Marina Nikhinson, MD
Those of us who see folks in individual psychotherapy sometimes fall into the trap of wishfully thinking that our patients live in a vacuum. We welcome them into our offices each week; devote our time, effort, and good intentions to their personal growth; if we are lucky, we accompany them to incredible depths during the hour they are with us. And then they return the following session, and we often hear something to the tune of, “our last session was great, but my father still won’t return my phone calls.” This is often a jolting reminder that in fact there is no vacuum, and we have to deal with our patients’ reality in and outside of sessions in order to help them heal and get better.
The role of family in individual psychotherapy is not easily defined. In fact, there is often much debate between the therapist, the patient, and the family members in what that role actually is. We can all agree that most of the time all interested parties are invested in helping the patient get the most out of treatment. However we often disagree on how to get to this goal. As a psychotherapist, I hope to partner up with my patient to help define what the goals of treatment are and what tools and maps we will use to get there.
FEELING WORLDS APART
At times, patients come to therapy feeling their ties with family members have been severed in irreparable ways. They prefer to mute their interactions with the family, figuring out a path on their own. They hope and rightfully expect that their confidentiality will be protected and respected by their therapist. These boundaries are ethically and legally important, and must be observed in a careful, thoughtful way. In these situations, families often feel cut off, worried, and fearful. They understandably have trouble allowing the patient some space to sort things out, which often puts more tension on the already strained relationship. In these circumstances, for the therapist there must be a delicate balance between aligning with the patient’s experience to gain understanding and trust and developing a sense of what may be most effective for the patient in their family relationships long term. This balance is a very challenging piece of treatment, as financial and logistical matters introduced by family concerns often become part of the treatment focus. Over time, it is useful to work in individual therapy on ways to explore with the patient the family conflict, especially as it relates to practical issues of care giving, finances, and living arrangements, as well as opportunities for improving communication in the family in a safe and comfortable way. Often psychotherapists will identify a need and recommend a referral for family therapy work so that individual psychotherapy can proceed in a less disrupted manner.
WHEN CLOSE KNIT IS TOO CLOSE
Alternatively, patients may also seek out individual treatment as they look for ways to engage with the world outside of their immediate family. There are many varieties of family structures that are culturally, economically, and socially influenced. At times, families become so close that natural boundaries do not develop properly allowing younger family members to become more independent and self sufficient. This presents a dilemma for the individual therapist, as patients are often ambivalent about what they would like to gain from treatment, fearful of modifying the close relationships, hoping to find their way in life without adequately separating from their families. Their loved ones feel an understandable pull to be intimately involved in their treatment just like they have been involved in other aspects of their lives. However, individual psychotherapy by its definition helps the patient form a healthy one-on-one relationship with the therapist in order to grow emotionally and psychologically. Many times, as patients continue in their individual treatment they develop a sense of separation and independence, which may be disruptive to their home environment. The therapist’s tendency in these circumstances may be to help the patient define flexible boundaries and limits with the family that will be conducive to growth while allowing the family to adjust slowly to the changes happening with the patient. Once again, family therapy work with a trained psychotherapist may be helpful in reinforcing, processing, and helping everyone involved adjust to the personal growth the patient is experiencing through their individual therapy.
THE LIMITS OF FAMILY
When I meet with families of my patients, one of the most common questions they ask is what can they do to help. Some ask because they struggle with watching their loved one in pain and they are fearful of the unmentionable outcomes of psychiatric illness that creep up in their nightmares. Others ask because they’ve been through treatment themselves and wonder what the path will be like for their family member. In response, I will often suggest that they ask questions, as to not assume or presume that they can understand the experience or have the right advice. I suggest that they listen to the answers and truly hear what their loved one is saying or asking of them. So many emotions play into families’ responses to watching someone struggle with psychiatric symptoms – guilt, fear, grief, sadness, even depression of their own. While many family members express a strong desire to help, they often don’t know how and they become overwhelmed by strong emotions which impair their ability to be effective. Professional help is often essential in bringing healing and peace to families, not just patients. I encourage families to establish and respect boundaries, only offer support they are capable of providing. I recommend that they take time to care for themselves and make their own well being a priority in addition to caring for their loved one. What my patients often need the most is the comfort of knowing that their families will survive their illness. The wisdom in what families can do often lies in knowing when they cannot be helpful and handing that responsibility over to mental health professionals.
Psychiatric emergencies present a special challenge for individual therapists. We often rely on families and friends of our patients to monitor safety, as they have much more access to patients at home. Yet, breaking confidentiality at times comes at a price of breaking trust and damaging a carefully nurtured therapeutic relationship with the patient. I find it helpful to engage family members and the patient in an open discussion about an emergency plan of action in a proactive and ongoing manner; a discussion of what to look for, how to know when the patient is in trouble, and what to do about it can be helpful and calming for all parties involved. While therapists usually want to err on the side of caution when it comes to breaking confidentiality of our patients, when safety is a concern, families, patients, and therapists all benefit from a clear plan.
IMPROVING THE CHANCES OF SUCCESS
So what can be done to help our patients and empower their families? Obviously, there are many factors to successful treatment, and psychiatric illness can be notoriously difficult to get under control. Nevertheless, working together we can help increase the chances of a good outcome. My primary target with any patient is to build an alliance that will blossom into an effective therapeutic relationship. Oftentimes it is as equally important to engage the family in understanding what my patient’s needs are. Respecting each other’s limits, understanding the patient’s point of view, validating the hard work the patient is doing to improve – all of these elements are essential in helping heal the rifts families often experience. I also hope to build a bridge with the family until the patient feels comfortable communicating with them effectively and directly. The difficult work in individual therapy a patient does will inevitably influence their relationships. The family is a dynamic system which will undoubtedly feel and respond to the growing pains of the patient’s psychotherapy. The ultimate recommendation I often make to help all participants become educated and well informed is engaging in family therapy work. As an individual therapist, I always hope to work with the family therapist in partnership to forge the most effective way forward for my patient and their family.
Find Part 2 of this dialog here.