Family Therapy for Caregivers: From Inpatient to Private Practice
Starting out in behavioral health
When I started working for inpatient behavioral health units in 2015 as a recreation therapist, my focus was supporting patients through educational and interactive group therapy to promote wellness, healthy habits, and leisure to aid them in recovery. I didn’t have any family interaction in that role but would often see visitors with patients come drop in from time to time. Patients typically looked forward to these visits, and I had always been curious what that must have been like on the family’s end, trying to help their loved ones who were hospitalized.
Family involvement from a social worker’s perspective
When I shifted to a social work position after grad school in 2020, I was at an inpatient unit in a different hospital, and while eager to be more involved in supporting family dynamics, it turned out visitors weren’t permitted due to COVID protocols. I quickly realized how integral families still were to the treatment patients were receiving and how much of a difference it made depending on the level of support, involvement, access to resources, and investment in their loved one’s recovery and discharge plan. I had 11 patients on my caseload, with varied mental health, housing, substance use, and physical needs. With those 11 patients came a range of 11 families: from estranged to highly involved ones, and all that was in between.
Without visitation, I found myself on the phone with family members throughout the day, receiving calls asking for updates on involuntary court, inquiring what the mental health arrangements would be or when their loved one could discharge home, or wanting an explanation as to why they weren’t improving more. I also put calls out to family to discuss plans for transitioning or discussing safety concerns. There were a handful of families I tried to get ahold of but would never hear from. I noticed some had their own agenda, wants, and needs for their loved ones hospitalized, not always aligning with them, despite having good intentions. Perhaps family wanted them to go to a residential program or complete an intensive outpatient program (IOP), or they wanted them to agree to take all their medications or stay in the hospital until they were closer to baseline. This lack of alignment sometimes created challenges trying to figure out the best way to meet everyone’s needs upon discharge. My role was to help bridge the gaps and present options to patients and figure out what they were open to trying, as well as making recommendations to support their goal with discharging the hospital. While they weren’t always agreeable, it was important to advocate for their interests and requests, as long as safety was prioritized.
Bridging the gaps: family sessions to tackle discharge
It didn’t take long before I started initiating and facilitating necessary phone calls between patients, family members, psychiatrist, and myself to support patients with their discharge plan. A big focus was getting everyone on the same page, but also helping families set boundaries with what they’d need their loved one to agree to upon discharge home. Some conversations went smoothly and were productive, and others were distressing and proved to create more barriers that would impact discharge, such as family pushing back, lack of mental health resources, needing medication adjustments, or trying to find common ground on an appropriate timeline.
I recall a time where I was helping prep a family in advance of the group phone call on boundary setting with their adult son with schizophrenia and the family had other minors living in the home. There was naturally more hesitation and caution with the possibility of their son going back and what his behavior would look like with his younger siblings, if he could follow safety plans, etc. I posed questions to the family regarding what conditions their son would need to agree to (e.g. agreeing to a two-week continuance from court, taking his meds, and working with a case manager after discharge to explore long-term mental health housing resources), in order for them to feel comfortable with him discharging back home. They brought these up during the call, and I’d help review details with him, trying my best to assess if he was just agreeing for the sake of the goal to discharge vs actually committed to following what was being asked.
While there’s no guarantee he could follow-through, it was helpful to inquire further. We also created space to make sure he got to voice his needs (e.g. a phone, spending money, and no less restrictive order). Naturally, there was fear on both ends. The family was worried their son wouldn’t follow his plans and be at risk of getting detained and rehospitalized, as well as the impact returning home would have on their other kids. My patient was also fearful if the medication would work and if he could be stable after leaving. Despite these concerns, it was powerful and inspiring to see families do their best to come together and meet their loved one where they were at with compromise.
These conversations went well as a result of helping prep families ahead of time, sharing recommendations and discharge options, and encouraging boundary setting upon their loved one’s return. When these steps were followed, the discharge plan was more likely to be clear with agreement on next steps from all parties. Families had a good understanding of what their loved one needed and how to support them with ongoing mental health care, where patients were agreeing to follow the recommended discharge plan and demonstrate an ability to maintain safety with future-orientation about returning home. These moments felt very precious to get a glimpse into some of the incredible support that families brought to the table and the relationship between them, something I didn’t often see or witness because of the visitor policy.
Facing reality: family calls were not always a successful outcome
I remember one particularly difficult call. It was a patient with postpartum psychosis. When we got on the phone together, it was her mom, dad, and brother on the call. Everyone had a lot of requests for what they expected and wanted. I remember having to hold firm boundaries on my limitations with providing certain resources and recommendations for mental health care and clarify their role in helping make arrangements for her discharge plan. The patient wanted to be discharged home, while the family wanted more time to prepare for her return. Emotions were high. Everyone was frustrated, nor were they shy about vocalizing their concerns and grievances with the hospital process and what level of support we were offering.
As much as I tried to be clear on expectation setting, addressing safety concerns, and trying to collaborate with the family on their part to support our discharge, this was a call that didn’t go smoothly. It felt uncomfortable and upsetting to not be able to all get on the same page on behalf of the patient, who was working hard to get stabilized. I say this to highlight not every family interaction will go well, and not everyone will be as cooperative and agreeable as my first example. People will get upset at the process, systems in place, and even at their own family members or loved ones who are sick.
We’d muster through difficult and upsetting conversations to try and hear everyone’s side, while balancing the needs of the discharge timeline, with patient readiness, and family’s ability to provide ongoing support. I think back to this call and can admit there were a lot of cooks in the kitchen, so much that the focus was less on what the patient wanted, and more on the family being heard. I would certainly approach that conversation differently knowing what I know now.
I’d like to note family sessions more often occurred with the highly involved families and cases where discharge was more complicated, and expectations needed to be clear and explicit for everyone. Sadly, not all patients had family involvement or even involvement that prompted family sessions, but these types of sessions were more often than not effective for those with higher or more complex needs.
Shifting to private practice and offering therapy for mental health caregivers
When I left the hospital and started my private practice, I believed there was an unmet need with supporting mental health caregivers: the family members on the front lines caring for the patients I was working with as an inpatient social worker. I wanted to close the gap and offer specialized therapy specifically for these family members. I started off just offering individual therapy for caregivers- spouses, siblings, adult children, parents, and relatives of those with bipolar disorder, schizophrenia, psychosis, depression, and suicide attempts. I thoroughly enjoyed finding a way to meet the needs of these individuals, having worked with people similar to what their loved one has experienced and offering support, insights, recommendations, and skills for them to take better care of themselves, while also being more effective in helping and building or restoring their relationship together.
Once I saw there was an interest in this type of support, I expanded these services to provide family therapy, but not the traditional family therapy with everyone all together. Family therapy specifically designed for caregivers, only to keep the people providing care at the center and focus, so they could get tools, language, and support to navigate the difficult situations they (parents, couples, adult children, siblings, or a combination) experience while helping their loved one. I knew it would be most effective by keeping the concentration on the family members themselves, as often times loved ones in crisis or with serious mental illness need a different type of support and refuse to engage in therapy. I also wanted to make sure the space felt safe for families to express their concerns without fear of things getting misinterpreted.
There’s no denying mental health resources are geared for patients, and less on the family, but it’s important not to ignore the family impact while they are going through their own experiences seeing their loved one struggle and heal. By engaging in family therapy, there’s potential for significant gain to align on the same page and maximize effectiveness when it comes to supporting loved ones with serious mental illness. A lot of harm can be avoided with damaging the relationship further by having a specialized guide to help along the way.
I’m so grateful for my experience working inpatient behavioral health over the years before transitioning to private practice. It’s been instrumental to see the side of the inpatient world and what it looks like to support individuals going through crisis, where now I can support families going through this with their loved ones.
Reach out for a free consultation for family therapy
If this sounds like you and you’d like more support or want to get on the same page with a defined plan to help your loved one, I offer individual and family therapy sessions for family mental health caregivers. Please contact me for a free 15-minute consult for individuals and 20-minute consult for families.
If you’re looking for a helpful book on communicating with your loved one with serious mental illness, I highly recommend I am Not Sick I Don't Need Help by Xavier Amador. You can visit the LEAP Institute to learn more about his method of communicating, one I utilize with family caregivers myself.
