Families in Psychiatry

Psychiatry can promote growth amid chronic illness


 

References

Promoting resilience, benefit finding, and post-traumatic growth help patients and families cope well with chronic illness. A resilient family has good problem-solving skills and communication, and a shared belief system (Fam Process. 2003; 42:1-18). Benefit finding coexists with feelings of burden, grief, and loss, and post-traumatic growth can occur despite grief and loss. Convening family meetings, for example, is a way to provide a therapeutic space for families and an opportunity to reflect on ways that chronic illness has affected the family, both negatively and positively.

What is coping well?

Resilient families cope well by identifying and solving illness-related problems, communicating about symptoms, negotiating role changes, and developing new interests as a family and new ways of emotionally being together. In addition, resilient families are able to adapt or change their life goals or health behaviors, such as improving diet, increasing exercise, and stopping smoking. A family member may work fewer hours, for example, and older children may give up some childhood activities to take on caregiving responsibilities.

Dr. Alison M. Heru

Dr. Alison M. Heru

Families do not usually think about how they cope; they just get along the best they can. Families may not consider how each family member’s individual coping style meshes with the coping styles of other family members. Illness management often is punctuated by crises where change happens quickly, without the family having time to deliberate on what coping styles might work best. Family changes can become fixed, therefore, not by choice, but by happenstance.

The initial stage of coping is “assimilative.” This is when the impact of the illness is being understood and absorbed. Emotional coping occurs when distress is highest, for example, at the beginning of an illness – when uncertainty exists about the diagnosis. Another characteristic of emotional coping is that it is characterized by attempts to regulate negative emotions. For example, family members may blame themselves or others, engage in wishful thinking, or become avoidant.

At later stages of illness, coping becomes “accommodative” after attempts to change or cure the illness have been found to be ineffective. Emotional coping can then be replaced with a problem-based coping style, allowing a stressor to be discussed and a solution chosen from several alternatives. Reflective coping, a related concept, is the ability to generate and consider coping options, and to recognize the usefulness of a particular coping strategy in a particular situation.

Psychiatric imperatives

While providing psychotherapy with these couples, it is helpful to:

• Help families differentiate between emotional difficulties such as “I am the primary caregiver, and I feel overburdened,” and more general practical problems, such as “I am happy to be the primary caregiver, but I need some extra help.”

• Describe coping to the family. Coping is a dynamic process, and coping styles change over time. Each person copes in their own way, depending on their experiences of illness and expectations of living with illness. In a family, the experiences and behaviors of all the individuals influence the way the family unit functions as a whole.

• Promote a balance between acceptance and change.

• Encourage the family to talk about their experience with others who are experiencing the same stressors.

• Give the family a handout that outlines different coping styles to get the discussion started.

• Provide a therapeutic space for family members to think together about how they want to cope and what coping well means to their family.

Developing dyadic coping

When dyadic coping takes place, couples cope as a single entity. Dyadic coping research is relatively new; most studies have been conducted in the past 15 years. Couples who use positive dyadic coping employ joint problem solving, joint information seeking, sharing of feelings, mutual commitment, and relaxing together. Meanwhile, couples who use negative dyadic coping hide concerns from each other and avoid shared discussion. A systemic review of dyadic coping in couples with cancer found that couples using positive dyadic coping styles experienced higher relationship functioning (Br J Health Psychol. 2015 Feb;20[1]:85-114).

Couples with good dyadic coping view the illness as “our problem.” This approach necessitates a shared understanding of the illness. The couple usually has prior experience working together as a team, for example, parenting and dividing roles within the house. They are able to relax together and provide emotional support, such as mutual calming and expressions of solidarity. Talking together about one’s worries and needs allows couples to share the experience more adequately. Dyadic coping is reflected in the amount of “we” talk.

The person in the family who copes “best” may provide the model for developing the family coping style. In a study of 66 couples faced with the stress of forced relocation, nearly all the couples adapted to the stress “as a couple,” rather than “as individuals” (Fam Process. 1991 Sep;30[3]:347-61). At the 2-year follow-up, each husband and wife developed similar coping styles, with one individual’s coping ability driving the adjustment of his or her partner. The need to adjust together or to adapt as a couple lessened the stress of relocation. Adaptation occurred through the development of shared meaning of the relocation that emerged from conversation within the couples. In other words, the couple developed a shared worldview. The coping style of the person who coped best was the strongest predictor of adjustment for both members of the couple. For most couples, the style of the person who coped best dominated.

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