Family Health

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[edit] Family Health

Thomas L. Campbell

David B. Seaburn

Susan H. McDaniel

Despite rapid societal changes in the structure and function of families, the family remains the most important relational unit in society and provides individuals with their most basic needs for physical and emotional safety, health, and well-being. The family plays an essential role in all aspects of health, illness, and medical care. In health care, family members may act as informants, customers for treatment, consultants, or part of the problem.

We define family as “any group of people related either biologically, emotionally, or legally.”^[1] This includes all forms of traditional and nontraditional families, such as blended families, unmarried couples, and gay and lesbian couples. The relevant family context may include family members who live a distance from the patient or all the residents of a community home for developmentally delayed persons. In daily practice, primary care physicians are most involved with family members who live in the same household.

This chapter presents a primary care approach to family health. We discuss the role of the family as an important source of stress, social support, health beliefs, and health behaviors and as the primary caregivers in chronic illness. The impact of serious illness on the family and the family's influence on the course of an illness are emphasized. We outline the basic principles of working with families in primary care, including how to understand the family context of presenting symptoms, the use of genograms, the role of family meetings and conferences, and the importance of working collaboratively with mental health professionals. These principles are illustrated with a case example from primary care.

The task of the family-oriented primary care physician is to consider the patient within the family context, to gain a broader understanding of the presenting problem or illness, and to access more resources for treatment. A family orientation does not mean always seeing family members together in the office. This chapter addresses both how to treat the individual patient from a family perspective and how to involve other family members in the patient's care when needed.

[edit] FAMILY HEALTH AND ILLNESS CYCLE

One way to consider the multiple ways in which the family plays an important role in health is the family health and illness cycle (Fig. 6-1). This model organizes the literature on families and health and provides a temporal sequence for families' experiences with health and illness.^[2] It also emphasizes the constant interaction between family members and health care professionals in all aspects of health and illness. Starting with health promotion and disease prevention, this section reviews the relevant research and clinical implications for each phase.

Figure 6-1 Family health and illness cycle. (From Doherty WA, Campbell TL: Families and health, Beverly Hills, Calif, 1988, Sage.)

[edit] Health Promotion and Disease Prevention

The family is the social context in which health promotion and disease prevention occur. The World Health Organization has characterized the family as the “primary social agent in the promotion of health and well-being.”^[3] A healthy lifestyle is usually developed, maintained, or changed within the family setting. Behavioral risk factors tend to cluster within families because members share similar diets, physical activities, and tobacco and alcohol use.^[2] In a 1985 Gallup survey of health-related behaviors, more than 1000 adults reported that their spouse or significant other was more likely to influence their health habits than anyone else, including their family physician.

Nutrition is an obvious family activity. Despite changes in traditional family roles, women still do most of the meal planning and preparation for the entire family. To counsel men with elevated cholesterol about dietary changes without involving their wives is unlikely to be successful. It is well documented that family members consume similar amounts of salt, calories, cholesterol, and saturated fats. Several randomized controlled trials have shown that involving the spouse in weight reduction programs significantly improves long-term weight loss.^[4] A number of “family heart” studies have demonstrated the effectiveness of health promotion programs targeted at families rather than individuals.^[5]

The initiation, maintenance, and cessation of smoking are strongly influenced by family relationships. Smokers are much more likely to marry other smokers, smoke the same number of cigarettes, and quit at the same time.^[6] Smokers who are married to nonsmokers or ex-smokers are more likely to quit and remain abstinent than smokers married to smokers. Support from the spouse or partner is associated with successful smoking cessation.^[7] In particular, supportive behaviors involving cooperative participation, such as talking a smoker out of smoking a cigarette, and reinforcement, such as expressing pleasure at the smoker's efforts to quit, predict successful quitting. Negative behaviors, such as nagging the smoker and complaining about the smoking, predict relapse.^[8]

In clinical practice it is more efficient and effective to conceptualize health promotion as a family activity and to counsel patients and their families together about healthy lifestyles. Other family members can be used as a valuable resource in facilitating changes in health behaviors. Exploring the family context, physicians can gain a better understanding and use more effective interventions to facilitate compliance with behavioral changes.

[edit] Vulnerability and Disease Onset/Relapse

As the most intimate social environment, the family is the major source of both stress and social support for most people. Most stressful life events, such as those ranked in the Holmes and Rahe Life Events Scale,^[9] occur within the family. The adverse effects of the two most stressful life events, the death of a spouse and divorce, are well documented. Family members, particularly the spouse, are the most important social relationships and account for most of the association between social support and health. The quality of the marriage seems to have a particularly strong influence on overall health.

Symptoms and health problems seen by the primary care physician are often related to stress within the family setting. Patients, however, rarely identify family stress as a source of their symptoms. Using a biopsychosocial approach, the astute physician can accurately assess the role that family stress may play in a patient's symptoms and decide what interventions are most appropriate and effective.

[edit] Illness Appraisal

Most health problems are managed at home, in the family context, without any involvement of the health care system. The appraisal of physical symptoms is a complex personal and social activity that occurs outside the professional setting. As every physician knows, some patients consult their physicians frequently about minor self-limiting problems, whereas others do not contact the physician until they are “at death's door.” Understanding how patients and families assess symptoms and decide whether to consult a physician can help the primary care physician better understand the patient's concerns and develop more effective treatment plans.

Most families have a “family health expert,” usually the wife-mother or grandmother, who is assigned and assumes the role as the expert in health matters.^[10] This individual is often consulted when a family member becomes ill, deciding what treatment should be given and whether a health professional should be consulted. Sometimes a patient may present to the physician solely at the request of another family member. For example, a middle-aged man may request a complete physical examination because his wife wants to make sure he does not have cardiovascular disease or other health problems. In such cases the physician should determine who is the “customer” and who is requesting the services.

Families usually have their own beliefs about health and illness, which may differ from medical knowledge or beliefs. These beliefs may affect whether a health professional is consulted and what treatments are used. If the physician's recommendations for treatment conflict with the family's belief system or the advice of the family health expert, the patient is unlikely to comply. Therefore the physician may inquire routinely about advice and recommendations the patient has received from others, particularly family members. When noncompliance is suspected, the patient and family's health beliefs should be assessed.

[edit] Acute Response

The diagnosis of a serious illness is one of the most feared and disruptive crises for families and challenges their coping skills. Few adults have escaped the dreaded phone call informing them of a health emergency, diagnosis of cancer, a heart attack, or death of a parent or other family member. The family's response to the crisis is influenced by their appraisal of the situation and their resources. Families may go through a period of disorganization, when their coping responses are inadequate to deal with the problems. Family members often assemble from around the country and put aside past problems and conflicts to help support and care for the ill family member.

What family members request and need most from health professionals during this acute period is medical information and emotional support. Lack of information about the condition, the treatment, or the prognosis of a loved one can be one of the most stressful aspects of the crisis. At this time, meeting with the entire family can be enormously beneficial, giving the essential medical information in a clear, concise manner and providing emotional support.^[1] Even when care of the patient is being provided by other medical specialists, such as surgeons or oncologists, the primary care physician can play an important role explaining the medical situation to the family and providing support.

[edit] Adaptation to Illness and Recovery

Many families cope effectively with the crisis stage of a serious illness but may have more difficulty coping with chronic illness. Chronic illness has become a nearly universal part of family life and requires families to reorganize themselves around the illness. One half of all persons over age 65 are limited in their activities by some chronic condition, and family members are the primary caregivers for these persons. Not only does chronic illness have an enormous impact on the family, particularly the primary caregiver, but how the family copes with the illness can influence the course of the illness.

The challenge for families with a chronically ill family member is to reorganize to meet the needs of the chronic illness without sacrificing the needs of other family members. The chronic illness can be viewed as another family member who disrupts normal family routines and demands special time and attention.^[11] Some families may try to ignore the illness, pretend that it does not exist, and avoid any changes in family life. Others may totally reorganize around the illness, always putting the needs of the illness and the patient first and neglecting the needs of other family members. At times, family members may become overprotective of the ill family member and overresponsible for care of the illness. In response, the patient may fail to assume the appropriate responsibility for the illness.

The primary care physician can help families adapt to the long-term demands of a chronic illness by meeting with them as a family or a couple and encouraging them to talk about the illness, especially their fears and emotional responses. Many families have never discussed the impact of a serious illness on their lives and can be profoundly affected by such meetings. Each family member can be encouraged to share feelings about the illness and its effects. The physician can help families decide whether they have achieved the desired balance between the patient's needs and the family's needs.

The following case example illustrates the interaction between family issues and development of cardiovascular disease. Jim Goldner, 47 years old, had multiple cardiac risk factors and had not seen a physician in more than 10 years. Although both his father and his grandfather died of acute myocardial infarction (MI) in their 50s, Jim continued to smoke a pack of cigarettes a day and rarely exercised. His family always believed that the men died early from heart disease and that little could be done to prevent it. Jim's father had quit smoking after his first heart attack but suffered a second and fatal MI a year later. Jim was not worried about his health because he felt well and could still beat his 12-and 15-year-old sons in basketball.

On the other hand, Jim's wife, Betsy, was very worried about her husband's health. She was constantly hiding and throwing out his cigarettes and had placed the entire family on a low-cholesterol, low-fat diet despite complaints from her husband and sons. She continually tried to have Jim see their family's primary care physician and even made an appointment for him, which he canceled.

Ted, Jim and Betsy's 15-year-old son, was having difficulties in high school and at home. The previous year he had flunked several of his classes and was repeating his sophomore year. He was frequently out past his curfew on Saturday nights, and his parents had caught him smoking and drinking. He had frequent verbal arguments with his father, who was furious at him for his behavior and tried to punish him by imposing stricter limits.

One Saturday night Ted returned home drunk at 2 AM, 2 hours after his curfew. Jim was enraged and began shouting at his son and shoving him against the wall. Betsy tried to restrain and reason with her husband, who simply yelled back at her. In the midst of this family argument, Jim began experiencing dull chest pressure. At first Jim ignored his symptoms, but as the pain increased, he became short of breath and had to sit. Betsy immediately called an ambulance, despite her husband's protest. In the emergency room, his electrocardiogram showed that Jim was having an acute anterior wall MI.

[edit] PRINCIPLES OF FAMILY HEALTH

This section outlines the basic principles of family health and illustrates their use through the case of the Goldner family. These principles are relevant for all types of primary care and for a variety of problems, ranging from simple self-limiting health conditions to complex biopsychosocial issues.

[edit] Use Biopsychosocial Approach

Since a family-oriented approach is based on the biopsychosocial model, the primary care physician must avoid a split between biomedical and psychosocial issues or problems in patient care. Using a completely integrated, biopsychosocial approach is difficult in clinical practice. Western culture and medical training place great emphasis on diagnosing problems as either physical or emotional and often focus exclusively on one aspect of the problem. The challenge for the physician is to evaluate simultaneously the biomedical and psychosocial aspects of the problem and to decide at which or levels of the biopsychosocial model to intervene. The family-oriented physician assumes that the family context will be relevant to most clinical problems, as illustrated in Jim Goldner's case. Dr. C had known the Goldner family for almost 20 years. He saw Betsy regularly for her Pap smears and to monitor her hypothyroidism. He had seen Jim twice almost 10 years earlier. He had initially seen Jim for tendinitis in his hand and had convinced him to return for a complete physical examination. At that time, Dr. C talked to Jim about his coronary risk factors, stressing the importance of stopping smoking. Jim never returned for his fasting lipid profile or follow-up. Dr. C was aware of Betsy's concerns about her husband's health and her son's problems.

In his initial history, Dr. C learned about the family conflict that had precipitated Jim's symptoms. He realized that these family issues would have to be dealt with after Jim's condition had stabilized and he was out of the intensive care unit (ICU). Dr. C met with the Goldner family—Betsy, the children, and Jim's sister—at the hospital the following morning. He explained the event medically, Jim's current condition, and the treatment plans. He answered their questions and encouraged them to share their fears about Jim dying. Dr. C reassured them that Jim was stable, that thrombolysis had been started promptly enough to prevent serious damage, and that they would be contacted immediately about any change. Dr. C wanted to meet with them again to discuss Jim's ongoing care after he was out of the ICU.

[edit] Assess Family Context of Presenting Symptoms

Since most health problems are influenced by, and also influence, the family, the physician should have some understanding of the family context of every patient. This may be as simple as knowing who is in the household, what treatments other family members have recommended, or who is the patient's primary caregiver.

Patients may have physical symptoms that are related to family stress or family problems. These physical symptoms may represent a stress-related illness, an exacerbation of an underlying chronic illness, or some type of somatization for which no physiologic abnormalities can be found. Experienced primary care physicians are aware of “red flags” that indicate the need for more complete exploration of the problem. These red flags may include stress-related symptoms (e.g., chronic headaches), unexplained or inconsistent physical symptoms, the patient's mood, or who accompanies the patient to the visit. In these situations the physician might ask the patient, “Have you had to deal with any recent changes or stresses at home?”

A few other simple questions can be used to assess the family context quickly. “How has this problem affected you and your family?” allows the physician to assess the impact of the illness on the patient and family. Family health beliefs can be explored by asking, “What does your family think may have caused or could treat this problem?” “How could your family be helpful to you in dealing with this problem?” or “What suggestions have family members made to you about this problem?” can begin the discussion of how to use family members as a resource. By being alert to red flags and addressing routine family assessment issues, the physician can begin to assess the situation effectively and efficiently.

[edit] Use Genogram for Family Assessment

The genogram, or family tree, is the most basic and useful tool in family-oriented primary care. It is a simple method for obtaining and recording basic family information that provides a visual record of the family^[12](Fig. 6-2). Although similar to the family pedigree, used to obtain family histories of genetic diseases, the genogram also provides information about family structure, relationship patterns, developmental issues, life cycle stages, and stressful life events. Fig. 6-3 shows the genogram of the Goldner family. Glancing at a patient's genogram gives the physician a “snapshot” of the patient's context and the family issues that may be relevant to that visit.

Figure 6-2 Genogram format. (Redrawn from McGoldrick MSW, Gerson R: Genograms in family assessment, New York, 1986, Norton.)

Figure 6-3 Goldner family genogram.

Many family-oriented physicians do a brief, skeletal genogram as part of the family and social history during the initial visit or physical examination. With practice, such a genogram can be obtained in less than 5 minutes and added to on subsequent visits. Patients are usually comfortable with providing family information and helpful in constructing the family tree. The genogram shows the patient that the physician is interested in all aspects of the patient's life. It also helps the physician to identify risk factors for inherited diseases and other problems. When the genogram is obtained as a part of routine practice, patients are more likely to reveal sensitive and important family issues, such as substance abuse or domestic violence.

The genogram is also helpful in caring for difficult and frustrating patients with complex medical problems. Little may be known about these patients' family and context. Using one appointment or 15 minutes to obtain a more detailed genogram can provide useful data about these patients and their problems. The genogram can help the patient and physician begin the gradual shift from a narrow focus on physical symptoms to a broader view of the patient's life circumstances. Jim's condition stabilized in the ICU, and he underwent cardiac catheterization, which showed distal narrowing in a branch of his left anterior descending coronary artery. During visits to the ICU, Dr. C began to talk with Jim about the events that precipitated his MI and about his cardiac risk factors. Dr. C obtained a more complete genogram related to heart disease in Jim's family. In the process, Jim talked about his conflict with his father and how Jim's father had dealt with his heart disease. Jim agreed to meet as a family with Dr. C to discuss his illness and how his family could help.

[edit] Explore Family's Developmental Challenges and Stresses

With the genogram and the ages of family members, the primary care physician can obtain a good sense of what developmental issues the family is likely to confront and whether these normative stresses are affecting the health of family members. The family life cycle is a useful conceptual framework for understanding family development.^[13] Similar to the individual life cycle, the family life cycle assumes that families go through different stages for which specific developmental tasks must be accomplished. Families who do not accomplish these developmental tasks at one stage may develop difficulties with subsequent family development. For example, some families have difficulties allowing young adult members to establish personal autonomy and independence. Young women sometimes become pregnant as a way to separate from their parents and start their own families. These women experience enormous stress as they try to live on their own, form an intimate relationship with a partner, and raise a child, all at the same time. They are at high risk for developing physical or emotional health problems.

Many normative family life transitions can be very stressful and can precipitate or exacerbate health problems. Many women and some men in their 40s are faced with the demands of caring for elderly and disabled parents while raising young children. The genogram allows the physician to identify quickly and explore these types of developmental stressors. Dr. C was aware of many developmental stresses faced by the Goldner family. The most immediate was their fear of Jim's premature death or disability. His wife was particularly concerned about whether he could return to his work as an automobile sales manager, which was very stressful. Ted's struggles to develop a sense of autonomy within his family and peer group was an obvious source of ongoing stress. Betsy's father had died 5 years previously, and her mother was declining physically and emotionally. Jim and Betsy had been contemplating whether to have her mother move in with them or find a supervised apartment for her. Betsy had recently gone through menopause and was concerned whether Jim still found her physically and sexually attractive.

[edit] Meet with Family Members

For many health problems, it may be helpful to meet and consult with a family member during a regularly scheduled office visit. Research has shown that family members often accompany the patient to the medical office, either remaining in the waiting room or joining the patient in the examination room. In the Direct Observation of Primary Care study, Medalie et al^[14] evaluated the content of more than 4000 office visits to 138 family physicians. They found that another family member was present during 32% of visits, most often when the patient was a child under 13 (97%) or elderly (25%) but also 12% of the time with adult patients. Overall, another family member's health problem was discussed at 18% of these visits. Botelho et al^[15] found that 39% of patients came to a family medicine center with a family member or friend and that two thirds of these accompanied the patient into the examination room. In a study of family practices in Ontario, one third of patients were accompanied by a family member or friend, who was usually described as an advocate for the patient.^[16] This research documents that family members frequently accompany patients into the examination room or are present in the waiting room.

Meeting and consulting with family members during a routine visit can be helpful whenever the health problem is likely to have a significant impact on other family members or when family members can be a resource in the treatment plan. The most relevant family member for adult patients is usually the spouse. Inviting the partner or spouse to accompany the patient should be considered with (1) diagnosis of a serious condition during a chronic illness, (2) noncompliance with treatment recommendations, (3) somatization or unexplained medical symptoms, and (4) health problems that have a significant interpersonal component (e.g., marital problems, sexual dysfunction).

Involving family members in a routine medical visit rarely takes extra time. Visits may even be more efficient when a family member can provide important information about the health problem. The examination or consultation room must have an extra chair for the family member.

When a patient has a complaint related to an interpersonal problem, the physician tends to support and empathize with the patient, inadvertently taking sides in the conflict. The challenge for the primary care physician working with families is to maintain a positive relationship or alliance with each family member and avoid taking sides in any conflict or problem, except when the patient's safety is at risk. The physician must avoid blaming other family members or siding with the patient against another family member. To listen repeatedly to a patient complain about another family member is similar to only prescribing pain medication for a peptic ulcer; the patient feels better acutely while the underlying problem worsens. Meeting with the patient and other family members can help the physician avoid taking sides in a family conflict and maintain positive relationships with everyone involved.

[edit] Meet with Extended Family

Although the primary care physician can use a family-oriented approach while seeing an individual patient or meeting with family members during a routine office visit, at times it is helpful to convene the entire family for a more extended family conference. The decision to convene a family conference usually depends on the seriousness of the health problem and its impact on the family. During a hospitalization the physician should meet with the family at least twice, on admission and shortly before discharge. Family members can often provide valuable information about the events leading up to the admission, and they want information about the patient's medical condition. Before discharge the physician can review the course of the hospitalization and the plans for outpatient care and can elicit any family concerns about the patient returning home. This latter visit recognizes that the family usually must assume care of the patient after discharge.

It is particularly important to meet with the family when the diagnosis of a terminal illness is made or when a patient dies. Family members are often in a state of shock and need information and support. Because of the strong emotions surrounding death in a family, often a high degree of denial can interfere with effective communication and the sharing of feelings. Death is often viewed as a failure by the physician and is often accompanied by feelings of guilt. This guilt may result in the physician avoiding the family when it is most important for both parties to meet. Physicians should routinely see family members for follow-up during the first 6 months after a loss. Dr. C met with the entire Goldner family before Jim left the hospital. He reviewed the events at the hospital and the treatment plans. At Dr. C's request, Betsy participated in the hospital cardiac rehabilitation program with her husband and agreed to continue as an outpatient. She went to the informational lectures and even used the treadmill to experience the exertion her husband could safely tolerate. The couple met with the hospital nutritionist to review Jim's diet, and they agreed to work together to help Jim stop smoking. Dr. C met with the couple alone to discuss how to resume their sexual activity. He made an appointment for outpatient follow-up for 1 month.

At the follow-up visit, Jim was doing well. He was actively participating in the cardiac rehabilitation program and had not smoked any cigarettes. Betsy was concerned, however, that Jim was doing too much physical activity too soon. He had returned to work full time and had put up the storm windows on their house the previous weekend. Jim complained that Betsy was always nagging him to “take it easy” and telling what he should and should not do. Dr. C helped the couple to negotiate a compromise. Jim agreed to cut back on some of his activities that were excessive and frightening his wife, and Betsy agreed not to monitor Jim's behavior. They agreed to return as a family in 1 month.

[edit] Assess Levels of Working with Families

When working with families in primary care, physicians should determine their level of involvement. As in other primary care areas, physicians must decide what level of skills and knowledge they have or want to have in a particular area. For example, when treating cardiac patients, physicians must decide whether they have the skills and interests to treat complicated post-MI patients in the ICU or whether they want to limit treatment to outpatient care of uncomplicated cardiac problems and refer other patients to a cardiologist.

Doherty and Baird^[17] have outlined five levels of physicians' involvement with families and the knowledge, personal development, and skills needed for each (Box 6-1). This classification was developed to recognize that all physicians work with families at some level and that some problems require the expertise of a trained family therapist. Most primary care physicians usually work at level two, providing ongoing medical information and advice to families, and level three, eliciting feelings and providing support to families. Level four, performing systematic assessment and planned intervention, usually requires additional training in family systems theory and its application. At this level, physicians can provide brief and focused primary care family counseling for uncomplicated family problems. More complex and chronic family problems demand family therapy, a specialty service that requires 3 to 5 years of training and supervision and that is beyond the interest and training of most primary care physicians.

Deciding whether to treat a family or marital problem with primary care counseling depends on the physician's interests, expertise, and availability. The physician who does not have the interest, time, or additional training in family counseling should refer these problems to a skilled therapist. Many family physicians, however, find these problems interesting, challenging, and enriching to their practice and want to counsel families.^[18]Box 6-2 shows the types of problems that typically can be managed in primary care counseling and those that usually require consultation and often referral to a mental health professional. Dr. C met with the Goldner family again 3 months after Jim's heart attack. For the first few weeks after Jim's return from the hospital, Ted had been on his best behavior, not wanting to upset his father. As Jim resumed his usual activities and returned to work, however, Ted resumed his previous behaviors, and the arguments flared up again. Dr. C explored the problem with the Goldners, asking each about the issues. He recognized that the family problems were serious and longstanding. It was clear that Ted was abusing alcohol and perhaps drugs and would need further evaluation. Dr. C also suspected that Ted's behavior had kept his parents' focus on him and that they were not dealing with serious underlying marital problems.

Dr. C recommended that the Goldners see Dr. M, a psychologist and family therapist with whom Dr. C often collaborated. Dr. C explained that he thought their issues were serious, could affect Jim's health, and deserved treatment by an expert in family relations. Because Dr. C had established their trust during Jim's hospitalization, they agreed to see the family therapist. An appointment was made with Dr. M while they were in the office, and a follow-up appointment was made with Dr. C for several weeks after that.

Many family and marital problems are too chronic, complex, or time consuming for the family physician to counsel. These problems necessitate referral to a marriage and family therapist.^[19][20] This specialty requires several years of supervised training after residency. Unlike the medical specialists whom family physicians meet and work with in the hospital, skilled therapists are not as easily found in the community. The most frequently used method for finding a good therapist is to ask respected colleagues whom they use and why. The American Association of Marriage and Family Therapy, the accrediting organization for family therapists, issues a directory of certified family therapists by city. Perhaps the most useful way to find a good and trusted therapist in the community is to arrange face-to-face meetings with several recommended therapists to learn about their interactive approaches, their theoretic orientations, and their interests and experience in interfacing with the medical system.

Counseling for referral is an important skill for primary care physicians to learn. It involves identifying key problems faced by the patient and family, including as many family members as reasonable in clarifying a desire for change, and contacting the appropriate family-oriented mental health professional. Patients are more likely to follow through on such referrals if the physician knows the professional by name. The physician should clarify the collaborative relationship with the therapist and that they will work as a team to provide care for the patient and family.

When referring a patient, couple, or family to a therapist, it is helpful to consult the therapist early in the process to share ideas and strategies and clarify the consultation or referral question. If the referral is the physician's idea rather than the patient's, it is often necessary to maximize the patient's motivation to see the therapist. Using the patient's language and understanding of the problem can help pitch the referral. Referring for an “evaluation” or “consultation” is

usually more acceptable than for “family therapy.” Some patients hear a referral for family therapy as meaning that their family is bad or in some way responsible for the current problem. Having the patient make the appointment with the therapist while still in the physician's office can also help facilitate the referral. With reluctant, difficult, or somatizing patients, a joint session with the therapist may be extremely helpful in facilitating a referral.

The timing of a referral to a therapist is important. With some patients and families, it may take months or years to reach an agreement about a therapy referral. After the couple or family members have gone for consultation or ongoing therapy, the referring physician must communicate regularly with the therapist and inform the patient and family that the physician will continue to see the patient and collaborate with the therapist. Regular communication between the physician and psychotherapist helps avoid confusion or triangulation and facilitates clear treatment planning and division of labor.

[edit] SUMMARY

To use a family health approach to primary care, the physician must know the multiple factors that contribute to a patient's problems. The physician then can decide which problems can be addressed directly and which should be referred to a mental health professional. A family orientation does not mean that the primary care physician must treat all the family's problems.

Family health focuses on the family context of a patient's health problems and offers new opportunities for working with patients and their families. Families are viewed not only as potential sources of stress in patients' lives but also as important resources in patient care. Working collaboratively with families can be a rewarding aspect of primary care and is easily incorporated into the physician's practice.

[edit] REFERENCES