1950s Systemic family therapy emerges simultaneously in the USA and Europe, absorbing the ideas of cybernetics and communication theory. Doctors, anthropologists, mathematicians and psychologists have developed ideas about the structure of the family, its crises, the system feedback. Psychotherapist Virginia Satir (1916–1988) was the first to consider the family as a whole as a client. British anthropologist Gregory Bateson (1904–1980) created the double message theory. This message is a paradox: for example, a mother expresses love for her child in words, but her behavior indicates hostility.
Definition
With a systematic approach, the client becomes not one person, not a couple, but the whole family as a whole. Any problem is considered not as a feature of the behavior or feeling of one of the family members (including children), but as a result of the functioning of the family as a whole as a system that is constantly developing. All processes occurring in the family system are both a cause and a consequence of each other.
Operating principle
Problems of one of the family members indicate broken relationships within the family. The psychotherapist tries to identify what purpose the symptom serves, which became the reason for therapy. Systemic family therapy examines how family members communicate with each other and often uses role playing games. In some cases, it is also considered family history, which may also be the source of the current problems. During therapy, the entire family and the system of relationships in it changes, and as a result, the behavior of its members changes.
Progress
A systemic family therapist can work with the whole family, with a couple, or separately with one of the family members, including the child. During the conversation, he analyzes the client’s habitual forms of behavior and his ways of reacting emotionally to words and actions significant people. Also considered family rules(for example, how and what they spend money on) and family myths(the family’s idea of who “we” are; for example, in the “close-knit family” myth, anyone who thinks badly of relatives is considered bad). The therapist then works with the client to explore new ways of interacting that enhance the client's or family's quality of life and relationships.
The work can use a genogram - a diagram drawn from the client’s words that reflects events in the family and the relationships between its members (love, addiction, breakup). Genogram analysis helps identify hidden sources of problems in family history that cause family members to behave in certain ways.
Indications for use
Sexual disharmony, difficulties in communication between parents and children, difficulties in creating long term relationship, loss loved one, divorce, psychosomatic disorders, child behavior disorders, emotional problems children – the topic for consultation can be any situation that worries the family. Family therapists also work with adolescent problems, such as addiction, suicide attempts, eating behavior. Some illnesses, such as depression or a phobia of a family member, affect the family as a whole. Family systemic therapy helps to cope with these problems if it becomes clear hidden meaning symptom.
How long? What is the price?
The appointment lasts 1–1.5 hours. Typically meetings occur once a week. The family system has sufficient flexibility, so in some cases one or several consultations are sufficient, but sometimes long-term assistance is required (up to 30–40 consultations). The price of one appointment is on average 2500 rubles.
Family therapy is designed to help families. It helps to cope with large-scale problems, and with very minor, and everyday problems. Family therapy is intended to eliminate problems in the family or contribute to overcoming existing disharmony in the family.
Family therapy can be useful enterprise, both for a married couple, and for a broader definition of “family”, which includes relatives and close friends. What should you expect from family therapy? Family therapy may be presented over multiple sessions or visit cycles. Some classes can be attended by all family members, while others can be strictly individual or couples meetings. That is, the psychologist talks with each spouse separately in order to more clearly form a picture of the problem presented.
How can family therapy help?
Heart-to-heart conversations are often effective way help the family coexist and function in a more peaceful way, because married couples will see their problems and learn to solve them. Family therapy can be especially effective in multigenerational families because generational issues can often cause resentment and misunderstandings between family members. What does family therapy consist of? Family therapy offers open form for family members to discuss their thoughts and feelings without fear of physical or mental attack. Psychologists help family members cope with personal problems, as well as the problems of other family members, and create positive dynamics in family. By offering an opportunity for open conversation between members of the household, family therapy often helps create a more pleasant, comfortable environment in the home.
There are several types of family therapy
Family therapy comes in three main types. The most common type of family therapy is family systems theory, which suggests that the family is a unit of society that works better in unison rather than separately. Other types of family therapy focus on psychological dynamics family and behavioral problems of individual family members.
The benefits of therapy for married couples are the ability to smooth out conflicts and learn to control one’s feelings in a given situation. Understanding how to resolve conflicts can also help you anticipate future problems and avoid them entirely, or resolve them quickly. Couples may feel more satisfied with their relationship after visiting a therapist. It is important to understand that only collaboration over problems in relationships and in your family, will lead you to effective results.
Family therapy is one of the main approaches in modern psychotherapy, the essence of the
which is that as a “client” for family therapist performs not indie
a species exhibiting certain disturbances, and its entire family.
Psychopathological symptoms
are considered as a function of inadequate intra-family communications, manifesting
in specific rules, myths and patterns of interaction of a given family. Families-
This therapy is aimed at optimizing family environment patient (psychotherapy
families), using the group family effect for therapeutic effects on
patient (family psychotherapy).
Goals of family therapy: improving interpersonal communication, increasing auto-
tonomy, increased empathy, optimization of leadership style in the family, increased efficiency
role performance, elimination of conflicts, reduction of symptoms in one or more
family members, increasing the efficiency of completing tasks. Ignoring the indicated
For certain purposes, family therapy can be reduced to mutual psychosexual “adjustment” of the spouse.
talk to each other.
Objectives (and, accordingly, models) of family therapy: mobilization, reassurance, personal
nal reconstruction. The main task is to help the family understand the essence of the incident.
ongoing process and contact deep conflict, which underlies the incorrect
relationship with a family member. Methods of redesign and positive
representation. In the process of family therapy, maladaptive rules are changed, which
act in the family, a general deep awareness of the dynamics of relationships between
generations, a balance is established between personal and family factors, establishing
Mutual direct contact and communication are established, mutual accusations and the search for goats are eradicated.
la absolution.
At the same time, psychoanalysts pay attention to social influences, projection models and
identification, “unfinished business” or trauma in the parental family, sublimation of frustration
tions, mechanisms of coping behavior and adaptation, “keys” to the unconscious
identified patient. At communicative approach V. Satir strives to determine
pour who is at the center of the communication process, who are the stars in the family
group, who is isolated, who interferes with the communication process, who supports it.
The most common approach in family therapy is systemic, based on theo-
ria, according to which the family is a system seeking to preserve wealth
balance, regardless of the degree of maladjustment. One of the main goals is to determine
homeostatic role, sometimes pathological, which is “identified” (by the family)
the patient plays in this system. Within the framework of systemic family therapy, S. Minukhina focuses
are based on patterns and forms of intrafamily interaction, distribution of power,
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decision making, boundaries, proximity of family members and distance between them, alliance
collusions, roles, rules, similarities and complementarities.
IN last years there is a shift in the focus of family therapy from the level of communication
cation in the family to the level of its organization. The emphasis is on the problems of hierarchical non-
engruence, when two simultaneously acting, but excluding, collide in a family
strong structures that interact with each other. Increased attention is paid to metaphors that reflect
in symptoms and patterns of intrafamily interaction, there is growing interest in understanding
study of the specificity and psychodynamics of the symptom.
A psychotherapist organizing work with a family has to solve the following problems:
Should I work with the whole family at once or with individual members first?
Should I work with the family alone, with a co-therapist or with a therapeutic team?
Should you invite your family over or go to their home?
Should you use a directive or non-directive style?
Start with the most important ones family problems or from private ones?
Have detailed plan actions or act “according to circumstances”?
Representatives various schools solve these issues in different ways. So, S. Minukhin and D. Haley
require the psychotherapist to have a directive position and an active role in therapy. Rogers and Skinner
defend the principle of non-directive family management. C. Madanes, Selvini Palazzoli and others
representatives of strategic family therapy carefully develop a work plan, providing
maturing the manifold impacts on the family. V. Satir prefers to continuously combine
diagnostic and psychotherapeutic measures and does not recognize pre-planning
work. K. Whitaker acts empirically, relying on intuition and experience.
The answers to the above questions should not be determined by theoretical orientations.
ies or characterological characteristics of patients. They must be decided depending on
depending on the characteristics of the family, its problems, and working conditions. For example, during the period of acquaintance with
family, whose members are distinguished by authoritarianism and rigidity of relationships, may
Non-directive style is possible; at the time of setting certain tasks it is preferable
use a directive style; overcome the restructuring of relationships caused
frustration is better re-established using a non-directive style; reaction to relapses of unfavorable
A positive family relationship may require directiveness.
According to E. Ziplu, a family therapist must master pedagogical approach, be able to clarify
the thread of the family's goals, not to incline the family to any type of relationship, to honestly admit
the limits of your capabilities. He must work as a single “team” with his family, emphasizing-
wat positive role families in the therapeutic process, with understanding and compassion for
go to intense emotional manifestations in family. He should help the members
families in their development, inform the family about a wide variety of treatment options, help
to help the family in psychological and medical education with the help of popular science
literature, provide the family with information about possible social assistance, be ready
You can come to the aid of the family at any time.
From the point of view of a number of psychiatrists of the second half of the twentieth century, this disease develops with complex dominant-subordinate relationships in the family.
G. Bateson et al. (1956) and T. Lidz et al. (1957) believed that parents of patients with schizophrenia are cold, strive to dominate and often provoke conflicts and quarrels in the family.
G. Bateson (1978) wrote about the phenomenon of mutually exclusive coercion (“ double bond"), often found in the family of a person with schizophrenia.
The relationship between the parents of a patient with schizophrenia in most cases is of a conflictual nature, at the same time they are quite confusing, and, despite the tension family relations, divorces are relatively rare here.
IN In families that include people with schizophrenia, distorted communications almost always occur, peculiar interactions: positive and negative coalition, ignoring position.
With a positive coalition, the strategy of controlling behavior, the patient’s condition, and continuing the course of therapy dominates. At negative type The leading coalitions are attitudes of denial of the disease, a rejecting position in relation to diagnosis mental disorder, treatment, help from other family members. With an ignoring position, a cold, indifferent attitude and rejection of the mentally ill relative are noted. In this case, contacts between family members often have a formal connotation. Family relationships are usually characterized by polarity, both in relation to the patient and to problems associated with accepting the fact of the presence of the disease, developing correct behavior, understanding the need for long-term therapy (Kuleshova N.A., 2005).
Many psychotherapists believe that it is worth regulate the time of communication between family members of a person with schizophrenia between themselves.
Families of patients with schizophrenia, from the point of view of even the patients themselves, are quite hierarchical and closed. This is facilitated by: the desire to outwardly present the family as prosperous and the over-involvement of loved ones, most often the mother, in the life of the patient (Dolnykova A.A. et al., 2007).
It is absolutely clear that family members of a person with schizophrenia may suffer from various mental disorders. These can be schizophrenia spectrum disorders, as well as neurotic, affective and psychosomatic disorders. Possible relatives of a person with schizophrenia personality disorders, alcoholism, drug addiction. In connection with the above, parallel treatment of relatives of a person suffering from schizophrenia is almost always necessary.
The attitude towards the patient in the family circle is often complex nature, on the one hand, close people show excessive pity, on the other hand, they do not notice mental disorders that are clear to someone else’s eye.
Psychoeducation plays an important role in the process of providing assistance to the family of a patient with schizophrenia.its members.
Most people have a vague idea about clinical manifestations and features of the course of schizophrenia.
The patient’s relatives have even less information about drug and especially psychotherapeutic treatment and forms of psychosocial assistance for schizophrenia.
Often the patient rejects the diagnosis of schizophrenia, considers it frightening, hopeless, and erroneous.
A similar attitude towards the disease may also occur among the patient’s family members. In addition, the very meaning of the diagnosis remains hidden from the patient and his environment. Usually there is an excessive exaggeration of the danger of schizophrenia, fear of this mental disorder. We also encounter misdiagnosis of the disease, especially as a consequence of excessive expansion of the boundaries of schizophrenia, ignoring research data nervous system, the results obtained with psychological assessment the patient's condition.
Often, the stigma of a diagnosis prevents its revision, even if the characteristics of the course of the disease exclude a diagnosis of schizophrenia.
Family therapy is of particular importance at the stage of the first psychotic episode. During this period, the reaction of the patient with schizophrenia and his relatives to the diagnosis of the disease is extremely acute. They are experiencing severe stress, being in a traumatic situation, hidden family conflicts may intensify during this period. Lack of understanding about the disease and the features of its treatment often aggravates the state of stress among the patient’s family members. It is necessary to mitigate this reaction by forming an adequate attitude towards the disease, emphasizing the need for its long-term therapy, as well as the importance of following a daily routine, correct alternation work and rest.
The patient's relatives can help Negative influence on the state of a patient with schizophrenia, if they are emotionally expressive, violently express their feelings, picky, aggressive or hostile towards the patient, do not understand his actions and statements.
With a certain degree of convention, one should assume that the family of a patient with schizophrenia is just as affected by the disease as he is. At the same time, the family can also be a source for the patient social support, therefore its members should be maximally involved in the treatment and rehabilitation process.
In some cases, the psychotherapist is faced with the desire to place responsibility for the microclimate in the family on or with closed relationships between the patient’s family members. Often, from the very beginning of therapy, the patient’s relatives and the patient himself strive for separate communication with the specialist, mistakenly believing that in in this case the conversation will be more frank, and psychotherapy will be more effective. At similar situation the psychotherapist should pay attention to strengthening the trusting relationship between the patient and his relatives.
The patient can manipulate family members and the psychotherapist, demanding that information about the psychotherapy process be withheld from relatives, insisting on frequent changes psychotherapist. In such cases, it is important to clarify Negative consequences such tactics complicate the process of psychotherapy and reduce the level of its effectiveness. In our opinion, even if the patient resists, without his approval, the psychotherapist has the right to inform the patient’s family members about the progress of the psychotherapy process, provided they maintain medical confidentiality.
It is especially relevant to work with family members at the stage of formation of remission, immediately after stopping a relapse of schizophrenia or when it is threatened.
Our experience has shown the effectiveness of parallel therapy for the patient’s relatives already at the stage of relieving the psychotic episode.
Family therapy for schizophrenia is especially relevant for families of patients young, however, it requires special training of personnel.
In some cases, family members of a person with schizophrenia are characterized by a tendency to self-blame and search for the causes of the disease. Often relatives overestimate the possibilities of therapy and blame the doctor for its failure.
Families of patients with schizophrenia show excessive emotional expressiveness, especially on the mother’s side (hostility, nervousness), avoidance of solving the father’s family problems, excessive criticism of the patient on his part.
Excessive “expressiveness of emotions” of family members of a patient with schizophrenia (expressed emotion) affects the frequency of relapses of this mental disorder. The patient’s immediate environment affects the course of the disease. Frequent criticism, hostility, excessive involvement of one family member in personal life another and the lack of warmth - all this contributes to the occurrence of relapse of schizophrenia (Brown G., Birley J., 1968). Vivid expression of emotions is a fairly stable phenomenon, usually reflecting the usual style of communication in the family (Miklowitz D. et al., 1984). Moreover, this phenomenon is reproducible transculturally and reflects the difference in the course of schizophrenia between industrialized and developing countries(Barrelet L., et.al., 1988). According to H. Grunebaum (1986), deviant behavior parents is an additional stressor for a patient with schizophrenia, creating in him the cognitive dissonance and contributing to increased psychopathological symptoms, which in turn increase emotional expression in parents, thereby completing a vicious circle.
Rigidity and pseudo-solidarity - common signs family of a patient with schizophrenia (Eidemiller E.G., 1978).
The relationship between a mother and a child suffering from schizophrenia is usually very close, the relationship with the father is often close, less often distant. Psychiatrists have noticed that a patient with schizophrenia usually only child in the family (Ispolatova E.N., Denisenko M.A., Sofronov I.P., 2005).
Most experts are confident that the “mother of a schizophrenic” is usually the leader of the family, often endowed with paranoid character traits (Lichko A.E., 1985).
The emotional intensity of the relationship with the mother, who usually dominates the family and overly cares for the patient, is a typical phenomenon, while the patient strives to escape from this care, and the mother either feels sorry for him or shows irritability, complaining about the lack of personal life.
More than 80% of mothers of patients with schizophrenia avoid discussing the problems of the disease even with loved ones, reproach themselves for it, fear for the fate of the patient after their death, and see the main manifestations of the disease in everyday helplessness, isolation, and absent-mindedness of patients. Moreover, 40% of mothers believe that doctors general practice neglect the complaints of their loved ones, 45% do not find understanding from psychiatrists, 70% strive to be heard when choosing treatment, need information about the disease and its treatment, benefits for families and want to see their doctor often. 85% of mothers accept the fact of mental illness and see the benefit of treatment mainly in the rare placement of the patient in a hospital. These mothers believe that patients need useful leisure time, employment and learning skills independent living(Levina N.B., Lyubov E.B., 2006).
The patient's aggression towards the mother is often a consequence of the overprotection that the latter shows. The patient often demonstrates ambivalent attitude towards the mother, on the one hand, excessive dependence on her, on the other - hostility.
On the part of the patient’s father, we most often encountered detachment, “flight to work,” into the “autonomous world of hobbies,” while the patient strives to gain his father’s attention and spend more time with him. The coldness of brothers and sisters, their detached position towards the problems of a patient with schizophrenia is a frequent picture in his family.
Among the tasks of family therapy for schizophrenia is the correction of family members’ expectations regarding the prognosis of the disease, the patient’s social and labor status, and the effectiveness of treatment.
It is necessary to correct the point of view of relatives of patients regarding the fatal attitude towards hereditary burden of schizophrenia.
Members of such a family are shocked by the diagnosis of the disease, often try to shift responsibility for the results of treatment to the doctor, distrusting psychotherapeutic methods of influence and avoiding family therapy. However, the psychotherapist, showing sufficient persistence, must strive for psychotherapeutic work with the patient’s family.
In many countries, it is considered extremely important to maintain frequent contact with the patient's family from the first moments of diagnosis of schizophrenia. So, in particular, the Norwegian Psychiatric Association, recommends interacting with the patient’s relatives by telephone within three days after the patient’s hospitalization. The association also recommends not starting to treat the patient with medications for one to two weeks after identifying the diagnosis, in order to be able to clarify the diagnosis and make more required assessment patient status. Assessing the status in the dynamics of the treatment process is also considered an important component of the latter.
Family therapy in the presence of a patient with schizophrenia requires a certain flexibility of the psychotherapist. It is difficult to give any specific recipe here, but most often family psychotherapy begin with individual meetings psychotherapist with each family member separately. Such tactics can be especially recommended for novice psychotherapists.
Traditionally, family therapy begins with diagnosis family system, determining its type, period of development, assessing intrafamily relationships, clarifying role behavior family members.
When working with family members of a person with schizophrenia, psychotherapists try to adhere to the “concept of expressed emotions.”
When “treating the family,” the following are appropriate: “bifocal therapy,” structural family therapy that delineates the boundaries between generations. Most therapists speak negatively about systemic and analytical therapy for the family of a patient with schizophrenia.
Treatment options for the family of a person with schizophrenia:
- Group cognitive-behavioral therapy for patients and their relatives during the hospital stay, including elements of psychoeducation, coping training and training in medication management skills.
- Behavioral family therapy sessions at home.
- Outpatient psychodynamic groups.
- A combination of group and individual therapy for family members aimed at reducing the severity of emotional expression.
- Discussion club for patients and their relatives.
Popular Behavioral family therapy techniques, developing the skills of proper communication in the family, and paradoxical forms of family therapy, as if leaving in the shadows true intentions psychotherapist.
Efficiency has been tested numerous times problem-oriented family therapy patient with schizophrenia, including specially developed techniques. Problem-oriented therapy partly overlaps with sociotherapy and psychoeducation. Typically, problem-oriented therapy involves teaching families mutual support skills and the ability to help themselves. A psychotherapist working within problem-focused therapy may consider various problem-solving strategies through role-playing.
You can work with groups of family members using " colloquial forms psychotherapy", providing for relatives of patients necessary information. Such groups can function without patients. The effectiveness of such groups in terms of emotional relief for family members has been noted. However, these forms of assistance to relatives of patients with schizophrenia cannot be an alternative to full-fledged family therapy.
The family of a person with schizophrenia should be integrated into the wider social network help for people suffering from this mental disorder.
There are at least four definitions of family psychotherapy. First: family psychotherapy is a form of conducting the main method of psychotherapy in relation to the problems of a specific family (analytical family psychotherapy, behavioral, etc.).
Second: family psychotherapy is a set of techniques and methods of psychotherapy aimed at correcting the psychological, social and biological status of the client in the family and with the help of the family. According to this definition, the family contains both sanogenic and pathogenic potential.
Third: family psychotherapy - methods of psychotherapy within an independent direction, based on certain theories (systems, cybernetics, communication channels, etc.).
Fourth: family systemic psychotherapy- this is a system psychological interactions two living open systems- family and psychotherapist in order to optimize the functioning of each [Eidemiller E. G., 2002].
Family psychotherapy includes structural family psychotherapy, strategic family psychotherapy, behavioral family psychotherapy, etc.
In the structural approach, the adolescent is considered as a “symptom carrier”, and the family as the patient. The goal of structural interventions is to change the structure of the family to improve the functioning of all family members and create a more balanced family system. For example, in a rigid family, organize more open communication and negotiations; in a chaotic family, help build hierarchical structure, restore parental control and cooperation in the marital subsystem, which will ensure adequate management of the family and raising children. In a fragmented system, the therapist facilitates unification of the family on the basis of helping the “identified patient” and clarifying the possible benefits for all family members. It is important to note that the goals set for changing family structures must correspond to the pace at which the family perceives feedback.
Dysfunctional families often take an all-or-nothing approach to considering possible changes. They often fear that if changes occur in the family, they will be extreme in nature. For example, handing over responsibility to a teenager in a "tangled system" may be difficult because of the mother's fear of him being completely separated from the family and facing marital problems.
In strategic family psychotherapy, the main importance is given to the analysis of violations of the family hierarchy. The strategy used in this psychotherapeutic approach is based on the manipulation of power. In other words, the psychotherapist redistributes power among family members. It is believed that behavioral deviations put young man for more high position compared to parents on the family hierarchy ladder. Hierarchy in a family is determined by the invariably repeating sequence with which one family member tells another what he should do. In families where serious deviations in children's behavior are inherent, the psychotherapist is faced with a situation in which adolescents, while continuing to be economically and emotionally dependent on their parents, refuse to do what their elders demand of them. Psychotherapeutic interventions used by representatives of this school serve to establish a hierarchy in the family in which parents begin to occupy a higher position in relation to young people. The content of communications between parents and children includes messages about parental expectations addressed to children, as well as about the rules that elders expect to be followed, and, finally, about the measures that will follow in case of violation of the established rules. When a teenager loses power over his parents, he begins to behave in accordance with social requirements.
The behavioral direction of family psychotherapy is based on the principles of learning theory. Techniques and methods of classical, operant and other types of learning are used (contracts, token system, parental competence training, problem-solving approach).
In modern family psychotherapy, the dominant trend is the development of constructivist or narrative psychotherapy. There is a direct translation of this word from English - narrative (literally - telling, describing, narrative, visual-figurative). The latter approach is considered more “humane”. The stories told by the client can be sad and comical, and the conclusions can be absurd. This division, in our opinion, is arbitrary. Often one psychotherapeutic session uses many combined techniques. As one millennium changes to another, the boundaries between different approaches family psychotherapy are erased. For example, in structural psychotherapy, as in behavioral psychotherapy, the starting point for psychotherapeutic intervention is observation of the behavior of family members. In strategic family therapy, the formulation of hypotheses and tasks by the psychotherapist brings his position closer to directiveness behavioral approach. So, for example, when collecting a family history using a genogram, a family history is compiled, “metaphors”, “symbols” and “themes” are taken into account. In each area of family psychotherapy, you can find certain positive strategies and use them in working with children and adolescents.
In general, it is necessary to identify which dysfunctional family patterns can be changed. The affective, behavioral and cognitive expectations of each family member are taken into account. Regardless of the approach used, the family must be actively involved in treatment.
The target of intervention is not only the dysfunctional family, but also the family in crisis. A dysfunctional family is a family in which the performance of a certain function/s is impaired. A well-functioning family is one that creates or adopts rules through which each family member and the family as a whole meet their needs for self-actualization, growth, change, acceptance and approval. It is important to find family resources, abilities and motivation for change, and focus on solving current problems.
Common goals different methods family psychotherapy can be imagined in the following way: a change in a number of ideas (attitudes, assumptions) in the family about the problem presented; transformation of family members' views on their problem from individual-personal to systematic approach; modification of the permeability of boundaries between subsystems; Creation alternative models solving problems through direct or indirect intervention; a decrease in the emotional involvement of family members in the symptomatic behavior of one of its members; correction various forms hierarchical inconsistency; interrupting dysfunctional behavioral patterns taken from the parental family, bringing important “unfinished business” to the surface, revealing family secrets, improving the communication style between family members.
Family psychotherapy is special kind psychotherapy aimed at correcting interpersonal relationships and aimed at eliminating emotional disorders in the family, most pronounced in the sick family member. Typically family therapy focuses on more than one family member, although it may deal with one family member throughout the course of treatment.