The psychiatrist as interpreter* between patients and relatives
- Kristiane Myckland Hansson
- Jun 14
- 8 min read
Explaining diagnosis and symptoms
Mental health professionals can remedy the devastating communication patterns that tend to arise in the development and the aftermath of severe mental illness, by involving the family in the treatment and supporting them in their role as informal caregivers. In this essay I shed light on why and how the physician’s role as “interpreter between the patients and the relatives” can contribute decisively to improving communication and interaction among the family members.
When serious mental illness intrudes a family, this lifechanging experience often has a profound impact on the patient and those close to him or her. The devastating consequences for the patients and the burden that the relatives bear when a loved one struggles psychosis are well documented in the research literature. The consequences of serious mental health problems are not the main scope of this text; however, they serve as an important backdrop for understanding why family involvement is considered an effective, evidence-based treatment for this patient group, and why participants in our study repeatedly put in words the significance of involving the family.
What I have witnessed
As a mental health researcher for several years now, I have seen up close how severe mental illness can make people drift apart. I have witnessed how the illness can destroy our language, making it poor and fragmented, or even completely lost. I have learned how the illness affects how we communicate, how we solve problems, how we are together in the challenging situation that has suddenly arisen in our family. I have witnessed the stigma, the silence and the suffering that tend to surround families struggling with psychosis. I have also witnessed the sad, but often inevitable consequences of these processes; conflicts arising, patients losing their social networks, and relatives withdrawing because of finding themselves in such a state of exhaustion that they do not know how to care for the patient, much less themselves. I have also learned that many relatives do not know how to support their loved one, even though providing care and support is what they want the most. Most relatives support and help as best they can based on their perceptions and understanding of the situation. However, this help can lead to increased stress and strain and thus unintentionally harm the patient (see for example the research literature on expressed emotions). Patients and their close persons are often dependent on support and facilitation from the health services to navigate these challenging waters. Physicians hold a crucial role in these efforts.
Implementation of family involvement in the treatment of persons with psychotic disorders
From 2017-2024 I was part of a research group that implemented the national guidelines on family involvement in the treatment of persons with psychotic disorders in Norway (The IFIP-study). It was a cluster randomised trial conducted in community mental health centres with the aim of increasing and improving the use of evidence-based family interventions in mental health care. Family psychoeducation and basic family involvement and support constituted the core clinical interventions, supported by selected implementation measures. Throughout the project we performed a comprehensive data collection exploring various perspectives on family involvement in mental health care, among others how the stakeholders experienced participating in systematic family involvement and the significance of such interventions.
Psychoeducational family work is a structured therapeutic approach that involves educating family members about mental health conditions, particularly severe psychiatric disorders such as schizophrenia or bipolar disorder. It aims to improve the family's understanding of the illness, enhance communication and problem-solving skills, and reduce stress and conflict within the household. By involving relatives as active participants in the recovery process, psychoeducational family work helps to strengthen support systems, reduce relapse rates, and promote more effective coping strategies for both the individual affected and their family members.
Through focus group interviews and individual interviews with 75 clinicians and leaders in mental health care services, thirteen patients with a psychotic disorder, and sixteen relatives, we were provided with a bird’s eye perspective on the processes emerging in single family psychoeducational groups and how the various elements function within this model. Among others we learned a lot about how the interplay in families can improve when health care professionals systematically involve the family in the treatment and support them in their caregiver role. It became easier for the patients and their relatives to communicate when healthcare professionals acted as “interpreters” between them, but what mechanisms did this interpreter-role involve, and why was this so important for the patients, the relatives, and for the family as a whole? The interpreter-role involves several sub-roles, which I have given the following labels: the knowledge-provider role, the information-transmitter role, and the openness-promoter role.
The psychiatrist as a knowledge-provider
A recurring finding in the research literature is that relatives lack the necessary knowledge needed to fulfill their caregiver role. Psychoeducation is one of the core elements of family psychoeducation, providing a foundation for understanding and dealing with severe mental illness.
For example, if you know what causes hallucinations, what they might look like, and what one can do when observing a family member hearing voices or seeing things that are not visible by others, then you have a map that makes it easier to navigate when hallucinations occur. If you lack this insight, this map, you are groping in the blind. Groping in the blind when a person you love develops a psychotic episode is painful, confusing and exhausting, and it can reduce the chance that the patient will receive help early enough to prevent relapse.
When the psychiatrist provided crucial knowledge about the illness, symptoms, warning signals, prognosis, treatment and how to prevent relapse, and took her time to answer compelling questions, this enabled the patient and the family to a greater extent to master various aspects of the diagnosis and everyday life.
The psychiatrist as an information-transmitter
Another dimension of the psychiatrists' interpreting work concerned ensuring and strengthening the flow of information and knowledge about each other’s perspectives back and forth between the patient and his relatives.
In some cases, the therapist supported the patient in putting his own illness experiences into words. Some patients expressed during the interviews that they found it very challenging to explain what it was like to live with psychosis, their worries and stress, and that they felt that those around them did not understand how difficult it was at times. This could be due to cognitive impairment, for example. The psychiatrist helped to interpret and make this important information about the patient more accessible to those closest to them, so that the patient could be met with more understanding and tailored care.
We also learned that in some cases the patient became more responsive to what the relatives suggested and were more open to take in their thoughts and perspectives when the psychiatrist engaged in – and facilitated these conversations. Perhaps this is because the suggestion seemed more legitimate to the patient when a professional took part in the discussions and supported the relative’s point of view, or it could be because the therapist facilitated a room of trust in which all parties felt heard and seen. In one family, for example, the patient became more responsive to the father's input on a daily routine that he considered useful to the patient, compared to earlier times, when they had been discussing this solution on their own, always ending in conflict and rejection. This is an example of how the therapist enabled the father to be a resource in his daughter's life.
The psychiatrist as an openness-promoter
Being open about that someone in the family were having a mental illness were difficult for many of the participants, both patients and relatives. Several were not sharing with their surroundings their life situation and the difficulties they dealt with. This lack of openness also applied within several of the families, in fact some of our participants shared that they never had talked about the patients` diagnosis in the family, although she had been sick for years, and that this avoidance had created problems in various ways.
When the psychiatrist took on the openness-promoter role this meant that he created a space for the unspoken, a containing room to meet and talk about the things that really mattered in their lives, which was not possible for them to do on their own. For some, participating in a family psychoeducational group became an invitation “to go where it was hurting the most” while being supported by a professional. It must have taken courage and a strong desire for recovery to be able to address these unspoken topics. Participants portrayed how such conversations could be challenging and bring out both fear and nervousness, however, it was relieving to get the opportunity to see each other in a new light, to get help to understand each other better, and to experience that sharing openly with each other improved the family climate and supported recovery.
Finally, I also emphasize that in addition to improving communication and interaction, several patients and relatives expressed how the therapists had provided them with emotional support that was truly helpful in the demanding processes they were going through.
The mental health services have a responsibility to build bridges
In April I gave a plenary presentation at the annual ISPS-conference in Norway (The International Society for Psychological and Social Approaches to Psychosis). The overarching topic for the conference was The Beauty of the Bridges. Mental pain arises in relationships, mental pain heals in relationships (my translation). Contributing to this conference was rewarding as the bridge metaphor truly resonated with what we have learned in the IFIP project, and furthermore my experiences with hundreds of encounters with people who carry life experiences of loss, grief, and despair throughout my career. People suffering from serious mental illness are at increased risk of losing their social network. Having a “loving crew” surrounding you when you are battling illness and life crises is significant for recovery. It is life-giving. The red tread in my presentation was how family involvement as an integrated part of treatment has the potential to build bridges between the patients and their relatives, and between the relatives and the health care personnel. This bridging being realised through family psychoeducation is crucial when we are battling severe mental illness, when our language dissolves, when our social relationships are disrupted. The mental health services must take on the responsibility to support patients in maintaining their “crew” as part of the measures they apply to provide effective treatment. In this essay I have tried to reveal how psychiatrists and other health professionals can contribute to this responsibility by taking on the role as an interpreter between patients and relatives.
Links
Would you like to learn more about the IFIP-study, please see our website: Family involvement during severe mental health problems - Institute of Health and Society.
Email address: k.m.hansson@medisin.uio.no
Acknowledgements
I would like to thank Irene Norheim for engaging with me on in this topic when finalising the manuscript.
The IFIP-study and subsequent studies are funded by The Norwegian Research Council and Foundation DAM via The Norwegian Council of Mental Health (grant number 2023_FO426566).
*We use the term interpreter in this essay because it aligns with the theme of this issue, which focuses on translation. In our context, however, terms such as facilitator might be more natural or commonly used.
