A Family Therapeutic Consultation

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DK: I’d like to talk about   what I do when I’m asked to do  a consultation in the context of a psychiatric clinic. I call this method  the Therapeutic Consultation Interview with the extended family. This consultation interview gives an impression of how a family works, in a broader sense, beyond the reason the family members come to the clinic, which is usually a byproduct of the larger family process. It gives the practitioner and the family a chance to browse in the reference library of the past.

Part of what I am attempting through this blog is to create a sense of an alternative way to think about what we call “emotional and mental disorders” or “mental illness” or “psychopathology”. At the heart my thinking is the assumption that all those above troubles are grounded in interpersonal experience until proven otherwise.

puzzle-piece-fragment-1I might even say with a sly smile, “I don’t believe in people. A people is only a fragment of a family.” What has happened in Modern Conventional Psychiatry given its preoccupation with medicalized pharmaceuticated treatments is that psychiatrists lose sight of context. Let’s say there are several contexts that make up the context: relational context (who is mad at who, who is bonded with who?), experiential context (What is going on in the situational dynamics of and around the family) and symbolic context (what has happened in the past and how does the past influence the present?). These contexts are woven together to make a large, stable and intricate family basket.

But even if practitioners pay some attention to context, they may not know what to do with what they know. There is an art to setting up a consultation interview and then to conducting a family consultation interview. I am not going to go into that territory in this entry.

A major method for working with families  is to make use of a Therapeutic Family Consultation. I see the family fragment with the therapist, and we expand the interview by adding people who are concerned about the outcome of the present situation. Supposing the identified patient is a 45-year-old depressed man. The psychiatrist has seen him for two months. There has been little change. He had his wife join for an interview. They didn’t comment on it, but she seemed a mixture of angry and distant from him. The psychiatrist is frustrated that there has been no change. He is considering changing the medication. They have two children age 8 and 12. The consultation interview could include husband, wife and the two children. Or another possibility would be to include not only the children, but the depressed man’s family of origin, mother father, siblings.

The interview with the extended group begins when the consultant says to the practitioner, “How about if you bring me up-to-date on the situation?” Then while the family listens the practitioner tells the consultant about the situation and what he has been attempting. This is a matter-of-fact presentation, not a time to expose secrets or to surprise the family with as yet unarticulated issues. The consultant asks, “Have you learned much about the family?” The practitioner reviews what he knows and even what he thinks.

Then the Consultant does what I call a “family stress interview”. He pays attention to the family and how it works. The interviewing style depathologizes the identified patient, keeps the patient’s problem and symptoms in the background, to the extent possible. I call it a stress interview because it has the possibility of destabilizing how the family views the current crisis.

Unknown-1It is my view that a psychiatrist’s (child and/or adult) work with almost any clinical problem, especially when an impasse arises, can benefit from a consultation interview with the extended family. I do these consultation interviews in psychiatric inpatient units, in the psychiatry or psychotherapy clinic, in the family medicine clinic, in the pediatric clinic; wherever a therapeutic impasse might occur. Impasse: the patient is seeking help, the practitioner is attempting to provide help. Both are frustrated.

The consultation interview is helpful in the following ways:

  1. From a purely pragmatic view, it helps the family group to understand the practitioner’s view of the problem and its implications. If powerful family members do not support a diagnosis and the subsequent treatment plan, chances are the practitioner’s efforts will be stymied.
  2. The interview gives the practitioner a vast amount of information about the personal context in which the identified patient lives and helps the practitioner modulate the treatment appropriately.
  3. The family can learn a great deal about each family member, and about themselves as a group. When the interview does not have this implicitly therapeutic effect, it is usually because the family is being overcautious and the therapist is too polite to say anything about their cautiousness. It is not unusual for a nuclear family with a disrupted member to feel cut off from their extended family. The interview sometimes restores attenuated relationships.
  4. “Something happens” in these interviews. It is seldom clear what that “something” is, but as a result of that “something” there is often a therapeutic shift in the family relationships or the triangular doctor/family/patient relationship. The something that happens usually occurs within 6-8 weeks after the interview. I believe the “something” that happens comes out of the family process, implicit fragments of health, not out of maneuvering by the practitioner.

In another entry I can explore the “something” that might lead to a therapeutic shift. My hypothesis is that the “something” is related to unconscious experience. It happens as a result of the family getting together to reflect on itself. What is called the unconscious is more accessible with the extended family present. I attempt to connect unconscious mental processes to family experience. I will describe how that might work in a later article.

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