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.
Table 11-8.Family intervention. ||Download (.pdf) Table 11-8. Family intervention.
|Step ||Objective ||Statement |
|Analyze, and “bring the pain into the room” || |
Understand the major conflicts in the family system.
Understand how the sick role functions in the family system.
“Bring the pain into the room,” that is, help the patient (and family if present) experience the pain of their problems during the interview.
|“Your [family problems] are serious and painful, and you have not been able to resolve them on your own.” |
|Reframe || |
Direct the patient’s (and family’s) attention to the underlying family problems and away from the sick role establishing somatization, excessive functional impairment, or dysfunctional self-care behavior.
Endorse the patient’s objectives while separating them from the use of the sick role to obtain them.
“In addition to your [symptom/problem] these family problems are equally worthy of attention.”
“Even if you were in perfect health I could understand why you would want your [family problem] resolved in a way that meets your needs.”
|Empathically witness || |
Provide emotional support and empowerment to the patient.
Enhance the therapeutic alliance.
|“I am so impressed with how well you are doing despite all your problems.” |
|Refer || |
Provide access to and educate patients about psychotherapeutic intervention.
Address resistance to psychotherapeutic treatments.
|“You have important questions about how to improve your family situation; therapy is a way of answering those questions.” |
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.”
CASE ILLUSTRATION 1 (CONTD.)
Ariana greatly appreciated the opportunity to describe the situation at home, especially when the physician expressed sympathy for the burden that Estelle’s illness placed on everyone and for the disappointment resulting from Ariana’s failed marriage. The physician now had a general feel for Ariana’s family. It was clear that Ariana needed to be labeled as “sick” and that every diagnostic test, referral to a specialist, and symptomatic treatment helped create a compensatory alliance establishing the sick role. Ariana, clearly feeling that the physician was on her side after the genogram interview, readily agreed to a family meeting.
During the family interview, the tremendous burden placed on the family by Estelle’s visual impairment, deafness, and diabetes became painfully clear as the physician struggled to communicate with her, a process that required writing notes in letters 6 in. high, or having Ariana or her mother slowly and carefully speak so that Estelle could read their lips (Estelle was unable to read anyone else’s lips, and the family had tried but failed to learn sign language). It became clear how much the family depended on Ariana and how she stepped ambivalently into the fray whenever Estelle needed attention.
When the subject turned to Ariana’s failed marriage and social life, the mother (Maria) expressed some hope, immediately labeled as ridiculous by Ariana, that she (Ariana) would get back together with her ex-husband. Ariana said, “with all this,” meaning the problems with Estelle, “how can I find time to get involved with anyone?”
Further discussion revealed that Maria was a worrier and was constantly preoccupied with whichever of her children was having difficulties, especially medical problems. Ariana’s medical problems elicited sympathy from her mother, who suggested that since Ariana was no longer married, she should move back into the family house.
Ariana immediately rejected the offer and said that her medical problems were the primary reason she could not move back into the house; she didn’t want her mother to see her when she was sick because her mother would worry too much. Ariana added that when she was feeling sick, she needed to stay home by herself, and at these times she didn’t even answer the phone or know what was going on in her parents’ house.
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.”
CASE ILLUSTRATION 1 (CONTD.)
The family admitted that the current situation was indeed painful and that they had not been able to solve the problem despite their best efforts. The physician was able to tell Ariana and her mother: “I am so impressed with how well you are both doing despite the tremendous problems you have had to deal with.” The physician also remarked on the magnitude of the sacrifice Ariana had made, neglecting her own social life to be available to the family. The physician also commented that it was easy to understand how this area of Ariana’s life might be difficult for her to deal with because of her past problems.
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).
CASE ILLUSTRATION 2 (CONCLUSION)
“I am sorry that your headache is still bothering you. Your wife and daughter are still fighting, aren’t they? It’s too bad that you haven’t gotten to the therapist yet. I truly wish that there was more that I could do for you. Now, why don’t we check your blood pressure.”
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.
CASE ILLUSTRATION 1 (CONCLUSION)
The physician (1) referred the family for family therapy to explore better approaches to coping with Estelle’s medical problems; (2) suggested that Ariana would benefit from individual counseling to explore her difficulties in forming a satisfying intimate relationship; (3) asked Maria’s physician to consider the diagnoses of dysthymia and major depression; and (4) recommended that the family try to obtain a home health aide for Estelle to give Maria a break. The family agreed to all four of these suggestions. When Ariana returned for her next visit, she still had numerous symptoms but spoke of them only briefly, allowing the physician to turn the discussion to what was going on at home. Ariana reported that the family had taken no steps toward family therapy and that she was still considering whether to go to individual therapy. She did report feeling more comfortable setting limits on her mother’s expectations of assistance in dealing with Estelle, and reported success in obtaining a home health aide for Estelle. Maria had been placed on an antidepressant, made a few visits to a community mental health center, and was much less symptomatic.
Eight months later, Ariana entered individual therapy and her somatization decreased dramatically and her limit-setting improved. Eventually, she started dating and entered a steady relationship but has not married.