General Issues Regarding Inclusion of a Family Members in Treatment

We have discussed several ways to include family members in cognitive-behavioral treatment for depression. A few final issues cut across the various interventions and bear mentioning.

First, whenever multiple family members are involved in a session, even if it is not for formal family therapy, it is useful for the therapist to keep a few principles in mind. It is important to acknowledge that everyone in the room is having different thoughts and reactions, not just the identified patient. All family members need a chance to talk about their reactions and to feel understood. If someone has a lot of reactions, the therapist might ask him/her to write them down to avoid interrupting other people as they talk. Also, in terms of pacing, it is important to move with the slowest person and to check continuously to make sure that everyone understands the information being presented. Finally, it is ideal if the family members finish the session with a common understanding of the problem, or at least agree on ways to manage the problem.

Second, one or two "family meetings" can be useful even if the therapist believes more extensive family intervention is indicated. Some families are wary about the idea of family therapy; however, they may agree to a few family meetings. If the therapist can build a good alliance with family members and help them to have a better understanding of their problems and of what therapy involves, they may be more willing to participate in formal family therapy.

Third, we would like to touch on some of the obstacles to including families in therapy. One obstacle may be the individual therapist's level of skill and comfort in conducting family therapy. More skills and training are needed as one engages in more complex and involved family interventions. We believe that even without a lot of previous experience, most cognitive therapists can conduct a family meeting (perhaps in consultation with a more experienced colleague). Obviously, if the therapist feels that family therapy or a particular family therapy-related issue is outside of his/her scope of expertise, then he/she will need to provide a referral for the family. A second obstacle is family resistance to being part of therapy. The therapist may overcome some resistance by being willing to talk to family members on the phone, explaining what a given session will involve and reassuring the family members that the purpose of the meeting is not to place blame.

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