FAMILY STRESS & COUNSELING

Thomas L. Campbell, David Seaburn, & Susan H. McDaniel

LIZA D. MARIPOSQUE, M.D.2ND Year FAMED Resident

May 19, 2009

DIMENSIONS OF FAMILY STRESS

FAMILY STRESS:

- occur w/n the family (intrafamily) - acute

- outside events (external stress)

- normative transitions

- nonnormoactive crises – occur out of phase or sequence in the life cycle.

PRINCIPLES FOR DEALING WITH FAMILY STRESS

1. Understanding family context of every patient’s problem.

2. Biopsychosocial approach

3. Maintaining alliance w/ each family member & to avoid taking sides in any conflict.

4. Assess & treat family problem.

5. Specific plans for conducting a family conference

6. Helping family members to decide how they want to deal with the problem.

- not to fix or cure the problem.

7. Family counseling or referral to family therapist

8. Establish a collaborative relationship with a family therapist.

1. Understanding family context of every patient’s problem

physical symptoms – represent some types of somatization for w/c there are no physiologic abnormalities:

- simple stress-related symptoms

- full blown somatization d/o

- exacerbation of underlying chronic illness

- psychiatric problems

Techniques in detecting Family stress:

Red flags – psychosocial factorsBasic understanding of the family

context of every patient visit.

Problem case

Margaret Schafer is 56 y.o & suffers from

Obesity and mild HPN. She has been w/ Dr C’s patient for several years, seeing her for 6 months to monitor her BP and to attempt weight reduction. On her most recent visit, she complained of frequent HA, knee pains,, and feeling tired most of the time. On examination, Dr. C noted that she had gained 20 lbs since her last visit and w/ glucosuria.

Dr. C inquired about her mood and learned that she was moderately depressed, had frequent crying spells, and had lost interest in her work and hobbies. She was not suicidal but felt helpless to change her situation. When asked how these problems were affecting her relationship w/ her husband, Mrs. Schafer gave a long litany of complaints about him, saying that he ignored her and her problems, refused to help out w/ household jobs, and was spending more and more time at his job. They had not had sexual intercourse in over a year.

At a ff-up visit 1 wk later, Dr. C reviewed Mrs. Schafer’s laboratory results & discussed his assessment w/ her. He explained that she was suffering from a major depression and that it had cause her to gain additional weight, w/c had precipitated diabetes. He prescribed an oral hypoglycemic and an antidepressant, Fluoxetine (Prozac). He also suggested that the depression and the marital problems influence each other negatively and the combination of the 2 was affecting her physical health as well.

In this case, Dr. C thought it was important to intervene at 3 levels:

1.Treat the medical complications from the obesity

2.Start antidepressant

3.Discuss marital problems

3. Maintaining alliance w/ each family member & to avoid taking sides in any conflict

Listen to patient’s storyEmpathize w/ themSupport Validate their assessment of the problem

Mrs. Schafer agreed w/ Dr. C’s assessment of

her marital problems and said she thought her husband’s “workaholism” was making her more depressed and causing her to eat more.

Dr. C interrupted her new complaints about her husband and explained that he thought it was important to address the couple’s problems, the he would be willing to try and help them. She said, she wasn’t sure how Dr. c could help, but she would appreciate anything he could do to them in making whatever changes were necessary.

4. Assess & treat family problem.

Patient can be coached w/ specific instructions as what to say to the family member.

Invitation letterReferral to family therapist

Dr. C explained to Mrs. Schafer that he did not know whether she or her husband would decide to change, but he thought it important for him to meet with both of them together to learn more about the problems they were having and how it was affecting her depression. Mrs. Schafer immediately claimed that her husband would never agree to counseling. Moreover, she explained, he could not get time off from his job during the day. Dr. C, suggested that she think more about it, and they could discuss it at her next visit.

Sensing that getting Mrs. Schafer’s husband into the office would be difficult, at the next visit dr. C asked her if she objected to him calling Mr. Schafer directly to explain the importance of his participation. She reluctantly agreed and gave Dr. C her husband’s phone number at work. Mr. Schafer was surprised to receive the call, but said he shared Dr. C’s concern about his wife’s health and her mood swings. Over the past few months, he said she had become so irritable that he had to avoid her to keep from being yelled at. Dr. C asked if he would be willing to join his wife at her next medical visit in 2 wks to share his thoughts about her health and any problems that resulted. Mr. Schafer cautiously agreed to accompany his wife if Dr. C thought that he might be helpful.

5.Specific plans for conducting a family conference

Gen. Goals:

- to join w/ the family

- establish specific goals

- facilitate discussions

- identify resources & support

- establish a a plan that the family can agree

Dr. C scheduled a 45-minute appointment to meet with the Schafers during an afternoon he normaly devotes to counseling. He began by thanking Mr. Schafer for joining his wife for the appointment and by explaining how helpful it was when a spouse was willing to participate in the partner’s medical care. He spent 5 min. learning more about Mr. Schafer, his work, and his interests. He then inquired about the rest of the family and began constructing a genogram. He turned to Mrs. Schafer & asked how she was doing. Then he asked her husband how he thought she was doing. This quickly interrupted into an argument about their relationship, w/c Dr. C interrupted. He explained that he could see that Mrs. Schafer’s medical problems had caused significant stress for both of them and their relationship, and he wanted to hear from each of them about those problems.

One at a time, Dr. C had Mr. & Mrs. Schafer describe their views of the marital problems, blocking any interruptions by the other. He inquired more generally about the history of their relationship and their family, focusing on their achievements, especially the raising of two children, who were noe adults. This history revealed that the couple had a stable relationship w/o major difficulties until 2 yrs ago, when their daughter, to whom Mrs. Schafer has been close, married and moved across the country. Since then, the couple had been having an increasing number of arguments, and Mr. Schafer was spending more time at work.

Steps for conducting a Family Conference:

I. Preconference Tasks

- set the stage

- review the genogram

- develop hypotheses

I. Phases of a Family Conference

II. Postconference Tasks

II. Phases of family conference

1. Socialize

2. Set the goals

3. Discuss the problem or issue (s)

4. Identify resources

5. Establish a plan

6. Helping family members to decide how they want to deal with the problem

- Goals: cure the disease or treat the symptoms.

- not to fix or cure the problem.

- responsibility to change lie w/ the patient & family.

- Physician’s responsibility: make Rx options available & acceptable

Towards the end of the 45 min. session w/ the Schafers, Dr. C gave the couple the ff assessment: “ I can that you are both experiencing a tremendous amount of stress. Part of your difficulty results from normal stresses experienced by couples when their last child leaves home and moves away, especially when the parents are close to the child as you are to your daughter. I think these stresses have been complicated by Mrs. Schafer’s health problems, which are stressful on their own, and by Mr. Schafer’s work demands. With all you are having to cope w/, it is not surprising that some of this has come between you and you are having some problems in your relationship”.

After soliciting the couple’s reaction & gen.agreement w/ assessment, Dr. C made a recommendation: “I am very concerned about the problems you are having, particularly because of their impact on Mrs. Schafer’s health. I am also concerned about their effect to your health Mr. Schafer, and wonder if you would consider coming in for gen. check-up. (Mr. Schafer nods). If two of you have found this session helpful. I would be willing to meet w/ you both for 4 or 5 sessions to see if I can help you sort out some of these problems & reduce the amount of stress you are both experiencing. Then I would see either of you separately for your medical problems. What do you both think?”.

7. Family counseling or referral to family therapist

depends on:

- interest

- expertise

- time availability

When to Treat & When to Refer Family Problems to a Family Therapist

Common problems seen during primary care counselling:

- Adjustment to new illness- Crises of limited severity- Behavioral problems- Mild depressive rnx- Mild anxiety rxn- Uncomplicated grief rxn

Problems commonly referred to a mental Health

Specialist:– suicidal/homicidal ideation

– Psychotic behavior

– Sexual/physical abuse

– Substance abuse

– Somatic fixation

– Moderate to severe marital & sexual problems

– Multiproblem family situations

– Problems resistant to change during primary care counseling.

8. Establish a collaborative relationship with a family therapist.

to share ideas & strategies clarification of consultation or referral

questions communicate regularly w/ the therapist

during/after therapy.Let patient know that they will continue to

see the patient & collaborate w/ the therapist.