Family psychiatry considers key issues
“Liminal” or “threshold” people are terms that Dr. Di Nicola uses to describe people at the margins of society. These are people who are most at risk for illness. Immigrants, one type of threshold people, tend to congregate in close family communities. Addressing the family as a unit acknowledges the family’s role as the bearer of culture, and as the bearer and interpreter of illness and health. Dr. Di Nicola states: “I believe that each family is the bearer of the culture within which it is embedded and the vehicle for intergenerational transmission, for maintaining culture, and for generating its own small scale cultural adaptations, yielding three yoked family functions: cultural transmissions, cultural maintenance/coherence, and cultural adaptation” (For details, see https://www.slideshare.net/PhiloShrink/cultural-family-therapy-integrating-family-therapy-with-cultural-psychiatry).
Working in global mental health
Once again, psychiatry is beginning to recognize the importance of the social determinants of health. Severe stress tied to rapid and massive culture change, social trauma that occurs with immigration, and the experience of refugees, war, incarceration, all affect the health of the family and individuals.
Dr. James Griffith, chair of the department of psychiatry at George Washington University, Washington, promotes the inclusion of families in global mental health. Few mental health providers are on the global stage, and so families essentially act as health care extenders. Prior to current hospital practice, families would stay in hospital waiting rooms and sleep by the patient’s bedside. Families took care of patients, feeding and changing them, and assisting the nurses. Families provided reassurance, support and comfort to their sick relatives and acted as their advocates. In China, in American mission-run hospitals, families were indispensable (“Family-Centred Care in American Hospitals in Late-Qing China,” Clio Medica, 2009;86:55). In the 19th century, fear of infectious diseases prompted hospitals to discourage this practice.
Today, in developing countries, families are still indispensable – both for medical and psychiatric care. Families can be educated and welcomed as members of the treatment team.
Understanding the patient’s family system and its relationship to the culture at large is indispensable when developing effective interventions. Providers who can initiate discussions with families about the stigma of mental illness, etiology, and relapse prevention, and set the stage for better patient outcomes. Families with cell phones can be given access to Internet educational and patient care programs.
Integrating families into health care
Dr. Eliot Sorel, an internationally recognized global health leader, educator, and health systems policy expert, advocates for moving mental health into public health. The fragmentation of the health care system makes it imperative that families understand the challenges of navigating the health care system. APA public health position papers can be amended to include the wording “patient- and family-centered care.” The integration of physical and mental health in the delivery of general health care allows for many opportunities for family involvement. Dr. Atul Gawande, the foremost physician spokesperson for health care reform, focuses on the need for team-based health care reform, from the bedside to population management. Family members are key people on the health care team.
Relational psychiatry and the DSM
Family psychiatry is sometimes referred to as relational psychiatry. The study of relationships range from courting behaviors, attraction, marriage, child rearing, interpersonal violence, and grieving. Attachment theory helps us understand the strong bonds between family members, and the formation of individual and family identity. At a social level, the bonds between the family and society/culture/community are looser but still strong and contribute to a sense of belonging.
There has been a strong push for including relational diagnoses in the DSM. The rationale for inclusion is twofold: to bring attention to relational difficulties and to bring validation to those diagnoses tied to insurance coverage and payment. For a debate with Dr. Marianne Z. Wamboldt about the pros and cons of the inclusion of relational diagnoses in the DSM see “Relational Diagnoses and the DSM,” Clinical Psychiatry News, Families in Psychiatry, Oct. 19, 2012).
Currently as psychiatrists, we bill family meetings and consultations using codes 90846 and 90847. Meeting families occurs as part of the initial assessment of the patient. This interview assesses for strengths and stressors in the family system, and can be billed as part of the initial assessment. With the move to population health care, we will begin to see changes in physician reimbursement and increased recognition of the role of families in contextualizing the patient’s experience.
Families and advocacy
The Mental Health Parity and Addiction Equity Act of 2008, or the Parity Act, requires health insurance carriers to achieve coverage parity between Mental Health/Substance Use Disorders (MH/SUD) and medical/surgical benefits. The MHPAEA originally applied to group health plans and group health insurance coverage, and was amended by the Affordable Care Act to apply also to individual health insurance coverage. The Parity Act was the signature achievement of former Rep. Patrick J. Kennedy’s 16 years in Congress. At the APA, Mr. Kennedy said: “The brain is an organ – a part of the body – and needs to be covered like all other organs.” He encouraged us to continue to advocate for the rights of people with mental illness. In his writing and advocacy work, he frequently references his own family. His is one of the many ways of doing family work.
