INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 9(1), 1978-79
STUDIES IN FAMILY-ORIENTED CRISIS INTERVENTION WITH HEMODIALYSIS PATIENTS*
STEPHEN B. LEVENBERG, PH. D. V. A. Hospital and University of Alabama Medical Center
CHARLOTTE JENKINS, R. N. DONALD J. WENDORF, PSY. D. University of Alabama Medical Center Birmingham, Alabama
This article describes a family-oriented crisis intervention approach to help patients with chronic renal failure adjust to the unique demands of home dialysis. In particular, home dialysis necessitates a working patientdialysis partner relationship that has very adaptive problem solving skills. A couple whose premorbid relationship is dysfunctional will soon manifest this under the stress of home dialysis. The family-oriented therapist initiates only the minimal change necessary in the relationship to achieve successful dialysis. In the home eaining stage the premorbidly dysfunctional couple seems best treated in individual interviews, whereas premorbidly functional couples respond more favorably t o conjoint interviews which capitalize on their underlying strengths. Couples in crisis who are dialyzing at home may require a highly structured, behaviorally-oriented contractual approach which includes all relevant family members. This “band-aid” approach temporarily reinstitutes successful dialysis while purchasing more time for the couple to develop new coping mechanisms. Finally, four case studies are presented, including one in which crisis intervention efforts failed.
Numerous authors have observed that chronic renal failure patients almost invariably experience adjustment difficulties following onset of their illness [l, 21 . Exacerbation of such adjustment difficulties is frequently associated with the advent of the hemodialysis procedure. Levenberg and Campbell
An earlier version of this paper was presented at the annual meethg of the Southeastern Dialysis and Transplantation Association, Miami, Florida, August, 1977. 83 0 1978, Baywood Publishing Co., Inc.
doi: 10.2190/MEQP-MTPN-GKVY-XJ2B http://baywood.com
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pointed out that the demands of the hemodialysis procedure only serve to further complicate the problem of redefinition of the patient’s life within the demands of his treatment . New expectations for h s own life must be achieved in order to accomplish a comfortable level of adaptation . A patient’s emotional support system is of great potential use in periods of such stress. Several disparate approaches to theory and intervention within the specialized field of emotional systems and its clinical arm of family therapy have enjoyed increasing popularity during the past twenty years [4-61. Perhaps one major commonality among the several approaches to family therapy is the acknowledgement that the individual’s behavior can best be understood-and, by implication, be altered-by comprehending hls dynamic role within the context of his emotional support system. Of course, the great majority of dysfunctional families d o not present themselves as having a “family problem.” Rather, a member of the family is presented as having some specific problem . This “identified” or “nominal” patient is the consumer of traditional mental health intervention efforts and, indeed, traditional psychiatric nosology of mental illness is couched almost exclusively in such individualistic terms . The family therapist “reframes” this intrapsychic view into one in which the family is assumed to operate in dysfunctional sequences which are expressed in terms of the “identified” family member experiencing the symptomatic behavior. Such hypotheses dictate alternate intervention strategies from the traditional one-to-one approach of traditional psychotherapy. To the family-oriented therapist, diagnosis of such structures is an evolving process , as opposed to the static pretherapy diagnosis of the theorist oriented to the traditional theory of intrapsychic events (for example [lo, 1 I]). The patients who have experienced chronic renal failure, and particularly those undergoing hemodialysis, offer the family-oriented theorist a variety of challenges. First, the patient is medically ill and does have a very monumental long-term adjustment to make [ 1, 21 . Secondly, medical treatment efforts have been directed at the ill patient from the first appearance of overt symptomatology . The patient-or more specifically, his or her illness-has been defined as the problem. Redefinition of the patient’s adjustment problem as the family’s adjustment problem is eased when home dialysis is chosen, inasmuch as successful home dialysis requires the patient and his/her partner (usually a close family member) t o work together in order to maintain the patient in optimal health. Using the concepts briefly outlined above, the following case examples will serve to illustrate typical family-oriented intervention strategies with hemodialysis patients in stress.
Crisis Intervention in a Home Training Setting Prior to home training, the patient typically has recently experienced substantial psychological relief that he is alive. He has recovered medically t o
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the point where he can at least be uncertain as to what his future limitations will be, whereas the patient had faced certain long-term physical limitations that he expected when the disease was in the more acute stages [ l ] . As home training begins, he realizes that the real adjustment still lies ahead. Full of new uncertainties, the training rapidly assumes an acute focal point for anxieties regarding the future. Couples (patient-partner relationships which may or may not be a marital unit) come to home training with well established patterns of behavior and family interactions which they have previously used to lower high stress levels in the system. Based on the family systems theory model, two divergent intervention strategies have been found to be most effective. The choice of strategy depends on the diagnostician’s judgment as to whether the couple interacts functionally or dysfunctionally when not under the stress of hemodialysis training. This diagnostic judgment is quite important, for the goal of crisis intervention is to solve the crisis using the system’s strengths, exiting the case when the system is functioning at precrisis levels. Reorganization of basic structural patterns of interaction is not usually a goal unless required for the institution of minimally successful dialysis. THE ”HEALTHY“ RE LATlONSH IP
Mr. and Mrs. B. both come from very poor socioeconomic b-rounds. Currently in their forties, they have been married for eight years and both are employed. Mr. B. had never been seriously ill until 1976 when he experienced dizziness, was diagnosed as hypertensive, and six months later required chronic hemodialysis. Two weeks after entering home training, Mr. B. began exhibiting moodiness, sometimes being overly critical of his spouse’s technical skills with the dialysis machine or behaving in a morose and withdrawn manner. He began taking a less active role in the learning process. At home his personal hygiene deteriorated, he began drinking away from home and avoided talking with his wife. Mrs. B.’s behavior vacillated between over-protectiveness and a nagging insistence on doing things her way. At this time the B.’s were referred to the second author. Both were seen individually for the purpose of providing an atmosphere that would be conducive to ventilating feelings, identifying underlying problems and to plan what short-term interventions could be used. The ultimate goal was to reduce the anxiety level in the system such that the couple could complete home training. A diagnostic family-oriented interview tended to confirm the impression that this relationship had once been close and constructive; thus, reestablishing this relationship was one of the therapeutic tasks. The family therapist is also able to utilize intrapsychic concepts to assist him in his interventions. For example, Mr. B. was quite clearly emasculated by his dependence on his wife, by his physical illness, and by the loss of both sexual functioning and occupational independence. Mrs. B. was experiencing
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increased anxiety from sensing the added burden of keeping her family together, while at the same time feeling frustrated and resentful toward her husband for n o t trying t o help her. When seen together, the B.’s were gradually directed into verbal interaction with one another. They became more relaxed as they identified similar feelings concerning dialysis. Each was then encouraged to make suggestions regarding what each could do to make dialysis less stressful. Contracting for communication surrounding dialysis procedures was instituted. The therapist used role rehearsal, that is, talung the place of the patient in an interaction, to demonstrate how one might acknowledge how he was feeling and how supportive responses might be used to aid in completing the dialysis procedure. During this time, Mr. B. faced the prospect of nephrectomy. The therapist’s task at this point was to facilitate a discussion between them for Mr. B. to ventilate his fears of permanently losing his “manhood.” “Reframing” the problem as one that they both faced was a major breakthrough made possible by the healthy quality of their relationship. Similar techniques were used with Mrs. B. to help her ventilate her feelings regarding her caretaker’s role. Seen alone, role reversal (each spouse assuming the role of the other) and modelling (where the therapist demonstrates a particular interpersonal behavior skill) techniques were employed to help them experience for themselves the feeling of being parented by another adult. By the end of home training, Mr. and Mrs. B. were again working together, communications appeared more effectual and affectional, and the anxiety in the system had been substantially reduced. Mr. B.’s personal appearance had improved, his drinking decreased and he began to take more interest in the activities at home. One month following completion of home training, Mrs. B. underwent an unexpected mastectomy. This staggering development provided the therapist with an opportunity to use Mr. B. as the “parent.” In helping 3is wife deal with her loss Mr. B. reestablished himself in his more comfortable role in the relationship and was of obvious value to his spouse. This approach reinforced the couple’s mutual dependence on each other. A pleasant aftemote of this case is that Mr. B. received a kidney transplant from his sister and is returning to full functioning. THE “UNHEALTHY” RE LATIONSHIP
Mr. and Mrs. J., in their mid-thirties, have been married for ten years. Both spouses had experienced a previous marriage ending in divorce. Mr. J. had experienced a life of continual sickness as a brittle diabetic since the age of eleven. With the onset of kidney failure for Mr. J. he also experienced a decrease in vision and became totally disabled. In the interim before home
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training he became increasingly angry, took his medications at random, ate poorly, withdrew from responsibility at home and entered home training via a wheelchair, stating that he could do nothing to help himself. Under stress, this couple became increasingly separate and isolated emotionally from each other. MIS. J. became increasingly anxious, and during home training she withdrew more and more from the partner’s role. She complained that she could not express her anger toward Mr. J. and did not want to dialyze him, claiming that she might do something incorrectly, thus causing his death while on the machine. The therapist came to the conclusion that this couple’s underlying relationship was not of mutual support but rather one of isolation, somatic defenses, and projection onto the other spouse. At this point, a treatment decision was made to deal with the couple on a one-to-one basis, since their relationship strengths did not seem sufficient. In separate interviews, Mr. J. directed his frustrations at his illness and the limitations it had created for him, while Mrs. J. expressed mixed feelings regarding her husband. She stated that if she failed to care for l i m and he died, she would feel responsible, no matter how miserable he had “niade” her feel. Separate interviews were continued for several weeks during the course of home training to establish a healthy therapeutic relationship. At this point the therapist began making attempts to explore what each could do for themselves to complete dialysis training successfully. Mr. J.’s use of his poor vision as a manipulative tool enabling him to maintain a position of dependency on his wife was gradually overcome, and he learned several dialysis tasks not dependent on adequate vision. Mrs. J. was taught positive reinforcement techniques to reward her husband in his new behavior as he became more autonomous. Assertive behavior techniques were rehearsed with her for use when Mr. J. became sullen and refused to assist. A conjoint session was then held in order to cast Mr. J. into the role of the expert, thus providing a way in which Mrs. J. could obtain her spouse’s assistance when unexpected anxiety-producing situations occurred with the dialysis procedure. By the end of home training, Mr. and Mrs. J. both appeared to have a brighter affect and a return to higher levels of functioning. For example, Mr. J. ceased using the wheelchair and took an increasingly active role in his own dialysis. Mrs. J. appeared more able to rely on her husband for assistance, and her fear of home dialysis subsided. A followup interview several weeks after the couple began home dialysis revealed Mr. J. desiring more independence outside the home and exhibiting less somatization. His wife appeared apprehensive at t h s prospect, reminding him that he was disabled and was not able to function independently. It appeared that Mrs. J. needed to see her spouse as dependent, infantile, and in need of protection. It was clear that her behavior maintained certain of these behaviors in him. Crisis intervention family therapy does not dictate an exploration of these important,
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but irrelevant conflicts in a system. Thus, support and encouragement were offered to both sides. Both were encouraged to negotiate a compromise, and this proved sufficient to allow them to continue at their previous level of adaptation. These two cases represent divergent strategies for family-oriented crisis intervention in a dialysis setting. With the healthy couple, conjoint sessions were the rule in order to capitalize on their relationship strengths and their ability to work closely together. The unhealthy relationship dictated an initial therapeutic strategy of individual interviews for each member of the system. It is our impression that this choice of treatment strategy is related t o the success of crisis intervention efforts in dialysis settings.
Crisis Intervention in a Home Dialysis Setting Patients dialyzing at home offer the behavioral scientist more of a challenge. More heterogeneity of problem content seems apparent; often individuals outside the couple but within the emotional system impact on the dialysis treatment; and finally, information gathering is more difficult since the couple’s usually distorted self-report must be relied upon as opposed to a nursing staffs objective observations. THE COUPLE THAT SHOULDN’T HAVE SUCCEEDED
Crisis intervention permits its user t o ignore irrelevant, albeit serious psychopathology that fails to impact on the dialysis situation, as only the minimal change required to nurture a successful dialysis relationship is necessary. Mr. E. and Mrs. A. represent a successful “band-aid” approach, in that multiple, highly-structured interventions have been successful during their ten months of home dialysis. No doubt similar interventions will be required in the future. Both are poverty-ridden, rural, illiterate, psychologically primitive “borderline functioners” in their late fifties. They livt in a common law marriage of some ten years duration, residing in separate homes within view of each other. Both have a history of chronic alcohol abuse, although Mr. E. ceased drinking several years ago after experiencing acute unexpected renal failure. Their primary sources of income are social security disability and bootlegging. Finally, Mr. E. lives with a controlling, continually interfering older mother, and Mrs. A. resides with her multiproblem adolescent daughter. They managed to successfully complete home training due primarily to direct interventions of the nurse-trainer, exhibiting daily non-problem-solving conflict over the mechanics of the dialysis procedure. Two months subsequent to home training, Mr. E. appeared at the unit, alleging that Mrs. A. was drinking and refusing to dialyze him. He said he was always afraid she would make a mistake or abandon him to die. Mrs. A. claimed he was always critical of her
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technique and “won’t let me do it my way.” She appeared to be in a near inebriated state. A conjoint interview revealed that the intrusion of Mr. E.’s mother was the key feature. Mr. E. typically used her as a back-up dialysis partner in case Mrs. A. was drinking and as ammunition to confirm his criticisms of MIS. A.’s dialysis techniques. This undermined Mrs. A.’s expertise and confidence, leading to continued drinkmg..The mother, who is in competition with Mrs. A. for Mr. E.’s attention, believes Mrs. A. has her son under a “hoodoo” spell. So, she gladly colludes with Mr. E., leaving the couple’s dialysis overwhelmed. Finally, Mr. E. has tried to rely on his mother’s bootleg whiskey customers for back-up dialysis aid. The therapist first brought the mother into the therapy room, inasmuch as the working hypothesis centered around changing her behavior as the key to reinstituting minimally successful dialysis. Using a directive, behaviorally oriented approach, the family members were persuaded to accept certain negotiated changes, including the following: 1. During dialysis, the dialysis room was to be off-limits to all except Mr. E. and Mrs. A.; 2. Mr. E. was to rely solely on Mrs. A. for dialysis; 3. Mrs. A. agreed not to drink during dialysis; 4. Mr. E. was identified as being in charge of dialysis with Mrs. A. as consultant; 5. Mr. E. agreed to allow Mrs. A. time to express her feehgs and to take her out more often.
With close supervision from a respected unit nurse, the couple was able to reinstitute minimally successful dialysis. As one might expect, the “band-aid” held for two months when Mr. E.’s mother once again intruded into the dialysis setting and Mrs. A. was again refusing to dialyze Mr. E. The family was brought into the therapy setting where only the RN staff member was present. Using the third author as consultant, she was successful in reestablishing the contract with similar directive interventions. An underlying assumption which has proven accurate is that this couple, although legion with problems, could successfully dialyze if they were left to deal exclusively with each other. The essential principles utilized within the crisis intervention family-oriented therapy were specific goal setting, a directive, behavioral focused approach, and the use of indigenous house staff to capitalize on the relationship between nurse and patient. THE COUPLE THAT DIDN‘T SUCCEED
Dialysis couples appearing psychologically healthy infrequently surprise dialysis staffs by failing miserably at the task of home dialysis after completing home training with ease. Reasons given for failure are varied but
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rarely will the couple identify interpersonal discord as a causative factor. The naive but well-intentioned staff assumes that the couple functions well, inasmuch as there appears on the surface to be a notable lack of interpersonal problems, past or present, despite the fact that the couple is obviously under unusual stress. This, however, is viewed by the family-oriented theorist as a pathognomonic feature of the system: problem-solving strategies are absent in the relationship, and the couple maintains anxiety at tolerable levels through the mechanisms of denial and repression. Reverend and Mrs. G., married for thirty-five years, have lived a productive, childless life as leaders of a rural Methodist church. Reverend G . served as pastor for twenty-two years, with his wife as his assistant and church clerk. Following Reverend G.’s renal failure in 1974, they were quickly accepted for home training, where they learned the procedure over a three month period. During this time, the dialysis nurse noted that the couple failed to interact meaningfully when Mrs. G. obviously needed assistance in learning the procedure. At such times, she would become near-tearful, excessively demanding of nursing assistance, and overtly anxious. Reverend G . would withdraw into silence and apparent lethargy. They never argued, of course! Often, Reverend G. would experience rapid hypotensive episodes during dialysis that seemed to be temporally associated with periods of potential conflict with his wife. Nonetheless, they completed the program and a machine was placed in their home. Almost immediately, the couple jointly began a continuous stream of complaints about the machine and its “malfunctions.” The machine was serviced in their home, and, t o mollify the G.’s, it was returned to the hospital for a complete overhaul. A dialysis nurse visited their home on a dialysis day and observed the couple dialyzing. She confirmed that the machine was mechanically intact and further observed Reverend G. failing to participate at all in his own dialysis, much to Mrs. G.’s dismay. The nurse was not able to persuade Mrs. G. to direct her obvious frustrations at her husband. Home dialysis continued to proceed erratically until Reverend G.’s condition exacerbated into periods of toxic psychosis. Reverend G.’s job performance also rapidly declined and he now appeared sullen, angry-although this was denied-and depressed. At this point, the referral was made. Following several conjoint sessions, it became apparent that this couple was unable to express conflict or to engage in interpersonal problem-solving. Conflict situations such as dialysis were avoided by a shared but brittle defense of blaming the machine. With additional time a family-oriented therapist might have been able to assist the G.’s to institute problem-solving skills into their relationship. This was a time of acute crisis, however, and crisis intervention draws on strengths in a system rather than altering the nature of the system itself. Thus, crisis intervention techniques were ineffective. In fact, a therapeutic alliance with the couple could not be obtained on any basis other than sharing their animosity
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toward the dialysis staff and the machine. Soon thereafter, the church retired the Reverend on a small pension, and the couple relocated near the hospital where they now dialyze at the unit. Crisis intervention in this case failed. Indeed, the referral to the familyoriented therapist was perceived by the couple as one more way in which the dialysis staff ignored their pleas that the machine was malfunctioning. From this case, it can be surmised that a family-oriented diagnostic interview prior to home training might have averted this chain of events. The lack of conflict and lack of problem-solving skills in the relationship would have served as a red flag to avoid placing this couple in home training. As in the traditional modalities of individual psychotherapy, the massive use of denial, . repression, and projection suggests a poor prognosis for interventions requiring a therapeutic relationship. The use of paradoxical techniques  might offer a more productive approach to such cases.
Conclusion Family-oriented approaches to diagnosis and intervention appear to possess tremendous therapeutic “power” in the dialysis setting. As the last case suggests, however, certain emotional systems simply are unable to tolerate the anxiety inherent in the home dialysis procedure. Routine screening by a family-oriented theorist can be of great cost-benefit efficiency to the dialysis staff experiencing high numbers of home dialysis failures. Finally, familyoriented crisis intervention can best be understood as a “band-aid” approach with real value when therapeutic goals are modestly specified as maintenance of home dialysis and the buying of additional time for couples to develop their own adaptive mechanisms. The ease with which indigenous dialysis staff can be taught to effectively implement and to maintain crisis intervention strategies only increase its attractiveness and plausibility as a primary therapeutic strategy.
1. H. S . Abram, Survival by Machine: The Psychological Stress of Chronic Hemodialysis, Int. J. Psychiat. in Med., I , pp. 37-5 1, 1970. 2. F. Reichsman and N. B. Levy, Problems in Adaptation to Maintenance Hemodialysis, Arch. Intern. Med., 130, pp. 859-865, 1972. 3. S. Levenberg and L. Campbell, An Eriksonian Approach to Long-Term Adjustment to Hemodialysis, J. Amer. Assn. of Nephrol. Nurses and Tech., 4, pp. 19-23, 1977. 4. J. Haley, (ed.), Changing Families: A Family Therapy Reader, Grune and Stratton, New York, 1971. 5. J. Haley, Problem-Solving Therapy, Jossey-Bass, San Francisco, 1976.
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6. S. Minuchin, Families and Family Therapy, Harvard University Press, Cambridge, Mass., 1974. 7. V. Satir, Conjoint Family Therapy, Science and Behavior Books, Inc., Palo Alto, Calif., 1964. 8. Diagnostic and Statistical Manual of Mental Disorders (second edition), American Psychiatric Association, Washington, D.C., 1968. 9. J. Haley, Strategic Therapy When a Child is Presented as the Problem, J. of Child Psychiat., 12, pp. 641-659, 1973. 10. K. M. Colby, A Primer for Psychotherapists, The Ronald Press Company, New York, 1951. 11. R. A. MacKinnon and R. Michels, The Psychiatric Interview in Clinical Practice, W. B. Saunders Company, Philadelphia, 197 1.
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