Medical Family Interviewing
Kathy Cole-Kelly, M.S., M.S.W.
Professor of Family Medicine
Case-Western Reserve University
Cleveland, Ohio
Why family?

Families are a part of medical practice!
 Impact
of illness on families

Impact of the family on health

Prevention and Health Behavior Intervention
Families in Family Practice
(Direct Observations of Primary Care - Stange et al. 2000)
 addressed
family issues (70% of visits, 10%
of time)
 family
 care
member present (35% of visits)
provided to another family member
(18% of visits)_
Families part of medical practice
 35%
had family member there
 Non-patient
family member asks questions
about their own health
 Patients
in the waiting room!
Impact of Behavior Change of
Individual on Family System
 Family
mobile
 Family
Rituals
 Hidden
Patients
Impact of the Family on Health
 The
research: A brief summary and
backdrop to working with families in
medical practice
Family relationships have a
powerful influence on health
“The evidence regarding social relationships and
health increasingly approximates the evidence in
the 1964 Surgeon General’s report that
established cigarette smoking as a cause or risk
factor for mortality and morbidity from a range
of diseases.” (House et al. 1988)
Emotional support has the most
impact on health.
6
months after MI, women w/ few
emotional supports had 2-3 times the
mortality rate of other women (Berkman, 1992)
 Group therapy shown to prolong survival
in metastatic breast cancer (Spiegel, 1989) and
melanoma (Fawzy, 1993)
For adults, marriage is the
most influential relationship.
 Widowed
and divorced persons have
higher morbidity and mortality.
 Men have higher death rates in the first 6
months after the death of their spouse.
 Divorced and unhappily married persons
have poor immune function. (Kiecolt-Glaser,
1987)
Negative or hostile relationships
are the most damaging.
 Family
criticism is associated with poor
outcome for smoking cessation, weight
loss, diabetes, asthma, and depression.
Protective family factors
 family
closeness, connectiveness
 caregiver coping skills
 mutually supportive relationships
 clear family organization
 direct communication about the illness
 (Weihs,
Fisher & Baird, 2002)
Family risk factors
 conflict,
criticism & blame
 psychological trauma related to disease
 external stressors
 family isolation
 disease disrupts developmental tasks
 rigidity and perfectionism
 (Weih,
Fisher & Baird, 2002)
Family Relationships &
Health
 relationships
influence physiology and
health behaviors
Pathways for families’
influence on health
 Direct
or biological pathway
 genetic
 Health
influences, contagion
behavior pathway
 life
style (diet, exercise, etc.)
 adherence to medical recommendations
 health care decision making
 Psychophysiological
pathway
 psychoneuroimmunology
Types of Family
Interventions
 family
oriented approach with individual
patient
 meeting with patient and family members
 Family
medical interview
 Family therapy-making referral
The Therapeutic Triangle
Patient
Physician
Family
(Doherty & Baird)
Thinking Systemically
 Talking
with the fiance as well as the
patient—being aware of their dynamics.
 Looking
for others in the patient’s system
that will encourage or discourage health
behavior change
Thinking systemically

Patient wants to quit but worried about how she’ll
handle stress and her husband’s nagging:
 LINEAR:
MD tells husband not to nag and tells patient
way’s to reduce stress.
SYSTEMIC:
 Thinking what the husband can be rewarded with by
less nagging as well as the wife having the reward of
his support.
 Helping patient brainstorm sources of stress.
Helpful family-oriented
questions





Has anyone else in your family had this problem?
What does your family think might have caused or
could treat this problem
Who is most concerned about this problem?
Have there been any other stresses in your family or
your life?
How could your family be helpful to you in dealing with
this problem?
Family medical interviews
 In
response to smoker’s request or when
another family member is present
Family therapy
 focuses
 little
on dysfunction within the family
or no education about the disease
 provided
by skilled mental health
professionals
Smoking and families
 smoking
runs in families
 smokers marry other smokers
 couples smoke the same amount & quit at
same time
 partner support helps smoking cessation
 partner criticism impedes cessation
How to integrate family in
primary care with smoking
cessation?

family oriented interview with individual patient

involving family members in routine office visits
 family
conferences or meetings
Simplified Family
Assessment
 family
structure
 family development
 family stress
 family support and resources
 Family health beliefs
Family structure:
The genogram
 biopsychosocial
snapshot: include genetic
relational information, health behaviors
and patterns
 most
efficient record keeping
 particularly
helpful in looking for patterns
of smoking---during pregnancy etc.
Family development:
The family life cycle
 families
go through stages
 each stage has developmental task
 failure to accomplish task will result in
difficulties or symptoms
 QUESTION: what developmental tasks is
this family dealing with? How high is the
stress at this point. Is this an acceptable
time to make health behavior change?
Stages of the family life cycle‘traditional’
Leaving home: the unattached adult
 Couples and pairing

 Pregnancy
and childbirth
Families with young children
 Families with adolescents
 Adulthood and middle age
 Graying of the family
 Death and grieving

‘Family’ support
 Family
members
 Extended family
 Friends
 Neighborhood Workplace
 Community
‘Family’ stress
 Family
members
 Adolescents
 Infants
 Care-giving
 Work
 Neighborhood
$
 Health
insurance
Patient and Family Beliefs about
change
 What
caused the smoking to start
 What could help the patient to stop
 What could create exacerbations
 What family members believe in potential
for change
 What others have contributed to beliefchange potential. (workers, extended fam)
Basics of Medical Family
Interviewing
 Join
with family members
 Empathize without taking sides
 Elicit views & opinions of family members
 Involve family members in helpful ways to
patient
Join with the family
Make contact with each person
 Greet and shake hand of each family member
 Establish family member’s relationship to patient
 Obtain patient’s permission to talk to other family
members
 Involve family member from the beginning by
asking a question
 Demonstrate respect-show interest in work,etc.

Empathize w/o taking sides
 Develop
alliance w/ each family member
 Use
non-verbal strategies—eye contact,
seating
 Avoid
triangulation
Elicit views/gather information
Helps to understand potential for change.
 Helps to understand potential for nagging!
 Gather non-verbal information
 Explain interest in hearing each person’s
perspective
 Benevolent traffic cop if necessary
 Avoid questions that encourage blame
 Use of re-frame—especially with criticism

Enlist family members in plan
 See
family members as tremendous
resource for change
 Many health behaviors are family acivities
 Spouses or partner more likely to influence
health habits than anyone else
 Support associated with successful smoking
cessation (no nagging approach!)
 Help patient negotiate with family members
Your options in primary care
dealing with smoking and
pregnancy:
 Being
family oriented with individual
patient
 Having a medical family interview
 Referring to a family therapist, working
collaboratively