THE USE OF COUNSELING SKILLS IN FAMILY MEETING

Tabaranza, Brigitte Ulrike M.D.

FAMILY(Family Systems Theory)

Is composed of all emotionally significant people bound together by enduring ties, the minimum requirement in a family meeting is the presence of persons considered to be emotionally significant to the patient and clinically relevant to the patient’s illness.

IMPORTANCE OF FAMILY MEETING IN FAMILY PRACTICE

• Patient care should ideally occur within the context of the family.

• The ability to call for and facilitate a routine family meeting for a number of serious or chronic problems is regarded as the hallmark of a family-oriented physician.

IMPORTANCE OF FAMILY MEETING IN FAMILY PRACTICE

• This ability includes Level 3 and 4 interventions using the paradigm of Doherty and Baird (1987).

• It is essential for family physicians to have the basic skills in bringing together patients and their family members in cases where their cooperation is important; and in such case family physicians act as family counselors.

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• Level 1: Minimal emphasis on the family• Level 2: Providing ongoing medical information and advice• Level 3: Eliciting feelings and providing emotional support• Level 4: Systematic family assessment and planned intervention• Level 5: Family Therapy

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• Physician consider dealing w/families as necessary only for practical and medico-legal reasons.

• Often chosen by physicians w/busy clinical practice owing to time pressure.

Level 1: Minimal emphasis on the family

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• This also characterizes much of the training in medical schools, which focuses principally on biomedical problems.

• Limited to advise on medico-legal issues.

Level 1: Minimal emphasis on the family

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• Here, physicians understand the triangular nature of the doctor-patient-family relationship and regularly communicate with families primarily about medical issues.• Respectful listening is the

key skill needed yet no intervention is involved.

Level 2: Providing ongoing medical information and advice

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• Skills in identifying gross family dysfunctions that interfere with medical treatment are necessary to allow referrals.• Individual interventions

involving the provision of ongoing medical information and advise but focusing mostly biomedical issues and only minimally on emotional support.

Level 2: Providing ongoing medical information and advice

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• Requires physicians to have an understanding of normal family development and responses to stress.• Support, encouragement, and a preliminary assessment of the family’s functionality are activities necessary.

Level 3: Eliciting feelings and providing emotional support

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• Interventions that involve both health education and emotional support to deal with psychosocial impact of the illness but stops short of psychosocial therapy (CEA Model for individual health education).

Level 3: Eliciting feelings and providing emotional support

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• Physicians have a background knowledge of the Family Systems Theory.•Needs to be skilled enough to assess family functions and carry out short-term family-level interventions.

Level 4: Systematic family assessment and planned intervention

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• Interventions requiring systematic assessment and structured brief models of therapy that can be handled at the primary care level and taught within the context of a 3-year residency in Family Medicine (e.g. Rogerian counseling and some forms of Cognitive Behavioral Therapy).

Level 4: Systematic family assessment and planned intervention

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• This level entails planning an organized therapeutic approached to bring about major changes in the family system.

Level 5: Family Therapy

5 Levels of Physician Involvement with Families (Doherty&Baird,1987)

• Providing therapies which requires extensive training and supervision beyond scope of Family Practice.• Interventions involving deep therapy that requires additional formal training.

Level 5: Family Therapy

Who Should be Invited in a Family Meeting?

• In general, all the members of a patient’s immediate household, as well as family members and friends affected by the illness, should be invited to an initial family meeting.

Who Should be Invited in a Family Meeting?• Children are particularly important

to include especially in cases that involve psychosocial problems as they offer important and useful information about a problem, either verbally or non-verbally.• If attendance is limited, which

family members to invite depends on the nature and severity of the presenting problems.

When Should Family Meeting Be Convened?•Generally, there is no strict criteria on when to bring the family together for a meeting.

• It is also good to convene the family whenever it is felt by the physician that such meeting will be helpful to all people concerned.

When Should Family Meeting Be Convened?• The decision to call and conduct a

family meeting ultimately depends not on the particular problem or situation, but upon the skills and interests of the physician.• Patients and family members are

usually eager and willing to attend family conferences especially when the family wants to received information or share feelings about the patient’s illness.

Types of Problems or Situations for which a Family Meeting is Recommended:

• Serious chronic illness• Serious acute illness• Terminal illness and death• Psychosocial problems• Lifestyle problems• Non-compliance with treatment• Treatment failure• Routine prevention/educational

care

Family Counseling• Reviews revealed that increased levels of patient’s

satisfaction and compliance is achieved when the patient participate in the clinical conversation more assertively, for this encourage them to expression of ideas, concerns, and expectations...and the same principle can be extended when dealing with the family.• The family-oriented counseling approach presented here

is based on the psychoeducational model that generally focuses on helping the family cope more effectively with an illness or a disorder (assuming that the family is healthy and doing its best to cope with the illness).

Two Key Elements of the Approach in Family Couseling:

•Education:• Providing specific guidelines for illness management and assistance with problem-solving skills.

Two Key Elements of the Approach in Family Couseling:

•Psychological Support:• Consist of providing empathy, an opportunity to share feelings, and an assessment of how the family is coping, including expanding the family’s social network.

Types Methods Used in Family Counseling• CEA Method of Dr. Allan Dionisio (2002, 2005)• Modified Intentional Family Method of Howard Clinebell

(1984)Regardless of the method used, dealing with the families is definitely more difficult than dealing with the patients because there are more people to listen to and take into consideration.

The key Principle is to remain neutral, giving each member a chance to speak and be heard

Consideration In Family Counseling

• Important questions should be directed to each family members, their thoughts and feelings should be reflected back before proceeding to the other questions.• Rules have to be laid down at the start of the meeting emphasizing each person’s right to speak without being interrupted.

Consideration In Family Counseling

• The doctor-counselor must steer the family back to the issues at when the discussion strays or when an argument between family members arise.

• Family members should sit in a circular formation, allowing them to choose their preferred seats while the doctor-counselor reserves a place for himself/herself.

Family Counseling Using CEA Method• CEA : it is a structured technique that combines

health education and counseling, proposed by Dr. Allan Dionisio.• C : Catharsis• E : Education• A : Action

• Can be applied in family counseling, specifically at Level 3 family involvement where education and family support are necessary skills.• Follows the same step as that of the individual CEA

Catharsis• This phase seeks to define the clinical problem from the family’s point of view, by:

1. Explore the patient’s and family’s understanding of health.

2. Identify the emotionally critical misperceptions that influence the behavior of both patient and family members.

3. Reflect on /probe the feeling.

1. What do you call the illness/disability?2. What do you understand about the illness/disability?3. What do you think has caused the illness/disability?

Useful questions to ask the patient to explore his/her feelings:1. How do you feel about your sickness?2. How does your family reacts to you?3. How do you feel about there reaction?

Useful questions to the family members to explore their feelings:1. How does his/her sickness affect you?2. How do you feel about his/her sickness?

Education

• This phase involves either correcting the emotionally critical misperception (ECM) identified or affirming the correct perception of the disease.

• It can involve the characteristics of the disease:• Etiology• Signs and Symptoms• Treatment

Action

• This phase addresses the patient’s problem by way of treatment.

•Goal-setting is included by asking for active client participation in the treatment plan.• Treatment • Closing and Follow-up.

TREATMENT 1. Share the findings with the patient and the family.2. Involve the patient and the family in the

management plan up to the appropriate extent (goal-setting).

3. Further discuss the treatment to correct remaining misperception.

Sample Questions:1. What type of treatment do you think would be

most helpful?2. What important results do you expect from this

treatment?3. What might make healing difficult for you?

Closing and Follow-up:1. Ask for clarificatory questions or important

learnings.2. Perform a feeling check.3. Set a specific date and time for a follow-up.

Family Counseling Using the Intentional Method

• This method is helpful when the psychosocial issues involved are so intense that a simple CEA method is not enough.• Family sessions would be longer, each one lasting 45

minutes to one hour, in these manner the family physician is now providing primary care family counseling of the sort that mental health professional provide and which is congruent with Level 4 Family Intervention (which is much deeper than CEA but not as extensive as the specialized family therapy in Level 5).

Family Counseling Using the Intentional Method

• The primary health care therapy focuses on family patterns directed to the medical problem.• Family Physicians monitors progress and refers to a family therapists, psychiatrist, or clinical psychologist if the problem is not amenable to primary care treatment.

—difficult especially on getting the family to agree to a referral .

Establishing Rapport

• This phase is the process of establishing a trustful relationship with the members of the family.

• It is prudent to start with the least familiar or with the person who seems furthest removed from the problem including children to make them feel at greatest ease right away.

Ventilation• This phase can either commence with questions

on how everyone is doing, beginning with the family member who appears to be the neediest, or with an open invitation for the family members to talk about their particular concern.• Once the family members starts to talk about

their concern, the doctor-counselor would instinctively ask for the history of the presenting problem on its onset, previous efforts to cope and how the problem affects them.

Awareness of Strength• This would help the family to see some hope and feel

something positive in the situation.• This would lead them to start thinking objectively

about the situation and on the part of the counselor, this would set the stage towards closure.• This is the start of the structured questions of what

keeps the family going, what gives them the strength, what gives them hope would be helpful and the family physician can ask them to say, “In spite of everything, what I still appreciate in our family is….” .

Identifying Needs• The doctor-counselor can now help the family define issue clearly.• To pave the way for change, each member should articulate the unmet needs that have caused or created the crisis situation and influenced a particular behavior.•Here , you can then ask family members to specify the changes they would like to see or the needs they would like to see or the needs they would like to be met by the family

The family members should be ask to finish the line,

“What I want or need from this family is …..”

Action Plan• By asking family members to specify specific behavior each one of them needs from the family, doctor-counselor has begun the process of helping them find a solution to their problems.• In negotiating a family change plan, it is essential to work out an agreement about precisely what each one is willing to do to meet the needs to others.• Further problem definition will continue during subsequent counseling sessions if necessary.

Follow-Up

• Frequency and duration of follow-up will depend upon the problem situation and the skill and interest of the doctor-counselor.•He/She should not hesitate to refer when it is time to do so.

THANK YOU!!!