Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.
She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.
Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.
"But it is because of my illness; I am not mental," she says.
"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.
"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."
About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).
I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.
What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:
• How has the illness changed things between you?
• How do you respond when your spouse gets ill?
• What can your spouse do that will help you get better?
• Can you ask your spouse for help and support?
• Can you work on your spouse’s health problem together?
• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?
• Are there times in the past where you have successfully solved difficult problems? How did you do that?
These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.
Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.
Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.
How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?
If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.
For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):
• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.
• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.
• Help the family deal with the losses that chronic illness can create.
• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.
• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.
• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.