THE NEED FOR FAMILY INVOLVEMENT IN ASSESSMENT AND TREATMENT

Gabor I Keitner M.D.

Professor Department of Psychiatry

Brown University, Providence, RI

There are many reasons why psychiatrists do not assess or treat families.  Meeting with families is often perceived as not being cost effective given current reimbursement systems.  Equally important is a lack of training for psychiatrists in meeting with families, not only to gather information but also to help them learn how to deal with each other and their loved one's illness. 

Family therapy skills are not part of the “core competency” requirements for residency training programs.  Without proper training working with families can be perceived as being more threatening than working with individuals.

Families have a powerful influence on health equal to traditional medical risk factors.(1) Families can be a reliable source of information about a patient's problems, baseline level of functioning, who the patient is, and how she/he functions in the community. They can provide a longitudinal perspective on the patient's dealings with others and the world. How a patient interacts with his/her significant others and how they in turn interact with the patient, greatly affects the duration of  problems, the likelihood of their resolving or recurring over time.

Problems in the family in dealing with an illness may come to the attention of clinicians in a variety of ways. Patients may be non-adherent with treatment. There may be lack of improvement in spite of following treatment recommendations. Patients may show signs of anxiety and sadness along with feelings of being alone to deal with their illness, not receiving sufficient support or feeling blamed. There may be persistent disagreements and misunderstandings between the patient, family members and treatment providers. Patients may also directly express concern about relationship problems, especially if asked.

FAMILY RISK AND PROTECTIVE FACTORS

There are a large number of family based risk factors that adversely influence the onset and course of illness. These include: poor conflict resolution, low relationship satisfaction, high interpersonal conflict, criticism and blame, intra-familial hostility, lack of congruence in disease beliefs and expectations, poor problem solving, extra familial stress, lack of extra familial support systems, poor organization, inconsistent family structure, family rigidity, low cohesion and closeness, and presence of psychopathology in family members. 

Conversely, there are many protective relational factors. These include: good communications, good problem solving skills, adaptability, clear rolls, achievement of family developmental tasks, mutual support, open expression of appreciation, commitment to the family, extra familial social connections. (1)

Most patients prefer that physicians involve their family in their care. Family members can help patients to  adhere to treatment recommendations. Families can help to keep track of medication side effects and prodromal and residual symptoms. They can assist in sharing responsibilities, lessen the patient's anxieties and facilitate as well as encourage communication between providers. (2)

IMPROVED HEALTH OUTCOMES

Family research clearly demonstrates that working with families of patients is an empirically valid practice.  Family interventions have been shown to be helpful in managing medical illnesses such as hypertension, low back pain, diabetes, systemic lupus erythematosus, and dementia.  Evidence based family interventions have been described for psychiatric illnesses including: alcohol dependence, PTSD, schizophrenia, bipolar disorder, major depression, borderline personality disorder, conduct disorder, ADHD, eating disorders and obsessive-compulsive disorder. (3, 4)

FAMILY ASSESSMENT

The family assessment is the first step in determining both the need for further interventions and the specific areas of family life that might need to be addressed. Family assessment should focus on adjustments related to the diagnosis of the illness, clarification of treatment options, and collaboration in carrying out the treatment plan. A proper assessment should also identify family strengths. The family needs to feel understood, respected, and validated. They do not want to be blamed for their loved one's problems or judged for their perceived deficiencies. It is the job of the clinician to put families at ease and to make them feel comfortable enough to participate openly in the assessment process.

It is important to orient the family to the interview process, so that they know what to expect and to establish an open and collaborative relationship with them. The therapist should ask family members to identify all current problems in the family including the problem(s) that precipitated the meeting. The therapist should then assess ways in which families are organized and function and pay attention to family transactional styles that appears to be related to the presenting problem. The McMaster Model of family functioning is one way to conceptualize family functions and a systematic way of collecting and organizing that information. (5,6)

FAMILY INTERVENTION

There is reasonable empirical evidence that family interventions, as adjuncts to medical treatment, provide benefits to patients and family members above and beyond what they receive from usual medical treatment. Family interventions can be broadly divided into two groupings, psycho educational and relationship focused. 

There is no evidence that one type of family therapy is consistently superior to another. It is advisable to become proficient with at least one approach to assessing and treating families in order to become comfortable with including families in the treatment process. One such approach is the Problem Centered Systems Therapy of the Family. It is practical, clearly articulated and has been tested for efficacy with families of patients with mood disorders. (7)

Some of the common goals of effective family therapies include: increased knowledge about the illness, decreased guilt, redefinition of problems, increased use of adaptive coping mechanisms, improvement of communication skills, problem solving skills and parenting skills, clarification of boundaries, insight regarding current transactions and historical factors, decreased conflict, work on family of origin issues. Family interventions can be implemented successfully at all phases of illness: to prevent disease, to reduce chronicity and to improve functioning in the chronic phase.

Not all families of psychiatric patients are dysfunctional and not all families need family therapy.  In fact, many families deal very effectively with recurring, chronic and severe illnesses. Even well-functioning families, however, can benefit from information about the illness, validation of effective ways of coping, and reinforcement of resilience in the face of major stresses.  Being clear about what constitutes functional or dysfunctional families and about normal versus pathological ways of dealing with difficult situations is an important base from which to be able to evaluate the functionality of any family. 

Meeting with families to assess their ways of dealing with an illness, to provide information, to provide support and to enlist their participation as collaborators in the treatment process should be a routine part of psychiatric care.

References.

1. Campbell, T. L. (2003). The effectiveness of family interventions for physical disorders. J of   Martial and Family Therapy, 29(2), 263-281.

2.Fisher L: Research on the family and chronic disease among adults: Major trends and directions. Families, Systems, and Health 2006;24:4:373-380.

3. Hartmann M, Bazner E, Wild B, et al. (2010). Effects of interventions involving the family in the treatment of adult patients with chronic physical diseases: a meta-analysis. Psychother Psychosom 79:136-148.

4. Heru A.M. (2006). Family Psychiatry: From Research to Practice. Am J Psychiatry 163(6):962-968.

5. Ryan CE, Epstein N, Keitner GI, Miller I, Bishop D: Evaluating and Treating Families:  The McMaster Approach.  New York, Routledge Taylor & Francis Group, 2005.

6. Keitner GI, Ryan CE, Epstein NB (2006). Family assessment. In: Goldbloom D (ed). Psychiatric Clinical Skills. Mosby Elsevier, Maryland Heights, MO pp 327-338.

7.  Keitner GI, Heru AM, Glick ID (2010). Family Assessment; Clinical Manual of Couples and Family Therapy. American Psychiatric Publishing, Washington, pp 63-92.

PSYCHOTHERAPY: TOO EXPENSIVE NOT TO PROVIDE

SUSAN MCNAIR MD, FRCPC

I have a patient in my practice that I have being seeing weekly for several months.  Together we work through problems he has had in the past week, with coworkers or family members or with his mood.  He is increasingly capable of seeing how these small weekly miseries relate to the abuse and neglect he endured as a child. 

 My job is to listen intently, and to shine light more directly on the pain of this – a yawning chasm that, for years, he saw as unrelated to his present difficulties.   I bill OHIP, the Ontario Health Insurance Plan, for each hour that he spends in my office.  

When he first presented, he indicated that he had seen several physicians for anxiety and depression-related complaints, as well as vague and undiagnosed physical problems which had each been thoroughly investigated with blood tests and x-rays.  He had daily suicidal ideation of varying intensity.  He had had 2 month-long hospital stays, tried 5 different antidepressant medications with variable effects and side effects, and had also had 2 courses of 12 sessions of cognitive-behavioural therapy which had been the most helpful interventions to date.  

 However, he still missed an average of one day a week of work, underachieved while at work due to anxiety, and had been on short-term disability 3 times in the past 5 years.  Sometimes, to his embarrassment, his wife would also miss work to stay home with him, worried by how unsafe and unwell he seemed.  “Defective”, he said, best captured how he felt about himself.  He was planning to apply for a disability support pension, despite his high degree of educational attainment.

This patient (an example based on several patients I see) well demonstrates the high cost of mental illness.  The economic impact of illness involves direct, indirect and human costs.  Direct costs are those incurred to treat the illness and rehabilitate the patient.  In this patient’s case, the cost of psychotherapy sessions are direct costs, as are his 2 previous hospitalizations, prescription medications, investigations for physical symptoms, and previous psychotherapy.  Many studies would also include his income support from short term disability and the disability support pension as direct costs.  

In 2011 in Canada  direct costs of mental health care were estimated at $42.3 billion (1).  Outpatient appointments for interventions such as psychotherapy account for only 8.5% of this total figure. Community services (27%) and income support (22.9%) dominate, with inpatient hospital care (16%) and prescription medication spending (15%) close behind (1).

Indirect costs, by contrast, refer to the various losses sustained in productivity due to illness.  In this patient’s case, for instance, his missed work days, decreased productivity while at work, and his withdrawal from the labour market would all be reflected as indirect costs of mental illness.  In addition, his wife’s loss of productivity as his caregiver would be reflected here as well.  These costs are clearly more difficult to measure, but one established method is to estimate the hours of work participation lost and multiply this by hourly wages.  Using this method, a 2012 study estimated that the Canadian economy may be losing almost $21 billion each year from lost productivity due to mental illness (2); an earlier 2006 study estimated lost caregiver productivity separately at almost $4 billion (3). 

These are the figures that spell “emergency” most clearly to governments, as each productivity loss spells lower tax revenue and consequences for public finances.

Finally, human costs: the pain, distress and loss of enjoyment of life incurred by mental illness, which are at once the most difficult to estimate and the most clinically pressing.  In economic terms, using a measure of disability-adjusted life years, this cost was estimated at $20.3 billion dollars in 2006 (3).  In human terms, this means a tide of misery not expressible as a dollar figure.  This is a mental health emergency for clinicians and, of course, for patients.

Professor Lord Richard Layard, a renowned economics professor and founder of the London School of Economics’ Centre for Economic Performance, spent most of his career tackling economic and GDP-impacting social issues in the UK such as unemployment and poverty.  But in more recent years he has turned his attention to the problem of mental illness.  He used his influence in academics and government to call for improved access to psychological therapies covered by that country’s National Health Service, under the aptly named “Improving Access to Psychological Therapies (IAPT)” initiative.  His argument for this was accepted as sound economics: according to the calculations of the Centre for Economic Performance, a one-time expenditure of on average £750 for a course of psychotherapy (10 sessions of CBT at £75 a session) resulted in cost savings of £750 per month in decreased direct costs and recouped indirect costs.  If government-funded psychotherapy resulted in just one month of improved function, he reasoned, this approach pays for itself (4).

Over the years since its initial rollout the IAPT has shown itself to be a cost-effective programme, although session costs were higher than expected (5) and functional recovery rates in the demonstration sites have been between 50 and 55%, with 5% returning to full employment from receiving sick benefits (6).  Remarkably the programme is described as cost-effective despite the fact that a full 55% of the patients referred did not in fact complete a course of treatment – they did not attend an initial appointment, declined after 1 or 2 sessions, or dropped out (5).  Perhaps this high drop-out rate is because the therapeutic alliance was not established early, or perhaps because CBT did not seem to address their problems. 

 As a national funding body the NHS has a responsibility to limit its funding to evidence-based treatments, and for decades CBT has led the way in the number and quality of available studies.  However, in fact the policy nowhere indicates that this approach should be limited to CBT.  Rather, the message is that effective psychotherapeutic treatments are economically sound additions to a publicly-funded healthcare system.  Results offset spending. 

Several months later, my patient still deals with anxiety and low mood.  But he can’t recall the last time he missed a day of work because of it.  His suicidal ideation is an occasional fleeting thought rather than a persistent daily grind.  He has days when he enjoys himself and the life he has built. He is being groomed for a promotion at work  and is now confident in promoting his ideas.  The thought of a disability pension is far from his mind.  His wife has also changed jobs –something she had not felt comfortable doing before.  We are gradually, but definitively, preparing for his discharge.

Has this therapy been expensive for the province to provide? 

Certainly it would have been prohibitive for the patient to afford out-of-pocket.  But what savings have been made by 1) avoided hospital stays 2) an avoided disability pension 3) vastly decreased missed work days 4) more work productivity 5) increased caregiver productivity and income 6) decreased visits and investigations for physical symptoms related to anxiety and depression 7) decreased use of resources not ultimately helpful to him (ie. further CBT) 8) a promotion in keeping with his training and skills?   

And what are the reduction in human costs and the improvement in quality of life worth?  It has been argued that it is not economical for psychiatrists to provide longer-term psychotherapy, but until there is an effective publicly-funded psychotherapy strategy in Ontario, I will continue – it is too expensive not to provide.

Notes *The patient example provided is based on representative data from a psychotherapy clinic and do not identify any one patient.

References:

1 1.   Smetanin P et al., The Life and Economic Impact of Major Mental Illnesses in Canada, RiskAnalytica, Report commissioned by the Mental Health Commission of Canada, December 2011.

2 2.   Conference Board of Canada, Mental Health Issues in the Labour Force: Reducing the Economic Impact on Canada, July 2012.

3 3.   Lim K-L  et al., How Much Should We Spend on Mental Health?,  Institute of Health Economics, Alberta, September 2008.

4 4.   The Centre for Economic Performance: Mental Health Group., The Depression Report: A New Deal for Depression and Anxiety Disorders, London School of Economics and Political Science, 2006.

5 5.  Radhakrishnan, M., Cost of Improving Access to Psychological Therapies (IAPT) programme: An analysis of cost of session, treatment and recovery in selected Primary Care Trusts in the East of England region.  Behaviour Research and Therapy, 2013, 51(37-45).

6 6.   Clark, D., Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, 2009, 47(11), 910-920.