Tips for speaking with patient's families.

[medstudent234]

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As a psych resident I'm obviously spending a lot of time calling patients' families and getting collateral on their functioning at home. One of the most demoralizing things I hear from families over and over is their frustration and often desperation about how their loved ones are making poor decisions, not following up with care, not seeing their therapist/psychiatrist, not taking meds, using substances that compromise their care, etc. I was wondering how to approach this? What tips/advice can I give to families besides normalizing it by saying that a lot of people with mental health issues often have this challenge and find that doing what is best for them is not an easy thing? Honestly these families are making me feel desperate and demoralized myself, about the limited things I can offer patients if engagement/follow up with care will be poor. 🙁

 

[birchswing]

I'm not a doctor but I'm a person with mental illness.

I'm not a huge fan of everything NAMI does, but supporting families is one thing they do well.

Tell them to go to the meetings. They have an initial program you can through and then also support meetings.

 

[DD214_DOC]

Stop calling them?

 

[smalltownpsych]

All humans struggle with family members who don't take care of themselves very well, with the possible exception of the Trumps. 🙄 In my family, we just call it Thanksgiving dinner. If you don't have a depressed relative who drinks too much then you're the outlier, I'm pretty sure. I say this because understanding ourselves and our own views and patterns of thinking and behaving is the essential first step in helping others to address their own.

Birchswing is right on the money with suggestion for helping the family find additional support from others with similar difficulties. I also coach families on how to extricate themselves from the control dynamics and other unhealthy patterns of interacting that often develops in order to help both themselves and their loved one. The families' hope is that someone or some medication will fix the patient or that the patient will finally do what they are supposed to so that they don't have to worry about it anymore. That pattern doesn't work very well.

 

[thoffen]

When involving families, I do think it's critical to determine the role you are aiming to fill and the boundaries of the interaction. You can predict what you're getting into often based on patient interactions, but not always. I think some conscious thought into these things going in is really important: e.g. clearly stating (and enforcing) a time boundary and an explicit purpose for the call and having a plan for further follow-up communication (not necessarily by you) should it be appropriate.

Things like referring to NAMI is an appropriate intervention when your purpose is information gathering, for instance. Failing to confront a family about getting off track when you have limited time is a major mistake. You can do this compassionately, and, if failing to succeed, I'd rather stick to the established time boundary and provide an opportunity for further contact than get roped into inappropriately supporting someone who is not your patient; doing that might actually be harmful.

 

[DD214_DOC]

There shouldn't be a compulsory need to obtain collateral from family on every patient. I wouldn't do it unless I had an actual reason to. Gathering information without a purpose wastes time and complicates things.


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[cookymonster]

Concur with above. As a resident you are asked to gather collateral not because this is a specialized skill you as a physician bring to the team, but because it is unbillable grunt work delegated to its least expensive members. If you can delegate it further to the med students, do it.

As for the specific scenarios you describe, when families ask how to support a self-destructive patient, I find a way to explain to them House of God Law #4: The Patient is the One with the Disease. Most families understand that the patient has to have some desire to get better, and they may have some inkling of what enabling means, but it also helps to emphasize that they can't work any harder than the patient and disengage if necessary and get their own needs addressed if what they've done hasn't worked.

 

[Armadillos]

As an intern I used to always avoid calling families unless absolutely necessary. Now I've sort of swung the other way and kind of enjoy it. A lot of families are super confused and scared by what is happening to loved ones and get a lot out of talking to a doctor about it. So I find that rewarding. Also makes for much fewer unexpected frantic phone calls/AMA discharges/last second sabatoged discharges/etc. if you have engaged with the family some early.

Granted, I'm sure I will feel differently as an attending when every minute I spend on phone with family is a minutes worth of work I'm not billing anyone for

 

[OldPsychDoc]

As an intern I used to always avoid calling families unless absolutely necessary. Now I've sort of swung the other way and kind of enjoy it. A lot of families are super confused and scared by what is happening to loved ones and get a lot out of talking to a doctor about it. So I find that rewarding. Also makes for much fewer unexpected frantic phone calls/AMA discharges/last second sabatoged discharges/etc. if you have engaged with the family some early.

Granted, I'm sure I will feel differently as an attending when every minute I spend on phone with family is a minutes worth of work I'm not billing anyone for

But with luck you'll have a social worker to do it for you!

 

[Dharma]

Be nice. Learn how to obtain the info you need without being a total DB. And of course, works towards the mastery of finding that tiny little space to get your word in and get out of dodge. Easier said than done has been my experience thus far.

 

[SeniorWrangler]

For inpatients, try to find the nicest, most responsible one of the pack and just talk to them. There's always at least one, usually the one who looks apologetic as their cousin/sibling/uncle yells at you. Explain up front why you're calling and that you have specific questions and not much time to go over them. Be empathetic without trying to solve their problems, they're usually in a bad place facing limited options.

 

[Jules A]

But with luck you'll have a social worker to do it for you!

Absolutely and I would hope this is an expectation rather than a gift. As a general rule when treating adults I attempt to avoid family contact unless they specifically insist on speaking with me and in those instances my social workers have thoroughly vetted them so I'm usually able to have a brief, focused conversation.

 

[DD214_DOC]

I'm telling you, stay off the phones unless absolutely necessary. When it is, make someone else do it.