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Chapter: Essentials of Psychiatry: Relational Problems

Treatment of Relational Disorders

The primary goal of treatment is to bring the relational unit to a more satisfying, organized and less conflictual level of functioning.



Specific Goals of Treatment


The primary goal of treatment is to bring the relational unit to a more satisfying, organized and less conflictual level of function-ing. The mediating goals of treatment are focused on improve-ment in the specific areas of functioning of the relational unit (i.e., structure, communication, affect expression, problem solving). In relational units where one member is suffering from a mental disorder or medical condition (e.g., schizophrenia, depression, childhood disruptive behavior disorder), additional goals include the reduction of individual symptoms and improvements in psy-chosocial functioning.


Treatment Format


Relational problems are best observed and treated directly in a family format in which the conflicted family members are pres-ent with the therapist. However, there may be certain situations in which relational problems are more conducive to change within an individual treatment format. For example, relational problems related to an individual with a mental disorder (e.g., a 25-year-old son with schizophrenia, in conflict with his mother and father) may in some cases best be approached by individual sessions with the affected person. Further, when one adult in a family unit is depressed, individual interpersonal or cognitive psychothera-pies may be used and focused on conflict resolution.


Treatment Strategies and Techniques


The specific techniques available to family therapists can be divided into five categories: psychoeducational, cognitive– behavioral, structural, strategic–systemic and insight-oriented. Psychoeducational approaches are most helpful when there is a family member with a specific medical or psychiatric disorder, and the family can utilize information on how to manage the dis-order with the least tension and stress on the patient. Cognitive– behavioral techniques are useful in improving communication and problem-solving skills and the positive interactive behaviors in marital-family units. Structural and strategic–systemic ap-proaches are most useful in rearranging the repetitive interac-tions in a family that constitute the boundaries and alliances in the social system.


In practice, there are many common elements and much eclectic usage of strategies and techniques across the various schools of family intervention. Family therapy shares many of the common treatment elements with other forms of psychotherapy. All psychosocial treatments require the development and mainte-nance of a good patient–therapist relationship, or therapeutic alli-ance. There is an assumption that most patients experience some degree of corrective emotional experience, or reliving of signifi-cant life experiences in the presence of an empathic therapist who demonstrates new ways of relating. In this context, the patient (or patients) is able to identify with the therapist and utilize the behaviors discussed and modeled. In all forms of psychotherapy, there is a certain degree of transmission of new information. The learning can be about methods of behavior, ways of think-ing, or increased awareness of complex emotions. Most therapies involve some shaping of people’s behavior through implicit and explicit rewards for behavior considered appropriate, and dis-couragement of behaviors considered harmful. This shaping can occur through advice, suggestion, persuasion, role-playing and practice.


Standard Approach to Treatment


There is increasing evidence for the efficacy of family and mari-tal interventions in the treatment of a broad range of relational problems and psychopathology. However, several specific ques-tions about treatment efficacy can be asked here in reference to the previous review of relational difficulties:


·   Do the specific relational difficulties (i.e., structure, communi-cation, affect and problem solving) respond to intervention?


·   Do the individual disorders associated with relational prob-lems (e.g., schizophrenia, affective disorders, adolescent delinquent behavior) show improvements in illness course when the relational problems are at least part of the focus of intervention?


Research suggests that family treatment is effective with schizophrenia, affective disorders, adolescent and child acting-out difficulties and eating disorders. In terms of strategies and tech-niques used in the family and marital treatment formats, there is substantial evidence for the effectiveness of cognitive–behavioral and psychoeducational techniques, with few data on the other approaches. Future studies should compare the efficacy of (and esti-mate the relative treatment effect sizes attributable to) family therapy versus competing therapies (i.e., individual or group therapies). Fu-ture research should also determine the optimal format in which to administer family treatment (i.e., home-based versus clinic-based; individual families versus multifamily educational groups).


Medical Comorbidity


Relational problems can cooccur with virtually any general med-ical condition. In most cases, it can be convincingly argued that a medical condition in one member (e.g., cancer) can promulgate relational problems between this member and other members or between two other members of the family (e.g., a husband and wife who develop marital problems stemming from disagree-ments as to how to treat their daughter’s juvenile-onset diabetes). In some cases, the relational problems may have prognostic value for the course of the medical condition and thus may become a focus of ancillary treatment.


Numerous attempts have been made to link the family constructs listed earlier (i.e., structure, communication, expres-sion of affect and problem solving) to the concurrent severity or future outcome of various medical conditions. For example, Koenigsberg and coworkers (1993) examined levels of spousal EE in relation to glucose control in diabetic patients. The number of critical comments made by a spouse significantly predicted glycosylated hemoglobin levels (a measure of glucose control) in the patient, the latter having been measured for the 2- to 3-month period before the interview.


There is evidence that enhanced family problem-solving may be a protective factor in the course of certain medical condi-tions. Using a pattern-recognition procedure, Reiss and associ-ates (1986) examined the problem-solving interactions of fami-lies in which one member had end-stage renal disease requiring long-term hemodialysis. High family scores on “delayed closure” during a problem-solving task indicated that a family was “en-vironmentally sensitive”, open to new information in choosing solutions, and willing to introduce new solutions when new in-formation was available. The authors found these high scores predicted fewer medical complications in the affected family member during a 9-month follow-up period.



While family-based interventions for medical conditions have not been sufficiently investigated, there is some evidence of their utility, particularly for the treatment of chronic childhood diseases) where families are faced with numerous challenges in promoting health and adjusting to often-complex medical regimens. Family-based psychoeducational interventions in the treatment of sickle cell disease have resulted in greater disease knowledge among participating families when compared with treatment as usual. In a clinical trial, behavior family systems therapy with adolescents with insulin-dependent diabetes mel-litus resulted in lower diabetes-specific family conflict and im-provements in the parent–child relationship when compared with treatment as usual and to an educational support group.


It is clear that chronic and progressive medical illness cooc-curs with a host of relational difficulties that may in some cases bode poorly for the outcome of the medical condition. In most instances, these relational disturbances seem to arise in reaction to the medical condition and are not apparently causally related to the disorder itself. Family or marital intervention in medical conditions may, however, reduce the tension in the household and the level of burden and psychosocial stress experienced by the caretaking family member(s), which could in turn provide a more protective environment for the ill family member.


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