Working With Families in Medical Settings

A Multidisciplinary Guide for Psychiatrists and Other Health Professionals

Alison M. Heru

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780415897006
• eBook ISBN:
  9781136641572
• Topic: Psychology
• Subtopic: Medical Theory, Practice & Reference
• Index: Psychology

Working With Families in Medical Settings provides mental-health professionals with the tools they need to figure out what patients and families want and how, within the constraints imposed by 21st-century healthcare setting, to best give them the care they need. Psychiatrists and other clinicians who work in medical settings know that working with a patient with a chronic illness usually entails work with that patient's family as well as with other medical professionals. Some families need education; others have specific difficulties or dysfunctions that require skilled assessment and intervention. It is up to the clinician to find productive ways to work with common themes in family life: expressed emotion, levels of resilience, life-cycle issues, and adaptation to illness, among others. Enter Working With Families in Medical Settings, which shines a spotlight on the major issues professional caregivers face and shows them how to structure an effective intervention in all kinds of settings. Psychiatrists, particularly those in psychosomatic medicine, and other clinicians who work with the medically ill will find Working With Families in Medical Settings to be an essential resource and guide to productive relationships with patients and their families.

Part I

Family Theory and Research

Overview of Part I

Chapter 1: Family Research

This review of family research provides the rationale for including families in the care of the medically ill. The field of family research is vast, and studies and reports are scattered throughout many books and journals. The research presented in this chapter is described under the headings of family factors influencing biological processes, family health beliefs and behaviors, social support and marital quality, and family protective and risk factors. The evidence-based family interventions are described under the headings of promotion of healthy behaviors, family interventions in acute illness, and family interventions in chronic illness. Three meta-analyses of family treatment outcomes are presented. The examples of family research given in this chapter are chosen for their ease of application to the clinician's daily practice.

Chapter 2: Family Factors in Promoting Health: The Case of Childhood Asthma

In this chapter, Drs Fred and Marianne Wamboldt present highlights from their family research in childhood asthma. This chapter identifies the family factors that influence self-management behaviors. The authors state that special attention should be given to families whose illness narratives and stories suggest they are not confident in their plan to manage asthma. The community and broader sociocultural context of the family is an equally important factor in influencing asthma outcomes. The authors make recommendations for involving the family and the community in the clinical management of asthma.

Chapter 3: Family Adaptation to Chronic Medical Illness and Disability: An Integrative Model

Dr John Rolland describes his integrative model of family adaption to chronic medical illness and disability. He presents a normative model for the psychoeducation, assessment, and treatment of families living with chronic illness. Dr Rolland describes psychosocial types of illness and the time phases of illness. In his family assessment section, he introduces the importance of multigenerational legacies and the interweaving of illness, individual, and family development. Health/illness beliefs serve as a road map for families as they struggle with adaptation to illness and engage with the health-care system. He illustrates his integrative model with case examples.

1 Family Research

• Family research outcomes depend on who, what, when and how families are studied.
• Family factors influence biological processes, disease onset and course.
• Good quality relationships are associated with better illness outcomes.
• Family interventions prevent disease, hasten recovery, and improve patient functioning.

Introduction

Family research encompasses many topics: family factors that influence biological processes, family health beliefs and behaviors, social support and marital quality research, and evidence-based family interventions. Family research includes the study of healthy couples in the community, families with loved ones who are recruited from hospital settings, and patients and their families at the end of life. Researchers in these different fields use their own definitions and conceptualizations of family issues, which makes it difficult to generalize from specific studies to families in general. It is a significant undertaking to assimilate the diverse findings into a coherent body of knowledge that can be useful to the busy clinician. Nevertheless, when the body of evidence is presented, it becomes clear that family factors have a significant influence on health and that family interventions can prevent disease, hasten recovery from acute illness, and improve functioning in chronic illness.

WHO to Study

The easiest family group to study is a family dyad. This dyad is usually an identified patient and their significant other, such as a parent and their ill child, or a patient and their caregiver. Rarely are whole families studied, although there are notable exceptions, such as Kazak's interventions to reduce the emotional impact of the effect of childhood cancer on mothers, fathers and siblings (Kazak et al., 2007). An area of growing interest to family researchers is the transition of children with chronic illness into adulthood (Claessens et al., 2005). This transition involves both individual and family developmental stages, as well as the transition from a supportive pediatric care environment to a more independent adult care environment.

Most family research has been carried out on white middle-class couples who volunteer through outpatient clinics, support groups, or posted advertisements. Much less family research has been carried out with families in poverty, minority families, single parent families with or without extended family support, blended families or lesbian, bisexual, gay, transgender (LBGT) families. Families in different cultures can have very specific caregiving concerns (see Chapter 8). Research constructs may need to be modified or constructed de novo in order to accurately assess and address these diverse family constellations and structures and the specific family concerns in different cultures (Bernal and Domenech Rodriguez, 2009).

WHEN are Families Studied?

Adaptation to illness unfolds over time. The family has specific and different adaptive needs depending on the stage of the illness and the developmental stage of the family (see Chapter 3). Families are “in crisis mode” when coping with an acute stressor and routine family tasks can be neglected. Families develop strategies over time to manage the stress of coping with chronic illness, although these strategies may develop without much contemplation or forethought. Researchers should take into account this developmental and adaptive process when assessing families and testing interventions. There are only a few longitudinal studies of families coping with chronic illness and only a few prospective studies of families where the impact of illness has been studied from its onset through the family life cycle. End of life is a particularly difficult time to study families, as grief inhibits the family's ability to engage in research (see Chapter 5). Families may be more receptive to family interventions at earlier stages in their adaptation to illness. Clinical experience suggests that families are more likely to engage in treatment at the time of crises.

WHAT to Study?

Family researchers study a vast range of topics, from individual biological factors to the whole family adaptation to illness. Early family researchers focused on the importance of good social support (Revenson and Majerovitz, 1990). However, initial attempts to measure social support consisted of simply asking patients if they had good family and social support. Over time, researchers have found that good support influences illness outcome through many different pathways e.g. medication adherence, lifestyle changes, and relationship quality. The study of family support has become more sophisticated with specific measures of family functioning being linked to patient outcome.

Key aspects of family relationships that affect patient outcome include the family perception of illness demands and individual, dyadic, and family coping styles. Family conflict more commonly occurs at transitions in family life stages, For example, family conflict during adolescence is linked to difficulties managing diabetes (Anderson et al., 2002). Adaptation to illness is an important process and the target of many successful family interventions.

HOW do we Study Families?

How to study the family is determined by what the researcher wants to measure. Individual biological processes are measured in the laboratory or hospital setting. The subjective experience of individual family members is measured through self-reports or interviews. Family interactions are measured using structured family interviews or family observation. Family interactions are complex to measure and require specific training to identify dysfunctional family patterns.

As manipulation of data becomes more sophisticated, the association between variables can be examined more closely. For example, for many years, no clear association between marital quality (MQ) and patient illness outcomes was found. However, when researchers began to differentiate between good and poor marital functioning, improved illness outcomes, especially for women, became apparent for patients with good MQ (Heru, 2010).

Family Assessment Tools

Many family assessment tools are useful for studying families with medical illness. One family assessment tool that measures the family emotional environment is the Camberwell Family Interview (Vaughn and Leff, 1976). This two-hour interview tool assesses expressed emotion (EE). EE is a construct made up of three components: the number of critical comments, the expression of overt hostility and the degree of emotional over-involvement in the family. EE has been well researched in different cultures. In Latino cultures, a related construct of family warmth is more predictive of good outcome than the EE score (Lopez et al., 2009). In Western countries, patients with medical illnesses who live in high EE families have poorer outcome (Wearden et al., 2000).

McCubbin's resiliency model of family stress, adjustment, and adaptation (McCubbin et al., 2002) describes how families' experience of stress is modified by their strengths. After working through the adaptation phase, the family works together to perform the roles and responsibilities to meet the challenges of the illness. The family stress theory, based on Hill's ABC-X model, provides the underlying theory for the resiliency model (Ingoldsby, Smith, and Miller, 2004). According to Hill's model; A represents the stressor event; B represents resources, or the family's capabilities in adapting; C represents the definition the family gives to the situation, or the “meaning-making” of the illness; and X represents the degree of crisis the family experiences. Families with limited resources and negative “meaning-making” will experience a greater crisis, whereas families with resources and positive “meaning-making” will experience less of a crisis. The resources that individuals and families have to cope with stressful events are an important component of family stress theory (Hobfoll and Spielberger, 2003).

The Family Environment Scale (FES) assesses family cohesion, conflict, and control (Moos, 1986). Cohesion measures the level of family commitment and provision of support. Conflict measures the degree of discord and expressed anger in the family. Control measures the rules and rigidity within a family. The Family Relational Index is an associated brief screening tool that can be used in families with medical illness (Moos and Moos, 1981).

The Dyadic Adjustment Scale (DAS) (Spanier, 1976) and the Abbreviated Spanier Dyadic Adjustment Scale (ADAS) (Sharpley and Rodgers, 1984) measure perceived agreement regarding philosophy of life and aims, goals, the frequency of stimulating exchanges of ideas, and of working together on a project. Asking patients to rate their level of satisfaction with their marriage, on a one-item Likert scale, was found to have a sensitivity of 86% and a specificity of 86% when tested against the thirty-two-item DAS (Bailey, Kerley and Kibelstis, 2012). This one-item screen has been used in the primary care setting to identify the patient's satisfaction or dissatisfaction with their marriage. Knowing which families to refer for family assessment and family treatment is an important clinical need.

The Family Assessment Device (Epstein, Bishop, and Levin, 1978) is a self-report tool that has been translated into over twenty languages. It assesses family functioning in six family dimensions: roles, problem-solving, communication, affective involvement, affective responsiveness, and behavior control. There is an associated McMaster Clinical Rating Scale (MCRS) and an associated McMaster Structured Interview of Family Functioning (McSiff) (Ryan, Epstein, Keitner, Miller and Bishop, 2005). The “McMaster model” and its associated treatment model, the Problem-centered Systems Therapy of the Family (Epstein and Bishop 1981), are used to assess and treat families with medical illnesses and are described in depth in Part Three of this book.

Measurements of Coping

There are various models of coping that measure individual, dyadic and family coping. Dyadic coping styles are ways that couples “share” illness stressors (Bodenmann, 2005; Berg and Upchurch, 2007). The questions that clinicians would like researchers to ask and resolve are: what is the relationship between individual family members' adaptation to illness and the adaptation of the family as a whole? Is it always optimal for the family to adapt as a unit? What is the implication for the family when each member adapts individually? Is a mixture of individual and dyadic coping styles acceptable? Researchers and clinicians continue to learn about the process of the family's change and adaptation to illness. For example, avoidance has generally ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of Contributors
• Preface
• Part I Family Theory and Research
• Part II Involvement of the Family in the Health-Care System
• Part III Family Systems Assessment and Interventions
• Appendix
• Index