Michael Friedman, Ph.D.

Michael Friedman on Enlisting

Families in CBT for Depression

By Lynn Mollick & Milton Spett

        On June 4, Dr. Michael Friedman presented a NJ-ACT workshop on integrating families into CBT for depression. Research has shown that involving families in psychotherapy enhances treatment effectiveness. “Even small changes in the family can result in major changes for the patient,” said Dr. Friedman. “But you’re enlisting the family’s help. You’re not doing family therapy.”  Dr. Friedman suggested focusing on four areas:

          1) Assess Expressed Emotion (EE). The components of EE are: criticism/hostility, emotional overinvolvement, and validation. High EE predicts relapse. Therapists can reduce EE by reducing the family’s criticisms of and instructions to the patient. Also, therapists should encourage patients to tell their families when they do not feel supported by their families.

            2) Psychoeducation. Explain your model of depression and your treatment plan to the family. When family members learn about depression and its treatment, they will express less criticism and hostility toward the patient, and they will increase validation and support.         

Also tell families the following:   

            a) Depression is a common problem. One in four individuals will suffer from depression during their lifetime. 

            b) Depression is likely to be a chronic problem. After one episode, 50% will relapse; after two episodes, 75% will relapse; and after 3 or more episodes, 90% are expected to relapse.  

            c) Depression causes impaired functioning. Depression results in more lost days of work than common physical problems such as cancer, diabetes, or heart disease. 

            d) Marriage and other relationships suffer as a result of depression.    

            3) Problem Solving. Ask patients to choose two or three ways that the family can assist in their treatment. (It helps to prepare the patient for this question in an individual session.) Choose tasks that are easily accomplished, such as family outings and hiring or helping with childcare. To encourage behavioral activation, focus first on activities the family has enjoyed in the past. Suggest new activities when the patient’s depressive symptoms have improved. 

Do not let the family attack or blame the patient in the family session. Communication problems can be addressed, but if problems in the marriage or family are so severe that they interfere with problem solving, refer the family to another therapist. Always terminate family sessions if the patient objects.

            4) Trouble Shooting. Try to solve problems that interfere with treatment.  For example, talk on the phone with relatives who cannot attend sessions, develop plans for addressing suicidal ideation. 

         Dr. Friedman recommended a series of three family meetings. Each of the four areas listed above should be reviewed at each meeting, with greater emphasis on assessment and psychoeducation in the first session, and greater emphasis on problem solving and trouble shooting in later visits.

Other Issues

        Confidentiality should be discussed at the beginning of family sessions. Nothing the patient says privately to the therapist should be passed on. Everything family members say to the therapist should be communicated to the patient. The therapist’s responsibility is to the patient, not the family. [Some therapists disagree with this point and offer confidentiality to every family member.]

        At the end of the workshop, Dr. Friedman offered suggestions for working with other professionals: 

        1) Talk with every professional involved.

        2) Identify discrepancies among professionals’ goals and try to resolve them. When goals can’t be resolved, acknowledge the discrepancy to the patient. 

        3) Suggest no more than one intervention to another professional.

Although he was optimistic about families helping to promote psychological goals, Dr. Friedman was pessimistic about professionals collaborating, particularly in private practice.

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