TALKING WITH FAMILIES

Most families welcome the opportunity to meet a professional (usually doctor, nurse, social worker or chaplain, or ideally two or more together) to discuss the illness, ask questions and express feelings. (see Family Meetings)

Some families have communication problems. The aim of intervention is to help the family develop its level of openness in the face of stress. (see Communication Problems)

A great deal can be achieved in a single family meeting. The first few minutes are particularly important. Make initial contact, especially eye contact, with every person present. If one person feels left out or resentful it can prevent the whole family from communicating. Every individual present has an equal right to speak and be heard. Include children and talk to each one briefly (which demonstrates that they are involved).

Set clear boundaries for the first meeting. ("We have an hour now. At the end we can decide whether we need to meet again.") Towards the end find an opportunity to say "We have five minutes left now so I think we should..."

Avoid premature interpretations of a family’s behavior (which can rightly cause anger). Affirm their strengths. (“You have cared for him so well.”) They will volunteer their weaknesses.

«  You can challenge a family to change only when they feel their behavior has been understood, accepted and affirmed as their very best effort to cope with the crisis.

Allow the family to choose the first subject and to discuss what is important to them (“content”). This gives you the time to observe the “process” (who is dominant, who interrupts, who looks to whom for confirmation of what is being said, who is quiet, who agrees with whom). “Process” happens in any meeting. All behavior communicates something. Always observe “process” as well as listening to “content”.

Early in the discussion, focus on the principal aim of the meeting. This can be an opportunity for you to emphasize that the family is a system. (“This problem must be affecting you all. It often helps for everyone to talk together when there are worries.”)

You should view the family as a resource group. Examining a problem together makes it more manageable. (“Has this happened before? What else have you tried to do about it?”) The more the problem is re-enacted the better. Taking responsibility for the problem empowers a family to do something about it. The attitude that “Someone should do something about all this.” leaves the family powerless. Help the family to think of helpful things they can do to improve the situation. They then begin to feel better and communicate more openly.

Once the family feels you are on their side and that you like them, they will allow you to challenge assumptions. (“Why do you think his weakness is due to the medicine?”) Challenging assumptions does not involve disagreeing or imposing your opinions. It involves asking questions, often that nobody has dared to ask before. Change is painful and resisted. Families can only proceed at their own pace. By a process of affirming and then challenging (“the stroke before the kick”’) it is possible to move a family towards looking at painful issues together.

A fixed idea in a family is usually a group defense. (“In this family we don’t want sad talk.”) This need not be directly challenged. It is overcome by discussing practical issues and allowing the feelings to emerge. (“She’s stuck in her room all day long. Anybody would be sad.”)

Misunderstandings and upsets in a family are usually due to untested assumptions about each other. It is helpful to allow the family to listen to each other’s distress. (“How have things changed for each of you? Betty, will you start?”) Focus on the practical issues and the feelings will emerge. 

Criticisms within a family (“the blame game”) happen during a crisis as away of coping, and of avoiding discussion of painful topics. If a family focuses on the negative side of behavior it causes escalating tension. You should remember that all behavior (even unhelpful behavior) is usually adopted for good reasons. The counselor can reinterpret (“re- frame”) behavior as positive. (“So when you shout at your Mom it stops her worrying about your Dad?”)

Be open and factual. Present information in a straightforward way. Avoid euphemisms such as “passing away”, which reduce openness and imply that you are unable to speak directly about death (and therefore the family should not either). It is important, however, to use the family’s word for a particular concept before introducing new words. (“I knew I had a tumor but now you’ve said it's cancer.”)

«  The family’s understanding and attitudes need to be understood so that the therapist can relate to their belief system.

«  By being open and factual the counselor provides a model for the family to copy.

The counselor must establish at least one open relationship with the family members. Open discussion with an individual should best occur in the context of a family meeting. It demonstrates the safety of openness to the rest of the family. A discussion that occurs in isolation from the rest of the family can reduce communication within the family.

A common problem is collusion between family members to help avoid painful topics, leaving you unable to hold an open discussion. Identify the family member who seems most uncomfortable with the discussion, and gently explore that person’s experience of death, so that he can express his feelings. (“Have you known anyone else with cancer?”) You can also increase openness by offering reading materials or videos of other families in open discussion, or by getting two or more families together to discuss some of the issues. These methods can have a powerful effect in normalizing the family’s experience.

Respect the hope for life. It can be a great insult to discuss death with a family without discussing life. No one can think about death all of the time. The professional may be eager to assist a family with the issue of dying, but the family may have other important life issues to focus on, and we need to respect a family’s timing, and their need for balance.

Remain calm. The family is already stressed and will not be helped by further upset. You may feel powerful emotions but these need to be understood and controlled, otherwise you can collude with their responses (by avoiding certain topics or overreacting to particular issues). You may decide to express your own emotions, and even cry, if you feel this will encourage openness.

Allow crying but don’t let it block communication. Have tissues ready, but as they are handed to the person it is helpful to say “What made you cry just then?” or “Do you mind talking to me while you’re crying?” or “Does anyone else feel like crying?” or “Have you cried together before?” The moment of heightened emotion often comes when an essential topic is touched upon (or thought of) and discussing crying often opens up communication and brings great relief.

A family meeting should end with affirmation. Families who have had difficulty communicating and coming closer together can sometimes be greatly strengthened by a simple suggestion such as moving closer to each other in the room, or holding hands together for a few moments, or an exercise where they say the words "I love you" to each other. You need to demonstrate ("Come together and hold hands, like this, let me do it too, that’s it.") rather than give instructions.

You should end with affirming words. ("This is a family that is good at..." or "You have had the courage to face up to the worst and this can make you stronger together.") (see Communication Problems)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.