A recent extensive review of 20 years of research in family psychiatry demonstrates conclusively the need for family involvement in the treatment of psychiatric illness (1). It indicates that markedly improved patient outcomes occur when family members are seen as allies and offered support, assessment, and psychoeducation. Much of this research did not include family therapy in the traditional sense. APA Practice Guidelines for most DSM-IV Axis I disorders (e.g., schizophrenia, major depression and bipolar disorder [2–4]) include the expectation that patients’ family members will be involved in the assessment and treatment of these patients. According to the Residency Review Committee for Psychiatry (5), residents are required to learn how to ally with and communicate with families, provide psychoeducation, and have exposure to family therapy as part of the core competencies of residents.
However, the integration of these family skills into general residency training has not kept pace with research. Several papers written in the last 15 years, including a survey of 1500 recent residency graduates in 1998 (unpublished plenary presentation of J.L. Griffith, N. Smith, and D. Gitlin), speak to recently graduated residents’ use of family training and wish for more training during the residency (6, 7). An informal survey of past and present members of the Group for the Advancement of Psychiatry (GAP) Committee on the Family, the Association of Family Psychiatrists, and the psychiatry training interest group of the American Family Therapy Association, conducted by the GAP Committee on the Family strongly suggests that the majority of general residencies provide limited exposure to family systems. When available, teaching tends to focus on family therapy rather than integrating family systems thinking into ongoing psychiatric care as part of a biopsychosocial model. The faculty and residents indicate that families are consistently seen only in units where patients are dependent or incompetent (predominantly child psychiatry and geriatrics). They are far less involved with and gain far less information from families of adult psychiatric patients, particularly outpatients, between the ages of 18 and 65.
Indications that adult psychiatric training falls short are also given by consumer groups such the National Alliance for the Mentally Ill, which has consistently noted that family members are not usually involved in treatment planning and recommends improved collaboration between provider, consumer, and family (8). Families identify conflict with health professionals about treatment and lack of a role in the treatment of their relatives (9). Family members can be overwhelmed during a loved ones’ illness, and need support and reassurance from health care workers (10, 11). Disagreements between family members, or disagreements between family and health providers regarding aspects of care, may take time to resolve and are often frustrating to health care providers, families, and patients.
In 2006, the GAP Committee on the Family proposed a curriculum (including knowledge, attitude, and skills) for developing core competency in supporting families of psychiatric patients, and reviewed the issues of programmatic development, faculty needs, and model training program configurations (12). In this article the committee advocates that to respond to the research on patient needs and patient outcome, residency programs need to refocus their efforts. We suggest a coordinated effort to teach competency in family skills across the training years and in all training sites, and that coursework be focused specifically on what is needed at those training sites. To truly develop an appreciation of the interactional component of psychiatric illness, and to treat patients effectively, consistent effort must be put into reinforcing this model. Rather than learn “family therapy for the family cases,” we are proposing that residents be taught to form an alliance with family members in all settings, provide education, understand the family’s needs, and decrease caregiver burden, as part of a true biopsychosocial orientation.
A family-oriented approach requires an initial expenditure of time. However the benefits include improved patient outcomes and improved family well-being (1). Family members who attend psychoeducational programs feel less displeasure and worry about their ill family member and are more empowered in the community, in their family, and with the service system (13). Family members who participate in family education programs also have greater knowledge and self-efficacy and are more satisfied with the patient’s treatment than those who do not participate (14), and overall patient and family satisfaction is increased when families are involved in the assessment and treatment of patients (15).
Doherty and Baird (15) described five levels of family involvement for primary care physicians which could be applied equally well to psychiatry residents. These levels range from minimal contact at Level One to family therapy at Level Five. Residents trained to Level Four (i.e., assessment, education, and simple change techniques) are considered to have “family skills” and can support and manage families who do not require major change. Residents who are interested in more intensive training in couple/family therapy can be trained up to Level Five. Multiple well-researched models of family therapy have been developed; the choice of model can be left to the family faculty. For training up to Level Four, basic assessment and psychoeducation are included. Teaching methods can also vary as long as the material is taught, supervised, and reinforced throughout the program. We have found that modeling, via videotape or demonstration interviews, is particularly crucial for teaching session management skills.
Family Training throughout the Residency
Coursework in family skills is an important aspect of training, discussed in our previous paper and beyond the scope of this article (12). In developing clinical competency, however, the acquisition of effective clinical skills requires practice under supervision. When the patient is adult and mentally competent, patient autonomy is incorrectly seen as precluding family involvement in treatment planning. This is true even as hospitalizations grow briefer and the day to day care of severely ill people, both mental and physical, is handed over to family members. Recent Health Insurance Portability and Accountability Act (HIPAA) rules make the situation more problematic by restricting communication about the patient to third parties, resulting in the reluctance of many health care providers to discuss anything with family members.
Nevertheless, physicians often rely on families to provide essential information, provide patient support, monitor medications and treatment compliance, and keep patients safe between appointments. Competent family support is frequently the difference between relapse and continued functioning (1). In family oriented care, the family’s need for connection to the health care system is seen as useful whether or not the family appears “dysfunctional.” Patient confidentiality is respected, but information about medication, relapse prevention, and crisis planning is shared and consensus is reached about broad treatment goals. Maximizing patient functioning outside the hospital involves learning new routines and behavior patterns for all family members, including the identified patient. The psychiatrist who manages these issues as the “family doctor,” rather than turning the family over to the social worker, gains the family’s trust and a more accurate assessment of his or her patient’s state.
The goal of this article is to examine the ways in which training can become setting specific and most effective. This article discusses how family connection can be efficiently threaded through the training cycle, focusing on inpatient, outpatient, and consultation liaison, so that family connection becomes an integral part of patient care.
While some of the changes require trained family supervisors, others principally require mindfulness of the current research on the part of the faculty. Certain basic skills and attitudes are common to all training sites, while setting specific training offers an opportunity for the development of particular skills.
Family Skills Required in All Treatment Settings
1. An attitude of interest, empathy, and an appreciation of multiple points of view
The most critical change required of faculty and residents is an interest in family members as people with their own needs and history. A wider focus on the family supports the patient’s care. For example, a grandmother’s illness might not seem directly associated with a young man with a schizophrenic decompensation. If it is recognized, however, that his mother has become acutely depressed by the grandmother’s illness and is unable to cope with him or monitor his medications, the event becomes more understandable and the need for attention to the mother becomes clear.
One of the most effective tools for learning is a three generational genogram for all patients. Taking a three generational genogram (16) and drawing a family time line provides the resident with an understanding of multigenerational patterns and beliefs, patterns of psychiatric disorders in the family, and an appreciation of the lives of other family members. The use of the genogram is familiar to most medical students from the genetic basis of physical illness, and it is a short step to ask about personalities and family life over three generations. Residents must learn to draw genograms that include important family members who are not biologically related, (e.g., foster families, fictive kin) to fully identify varying family patterns and key family members. This process also develops empathy for the family. If supervisors assume that case presentations should include a genogram, a powerful message is given about the importance of family transmission of health and disease.
2. The ability to think systemically
The ability to think in terms of boundaries, subsystems, and feedback loops rather than linear cause and effect is critical to understanding interpersonal connections. Systemic thinking is also a critical part of community psychiatry, team building, and administrative work.
3. Family interviewing skills
Effective training begins by encouraging the resident to be available for brief family contact when the family visits. This is especially true on inpatient medical or psychiatric units. In outpatient clinics the family often brings the patient to the appointment, and a brief greeting or 10 minute meeting can develop an alliance. For assessment, education, or change oriented interventions the resident needs a specific interview protocol and agenda, discussed beforehand with the patient (if possible) as well as the supervisor. Sample interview protocols for inpatient (17, 18), outpatient (19), and consultation-liaison are available (20).
Residents must make a clear distinction between psychoeducational interviews, in which the focus is on helping the patient and family understand and respond to the patient’s illness, and family therapy, which is an in-depth assessment and treatment of relational issues (15). While both may be used in a particular case—for example, a depressed patient may also have marital problems which need direct attention—these are separate interventions and require a different focus of attention.
4. Collaborative treatment planning
Discharge planning should be a process that includes all members of the system—patient, family members, and members of the treatment team. Good discharge planning establishes a clear role for family members, helps define criteria for urgent intervention, and provides clear and realistic goals for treatment. Collaborative planning can also help draw clear boundaries and designate patient and family responsibilities. While family discharge meetings are common in most inpatient units, in the GAP committee’s experience what is most often missed is a discussion of the caregiver’s needs, and specific attention to areas where the family can support the patient, such as decreasing high expressed emotion or attention to early warning signs of decompensation.
5. Managing high levels of emotion
Distressed family members and/or patients can dominate a family meeting. The affect may be directed at family members or at members of the treatment team. Techniques to de-escalate intense emotional situations and manage hostility and conflict within a family setting are similar to techniques used in group psychotherapy and can be learned (21, 22). Supervising faculty can demonstrate these skills and then provide the resident with an opportunity to practice under supervision.
Psychiatric Inpatient Unit
Research indicates that the majority of residents prefer that family skills training begin early in the residency (6, 7). The inpatient unit is the ideal place to begin resident training in family outreach, as families tend to be more available, and residents are most open to developing schema that include them. Faculty should be available, particularly early in the training year, to supervise inexperienced residents when meeting with contentious families. Otherwise, in our teaching experience, the resident will be overwhelmed and will attempt to avoid future family meetings. If ward faculty are hard pressed for time, volunteer faculty can do family consults on the inpatient unit. In addition to the family skills described above, skills specifically related to inpatient families include:
1. The ability to conduct an interview with the patient present, regardless of their diagnosis, as well as meeting with the family privately when indicated
2. Appreciating and validating the emotional reactions of family members, such as anxiety, anger and withdrawal, to the patient’s illness and hospitalization
3. Taking seriously the family’s concerns about too-early discharge or inadequate follow up plans, and their questions about caregiving and further emergency care
4. Ensuring opportunities for family psychoeducation related to the illness of the patient, treatment options—both pharmacological and psychosocial—expected treatment, and prognosis
5. Ensuring that family members learn about the need for social support, respite, and self-care, and about family support organizations such as National Association for the Mentally Ill (NAMI), Depression Bipolar Support Alliance (DBSA), and online resources
Minimal changes in the process of care on the inpatient unit can provide an opportunity for large changes in the resident’s perceptions and experience. Examples include observing family interviews which cover the family’s history as well as the patient’s, adding a genogram form to the chart, insisting that residents be part of family meetings rather than leaving this to other personnel. This process orients residents immediately to family care, which then makes it easier to teach later in the program. The family skills needed by the resident for working on a short-term inpatient unit are described in more detail elsewhere in the literature (17, 18).
Psychiatric Emergency Room
Patients brought to the ER are often incapable of giving accurate (or any) history and are frequently brought by family members who have critical information to offer. Family members may have been personally involved in the emergence of the crisis and almost always have a stake in disposition decisions. In these situations, residents can develop skills in rapid history taking and alliance at moments of extreme stress. In supervision, residents can be specifically asked about the level of support and struggles of family members. Supervisors or appropriate faculty can give guidance about managing the family and helping them negotiate the hospital or outpatient treatment system.
Patients come to the outpatient clinic for individual treatment and it is the task of the clinician to evaluate the extent to which involving the family, either in evaluation or treatment, will be helpful. Often family involvement is ignored because outpatient psychiatrists tend to approach patients as adults capable of completely handling their own affairs. Concerns about confidentiality and privacy may appear to the resident to outweigh needs of an accurate history or identification of caregiver stresses. However, in many cases patient symptoms are heavily relational in nature. In addition, frequently a spouse or parent will be deeply involved in issues of medications compliance or coping with unexpected side effects of medications or therapy. If the patient is seriously ill, family members are expected to know what to do when crises occur, even if the treating doctor has not specifically consulted with them.
Whenever possible, patients on medication or those in danger of crises should be seen early in treatment with their partner/family to develop a general treatment plan. This should include education about the course of the illness, the role and side effects of medication, an agreement about what constitutes a relapse or crisis, when the physician or hospital should be contacted, and whether or not the family has a role in medication monitoring. In terms of confidentiality, the resident can distinguish between individual session content, which can be kept private, and case management issues such as those described above, which can be shared. In addition, particularly with impaired young adults living at home and unable to work, an agreement must be reached about family rules, especially about the structure of the patient’s day, alcohol, or drug use, and finances. The resident needs to emphasize that reducing stress in the system, both for patient and caregivers, is important to rapid recovery; this reduces the tendency to use historical issues to blame family members.
More functional patients who enter the outpatient clinic for exploratory therapy may not require (or may refuse) a family consultation. The resident’s task is to learn to what extent the problems are relational in nature and whether the family can contribute to treatment. For example, if the patient is in a committed relationship and is experiencing relational problems, a couple’s consultation, done either by the treating resident or a colleague, may be critical to determining whether couples therapy would be useful. Patients often present for individual therapy for such relational issues; for example, coming in to discuss divorce without first mentioning to their partners that they are dissatisfied and want relational change. Even well-functioning patients typically present a one-sided view of relational issues, and the treating resident who sees the patient and partner together (even for a single assessment session) gains a healthy respect for the amount of information missed by hearing only one side of the issue. We recommend that whenever possible the resident do the initial couple/family assessment rather than sending the patient directly for couples or family therapy, and that supervisors consistently encourage family assessment as part of teaching a biopsychosocial model of health and illness. If the patient is sent for couples or family work while continuing individual therapy, the resident should receive specific guidance on how to maintain appropriate contact with the family or couples therapist.
In our experience, particularly in the outpatient clinic, residents traditionally take the patient’s first “no” to a family meeting as a final decision. In the same way that one would not accept a “no” to medications without continued discussion, the resident with a patient in serious distress or with a relational problem must feel confident in believing that some family connection is part of treatment. If residents are allowed to avoid this, their own discomfort remains intact and the patient’s reluctance prevails.
Unless the patient is completely cut off from any family, outpatient treatment of addiction requires family involvement. Substance abusers tend to minimize their substance use, so corroborating information should be obtained from the family. Residents in this setting should learn about the effects of substance abuse on other family members, especially children and spouses (22). This setting is a good place to become familiar with behavioral couples therapy, as there is evidence that this has positive effects on sobriety, the spousal relationship, and violence reduction (23). Families need clear guidelines about how to treat the recovering patient, education about addiction, and strong encouragement to attend Al-Anon, Nar-Anon, or other appropriate groups.
Consultation and Liaison Service
On consultation-liaison, psychiatric consults may be used to determine whether a patient has a medical or psychiatric condition (or both), to help deal with conflicted patient-staff relationships on the floor, or to help a patient and family cope with serious/chronic illness, death or dying. As part of the assessment, a family member’s report of the patient’s history is often critical in determining when a patient’s symptoms occurred in order to decide if the medical regime is contributing to the symptoms. With chronic medical illness, the level of the patient’s incapacity and caregiver burnout need to be assessed. With staff conflict, problems often arise between anxious/angry family members and overburdened staff, especially if family members disagree about treatment decisions. This is an excellent place to learn about family decision-making and the complexities of the family/medical ward system. Listening to family members’ concerns is often the first step in ameliorating the situation.
In recently developed medical problems, families are faced with learning to cope and adapt to a family member’s illness. Family roles may change drastically, dealing with medical systems may produce helplessness or rage and family routines and habits are invariably disrupted (20). Psychiatric consultation with key family members near the time of initial diagnosis and at major nodal points during the course of the illness (e.g., re-hospitalization, recurrence, or progression of the illness, transfer to rehabilitation or hospice) can both facilitate the treatment process and support the family unit in a time of crisis. Convening families in this context is not difficult as family members typically visit their hospitalized member. However, it requires flexibility on the resident’s part—a willingness to meet with families in the late afternoon or early evening after typical work hours, or to conduct rounds during visiting hours. Dealing with death and dying issues, such as advance directives, is often difficult for residents who have not had much personal experience with seriously ill or dying family members. They may need specific support from supervisors.
The following points should be included in family meetings:
1. Emphasize that all family members are impacted by the strains and challenges of living with a major medical illness and address the immediate emotional and practical needs of the patient and family members such as guilt, shame, helplessness, and the reactivation of old family conflicts around illness decision-making.
2. Facilitate communication around illness and treatment-related issues and decisions. Inability for family members to speak to each other, or serious conflict among family members, particularly around areas of death and dying, often makes these processes far more painful and stunts family growth for years to come (24).
3. Help the family understand the illness in longitudinal and developmental terms. While this is true in psychiatric illness as well, physical illness alters the family landscape in very specific ways in terms of role change and grief within the family.
4. Understand the cultural and spiritual beliefs that guide the family. This is essential to fostering culturally sensitive collaborative care and helping the family make meaning of the illness experience.
The GAP committee proposes that consultation faculty consider the number of cases in which families are seen, and work to ensure that adequate family consultation is done by the residents. An extensive literature in family systems medicine is available (20) and can be included in the resident’s reading.
The Role of the Supervisor
Knowledgeable supervisors are key to resident comfort with families. Supervisors can encourage, demonstrate, or participate in initial family interviewing, and provide planning and postmeeting supervision when the resident is able to manage the session alone. Supervisors can support resident efforts to arrange a meeting, even if the patient is reluctant, and to make family meetings a normative part of care. Family life cycle stages (25), the effect of illness on family communication and functioning, family factors contributing to the patient’s illness, caregiver burden (26) and psychoeducation (27) are general family issues for residents and supervisors to discuss in supervision.
It is important for the supervisor to assess the resident’s response when working with families. Residents may be overwhelmed by the outpouring of affect from the family, especially if this is negative affect and directed at the treatment team members. They may feel embarrassed by their lack of knowledge of family issues—especially if they are unmarried and childless, and the family is older and complex—or may have transference responses to family members who remind them of their own family issues. Any of these issues may allow the resident to lose control of the session. Early supervision allows residents to learn to acquire information in advance, to deal with countertransference issues, and to learn to actively manage meetings. Further examples are available in the literature (17, 18).
It is important to have some supervisors available who are trained family therapists, and not all of these will be MDs. However, since research and good clinical practice suggest that these skills are needed for general psychiatric practice, we expect that a reasonable number of faculty should be able to teach basic interview skills and an attitude of interest and concern.
Family therapy electives can be arranged in the third or fourth year in specialized couple and family therapy clinics, the child/adolescent unit, or the general outpatient clinic. Residents interested in family therapy, often those considering child psychiatry, can begin to work with families more intensively.
The Process of Establishing Change
The process of integrating family work into a new treatment setting is a multistage process. As with any departmental shift, from the increase in biological training to the inclusion of cultural psychiatry, spearheading change comes most often through the Director of Training, heads of service, or through chief residents, and occasionally through consumer groups such as NAMI or cultural shifts which demand different levels of care (for example, the recent focus on cultural competency). Commonly, change in clinical practice begins in one area of the department and if the training director and family faculty are persistent, spreads to others. Those who are in charge of the scheduling—usually the Director of Training and Chief Resident—must ultimately be persuaded to make time in the training schedule.
Coordination of family skills training and a determination of how to assess this core competency in a particular residency can be developed by appointing one faculty person to oversee all family systems training, or by appointing a person in each treatment setting who will work to increase family outreach and connection in their setting. It is useful to start with one setting at a time where there are interested faculty members and residents. Available teaching staff, proposed patient or resident schedule changes, and possible alterations to patient assessment forms and residency evaluation forms must be assessed. In our experience as department members and teachers, a fairly minimal amount of increased family focused training time—increasing the number of observed family interviews, adding a sentence about family involvement to the patient’s chart, requesting that the supervisors support family meetings, or developing a family psychoeducation group—may deliver large changes in resident comfort with families. Some time should be spent teaching the unit staff that family involvement takes some effort in the beginning but is worth the trouble. While not all settings will be equally open to family involvement, efforts should be made to consider the possibilities and benefits of involving families in patient care in each setting.
Having family faculty participate in case presentations and Grand Rounds throughout the program is helpful in normalizing family and cultural issues as part of appropriate psychiatric care.
We do not underestimate the difficulty of establishing change of any kind in a complex training program. The process may be slow and time consuming, as many different faculty members must be persuaded to buy in, and time and faculty must be found. However, psychiatry programs always face the need to reevaluate their curricula in the face of advances in knowledge. If we are committed to evidence based research, to a biopsychosocial model of understanding, and to caring for patients efficiently and effectively, the evidence is very clear that family involvement is necessary to good care. If we know that, we must find ways to teach it.