At the NASW National Association of Social Work Conference-Ohio Chapter last week, dozens of workshops were offered. Often, in an emergency situation such as occurs at a busy hospital ED, you’re dealing with more than the patient and must consider the entire family. Therapists Marilyn Gale LISW-S and Julie Sheehan LSW, MSW developed their workshop presentation ‘Family Therapy Meets Crisis Intervention’ based upon years of experience through Cincinnati Children’s psych ED and PIRC-psychiatric intake response center. This includes intake calls, the physical ED environment and ED physicians, telemedicine-interview through an I-pad if off site, and having a crisis presence. It involves family therapy from a systems theory perspective.
“In a crisis, people are seeking homeostasis (balance). With an extended family, you’re dealing with the field beyond the nuclear family. This can help to explain the intergenerational transmission of attitudes, problems, behaviors and other issues,” Gale explained. Maybe there is a specific family pecking order in place with grandpa or grandma at the head. Other times, the oldest sibling takes the lead. Many holiday movies are about family dynamics. It’s something we share.
At this NASW-Ohio workshop, clinicians had the opportunity to explore best practice in working with families in crisis. It’s important to understand differentiation, the ability of each member of the family to maintain his/her own sense of self while remaining emotionally connected to the family. Healthy families allow for differentiation. In a transgender situation, some members (grandparents) may not accept disclosure, as the speakers continued with relevant examples.
A clinician often sees triangular relationships where 2 members triangle a 3rd member as a way of stabilizing their own relationship- as a child with two parents might play one off the other, or in the case of divorced parents. Example: Clark’s (middle) sister Mattie felt like the odd child out between two siblings, the oldest son (named after long line) and the youngest (golden boy). Her communications style was to become enmeshed with one, triangulating the other (out) and controlling information, access, and favors. By adulthood, she was mama’s favorite and the sons alternatively isolated. Place them all in an ED, in crisis with decisions needing to be made on behalf of a patient.
There are several types of family therapy interventions. Among ten, the presenters discussed:
- Listening and empathy- are skills which build rapport with patient and family. (We can use this skill in our own family dynamic.)
- Joining can accommodate to their style, such as mimicking terms, understanding and adapting to educational level. (We have different terms for things. Talking with a child may require accomodation.)
- Identifying a family rules and boundaries is helpful in understanding what a family finds acceptable. (Movie example: Meet the Parents)
- Understanding a family’s established hierarchies can extend to body language, seating position and who manages a conversation. For instance, does mom rescue him or speak for him? Perhaps it’s a matter of supporting the parents, or creating a circle. (At Thanksgiving, who sits at the head of the table? Who hosts?)
- Reframing is using the same fact in re-statement. In motivational interviewing, one asks, ‘what’s worked?’
In 6. Strength-based approaches, the task is to reinforce what works. The intervention of 7. ‘Checking,’ summarizes the situation to make sure folks are on the same page. With 8. ‘Exceptions,’ one identifies times when a situation is less likely to occur. This might involve using scaling questions- ‘on a scale of 1 to 10’ . . . or coping questions, ‘what were you doing when?’, ‘were there times when x is less likely to occur/less severe?’ In 9. ‘Externalization’ one might utilize a narrative to separate the problem from the person. Finally in 10. It’s important to develop a safety plan, a crisis plan for every patient, and educate the family.
In a crisis intervention situation you use the method which provides immediate short term help and prioritize what you need to do first. This goes for both clinicians and family members- who may not be thinking clearly. The purpose for any intervention is to reduce the intensity of the emotional, mental and physical behaviors to return to a level of functioning. Consider that in the Chinese language there is a character for the word ‘crisis’ in which one symbol offers a way, and another the opportunity for change. Gale and Sheehan explained that in the first part of the year 2015, 6500 families coming through the ED had a psych crisis where a decision needed to be made what level of care they’d require.
The speakers presented the audience with three representative scenarios, and the teams were tasked with deciding which intervention/s to use and how to assess the situation. In case 1, a 17 year old male was transitioning to female, depressed, cutting and expressing suicidal ideation in spite of anti-depressant medications. In case 2, a 12 year old adoptee with a disability was exceptionally sad about the adoption and missed the orphanage. The adoptive mother was distraught. In case 3, a 13 year old boy was anxious, avoided eye contact, expressed some suicidal ideation to a girlfriend at school and completely ignored his mother. Father was concerned about bullying over a potential sexual orientation issue. What would you do in each case? Thinking about your own ED visits, what might have been handled differently or better? At Pomegranate, as we evaluate every survey and each comment, it’s with an eye to continuous quality improvement, because even with some pretty great ratings, every situation presents differently, and every patient & family matters. There is always room to listen & learn.
[Photo credit: author, Katarzyna Bialasiewicz No. 57183032 Dreamstime]