Disruptive families in acute care settings

Published

I have been trying to search out information on a topic and am coming up dry. So, I'm turning to my on-line nursing community. Maybe I'm the only one that's had this experience. OR it's something that is negative in nature and not reported.

Here's the deal:

Adult med-surg patient. Nurse and patient getting along OK. But then... some family member/significant other comes into the room, and inserts themselves between the nurse and the patient. This is usually like a twisted sort of advocacy role.

Example: Older lady involved in MVA. Has a non-surgical back, burst fracture at T-12, being managed conservatively with a "turtle-shell" type brace, pain management, PT/OT. Has a daughter that lives about 50 miles away who has been calling the floor multiple times per shift telling us what mom wants and needs and demanding information. Finally, shows up. Sits down on mom's bed literally between patient and nurse, picks up my rounding log and states categorically that I was not in the room at any of the times noted, that the log is a complete fabrication and that her mother was ignored all day. The patient was passive. Didn't correct her daughter.

Another example: Mother of a 45 year old patient tells us we are not medicating her daughter with enough opiate. Then tells us we're giving the daughter too much ("she'll never get off that stuff if you keep giving it to her like that...") on and on. We are incompetent, we are ignoring her, we're giving her too much or not the right medication. Again, the daughter is passive, allows mom to drive all the action.

Another example: Chronically ill middle age woman, brought up from PACU with a lot of co-morbidities. From the jump her sister is taking the pulse ox off the patient because the alarm was disturbing the her (the patient). I explain purpose of pulse ox. Sister says I'm full of it and she doesn't see any reason for the alarm to go off until her sister is in the mid-70's range and if I can't make the alarm fit those parameters, she doesn't want it on at all. (No, the family member has no medical/physiological understanding, is clearly picking a number out of thin air.) Again, the patient is passive.

Common features:

1. There is nothing inherently defective in the nurse-patient relationship.

2. Objections of family member not rational, and are resistant to any explanation or education. (In fact, in my experience any attempt to educate or inform is taken by the disruptive family member as self-defensive excuses by the nurse and validates their complaints.)

3. This behavior places a barrier between nurse and patient that is poisonous, inhibits continuous assessment, treatment and evaluation. Basically short circuits the entire nursing process.

4. It is not directed at any particular nurse, since none of the nurses are competent in the family member's eyes.

5. Lots of threats and implied threats : "I'll contact my lawyer." "Who is the CEO of this place?" "Wait till I tell the newspaper how awful you all are."

Please help me NAME THAT BEHAVIOR? What mesh-heads can I use to search the literature? Is it just me? Do all nurses see this occur? If it's not in the literature, why not?

ANYTHING you can tell me would be appreciated!!!

as all have said, threats of violence or refusal to stop fiddling with the equipment = call security and get them out. (although most of you have said that you ask them to leave) if i really threatened, i let them know that they are making terrorist threats and are disturbing the peace and that 1 more threat and i will be making a police report and asking the police to arrest them. and i will. i do not get paid to be a dead or wounded nurse. i am not their therapist or their punching bag. only once have i actually had to have police come over but it felt quite empowering to report the individual. drunks or others who seem particularly out of control are escorted off by security pdq. threats of lawsuit = hand them the phone. and thell them that, since they are dissatisfied with my care or with me, i will no longer be their loved one's nurse. and i will switch assignments.

being proactive like diane 227 is a great way to head off or diffuse trouble. involving the family as much as the patient wishes is good, too. i think some people are terribly afraid of their family members but i can't solve every problem. if patients won't speak up, i figure they're afraid of being abandoned or maltreated by their rowdy family member. i try to get the patient alone and get to the bottom of it. i ask the pt what he or she wants me to do. i tell him that i have to have his cooperation and have him stand up for me against the spouse, child, parent or whoever is giving me a hard time. sometimes he will, sometimes he won't.

sometimes, i have asked the doctor to intervene and let the family member know that their behavior and their insults and threats are going to alienate the staff, which will cause us to refuse to care for their loved one or cause us to do the absolute minimum for their loved one, thereby limiting the exposure we have to threats, rudeness, and disrespect.

but there really are some people who just need to be removed from the scene because they interfere with the patient's healing. they are either feeling guilty or are sick themselves or too stressed by the many demands of their own lives and now have this sick family member to deal with and they just can't cope. but that is not my problem and i can't take them on as patients, too. i'm too busy caring for my actual patient. i'm not a saint and i do have limitations on my time, patience, and other emotions. i'm not god and i can't cure the ills of the entire world or even the small number of people who enter my world at work. they are going to have to be courteous or they have to go. and i have less patience now than i ever did before. i just don't have the time or energy to try to console them or cajole them or "understand" them.

a lot of times, ignoring them seems to work best of all. that is, i just don't reply when they say ugly stuff.

or, let's say they're removing the pulse ox. i put it back on and then look them directly in the eye and say, in my most ominous tone, "your mother needs this. this device tells me if your mother is getting enough oxygen. don't take it off again unless you are prepared for me to have security escort you out." they glare at me but i have yet to have anyone defy me. they eventually settle down and start acting better. sometimes, we end up laughing about it later.

horrendous what we have to deal with, isn't it?

Since when should administration interfere with a staff member filing a CRIMINAL COMPLAINT AGAINST A PERSON WHO COMMITTED ASSAULT? You have a legal right to call the police and press charges. There is no way I would allow any manager to bully me into not calling the police and pressing charges. JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Spokane, Washington

And if it is still within the statute of limitations, I'd still file that police report. Screw your manager. She's not the one who was assaulted and battered. Why do you think you need her permission? :angryfire:angryfire:angryfire Report it. Report it now. Or the next time those people come back, what will happen to you? And yes, I'm angry at YOU for being so docile!

Yes, I think this is a case similar in many respects to what I am talking about. The "advocate" is placing herself as the one-in-charge. I-care-more-and-I-know-what-is-best. But she did respond to your efforts. Apparently she didn't like being cut out of the information loop, but she left and appeared to understand you meant what you said. (And I like the re-direction you used... "drive safe, take care of yourself." Nice touch. Appropriate. You didn't denigrate her, or blow her off.)

But take that "I'm the only one who understands and cares for her" thing an order of magnitude farther along the crazy scale, and I think you have a picture of what I'm talking about.

Of course, there are family dynamics and people do have pain they might not tell you about and there are things in their history that you might not know and there could just be information in what a close friend or relative tells you that would be quite useful to know. Maybe they really do know what's best. We have to balance our own training, experience, and ego (yes, ego) with what they're trying to tell us. Nurses can be wrong. :idea: :uhoh3: :bugeyes:

Vis. calling the police.

I could have. I wasn't hurt. (I have really bad knees. If I hadn't fallen just the way I did, I'd have been injured, and would have crawled to the phone and called 911.) But my 1st choice has always been safety. My safety, the pt's safety and the safety of co-workers. In the short run, the safest thing to do was walk into the hall. Next thing on my priority list was to figure out what was going on. That's when I called the NAM, the attending and the psychiatrist.

The threat to me was potential. The immediate threat was to the patient (as it turned out, by her own manipulative behavior and her mother's by proxy ).

As far as "firing the patient."...

I have refused to be re-assigned back to a pt. But if I walk out during the initial confrontation, what happens to my colleagues? If I on-the-spot refuse to grapple with the issues this patient presents, I'm only passing the problem to another. As a staff, we MUST give care. (We are such a good team. I love my co-workers. When we see one of us hitting the wall with a crisis, we step in and cover our colleague's other patients.) So simply telling the patient I'm quitting, walking out, whatever... it just passes the problem on to another nurse. And, to make matters worse... they "win". They don't just manipulate me, now they get to manipulate all the nurses who are forced to adapt to a quick assignment change.

Nevertheless... I am convinced the administration sees these things happen and refuses to watch our backs. I don't know about you all... but I do my best, cover my butt and get ready to defend my actions to families AND supervisors, (and lawyers, though those threats have so far been empty.)

Specializes in Interventional Radiology.

okay- so i think everyone is missing the point here- this behavior should not be allowed. i have worked in icu/pcu for more than 10 years- not all as a nurse, but being there for that amount of time- it seems there's always someone that can surprise you with their behavior. but the bottom line is - this behavior is unacceptable. these people can make all the excuses they want about being stressed or dysfunctional families or whatever else they want. the biggest problem with the entire situation is that because we are now the big blue h hotel chain, we are expected to just take this kind of abuse.

personally, i have only had one completely outrageous family problem and i flatly told them that the behavior was unacceptable. they wanted to talk the the cn- so go ahead. the cn agrees this is inappropriate- but of course admin says- we have to be "customer friendly" and that includes our pt's families- it's just too much. all this pc crap and the behavior is just allowed. i refused to take care of the patient again. i just won't take that kind of treatment...i am just not paid enough for give up my self respect......

just my :twocents:

Specializes in ICU/Critical Care.

I understand that families are under stress. I can understand a hissy fit or two but I WILL NOT tolerate being shoved up against a wall and hit and in MY BOOK, that is assault and people who assault me will be prosecuted. Like Laurel said, we don't get paid enough to sacrifice our self-respect. I sure am not giving up mine.

LaurelRN08 ... I am not missing the point. I am currently trying to return to work because a patient assaulted me. She is awaiting trial, but is out in the community. There is an undertaking upon her by the police that she not attend to the emergency department unless its an "emergency". She has been to the ER (prior to the assault) daily for very minor things, to get fed and to get warm.... she had become a nuisance. So when I asked who gets to determine if she has a legit emergency I am told "she does" ..... haven't seen her (I am doing short hour shifts in an attempt to get back to full hours) in the ER since.

So, I do get the point, its assault and we should never tolerate it. I have had staff tell me I am not doing the right thing .... "poor patient" .... and I say bullcrap, I am doing the only reasonable thing to do.

Specializes in mental health; hangover remedies.
It's the same people that drive waitresses crazy over every little perceived misjustice involved with their getting mayo instead of mustard.

You can't beat proper mustard, eh Whispera? :uhoh3:

But anyhooos...

I think 1Tulip, and correct me if I'm wrong, that you are aware and understand the normal reactions of pt relatives such as grief, guilt, etc - but that there are some cases that don't seem to fit the 'norm'? I'm also reading that you are trying to understand what's the reason for this beyond the norm behaviour?

There are two trains of thought to behaviour: Personality and Pathology.

Personally, I believe all behaviour is pathological. It's based on what our brain perceives, how it interprets and how it decides to react.

But are these relatives suffering a pathological abnormality that causes them to abreact?

It's possible - but very difficult to establish.

Firstly, we don't know enough about the workings of the brain to say what is functional and what is dysfunctional.

Given the experiences, events and consequences of many of the patients I see in Mental Health - most of them are a consequence of a normal reaction to an abnormal situation. ie - any one of us would result in that way.

Given that a relative in hospital is not completely unusual but is an 'abnormal event' to some degree, this may be normal - for them - to react this way. It depends on a whole lifetime of events, their perceptions and the consequences of any reactions.

Secondly, in order to make any meaningful evaluation of behaviour it has to be done over time and in a variety of contexts and situations.

If this behaviour was totally out of context to their normal behaviour patterns then there is a significance of the event. If they're just continuing their usual behaviour then it is an unremarkable event - in a global context.

Thirdly, and in the analysis of your scenarios, all behaviour is perfunctory. It has a purpose. Understanding that purpose helps to understand the origin of the behaviour and also how to respond to it.

Again, in normal circumstances we have guilt/grief etc. But in these situations it seems as though you are perceiving these are not the (complete) reason for the behaviour and questioning another other possible reasons?

Is this an intuitive feeling you're having? I note your "common features":

Common features:

1. There is nothing inherently defective in the nurse-patient relationship.

2. Objections of family member not rational, and are resistant to any explanation or education. (In fact, in my experience any attempt to educate or inform is taken by the disruptive family member as self-defensive excuses by the nurse and validates their complaints.)

3. This behavior places a barrier between nurse and patient that is poisonous, inhibits continuous assessment, treatment and evaluation. Basically short circuits the entire nursing process.

4. It is not directed at any particular nurse, since none of the nurses are competent in the family member's eyes.

5. Lots of threats and implied threats : "I'll contact my lawyer." "Who is the CEO of this place?" "Wait till I tell the newspaper how awful you all are."

Are these too far from the norm of guilt/grief behaviour reactions to be extended behaviours?

I'm asking - I don't deal with a lot of that sort of relative behaviour.

If I were to hazard a guess on these 3 scenarios:

Example: Older lady involved in MVA... Has a daughter that lives about 50 miles away who has been calling the floor multiple times per shift telling us what mom wants and needs and demanding information. Finally, shows up. Sits down on mom's bed literally between patient and nurse, picks up my rounding log and states categorically that I was not in the room at any of the times noted, that the log is a complete fabrication and that her mother was ignored all day. The patient was passive. Didn't correct her daughter.
Over concern? This sounds like an extended guilt reaction. The daughter is being over-protective.

But I think you later stated there was some family behaviour about 'who best looks after mum' - and I'd say that perhaps daughter is behaving no different in the hospital setting than she does in the community setting?

To this end - if she's doing it as some sort of 'competitive' behaviour then addressing this might help to alleviate this.

Suggestion: Speak to daughter and tell her "I am so impressed by the way you attend to your mother. Even if you give me grief about doing my job you are there and that speaks volumes."

It's a BS job. Just to get her on side - as quite frankly, I doubt you're going to amend her ways in the time mum is in hospital. But at least this might ameliorate her a little and make her glow - and YOU did that, so she'll love you for it. :icon_roll

It's not a perfect remedy - it's a band-aid.

Another example: Mother of a 45 year old patient tells us we are not medicating her daughter with enough opiate. Then tells us we're giving the daughter too much ("she'll never get off that stuff if you keep giving it to her like that...") on and on. We are incompetent, we are ignoring her, we're giving her too much or not the right medication. Again, the daughter is passive, allows mom to drive all the action.
I did a really long winded post (just like this one!) on BPD in a thread here.

I think this is some pathology that predates the hospitalization. Maybe it's BPD. In one case, (the 45 yr. old) we had a stat psych consult. He dx'd the daughter (pt) as BPD. So it was the mother who was being played and the nurses were just part of the game.

Often you find people with MH issues have some dysfunctional family member behind them!

I wouldn't dismiss mum as being ''played'. Her daughter is probably BPD cos of mum and her antics.

[Edit: I think this 'qualitative analysis' of mum's behaviour indicates her problem -

"I will hasten to add that one of the incidents turned violent. The 45 y.o. BPD with the frantic mother,"

The BPD pt is a victim.

But now you're dealing with 2 dysfunctional people.

My suggestion would be to be empathic, validating, actively listen, compassionate - and then go do whatever you clinically have to anyhow. :uhoh3:

As Virgo_RN said:

That's generally how I handle these folks. I let them vent their little vents, appear to be listening, then go about caring for my patient the same way I would despite these people. While they think they've made an impact on the care their loved one is receiving, what they don't know is that their loved one would be getting the same level of care without their meddling. I figure I'm not going to change behaviors that they've had a lifetime to practice, so I just let them think I'm listening, while I do what I do.
As long as they feel part of the process, you will limit their disruption.

Again, a band aid fix - but I don't think you're talking about curing everyone - just getting your job done effectively and with minimal interruptions (in a caring way, of course).

Don't lie or deceive - it will bite you in the butt x20.

The aggressive behaviour is intolerable.

The pt is old enough to be charged and no reason not to.

It is possible to get the pt on your side - and they will stick up for you with mother.

But I'd get the psych team to take mum aside and speak to her to get her to back down. She'll be used to their involvement and hopefully they would have developed a 'rapport' with mum as well as daughter.

I don't think any ad-hoc "evaluations" by MH nurse would deter either of them much tho if they've been through the system.

Another example: Chronically ill middle age woman, brought up from PACU with a lot of co-morbidities. From the jump her sister is taking the pulse ox off the patient because the alarm was disturbing the her (the patient). I explain purpose of pulse ox. Sister says I'm full of it and she doesn't see any reason for the alarm to go off until her sister is in the mid-70's range and if I can't make the alarm fit those parameters, she doesn't want it on at all. (No, the family member has no medical/physiological understanding, is clearly picking a number out of thin air.) Again, the patient is passive.
Simply put - control freak. Most likely an over-reaction to a sense of inadequacy.

I expect the sister (pt) has had to put up with this all her life.

I'd respond with "Ultimate Force".

Get "The Doctor"* to tell her direct - as you would a bully - "If you continue to interfere with the clinical equipment I will have to TELL you to leave and will bar you from visiting again. We may even have to ask the police to investigate you for tampering with medical equipment".

Short & Simple.

* - sometimes male porters/orderlies wearing a white coat and stethoscope have been 'mistaken' for being a doctor - but they don't have to say they are or aren't.

I think you're right to review some relatives beaviours as not following 'contemporary grief/guilt' patterns. But it's going to be a wide and varied list of alternatives.

Hope this helps.

It was very good to hear from a psych person.

My thought as a med-surg nurse is that the cause of the disruptive behavior is not my concern. The pathology predates the operation/admission, I can't change it, and the bottom line is that the patient's well-being is at risk. BUT, having said that, a bit of insight into why people behave like loons may give me a tool or two to try and modify things enough to get through my shift (at least).

It does go against my grain to suck up to the disruptive family member. But... if I can take away their need to be the hero by giving them some cudo's then, hey... it's no skin off my nose.

I think that the concept of nurse abuse is at play here. Lots of responders have mentioned this. And yet... it seems to be an occupational hazard we're just supposed to roll over for.

In trying to research this, I have found some lit on violence against nurses (especially in ER and Mental Health settings. Not so much med-surg.) I have found another body of literature on "horizontal hostility" which is nurses being ugly to other nurses. And I've found some literature on doctors who abuse nurses.

But it seems as if the abuse of nurses by non-psychotic patients and/or their putatively non-crazy families is considered par for the course. It's as common as dirt. Why study it? Why complain? It happens all the time. Why do you think you're so special it shouldn't happen to you? Suck it up. Learn all these little nurse-tricks to "deal with" the anxieties/guilt/confusion/denial (whatever) that is underlying behaviors we find unpleasant and offensive.

Well. OK. I know it's common as dirt and I have the full bag of skills that usually resolves most normal interpersonal conflict. (And thanks to comments here, I'm picking up some new ones.)

But sometimes the acting out is NOT normal. And sometimes it IS unsafe.

Why isn't anyone studying or reporting, or examining or writing about the phenomenon? Is this a sort of academic self-loathing or scholarly self-neglect?

Specializes in mental health; hangover remedies.
It was very good to hear from a psych person.

I have a degree in BS. :bugeyes:

BUT, having said that, a bit of insight into why people behave like loons may give me a tool or two to try and modify things enough to get through my shift (at least).

I used to think all nurses/staff should be able and willing to tolerate MH issues like MH does across all areas - and "quick fix" answers weren't acceptable - but I was expecting way too much.

I don't see it as a fault of the health care team for not dealing with someone outside their specialty - I wouldn't have a clue how to deal with a

It does go against my grain to suck up to the disruptive family member. But... if I can take away their need to be the hero by giving them some cudo's then, hey... it's no skin off my nose.

That's the bottom line.

Many nurses/staff (ok, I'll stick to 'nurses' but it's not just nurses) get caught up in the emotion and the heat of it.

Being able to step outside the situation and put your personal feelings aside can help be more objective.

I was going to refer to the "dopeslap" method previously but didn't. This is not always an effective method and can result in serious repercussions. It can escalate the events immensely.

In trying to research this, I have found some lit on violence against nurses (especially in ER and Mental Health settings. Not so much med-surg.) I have found another body of literature on "horizontal hostility" which is nurses being ugly to other nurses. And I've found some literature on doctors who abuse nurses.

It's a huge area - you're looking at a mix of potentially -

MH issues; communication and barriers; self-awareness (as tactless nurses can often bring the events on by 'dopeslapping' everyone); personality construct theory; behavioural psychology; aggression; emotional regulation....

Well. OK. I know it's common as dirt and I have the full bag of skills that usually resolves most normal interpersonal conflict. (And thanks to comments here, I'm picking up some new ones.)

But sometimes the acting out is NOT normal. And sometimes it IS unsafe.

Why isn't anyone studying or reporting, or examining or writing about the phenomenon? Is this a sort of academic self-loathing or scholarly self-neglect?

You're right to pick up on it as an area worthy of study. I think 'basic' understanding is covered in grief/guilt and it's varied expressions and nurses are usually given a basic 'communications' tool box.

It suits for most cases and it's something that develops over time on an individual level.

But to reflect on my comment that sometimes tactless nurses are not self-aware enough to identify and diffuse such situations is probably an indication that not all nurses "get it".

I've seen enough average situations made worse by bad handling - and I've seen complex situations cause major disruption through lack of skill.

I think the current capacity to handle these type of cases easily exists without further skills training - but clever employ of resources.

eg: For excalating situations, experienced nurses have..err... the experience. And they should be able to identify (as have you) when matters are outside of 'scope'.

These, where they are recurrent problems, should be identified as a unique and significant problem and referred on a case by case basis to psych for Consultation & Liaison (if you have one of these in your hospital "C&L Psych" - use them! - but I'd recommend a nurse and not a doc as nurses are more behaviourally and practically equipped.)

Meanwhile, I'd suggest that experienced nurses can already identify when situations are getting beyond 'scope' but perhaps could increase their range of skills for resolving them.

Expanding knowledge of dealing with disruptive relatives by looking at the 'alternative' explanations for behaviour (and thus amelioration - or 'damage control') may be a worthwhile cause.

Specializes in mental health; hangover remedies.
But sometimes the acting out is NOT normal. And sometimes it IS unsafe.

Why isn't anyone studying or reporting, or examining or writing about the phenomenon? Is this a sort of academic self-loathing or scholarly self-neglect?

Just to add - 'histrionic behaviour' et al isn't a completely unresearched phenomenon. But it's a complex formulation of multiple attributes. (that's the BS degree talking :bugeyes: )

Simply put - you're having a regular psych event in a non-psych environment.

I'll see if I can find anything relevant in and post again later.

[Edit - my first search of "relationships disruptive causes hospital" turned up a million and quarter hits. Everyone one of them on page 1 relating to 'physicians' !!]

Specializes in mental health; hangover remedies.

There isn't much that jumps out - but these two seemed of relevance:

I like the sound of this one:

Nursing Administration Quarterly:Volume 31(3)July/September 2007p 209-218

Countering Workplace Aggression: An Urban Tertiary Care Institutional Exemplar

Phillips, Susan MSN, BC,RN

From Banner Good Samaritan Medical Center, Phoenix, Ariz.

Corresponding author: Susan Phillips, MSN, BC,RN, Banner Good Samaritan Medical Center, 1111 E McDowell Rd, Phoenix, AZ 85006 (e-mail: [email protected]).

Abstract

Purpose: The purpose of this process improvement project was to provide nursing staff with evidence-based knowledge and skills to manage patients and/or visitors with the potential for violence.

Significance: Current statistics describing workplace violence in healthcare settings are alarming. Workplace violence significantly impacts nursing practice and may contribute to physical injuries, psychological trauma, decreased productivity, and low morale among nurses. This is particularly germane to those nurses who have been inadequately trained to manage aggressive patients and/or family behaviors.

Rationale: Following a series of disruptive episodes on the pulmonary-medical service that occurred at our facility in the winter of 2006, an employee safety team was formed to address the issue of workplace violence. Around this same time frame, a team comprising system hospital representatives was also initiated to globally address workplace violence.

Methods/description: A Workplace Violence Education Program was devised to equip nurses with information, skills, and practical tools that will empower them when encountering clinical situations characterized by disruptive or abusive patient and/or family behaviors. The ultimate goal was to diffuse progressive, escalating aggressive behaviors in the clinical setting.

Findings/outcomes: Evidence-based approaches formed the basis of an educational offering focusing on workplace violence prevention and management. This informational intervention was devised to empower clinical nursing staff with knowledge to enhance judgment, decision making, and implementation of behavioral strategies to reduce the likelihood of patient/family behaviors escalating to aggression.

Conclusion: Interdisciplinary collaboration that included clinical experience, expertise, and knowledge generated from current literature reviews contributed to a successful educational program for nurses focusing on a historically neglected topic-workplace violence.

And this one is much older (1976!) but I would guess a lot of the process is transferable to understanding non-MH situations where it talks to the more complex issues of family dynamic.

Hosp Community Psychiatry 27:868-871, December 1976

© 1976 American Psychiatric Association

An Assessment of Family Reaction to the Stress of Psychiatric Illness

Carol Anderson M.S.W.1 and Susan Meisel M.S.W.1 1 University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Mental health professionals are beginning to recognize that the assessment ofa patient's immediate social environment, especially the family, is essential for proper diagnosis and treatment. The authors present a compre-hensive and practical plan for assessing the behavior of a family under the stress of an illness; they focus on six major factors, including the family's past reactions to crisis, the structure of the family and roles of its members, and the degree of Lsolation from other social-support systems. They also present a case example and make recommendations for therapy.

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