Engel’s biopsychosocial model is the current paradigm for psychiatric diagnosis, case formulation and treatment planning. The “biopsychosocial psychiatrist” understands that family is the earliest and most immediate social milieu. Family psychiatry provides the ideal bridge between the biomedical and psychosocial worlds. Family Systems Theory adds consideration of family and individual life cycles to the integration of biomedical, psychosocial, and behavioral dimensions. Application of family systems theory and therapy helps optimize the treatment and rehabilitation of individuals with severe and persistent psychiatric illnesses. In the family systems model poorly differentiated relationship patterns characterized by high anxiety and emotional reactivity impair optimal functioning. Therapeutic interventions are focused on direct assessment and change of counterproductive family relationship patterns that maintain symptomatic behavior. Reciprocal influences between biology, individuals, their families, and other social systems operate in cycles that maintain or reinforce disturbed behavior in the identified patient. Functional improvement results when emotional reactivity no longer blocks intellectual process. Recent reports from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) indicate that intensive psychosocial interventions are effective and have multiple benefits for individuals with bipolar disorder. Pharmacotherapy is first-line treatment for acute bipolar disorder episodes but of limited efficacy in resolving the disabilities highlighted in the DSM “functioning clause”. STEP-BD reports confirm the efficacy of Family Focused Therapy (FFT) to reduce time to recovery, delay relapse/recurrence, reduce relapse rates, improve patient functioning, reduce interepisode symptoms, improve medication compliance, and increase total time in recovery. Psychotherapy interventions are key components in effectively managing bipolar disorder Current evidence supports increased emphasis on family-oriented psychiatric practice. The Residency Review Committee for Psychiatry core competencies require psychiatric residents to be specifically taught how to assess the patient within the family and larger social system, how to formulate a treatment plan that includes these psychosocial elements, and how to support the family system. APA practice guidelines for schizophrenia, bipolar disorder, major depression, panic disorder, eating disorders, alcohol dependence and substance abuse disorders all include recommendations for early family involvement. Family psychiatry addresses the familial, social and interpersonal aspects of theses illnesses. Management of biologically based severe mental illnesses occurs within the context of ongoing transactional processes that can influence their future course and outcome. Family systems theory provides a practical and constructive approach for psychotherapy, allowing individuals to explore the rules of their family of origin, their role in it, and how that impacts their current relationships. Treatment techniques includes creating a multi-generation genogram that explores the functioning of a family as a whole; conducting interviews with parents, siblings and children; and boundary setting exercises to help the person shift nonproductive family patterns. A senior founding clinician famously stated: "When families come to me for help, I assume they have problems not because there is something inherently wrong with them, but because they've gotten stuck -- stuck with a structure whose time has passed, and stuck with a story that doesn't work." Systemic therapy can be used both on its own as well as in combination with other treatments. Family Systems Therapy is the treatment of choice for relationship difficulties, intergenerational conflict, and other problems endemic to the family life cycle. The Family Institute of Westchester web site provides numerous examples of predictable difficulties omnipresent in the life cycle for which a systemic perspective is ideally suited: “couples desperate to make some meaning out of their relationship, to learn how to raise children, impart values and feel less anxious in a terrifying world; families attempting to regain their equilibrium after a company downsizing; minority couples assailed by everyday racism; single women coming to grips with living in a married world; and families coping with a parent’s chronic illness or contemplating a future after the death of a loved one.” Intervention proceeds based on “the facts of functioning”, the existing patterns in real relationships. The treatment focus is on direct assessment and change of the relationships between individuals. The practice of family systems therapy is distinguished by how the clinician attends to the relationship system in diagnostic evaluation, problem formulation, and treatment planning. Family systems theory connects individual and relationship problems to the multiple triangles that surround and entangle them. It is not a method, but an all-encompassing theoretical orientation that views the family as a social system, with assessment and treatment of the problems of an individual member in the context of the family as an interactive unit. A systems viewpoint can be utilized regardless of how many people are physically present in the consulting room. Family Systems Therapy has a positive view of both the individual and the family. An approach that incorporates “the normative crises of the family life cycle” provides numerous opportunities for preventative mental health care. The brief long-term family therapy model proposes that the psychiatrist be available to each family and its various constellations or sub-systems in an ongoing fashion so as to avoid emotional cut-off and loss. There is a completion of each stage but no termination. Coming back for further treatment at another point in the development of the family is not seen as a failure, but a success in working through another stage of life cycle development. The goal is to solve problems in current relationships so as not to leave a damaging legacy for future generations.
February 3, 2010
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