate conflict, and triple lines to indicate dysfunctional over-involvement. At subsequent visits take a brief look at the genogram to recall the patient’s family context, and expand or alter the genogram as the family changes or new issues arise.

Focusing the Genogram

The type of information explored, the number of generations, and the level of detail included in the genogram depend on an initial sense of the importance of family issues. A detailed, comprehensive genogram interview going back more than one generation can be a powerful clinical tool but is too complex for everyday practice. The genogram must be “focused” on the most clinically useful information while providing the foundation for treating the patient in the context of the family. As with most clinical databases, it is harder to know what can safely be excluded than it is to include the entire range of family-oriented data. However, skillful parsimony is acquired with experience, and efficiency is produced by following three principles:

1. Engage patients and encourage active participation—they will take you to the heart of the story.

2. Focus the interview on family life cycle tasks and issues—they are almost always the focal point of stress and dysfunction.

3. Draw and examine the genogram—a picture is worth thousand words (e.g., picture a single mother, six children, parents, and siblings in another country; three different fathers in various places; and a new boyfriend).

Begin with the core members of the family, that is, household members, parents, children, and past and present partners and spouses. Identify the family life cycle stage of the patient’s family from the ages, relationships, and household composition of the nucleus of the patient’s family. As described below, the family life cycle stage will almost always predict the locus of stress, challenge, or conflict in the patient’s family system.

Inquire about the family’s responses to any known or presenting problems, and to issues identified using the family life cycle screening questions described later. If no significant major problems or dysfunctions are identified, stop the focused genogram interview when you understand the family well enough to take the family into consideration in addressing the patient’s medical and other problems. If significant family problems are discovered, continue with the four-step family intervention described later.

Figure 11-1 shows the skeleton of the genogram for Case Illustration 1. The amount of information you gather about each individual and the family should be guided by the evolution of your hypotheses about family function as you go along. When major family issues emerge from the shape of the genogram or the patient’s narrative, exploration of family relationships and history can be very focused. If the nature of family issues is initially obscure, but you suspect something important is going on, expand the genogram to include more peripheral family members and examine individual relationships more completely.

In general, it is useful to obtain brief descriptions of family members and important relationships, the history of major life events, immigrations, and comings and goings from the household(s). Record important information on the genogram as the interview progresses to create a picture of the family. Remember, the greatest efficiency in the genogram interview comes from the patient’s active participation.

Identifying the Family Life Cycle Stage & Predicting Stress & Conflict

Family Life Cycle Stage Assessment

Determining the life cycle stage of the family is the first task of a genogram assessment. The stages of the life cycle are a road map for exploring the important issues in the life of a patient and family.

The family life cycle consists of six stages (Table 11-2). Each stage is grounded in biologically driven and socially and culturally shaped patterns of individual development. The cycle usually “begins” with the separation of the individual from the family of origin (stage 1), followed by the formation of a new family (stage 2), the raising and “launching” of children into the world (stages 3, 4, and 5), and the family later in life (stage 6). Each of these stages is dominated by a theme and principal task. Each task requires two to four major changes in family structure and function. More often than not, family problems revolve around difficulty with one or more of the developmental tasks of the family’s life cycle stage. Of course, the family life cycle is grounded in a specific sociopolitical and cultural context that helps to determine and shape the themes and tasks of each stage.

The Family Life Cycle: Roles and Generations

With each stage of the family life cycle individuals acquire new roles: for example, from single adult to husband or wife and simultaneously to son or daughter-in-law. Note these roles as you and the patient scan the genogram. A directed open-ended question to screen for problems in each role is an efficient way of exploring the patient’s relationships: “What’s it like being a grandmother of six? Joe’s wife? The daughter of a 95 year old?” If the patient is suitably activated, the whole story may come out after the first inquiry: “Being a grandmother is great, it’s being a mother-in-law that I can’t stand!”

The Life Cycle and Patterns of Parenting

In probing for life cycle problems, be sensitive to the influence of culture, ethnicity, and social class on norms and expected patterns. Pay particular attention to the structure of the parental subsystem: the adaptational strategies of families with one parent, one “working” and one “child care” parent, two working parents, families with extended-family parenting, blended families, and so on have differences that can be anticipated.

Case Illustration 1: Discussion

Ariana (see Figure 11-1) is in the first stage of the family life cycle, an unattached young adult, in her case between families. Her divorce from her husband suggests difficulty forming a new family and moving on to the second stage of the family life cycle. It is noteworthy that the patient’s sister Estelle is still at home and having difficulty with the first phase of the life cycle.

Screening for Family Function

After drawing the genogram and determining the life cycle stage of the family, the next step is to screen for family problems (Table 11-4). An activated patient will do the work of screening for you and immediately describe the “real problems.” If the patient is reticent or the problem more obscure, the following strategies should aid the exploration.

Global Family Function

Begin screening for family problems with open-ended questions about global family function (Table 11-5). The tone and content of the questions should be nonjudgmental, and even normalize the presence of problems, for example, “All families have their ups and downs, how’s yours doing these days with all that is going on in your life?” An effective initial inquiry directs the patient’s attention to family issues, in general leaving the patient free rein to respond.

Screening for Family Life Cycle Problems

If a question about global function does not provide the necessary information, ask a few screening questions about the life cycle tasks that confront the patient’s family. For example, the genogram in Figure 11-2 indicates that this family will be dealing with the tasks of “the family with young children” and “the family with adolescents” (see Table 11-2). Six questions, one for each of the three tasks in these two different life cycle stages, can screen for life cycle problems (Table 11-6). However, it is likely that not all of these six questions will have to be asked to identify sources of difficulty, especially if the unique features of any particular family are used to select the initial questions.

Screening for Family Difficulty with the Patient’s Medical Problems and Symptoms

The presence of somatization is one of the most important indications for exploring the patient’s family, because it is usually driven by the patient’s and/or family’s need to have the patient occupy the sick role. An effective strategy for exploring the role of symptoms and medical problems in families is to follow the sequence: symptom—function—family response. Symptom—“Tell me about your symptom.” Function—“How does your symptom affect your functioning, your normal activities, and ability to do what is expected?” Family response—“If you can’t do these things, who does? What does your family do and say?”

Screening with Red Flag Problems

Whenever a problem associated with family dysfunction is present, the physician should screen for the family’s reaction and response (see Tables 11-4 and 11-5). Many of these problems are emotionally charged and stigmatizing. Nonjudgmental, normalizing, and directive questions are therefore critical. These issues often have immediate clinical and legal implications and raise issues of confidentiality that need to be addressed.

Screening for Problems in the Doctor–Patient–Family Relationship

Throughout the family assessment, consider what role you may be playing in the family system and be alert to the development of dysfunctional alliances with the patient or other family members. Ask the patient or other family members what reactions the family has had to health care providers’ suggestions or interventions. It is also useful to determine what the patient wants you to say to other family members. Often these hopes and expectations are implied by patients’ words or behavior rather than stated, because patients may not be fully aware of what they want, are too embarrassed to ask for it, or do not feel they have permission to make the request explicit.

Treating the Patient in the Context of the Family: Communicating about & Caring for the Patient’s Medical Problems

After completing the basic genogram, assessing the family life cycle stage, and screening for problems in family function, the practitioner should be able to provide basic medical care for the patient in the context of the family (Table 11-7). With the majority of families, the interventions described in this step accomplish the basic goals of family assessment and no further intervention is needed (see Table 11-3). A basic family assessment will, by itself, facilitate the following.

Enhancing the Therapeutic Alliance

Perhaps the most important consequence of conducting a family systems assessment is to enhance the therapeutic alliance among the patient, provider, and other family members. Patients’ perception that their physician cares for them is probably the single most important variable in the formation of a successful doctor–patient relationship. Few things accomplish this better than talking to patients about the most important people in their lives (see Chapter 2).

Communicating with the Family

Family assessment enhances communication with the family about the patient’s medical problems. This may involve educating them about the patient’s condition, discussing self-care regimens and monitoring family involvement with the medical regimen, facilitating the family’s role in decision making and advance directives, and helping the family adjust to changes in the patient’s functional capacity.

Assessment and Support

Assessing the family’s emotional response to the patient’s problems and providing needed support are challenging and rewarding family-oriented tasks. It is often difficult for the physician to witness the emotional distress experienced by patients and their family in the face of serious medical problems. The temptation to “stick to the facts” and restrict attention to biomedical issues is both strong and understandable, especially in light of the physician’s perception that he or she “can do nothing” about the emotional pain. It is important to understand that empathically listening to the family and the patient is a powerful therapeutic intervention in itself—even if it appears to “fix” nothing (see Chapter 2).

It is often possible to make simple family systems interventions by suggesting that families try new behaviors.

An appropriate intervention would be to suggest that the patient and his wife discuss the situation before the fights begin and try to develop a plan on which they both agree. If the family has the flexibility to respond to this suggestion, it may help them with the developmental life cycle challenge. If this intervention fails to help sufficiently, it may be a sign that further family assessment and interventions are required. It is important that suggestions be based on at least as thorough an evaluation as that produced by the preceding steps of this method; premature suggestions based on incomplete assessment are likely to fail.

Caregiver Collaboration

If the patient or family is receiving treatment from mental health specialists, the physician should actively collaborate, and they should consult with one another when issues come up that are relevant to the other’s expertise. Patients may attempt to play one health care provider against the other; for example, they may present somatic symptoms to the mental health specialist and attempt to engage the medical provider in issues being examined in therapy. Patients or family members may complain about the therapist, especially when the family or patient is being challenged to change. Active communication between treating providers is critical if this dynamic arises (commonly referred to as “splitting”).

Focusing on the Dysfunction

Some problems have a clear and potentially devastating effect on the family. Focusing the family’s attention on the problems associated with family dysfunction is a crucial clinical task. For example, if a patient or a member of the patient’s family has a problem with alcohol abuse or dependence, it is important to assess the family’s response, help the family accept the reality of the problem, and support their need to address it. Many families are waiting for just the kind of professional, extrafamiliar attention that the physician can provide. Validating their feelings, and providing information about resources such as Alcoholics Anonymous (AA), may be all that it takes to precipitate action.

However, the patient’s and family’s resistance to change may be so strong that basic family assessment is not enough to help them take action. In these cases, it is sometimes preferable to refer the patient to a mental health specialist without further family intervention. However, it is often necessary to proceed to the next level of family intervention to make a successful referral.

If serious family dysfunction is interfering with medical management, the doctor–patient relationship, or the patient’s functional status and quality of life, a more intensive, four-step evaluation and intervention is required (Table 11-8). The goals of family assessment and intervention as described differ from the structural systems changes that are employed in family therapy. Even if medical providers had the time and training, they could not treat families with commonly employed techniques that require forming alliances with different family members during treatment, because this process can threaten the trust required to deal effectively with the patient’s medical problems.

Step 1: Assessing the Family: “Bringing the Pain into the Room”

The previously described basic family assessment is the core and foundation of the first of the four steps of intervention with dysfunctional families (Table 11-8). The difference lies in the need to achieve three goals that go beyond a basic understanding of family functioning. The physician must (1) have a relatively complete understanding of the major conflicts or issues in the family; (2) understand how the sick role, if present (and it usually is), is functioning as a coping strategy for the patient and the family; and (3) conduct the interview so that patients can bring the full intensity of their feelings about the family problems out, that is, “bring the pain into the room.”

The first step of family assessment and intervention is complete when you can say, with confidence that the patient will agree, “It seems to me that the family problems we are discussing are extremely painful, and that you have been unable to resolve them until now.” Bringing the pain of the patient’s life “into the room” during the interview is an important part of the process because the shared knowledge will provide the rationale and impetus for the second step of the process, that is, reframing attention to the underlying family problems. The following techniques will help accomplish this first task.

Two features of the way in which family systems work, so called triangles and circles, can help guide exploration of family relationships. First, all dyadic interactions ultimately triangulate. We fully understand the way individuals interact only when we understand the series of triangular relationships they belong to. Second, families that are having difficulty, that are “stuck,” engage in a repetitive or “circular” sequence of behaviors that represents the best they can do to cope with their problems. For example, in their study of adolescents with brittle diabetes or poorly controlled asthma, Minuchin and colleagues often observed the following pattern: unresolved marital conflict erupts into an argument between the adolescent’s parents; the adolescent, in response to the stress of the fight, becomes acutely ill; the parents stop fighting and focus on caring for their child; the exacerbation of the child’s illness resolves; the unresolved marital conflict erupts into another fight, and the process is repeated. From this point of view, it is clear that the outcome of the seemingly dyadic parental conflict cannot be understood without knowing that the child and the illness are “triangulated.” It is impossible to understand the behavior of any member of this triangle without examining the interaction with both of the other two.

The triangular relationships among family members are caught up in circular patterns of interactions. The sequence of events that takes place in the adolescent’s family may be described in a linear fashion, that is, parents argue, the child is upset and gets sick, the parents stop arguing to help the child, the child gets better. The interruption of the fight, however, also prevents the parents from “finishing” their fight and resolving their problems, thus, the pattern inevitably repeats. Dysfunctional families are often stuck in such a repetitive, self-sustaining pattern.

It is important to understand how the “sick role,” created by the patient’s symptoms, is embedded in the family system, and how the whole family participates in it. There are no pure victims or villains in such a system: The adolescent is not merely the “victim” of marital discord; the child’s sick role and the acute exacerbations of illness have a powerful controlling influence on the inability of the spouses to resolve their conflicts. Looked at from a more positive vantage point, the child’s illness is performing the important function of modulating a marital conflict that might otherwise threaten the integrity of the family system more completely. The symptom is the product of and serves the needs of the entire family system. Though the price is high for all involved, and this “solution” is likely to fail in the long run, it is the best that the family can do at the moment to cope with the totality of their problems.

Patient-centered emotion-supporting interviewing techniques can be instrumental in “bringing the pain into the room” during the interview. A “one-two punch” that couples a statement giving permission to express feelings, combined with an open-ended question about an emotionally charged issue, is often effective. For example, you might say to a new grandmother whose single-parent daughter is hoping for child care for her new baby, “setting limits with your children so that you can be a grandparent rather than a nanny can be difficult and even cause a lot of guilt. How’s it been for you?”

Conducting a family meeting is a powerful technique for analyzing family systems. The objective of the family meeting is to have the family enact their interactions, and have other members directly report their responses to the patient’s sick role symptoms and behavior. If they enact “the pain in the room,” so much the better. The physician merely stops the action when it reaches its peak, concludes Step 1 with the statement, “It seems to me that the family problems we are discussing are extremely painful, and that you have been unable to resolve them until now,” and moves on to Step 2, “reframing.”

The physician concluded that Ariana’s somatization was embedded in the repetitive pattern of events dominated by her triangular relationship with Estelle and their mother. Ariana’s physical symptoms allowed her to remain connected to and receive attention and emotional support from her mother, and simultaneously allowed her to control the family’s expectations that she would always be there to help with Estelle. It seemed that Ariana’s reason for remaining away from her mother and Estelle was an illness, that is, something beyond her control. The desire to devote more of her life to herself, even though it was closer to the truth, would not be acceptable to either Ariana or the family.

Step 2: Reframing Attention to the Underlying Family Problems

The goal of Step 2 of family intervention, “reframing,” is two-fold (Table 11-8): (1) focus the patient’s and family’s attention on the underlying family problems, and away from physical symptoms and sick role-justifying problems; (2) separate the patient’s (or family’s) objective in using the sick role from the use of the sick role as a tactic to achieve the goal. This is done by recognizing the objective that the patient is pursuing and endorsing it as something that the patient is “entitled to even if [they] are in perfect health.”

Reframing, “In Addition to Your Pain …”

The transition from Step 1 to Step 2 occurs when the interview has “brought the pain into the room,” and patients are in touch with their distress, that is, when they agree with the first critical reframing statement, “It seems to me that the family situation you have just described is extremely painful, and that in addition to your [problematic symptom or behavior], this family problem is also worthy of attention.”

A critical component of the first reframing statement is “in addition to” in contrast to either “instead of” or “because of.” Even if your understanding, based upon a psychosomatic hypothesis, that family stress is “causing” the somatoform presentation, you must resist saying so. The legitimacy of the sick role and coping strategies that the patient and family currently need to function depends upon there being a “disease beyond one’s control” to justify the sick role. If the family intervention begins to have effect, and healthier coping strategies are adopted, then the family will be able to relinquish sick role-based coping. Until that time they must be allowed to retain the sick role strategy. Therefore, the goal of reframing is to establish a parallel concern directed at the underlying family problems. Occasionally, a patient or family member will be able to make the connection themselves: “Doctor, do you think that maybe my headache is being caused by all these problems?” In such cases, the psychosomatic hypothesis can be endorsed. The mistake is to make the connection before the patient and family are ready. This will result in the all too familiar, “Doctor, you think it’s all in my head. It’s not in my head, my pain is real!”

Reframing, “Even If You Were the Picture of Perfect Health You Would Be Entitled to …”

Unless your patient’s objectives in occupying the sick role are antisocial, you should be able to identify an essential core of their objective that you can endorse—a new grandmother who does not want to be mistaken for a nanny, a father who wants peace in his home and rules for his teenage daughter, a young woman who does not want to become her sister’s home health aide, and so on.

The second objective of reframing is to separate the objective from the tactic of occupying the sick role, and to empower the patient and family to adopt other, healthier strategies. This can be done by telling the patient, “if you were the picture of perfect health, you would be entitled to—be a grandmother not a nanny, have your daughter follow some agreed upon rules, set limits on your role in taking care of your sister, and so on.” This part of the reframing addresses the fundamental function of the sick role, which is to establish entitlement, and uses the authority of the physician to legitimate the desired entitlement on other, healthier grounds.

Case Illustration 1: Discussion (Contd.)

It was relatively easy to reframe the burden of caring for Estelle as a problem worthy of attention after the painful demonstration of just how difficult it was to just have a conversation with her. It was also easy to reframe Ariana’s desire to have some time for herself—a need she was unwilling to claim on her own—as something that would be important for “a woman her age” even if she was not ill. Ariana was willing to accept the suggestion that her failure to develop the kind of intimate relationship she desired was also a problem worthy of consideration.

Step 3: Empathic Witnessing: “I Am So Impressed with How Well You Are Doing Despite …”

The most immediate way to ensure that family intervention has a positive and therapeutic effect is to “empathically witness” the patient’s and family’s problems and their efforts to cope (Table 11-8). If the interview has succeeded in exposing the family’s distress and their best attempts to deal with their problems, the patient and family will recognize that the physician knows the family in a very intimate way. If the physician acknowledges the special nature of this awareness, and responds empathically to the patient and family, the effect can be very therapeutic. The general format for empathic witnessing is to say to the patient (or family) that having heard their story, and seen what they have to cope with, “I am very impressed with how well you are doing despite all your problems and difficulties.” It is helpful to remember that even if you cannot praise the patient’s behavior or accomplishments, you can usually empathically witness their efforts: “I am impressed that you want to be a good mother to your children.”

Step 4: Referral for Family & Psychotherapy

Referral for therapy is not always indicated. Very often a brief family intervention can empower patients and their families to address their difficulties with new energy, insight, and courage to change. However, when mental health intervention is indicated and proposed, patients and families may not readily accept it (Table 11-8).

Resistance to a mental health referral is common. Referral for therapy may make sense to the provider long before it does to the patient. Framing family problems as “in addition to” will help patients feel comfortable that therapy does not threaten their use of the sick role before they are ready to give it up. Resistance to therapy may be due to fear of dealing directly with painful and powerful emotions. Empathic witnessing and reframing can make this challenge seem more surmountable. Finally, patients may accept the reality of family problems yet not accept the fact that therapy will help: “What’s talking going to accomplish?” The process of therapy may indeed seem obscure to patients and it may be useful to restate problems as questions and describe therapy as the process of looking for answers. For example, “you have a serious question to answer. You have to determine how much child care you actually want to provide, and then how to talk to your daughter about it. Therapy can help you find answers to these questions.”

Sometimes, patients and their families never get to therapy. Even in that case, the reframing and empathic listening to the patient’s family story have a positive effect. After performing a family assessment and intervention, the physician may say the following to the patient who has not followed through with referral for therapy and who returns with persistent or recurrent symptoms (as did the father in Case Illustration 2).

The patient—aware that the physician has witnessed the family conflict—knows that the clinician understands the importance of the conflict at home and that this understanding is empathic. Hence, the physician does not have to repeat the assessment and intervention interview, merely recall it for the patient. The physician is in a position to respect the meaning of the patient’s symptoms without allowing them to divert the process of care into unnecessary testing, medication, or referrals for more evaluation.