Medical Family Interviewing

1. Medical Family Interviewing Kathy Cole-Kelly, M.S., M.S.W. Professor of Family Medicine Case-Western Reserve University Cleveland, Ohio

3. Why family? • Families are a part of medical practice! • Impact of illness on families • Impact of the family on health • Prevention and Health Behavior Intervention

4. Families in Family Practice(Direct Observations of Primary Care - Stange et al. 2000) • addressed family issues (70% of visits, 10% of time) • family member present (35% of visits) • care provided to another family member (18% of visits)_

5. Families part of medical practice • 35% had family member there • Non-patient family member asks questions about their own health • Patients in the waiting room!

6. Impact of Behavior Change of Individual on Family System • Family mobile • Family Rituals • Hidden Patients

7. Impact of the Family on Health • The research: A brief summary and backdrop to working with families in medical practice

8. Family relationships have a powerful influence on health “The evidence regarding social relationships and health increasingly approximates the evidence in the 1964 Surgeon General’s report that established cigarette smoking as a cause or risk factor for mortality and morbidity from a range of diseases.” (House et al. 1988)

9. Emotional support has the most impact on health. • 6 months after MI, women w/ few emotional supports had 2-3 times the mortality rate of other women (Berkman, 1992) • Group therapy shown to prolong survival in metastatic breast cancer (Spiegel, 1989) and melanoma (Fawzy, 1993)

10. For adults, marriage is the most influential relationship. • Widowed and divorced persons have higher morbidity and mortality. • Men have higher death rates in the first 6 months after the death of their spouse. • Divorced and unhappily married persons have poor immune function. (Kiecolt-Glaser, 1987)

11. Negative or hostile relationships are the most damaging. • Family criticism is associated with poor outcome for smoking cessation, weight loss, diabetes, asthma, and depression.

12. Protective family factors family closeness, connectiveness caregiver coping skills mutually supportive relationships clear family organization direct communication about the illness (Weihs, Fisher & Baird, 2002)

13. Family risk factors conflict, criticism & blame psychological trauma related to disease external stressors family isolation disease disrupts developmental tasks rigidity and perfectionism (Weih, Fisher & Baird, 2002)

14. Family Relationships & Health relationships influence physiology and health behaviors

15. Pathways for families’ influence on health • Direct or biological pathway • genetic influences, contagion • Health behavior pathway • life style (diet, exercise, etc.) • adherence to medical recommendations • health care decision making • Psychophysiological pathway • psychoneuroimmunology

16. Types of Family Interventions family oriented approach with individual patient meeting with patient and family members Family medical interview Family therapy-making referral

17. The Therapeutic Triangle Patient Family Physician (Doherty & Baird)

18. Thinking Systemically • Talking with the fiance as well as the patient—being aware of their dynamics. • Looking for others in the patient’s system that will encourage or discourage health behavior change

19. Thinking systemically • Patient wants to quit but worried about how she’ll handle stress and her husband’s nagging: • LINEAR: MD tells husband not to nag and tells patient way’s to reduce stress. SYSTEMIC: • Thinking what the husband can be rewarded with by less nagging as well as the wife having the reward of his support. • Helping patient brainstorm sources of stress.

20. Helpful family-oriented questions • Has anyone else in your family had this problem? • What does your family think might have caused or could treat this problem • Who is most concerned about this problem? • Have there been any other stresses in your family or your life? • How could your family be helpful to you in dealing with this problem?

21. Family medical interviews • In response to smoker’s request or when another family member is present

22. Family therapy focuses on dysfunction within the family little or no education about the disease provided by skilled mental health professionals

23. Smoking and families • smoking runs in families • smokers marry other smokers • couples smoke the same amount & quit at same time • partner support helps smoking cessation • partner criticism impedes cessation

25. How to integrate family in primary care with smoking cessation? • family oriented interview with individual patient • involving family members in routine office visits • family conferences or meetings

26. Simplified Family Assessment • family structure • family development • family stress • family support and resources • Family health beliefs

27. Family structure: The genogram • biopsychosocial snapshot: include genetic relational information, health behaviors and patterns • most efficient record keeping • particularly helpful in looking for patterns of smoking---during pregnancy etc.

31. Family development:The family life cycle • families go through stages • each stage has developmental task • failure to accomplish task will result in difficulties or symptoms • QUESTION: what developmental tasks is this family dealing with? How high is the stress at this point. Is this an acceptable time to make health behavior change?

32. Stages of the family life cycle- ‘traditional’ • Leaving home: the unattached adult • Couples and pairing • Pregnancy and childbirth • Families with young children • Families with adolescents • Adulthood and middle age • Graying of the family • Death and grieving

33. ‘Family’ support • Family members • Extended family • Friends • Neighborhood- • Workplace • Community

34. ‘Family’ stress • Family members • Adolescents • Infants • Care-giving • Work • Neighborhood • $ • Health insurance

35. Patient and Family Beliefs about change • What caused the smoking to start • What could help the patient to stop • What could create exacerbations • What family members believe in potential for change • What others have contributed to belief-change potential. (workers, extended fam)

36. Basics of Medical Family Interviewing • Join with family members • Empathize without taking sides • Elicit views & opinions of family members • Involve family members in helpful ways to patient

37. Join with the family • Make contact with each person • Greet and shake hand of each family member • Establish family member’s relationship to patient • Obtain patient’s permission to talk to other family members • Involve family member from the beginning by asking a question • Demonstrate respect-show interest in work,etc.

38. Empathize w/o taking sides • Develop alliance w/ each family member • Use non-verbal strategies—eye contact, seating • Avoid triangulation

39. Elicit views/gather information • Helps to understand potential for change. • Helps to understand potential for nagging! • Gather non-verbal information • Explain interest in hearing each person’s perspective • Benevolent traffic cop if necessary • Avoid questions that encourage blame • Use of re-frame—especially with criticism

40. Enlist family members in plan • See family members as tremendous resource for change • Many health behaviors are family acivities • Spouses or partner more likely to influence health habits than anyone else • Support associated with successful smoking cessation (no nagging approach!) • Help patient negotiate with family members

41. Your options in primary care dealing with smoking and pregnancy: • Being family oriented with individual patient • Having a medical family interview • Referring to a family therapist, working collaboratively