A Case Study in Family and Disease Management

Alison Heru, M.D.

Alison Heru, M.D., interim chair and professor in the Department of Psychiatry at the University of Colorado, Denver, had a 60-year-old patient, Mr. D, who had been diagnosed with end-stage lung disease. He was on the transplant list, but the nurse on duty reported he was angry and exhibiting signs of depression. When the resident treating him at the time asked if there were anyone in the family he could call — a typical question, Heru said — Mr. D responded, “My wife is very emotional. I try not to bother her.”

That was a “red flag,” Heru told the audience during her lecture, “Working with Families: When Illness, Patient, and Family Interact,” at the 7th Annual Stokes Endowment Lecture on Marriage, Family Life, and Human Sexual Behavior in April. As she explained, her focus has been on complexity in families, as well as how to inquire, intervene, and refer families for mental health treatment and how to distinguish between individual, family, and dyadic — or shared — coping. All three were present in the case of Mr. D and his comment about his wife.

“The resident accepted this comment at face value, but I of course suggested a family meeting,” Heru continued. At the session, she used what she described as “pearls.” The first was an assessment, a measurement of the family’s resilience: shared belief systems, family organization, and communication and problem solving. Or, more specifically, how were Mr. D and Mrs. D managing his diagnosis? Were they on the same page with treatment, did they share the same attitude? The short answer was no.

“The patient said, ‘Progress is too slow, I want the transplant sooner than later, the meds are making me irritable. I’m a practical person. I’ve come to terms with my illness, and realistically, my wife is emotionally limited,’ ” Heru recalled. When she asked him to elaborate, Mr. D said his wife had put up a wall, adding, “I think she hates me.”

In order to improve the couple’s communication and understanding of the disease, Heru focused on the second pearl: strengths. While husband and wife had strong practical problem-solving skills managing the business they shared and taking care of their children, those skills were lacking when it came to their relationship. Heru, in response, gave them a homework assignment: write down their hopes for the marriage. Mr. D wanted to better manage his stress while becoming more affectionate with his wife; Mrs. D wanted to have a happy household with no yelling, converse without setting off her husband, and be a better listener.

Heru also uncovered that the two had grown up in largely different households. Mr. D had a distant, rigid stepfather, while Mrs. D had a close, expressive relationship with her own father. Those parent-child bonds during the couple’s formative years helped to shape their coping styles as adults. “It was like [Mr. and Mrs. D] had never learned how to talk together about difficult things,” Heru said.

On a positive note, Heru felt that their lists were similar, and the homework assignment spurred change within the couple. It was at this point that Heru offered to stop treatment or refer them to family systems therapy; the couple wanted to continue.

As Heru delved deeper into their dynamics, she found that they adapted to the illness separately, not as a couple. “This resulted in Mrs. D getting depressed, withdrawing. When she did that, Mr. D got angry, which led her to withdraw more … this was the transactional pattern,” she explained. With this kind of behavioral transaction — withdrawing, anger — Heru asked the couple, “How can we stop this?”

“The husband decided he would make two little red flags, one for the kitchen and one in the living room. They had a great fun with this. Anytime they felt this transaction was beginning to go, they would raise the red flag,” Heru said. “It was very important to involve them in this … collaborative-type therapy.”

In the final stage of therapy, Heru focused on coping: Mrs. D felt Mr. D wasn’t coping the right way, while Mr. D felt he could cope however he wanted. “‘I don’t want sympathy, I’m a strong person, I can be angry if I want, I don’t want to talk to anybody, I don’t want to be said or afraid,’ ” Heru recalled Mr. D saying. “[Mrs. D’s] coping [mechanism] was to talk to others and express feelings.”

Coping tends to evolve over time, Heru noted. For couples, it can range from assimilative — marked by active efforts to improve the situation and potential emotional highs and lows — to accommodative. The latter involves a more problem-solving and reflective approach.

Heru, as is her method, provided information on individual coping to the couple and discussed dyadic coping. “Dyadic coping is coping as a team with shared decision-making about diet, exercise, schedule, shared beliefs about illness and meaning, and ‘we’ talk,” she said. She questioned the couple on their own use of “we” talk and potential dyadic coping, and asked, “Do you want to manage this illness as a couple?” This time, the answer was yes.

Heru closed by noting that when treating a couple like Mr. and Mrs. D, it’s important to understand the family as one of many systems, to look for strength and resilience, to differentiate between individual, dyadic, and family coping, and to use simple interventions when the opportunity arises. Such a comprehensive approach will no doubt help couples and families dealing with serious or debilitating illnesses, she concluded.