The variations of family tensions at family gatherings are endless: reenactments of sibling rivalry; favoritism; disappointments; unmet needs; failed expectations; feelings of rejection, abandonment, underappreciation. These tensions often are accompanied by a desire to right old wrongs and protect the vulnerable. Then there are the toxic or personality-disordered family members patients do not want to spend time with, the grieving for family members who have died or have been cut off from the family, managing the impact of divorce or job loss, handling the family member who has an untreated illness such as alcoholism. The list goes on and on.

Successfully navigating these rapids leads to positive self-regard and a sense of accomplishment. For patients with an illness, either medical and/or psychiatric, successful management might be crucial to their health. Those with diabetes need to be able to control their intake of sugars and calories or to say “no” to the pushy aunt when pressed to take more. For patients with epilepsy, increased ER visits were predicted by several factors, including holidays (Eur. J. Neurol. 2013;20:1411-6). There are more deaths from natural causes on Christmas and New Year’s than on any other day of the year (Soc. Sci. and Medicine 2010;71;1463-71). In contrast, suicide rates are actually lower at Thanksgiving and Christmas (J. Emerg. Med. 2014;46:776-81) and (Eur. J. Public Health 2014;pii:cku169). Stressful life events are known to be triggers for mood disorders (J. Affect. Disord. 2012;143:196-202), and tense holiday gatherings qualify as stressful.

As psychiatrists, we shape our discussions with patients with the goal of helping them identify situations that worsen other illnesses and situations that act as triggers. We might offer additional doses of medications to “help them through.” We caution against overeating or using substances to manage stress. We direct patients to one of many websites that provide helpful tips for managing the holidays.

We also help co-parents negotiate an amicable division of time with the children, and assist in getting adults and children come to terms with the “less than perfect family.” We help stepparents come into their new role. We remind blended families that new families need new traditions.

We are trained to resist providing specific advice for patients. However, we can employ strategic and educational interventions. Our patients are dealing with family issues AND mental illness. Discussing strategies helps our patients manage the stress of family gatherings.

Strategy 1: Differentiating levels of knowledge

Help the patient to think about her family’s understanding of mental illness. The public at large, including family members, can be very uninformed about mental illness. For those family members who have some understanding, they may be unsure about the best way to handle a relative with mental illness. They may feel that they should just treat them “the same” or “be tough” or “baby” them, or make special accommodations. Any strategy or intervention depends upon the family member’s level of understanding.

Each family member can be at different stages of acceptance of the illness. These different stages can sharpen division or create divisions in the family. This fracturing of the family will most likely occur along lines that show prior strain. Once this is known, the psychiatrist and the patient can have a more nuanced discussion about the best way to manage specific family members. The strategies can range from ignoring Uncle Bert when he makes ignorant comments, to helping Aunt Sadie who really wants to understand and be helpful.

It helps to remind patients that mental illness is common. According to the National Institute of Mental Health, one in four people will have an episode of mental illness in their lifetime. Also making statements like “My illness is as a common as diabetes” or “my treatment is quite specific” shows a mastery of the situation, rather than shame. If patients can use stock phrases with which they feel comfortable, the family will be more easily settled down.

Handouts on the patient’s specific mental illness that describe facts, such as prevalence and signs and symptoms, are useful. Family members can be very receptive to hospital or clinic educational information. These steps normalize the medical treatment and reduce the fear of the unknown illness. There is no need to make a big production around giving them these. Just have them on hand, in case someone asks. Inviting relatives to meet for an educational session with the psychiatrist can open up the dark and hidden aspects of mental illness, so having your business card on hand is a supportive gesture. Holiday gatherings are neither the time to clear up misunderstandings nor to work on resolving conflicts.

Strategy 2: Managing stigma

Some family members might react negatively because of the stigma of mental illness. A way to help the patient manage a relative who wants to discuss topics that are difficult is through role play. The psychiatrist plays the patient. The patient acts out the responses of the relative. The psychiatrist models good coping styles, using helpful stock phrases that the patient can then practice.

Relatives may say they do not “believe” in mental illness. As if illness could be a matter of belief! Do some relatives think that God and prayer, or hypnosis, or acupuncture and herbal medications are the cure? Help the patient be prepared through role play.

Strategy 3: Managing specific illnesses and symptoms

Patients with depression, bipolar disorder, or anxiety who experience family events as stressful can say to family members: “My doctor told me it is important to reduce my stress/maintain a low stress level. I will therefore take walks/naps or just be able to stay for a short time.” For patients and families that need more specific help to understand, the psychiatrist can provide the patient with a written list of instructions that the patient can present, like a prescription.

Strategy 4: Abusive or angry families

For families in which there is an abusive relative or past history of trauma, special considerations include making a decision about whether or not the patient should actually go. If they do decide to go, a short-time, limited visit works best. The psychiatrist can help the patient identify triggers to pay attention to, so that they can leave when needed.

Strategy 5: Advice about family members who seem to have their own illness

If a patient gives you information that leads you to believe that a family member has an untreated psychiatric illness or a personality disorder, offering some general advice is helpful. Recommend the avoidance of family drama. If other family members get into a scrap, it is not worth getting involved unless someone is in danger.

General comments are helpful: “While I cannot tell you what the issue is with your uncle, from what you are saying, it seems that he has a lifelong pattern of making a scene or provoking others or overreacting to benign comments. If I were in that situation, I would try not to take it personally, disengage, perhaps go to the bathroom, clear the dishes, or go outside for a breath of fresh air. Holidays are not the time to “try to sort things out” or “clear things up.” If there is a need to do this, a separate occasion or a visit to the psychiatrist can be suggested. A polite “ I am feeling tired, exhausted’ is an easy excuse to offer.

Strategy 6: When you don’t know the family dynamic

Often, there are issues that go back several generations, in which family members take sides. A daughter may look or behave like her father who perpetrated violence. This daughter can be unfairly treated. These types of situations can be difficult to ferret out. It is best to say something like: “This seems complicated and too difficult to sort out. Sorry, I cannot do better.”

One technique that can be helpful for the patient is the preparation of a family genogram. The timing of the genogram is important. It is worth considering whether this should be delayed to a time where the patient can be thoughtful and not prior to going to a family gathering that is anticipated to be stressful.

A genogram can help the patient see patterns that extend back through generations. It also can highlight people in the family system who are sympathetic or likely to know about mental illness. If 1 in 4 people have a serious mental illness in their lifetime, the genogram can shed light on these relatives. A genogram also can identify family strengths, thus changing the focus for the patient, from anticipation of conflict to anticipation of renewing and strengthening relationships.

Lastly, providing aphorisms is disarming. Aphorisms bring humor and wisdom to difficult situations. “Our family has its difficulties, but we also have our strengths.” “We have some issues right now, but thinking back through the generations, we have a lot to be thankful for,” or “Mental illness treatment will soon cure all ills.”

In summary, even if patients do not use this advice, the mere fact of thoughtful exploration and practice can help them feel more in control at stressful family gatherings.

Remember, if your patient decides not to attend a family gathering, provide strategies to manage spending the holidays alone. Avoiding these events can lead to feelings of isolation, abandonment, and loss. A plan to work or volunteer, or spend time with friends mitigates the emotional pain of the “not good enough” family.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013).

Families in Psychiatry: Successful strategies for fraught family gatherings