The Accreditation Council for Graduate Medical Education’s (ACGME’s) description of the core competencies includes the expectation that residents work with families (1). Teaching residents a set of family skills is also recommended by the Family Committee of the Group for the Advancement of Psychiatry (GAP) (2). Adequate family skills include conducting a family meeting and integrating family factors into a biopsychosocial formulation and treatment plan. Family skills are to be differentiated from family therapy, a psychotherapy that requires extended supervision. Although some residency programs include family therapy training in their curricula, few psychiatry residencies teach family skills, which can be taught by supervisors with an interest in this area. This article assists supervisors by identifying the typical barriers that residents face when beginning to work with families.

On review of the family research in general medicine, it is clear that families have a powerful influence on health, equal to traditional medical risk factors (3). Marital partners especially have influential effects on health, with emotional support being the most important type of support provided. However, negative, critical or hostile family relationships have a stronger influence on health than positive or supportive relationships (3). Family strengths, such as good parenting, can offset the effects of family difficulties on children’s development (4). Good family functioning, which includes clear, direct communication, collaborative problem solving, strong family structure, and good emotional relatedness, improves patient outcome (5).

Family factors also influence the course of psychiatric illness. Patients with major depression who have significant family dysfunction have a slower rate of recovery (6, 7). Conversely, good family functioning is identified as one of five factors that improves outcome in major depression (8). Families that demonstrate high levels of criticism, hostility, or emotional overinvolvement are known as high EE (expressed emotion) families (9). High EE is a “significant and robust” predictor of relapse in many psychiatric illnesses (10), such as schizophrenia (11), depressive disorders (12), acute mania (13), and alcoholism (14). How a family member perceives mental illness can also play an important role in the patient’s relapse. Critical relatives are more likely to hold patients responsible for their actions rather than attribute their behavior to the illness (15).

Family-based interventions reduce relapse rates, improve recovery of patients, and improve family well-being among participants, as shown by 30 randomized clinical trials (16). Family-based interventions are effective for patients with schizophrenia (10), bipolar disorder (17), borderline personality disorder (18), and alcoholism (19), and are potentially beneficial for bipolar disorder in children (20). In outpatients with major depression, couples therapy is as efficacious as medication and is more acceptable to patients (21). Other psychiatric illnesses also show benefits from family interventions (22).

Family involvement in patient care is recommended in the APA’s Practice Guidelines, especially in the Guidelines for Schizophrenia (23). The Guidelines recommend establishing a therapeutic alliance with the family, addressing the family’s needs and routine family meetings to exchange information on illness management. The Guidelines for Schizophrenia state, “On the basis of the evidence, persons with schizophrenia and their families who have ongoing contact with each other should be offered a family intervention, the key elements of which include a duration of at least 9 months, illness education, crisis intervention, emotional support and training in how to cope with illness symptoms and related problems.” The Practice Guidelines for Bipolar Disorder (24) and Depression (25) also recommend early family involvement and present the efficacy of family-based interventions. Practice Guidelines for other disorders, such as panic disorder, eating disorders, and substance abuse disorders, similarly recommend early family involvement and provide evidence of the efficacy of marital or family therapy.

Thirteen-year-old “Alice,” who lives with her mother, expresses the desire to live with her father. She is angry with her mother whom she describes as controlling and selfish. “Dr. M” tells his supervisor that the mother seems more concerned with her own feelings than her adolescent daughter’s needs.

Resident’s Concerns

“Aren’t Families to Blame for Lots of Problems?”

Psychiatry has a history of blaming the family for causing psychiatric illness and using pejorative labeling, such as the “schizophrenogenic” mother (26). Dr. M’s desire to be empathic toward the patient may unwittingly ostracize family members who are often a focus for the patient’s anger. It is important to ask residents to put themselves in the shoes of the family. “If this were your family member, how would you like to be treated, and what would you need to know?”

Supervisor’s Intervention

The supervisor asks Dr. M to think about the mother’s perspective. What might the mother feel? What has transpired over the past 13 years? Has the mother been the primary parent for 13 years and now faces the loss of her daughter? How can the mother manage her own feelings while supporting her daughter’s wish to live with her father?

Resident’s Response

Dr. M begins to realize how difficult it is for the mother, who has been the main support and caregiver for her daughter, to suddenly relinquish care. Dr. M imagines the mother may feel a sense of loss and may need support to honor Alice’s wishes. Dr. M wants to help the daughter express gratitude to her mother and help the mother understand that this is not a rejection of her but rather an attempt by Alice to develop a closer relationship with her father. Dr. M is now able to engage with the family in a more empathic way.

The nursing staff tells “Dr. N” that “Mr. B” is “a problem.” The nurses report that he expects special arrangements to be made for his 10-year-old son, “Chris.” He wants his son on a special diet, to play basketball in the gym each evening, and to have extended visiting hours. Mr. B presents the nurses with a list of questions about procedures on the unit, such as what happens if one child bullies another.

Resident’s Concerns

“I Have No Time to Meet With Families.”

Meeting with families improves patient compliance (27, 28), strengthens the alliance between patient and physician (29), sets the stage for future problem solving (30), and has a positive influence on patient outcome (31). Stating that there is no time to meet with the family may be a way of avoiding the family, especially if the family is perceived as “angry” or “demanding” or as expressing high levels of emotion which can be difficult for the resident to tolerate.

“What Does the Family Want?”

Family members usually see themselves as advocates and want to be involved with their ill relative (32). Families may express a sense of failure as they acknowledge their inability to resolve family problems and may express guilt or blame themselves for their relative’s illness. In a family meeting, family members may be anxious as they anticipate being discussed, criticized, and confronted. Children may fear being punished, getting their parents in trouble, or being caught in loyalty conflicts. Families state that they do not want lengthy and intensive interventions but family care that focuses on building rapport and communication with mental health professionals (33). Families therefore express several needs: to be included in the care of their relative, to be understood, and to be respected as concerned relatives who are doing the best they can.

“Shouldn’t I Wait to Meet With the Family Until After I Know the Diagnosis?”

Physicians may avoid meeting with the family if they do not have a definitive diagnosis and treatment plan, as they do not want to be seen as incompetent. Being straightforward with the family about the need to gather more information is acceptable to most families. Meeting with the family for a short time to explain the process will help engage the family and establish a collaborative relationship. The willingness of the resident to reach out to a family is reassuring to the family and is seen as supportive and caring.

Supervisor’s Intervention

The supervisor acknowledges the resident’s anxiety and wish to avoid the “hostile or demanding family.” The supervisor advises that the resident quickly engage the family because, if ignored, the family will likely become more “demanding.” The resident is encouraged to think about what it must be like for Mr. and Ms. B to have their son hospitalized. Do the parents feel responsible and blame themselves? Do they feel helpless and worried that their son has a major mental illness? Is their list of questions an attempt to gain some control and quell their fears? Are the parents advocating for their son? What do they understand about the process of hospitalization?

Resident’s Response

Dr. N arranges a family meeting for that day. In the meeting, he acknowledges the parents’ concerns and praises their questions as addressing important aspects of care. He then asks, “What is it like to have your son hospitalized?” Mr. B becomes tearful and talks about being an absent father when his son was young. Dr. N validates Mr. B’s sadness, supports his desire for more involvement with his son, and collaborates with him on how to spend more time with his son.

“Dr. P” is anxious about meeting with the large family of her patient, a 50-year-old Chinese woman with major depression. Preparing for the meeting, Dr. P reviews the literature about Chinese culture and mental health, which stresses the importance of respecting the reserve and dignity of the Chinese family. The patient arrives for the family session with her elderly father, three adult siblings, and two children. Dr. P greets the family and, to her surprise, the family begins to wail and talk non-stop in Mandarin. Dr. P is caught off guard and allows the family to continue crying and talking among themselves. Eventually she asks the family to focus on why they are here and speak in English. Dr. P then educates the family with an explanation of major depression, explaining the risks and benefits of antidepressant medication. Dr. P asks if the family has any questions. Several family members begin to voice their concerns, and Dr. P worries that she will lose control of the meeting and prematurely reassures the family that things will improve in a few days.

Resident’s Concerns

“I’m Afraid of Being Outnumbered and Not Understanding What Is Happening.”

Residents avoid families because they perceive themselves as unskilled. Residents often report feeling anxious in a family meeting because “there are too many dynamics and emotions flying around,” there is “difficulty keeping track” of the flow of dialogue, and they feel unable to incorporate the multiple perspectives of the various family members. Providing structure to a family meeting reduces dynamic interactions and gives the resident a road map for the meeting (34).

“I Have No Understanding of the Family’s Culture or Background.”

It is helpful to be knowledgeable about a particular culture, but sometimes, as in the case of Dr. P and the Chinese family, cultural descriptions do not “fit.” There is, therefore, benefit in presenting oneself as a naïve person, open to learning from the family about their culture and family structure (35). This attitude of respect, acceptance, and willingness to learn will help the family be more at ease in the interview.

Supervisor’s Intervention

The supervisor acknowledges Dr. P's efforts to educate herself about a patient’s culture and her confusion when the Chinese family began to weep; however, the supervisor thinks that Dr. P could have taken control of the meeting more quickly and recommends beginning a family meeting with an orientation as to the purpose of the meeting. The orientation should include the explanation that each person will have a limited time to talk, as it is important to hear from everyone. The resident can respectfully explain that she may need to interrupt to allow everyone time to speak. As the meeting progresses, the resident can refer back to her previous statement that she might have to ask a family member to stop talking. This may reduce potential feelings of shame or anger. The meeting also should include a discussion of diagnosis, current assessments, and treatment plan.

Resident’s Response

Dr. P recognizes that she lost focus when confronted with an unexpected display of emotion. She rehearses the following with her supervisor: “I see that everyone is very upset right now. Would you all like some time together before we start the meeting? I could come back in a few minutes and see if you are ready to begin talking.” The supervisor also suggests that if the family is unable to participate in a meaningful way, then the meeting can be rescheduled.

“Mrs. D” is 45 years old and has major depression. Her husband, “Mr. D,” refuses to accompany her to the first outpatient meeting. “Dr. Q” calls the husband to invite him in but is intimidated by the husband, who dismisses many of his wife’s complaints, although he does emphasize that their sexual relationship has become “a problem.”

Resident's Concerns

“No One Expects Residents to See Families.”

The resident may perceive the social worker or the marriage and family therapist as the person to meet with the family. Medical family therapists are becoming part of the team in many different specialties because they are cheaper, more attentive to patients and families, and because managed care increasingly wants to use them to bridge the gap between the medical profession and the family’s needs (36, 37). However, family medicine encourages all residents to meet with families on a routine basis (38), and psychiatry has traditionally valued family involvement. However, when asked, residents who have graduated state that the skills most needed after graduation and the skills least taught are family skills (39).

Supervisor’s Intervention

The supervisor points out that an assessment of the couple’s relationship is an important part of a comprehensive assessment, although the husband is reluctant to participate. The supervisor encourages Dr. Q to persist in her attempts to bring the husband in for an assessment.

Resident’s Response

Dr. Q agrees and calls the husband again. She explains to him that each patient receives a full assessment in the clinic and that an assessment of the family is an important part of the routine workup. After the assessment, the couple decides for themselves if they wish to enter couples treatment. The husband agrees, expressing relief that it is time-limited.

“Dr. R” is the therapist for “Mr. F,” a 48-year-old executive who presented with depressive symptoms and increased job stress. As individual therapy progresses, Mr. F begins to focus on marital issues. He is concerned that “Mrs. F,” his wife of 20 years, is pulling away from him and drinking heavily. Mr. F is anxious that his wife is involved with a co-worker and explains that when he tries to talk with his wife, she becomes upset and refuses to talk. Mr. F discloses that 2 years ago he had an affair with his secretary, which was devastating to his wife. Mr. and Mrs. F separated for several months at that time but then reconciled. According to Mr. F, they never sought any counseling and did not discuss the issue further. Dr. R recognizes that Mr. F and his wife would benefit from couples counseling but is uncertain if she should treat the couple or refer the couple to another therapist.

Resident’s Concerns

“Should I See the Patient and the Family Together?”

Dr. R is unsure whether she should meet with Mr. F and his wife. Is she too aligned with Mr. F? Would another therapist be more objective? Would Mrs. F accept Dr. R as an impartial therapist? Dr. R would like to treat the couple.

Supervisor’s Intervention

The supervisor encourages Dr. R to talk with Mr. F about bringing his wife into the office to participate in an assessment. This would provide Dr. R with the opportunity to assess Mrs. F’s use of alcohol and evaluate her receptivity to completing a couples assessment. Whether or not Dr. R will treat the couple can be deferred until Dr. R has completed the couples assessment. After the assessment, as part of the negotiation for treatment, Dr. R can offer treatment or refer the couple to another therapist. In deciding how to proceed, Dr. R can explain to Mr. F that couples work is very different from individual therapy. Mr. F would need to understand their individual work focuses exclusively on Mr. F’s concerns and that in couples therapy, Dr. R would also be focusing on Mrs. F's concerns and sometimes endorse her point of view. On the other hand, Mrs. F might feel that Dr. R could never be fair to her, in which case another therapist would be preferable. Fairness has been identified as one of five preconditions for change in couples therapy (40). If the psychiatrist is unable to establish an atmosphere of fairness, then working with the couple will be ineffective. The supervisor also discusses the use of family treatment in alcoholism (41) in case Mrs. F does need specific alcohol treatment. One such model, behavioral couples therapy for alcohol abuse or dependence, consists of weekly sessions over 5 to 6 months and the use of a daily sobriety contract (42).

Resident’s Response

Dr. R asks Mr. F to bring his wife into the next meeting for a couples assessment. Mrs. F is pleased to come in and readily agrees. Dr. R finds out that Mrs. F believes her husband also drinks excessively. Both want Dr. R to complete the assessment and treatment. Using a sobriety contract, Dr. R incorporates abstinence from alcohol into the treatment. Mrs. F assures Mr. F that she is not involved with a co-worker. The couple agrees to stop blaming each other for infidelities and to work on increasing trust and developing mutually acceptable hobbies and interests. After the couple’s treatment is completed, Dr. R continues to see Mr. F for a short while to work on managing stress at work.

“Harriet,” 9 years old, is admitted to the children’s unit for behavioral dyscontrol, bed-wetting, and weight loss. Her parents, who have separated, are embroiled in a custody fight over her and her 12-year-old brother, “John.” Harriet and John both live with their mother and visit on weekends with their father. “Dr. S,” a child fellow, has spoken at length with both parents separately. Both parents want to be actively involved in Harriet’s treatment.

Child Fellow’s Concerns

“Should I See the Patient and the Parents Together?”

Because of the acrimony between the parents, Dr. S wonders if he should meet with the parents separately or together. Should Harriet be in the meetings? Should her brother, John, come to the family meeting? Dr. S is afraid of being involved in the parents' legal battle over the children.

Supervisor’s Intervention

The supervisor suggests that Dr. S meet with each parent alone to discuss their concerns for Harriet. In the separate meetings, Dr. S is to assess whether the parents could successfully meet together with him to discuss Harriet’s problems. If the parents are able to put aside their differences and focus on what is best for their child, a joint session would be invaluable. If the joint session is successful, then Harriet and her brother can be included in the next meeting. An important part of working with this family is to help the parents appreciate their conjoint role as parents and that continued fighting hurts their children.

Child Fellow’s Response

Dr. S meets with Harriet and each parent separately. It is clear at these meetings that the legal and emotional battle between these parents is intense and that a family meeting together with both parents would not accomplish anything. This illustrates a realistic barrier to working with the whole family. There are also similar situations in adult psychiatry, for example, where the patient is a victim of domestic violence and is afraid of her or his partner. However, the standard of care should be to meet with the family, and only under exceptional circumstances should care be delivered in isolation from the family.

The reasons to meet with families are clearly articulated in the substantial body of research. Residents who master family skills and meet with families of their patients on a regular basis express disbelief that assessment and treatment of patients can occur without the families being involved. The barriers to working with families need to be made explicit and seen as part of the normal development of the psychiatric resident.