Medical Family InterviewingMedical Family Interviewing

Kathy Cole-Kelly, M.S., M.S.W. Professor of Family Medicine

Case-Western Reserve University

Cleveland, Ohio

Why family?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

Families in Family PracticeFamilies in Family Practice (Direct Observations of Primary Care - Stange et al. 2000)(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)_

Families part of medical practiceFamilies part of medical practice

35% had family member there

Non-patient family member asks questions about their own health

Patients in the waiting room!

Impact of Behavior Change of Impact of Behavior Change of Individual on Family SystemIndividual on Family System

Family mobile

Family Rituals

Hidden Patients

Impact of the Family on HealthImpact of the Family on Health

The research: A brief summary and backdrop to working with families in medical practice

Family relationships have a Family relationships have a powerful influence on healthpowerful 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)

Emotional support has the most Emotional support has the most impact on health.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)

For adults, marriage is the For adults, marriage is the most influential relationship. 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)

Negative or hostile relationships Negative or hostile relationships are the most damagingare the most damaging. .

Family criticism is associated with poor outcome for smoking cessation, weight loss, diabetes, asthma, and depression.

Protective family factors Protective family factors

family closeness, connectiveness caregiver coping skills mutually supportive relationships clear family organization direct communication about the illness

(Weihs, Fisher & Baird, 2002)

Family risk factorsFamily 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)

Family Relationships & Family Relationships & HealthHealth

relationships influence physiology and health behaviors

Pathways for families’ Pathways for families’ influence on healthinfluence 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

Types of Family Types of Family InterventionsInterventions

family oriented approach with individual patient

meeting with patient and family members Family medical interview Family therapy-making referral

The Therapeutic Triangle The Therapeutic Triangle

Patient

Physician Family

(Doherty & Baird)

Thinking SystemicallyThinking 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

Thinking systemicallyThinking 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.

Helpful family-oriented Helpful family-oriented questionsquestions

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?

Family medical interviewsFamily medical interviews

In response to smoker’s request or when another family member is present

Family therapy Family therapy

focuses on dysfunction within the family

little or no education about the disease

provided by skilled mental health professionals

Smoking and familiesSmoking 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

How to integrate family in How to integrate family in primary care with smoking primary care with smoking cessation? cessation?

family oriented interview with individual patient

involving family members in routine office visits

family conferences or meetings

Simplified Family Simplified Family Assessment Assessment

family structure family development family stress family support and resources Family health beliefs

Family structure: Family structure: The genogram 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.

Family development:Family development:The family life cycleThe 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?

Stages of the family life cycle-Stages of the family life cycle-‘traditional’‘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

‘‘Family’ supportFamily’ support

Family members Extended family Friends Neighborhood- Workplace Community

‘‘Family’ stressFamily’ stress

Family members Adolescents Infants Care-giving

Work Neighborhood $ Health insurance

Patient and Family Beliefs about Patient and Family Beliefs about changechange

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)

Basics of Medical Family Basics of Medical Family InterviewingInterviewing

Join with family members Empathize without taking sides Elicit views & opinions of family members Involve family members in helpful ways to

patient

Join with the familyJoin 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.

Empathize w/o taking sidesEmpathize w/o taking sides

Develop alliance w/ each family member

Use non-verbal strategies—eye contact, seating

Avoid triangulation

Elicit views/gather informationElicit 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

Enlist family members in planEnlist 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

Your options in primary care Your options in primary care dealing with smoking and dealing with smoking and pregnancy:pregnancy:

Being family oriented with individual patient

Having a medical family interview Referring to a family therapist, working

collaboratively