Providing care to families: a task for psychologists and psychiatrists at IPUB/UFRJ

Abstracts

INTRODUÇÃO: A família é um foco de observação e de intervenção, não somente para terapeutas de família, mas para todos que lidam com o paciente psiquiátrico. Em nossa pesquisa, realizada em 2005/2006, no Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro, investigamos as diversas formas como psicólogos e psiquiatras estão em contato com as famílias. Para além da especificidade profissional e das dificuldades apresentadas, nosso objetivo é o de oferecer maior visibilidade à presença da família, destacando a experiência desses profissionais. MÉTODO: Adotamos uma metodologia qualitativa, realizando entrevistas individuais. RESULTADOS E CONCLUSÃO: Os dados das entrevistas com 15 profissionais sugerem que os entrevistados, apesar dos obstáculos, mantêm contatos com as famílias dos seus pacientes. A sistematização dos diversos contatos torna-se necessária, a fim de que seja estabelecida uma rotina de assistência à família e sejam viabilizadas pesquisas que demonstrem a eficácia das propostas de intervenção.

Família; hospital psiquiátrico; intervenção

ORIGINAL ARTICLE

Providing care to families: a task for psychologists and psychiatrists at IPUB/UFRJ

Edna Lúcia Tinoco Ponciano^I; Maria Tavares Cavalcanti^II; Terezinha Féres-Carneiro^III

^IPhD. Researcher, Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Rio de Janeiro, RJ, Brazil. Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil.

^IIPhD. Associate professor, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.

^IIIPost-PhD. Professor, Department of Psychology, PUC-Rio, Rio de Janeiro, RJ, Brazil.

Correspondence

ABSTRACT

INTRODUCTION: The family is a focus for observation and intervention not only for family therapists but for all those dealing with the psychiatric patient. During our study carried out at the Institute of Psychiatry of Universidade Federal do Rio de Janeiro (2005-2006), we investigated the several methods used by psychologists and psychiatrists to work with the families. In addition to showing the specific professional approaches and some other difficulties, we aim at increasing the visibility of the family, highlighting the experience of these professionals.

METHOD: We used a qualitative methodology by means of individual interviews.

RESULTS AND CONCLUSION: Data from the 15 interviews suggest that, despite the obstacles, the interviewed professionals keep contact with the patient's families. Systematization of the several methods of contact is necessary so that family assistance can be provided on a regular basis and studies that show the effectiveness of the intervention proposals can be enabled.

Keywords: Family, psychiatric hospital, intervention.

Introduction

Family has become an object of interest and research in the mental health field since the 1950s, mainly in the USA, and such interest has spread to several countries. Classic examples of the beginning of these studies are the group from Palo Alto, CA, headed by Gregory Bateson,^1.2 and the study conducted by Laing & Esterson³ in England. After the importance of contacting the family during treatment was established, therapeutic proposals related to many different psychiatric diagnoses have been suggested.^4-10 Thus, families receive counseling on how to deal with the mental disease, based not only on the patient's diagnosis and the characteristics of his/her treatment but also including the relationship among family members, being a component of a model of care provided to the psychiatric patient.

At the Institute of Psychiatry (IPUB) of Universidade Federal do Rio de Janeiro (UFRJ), families receive care by means of several models. On a daily basis, the families are a focus of observation and intervention not only for family therapists but also for all those dealing with the psychiatric patient from admission to discharge.

At IPUB, since the late 1970s, a specialization program in family therapy is offered,¹¹ providing better systematization of the care delivered to the patients' relatives. This program was developed at the same time as a movement of reformation of psychiatry was emerging in Brazil. Such movement stands for the idea that psychiatric patients should leave the institutions and return to their communities.¹² Therefore, family care started to be available concomitantly with a change in the model of psychiatric care.

During the 1990s, patients and their relatives were engaged in the reformation of psychiatry, actively taking part in the planning of new mental health practices.¹³ The family becomes a partner in the process of psychosocial rehabilitation. With short length of hospital stay and at hospital discharge, the family is considered a resource that needs to used, in addition to playing an important role in the psychiatric patient's treatment and recovery. The new services must assure that patients have the right to have a shelter available for the periods of psychic suffering and that the family has the right to actively participate in the treatment.¹⁴ Within this context, we highlight the importance of studies that try to contribute to the implementation of Law 10.216/01, showing the relevance of the participation of the family and the society in the care provided to patients with mental disorder and suggesting possible manners to promote the patients' social reintegration.

Despite the pioneering characteristic of IPUB/UFRJ, there are few studies in this field and lack of systematization of such practices. Even after the importance of family participation has been highlighted, there is still much to be investigated regarding the interventions carried out at a psychiatric institution. The first step consists in acknowledging the link between relational context, mental health and clinical outcomes resulting from this perspective. Therefore, care routines that include the family and that are not exclusively performed by family therapists can be systematized.

Thus, it is necessary to realize that the family relationships and the events that take place within the familial environment are relevant for understanding the development and persistence of psychopathologies. Practical considerations demonstrate the need of paying more attention to family relationships because the family often is the first source of support and influence, becoming an essential part of the clinical intervention.^15-17 In addition, mental problems in one of the members of the family have a direct impact on the emotional well-being of the other members.¹⁸

Despite the relevance of family relationships, many professionals have little information about the theoretical proposal of involving the family in the psychiatric treatment or, even when they acknowledge the importance of involving the family, they have doubts about when it should be recommended and how to determine the appropriate referral. Hence, in their daily practice, these professionals conduct a family approach that is not supported by their theoretical-technical training. This gap in mental health professionals' training is filled by the experience of working at a psychiatric institution that makes it possible for them to have frequent contact with the patients' relatives. However, there is need of more support to the interventions that have been implemented by means of raising a debate connecting family and psychiatric disorder.

In our study, which was carried out during 2005 and 2006, we show the procedures used by psychologists and psychiatrics to make contact with their patients' families. Even though they do not have theoretical knowledge about the connection between relational/familial processes and mental health, the professionals we interviewed reported the need of involving the families in the treatment by means of contact with the therapists during the individual treatment process.

Due to several reasons, psychologists usually have contact with different members of their patients' families in different moments during the treatment. Although they are not adequately trained for that and there are few studies on this topic, psychologists need to establish contact with their patients' relatives.¹⁹ Taking into consideration the differences between the professions, psychiatrists also need to have contact with the families and they are not appropriately trained for that task either, which results in several obstacles because of the institutional routine and the urgency of meeting the needs of their individual patients.²⁰

In addition to showing the specific professional approaches and some other difficulties, we aim at increasing the visibility of the family, highlighting the experience of psychologists and psychiatrists that work at IPUB/UFRJ. Therefore, based on the observation of the fact that the families are involved in all services provided at IPUB/UFRJ, one question emerges: what types of contacts are established between the professionals and the families? Many of these contacts are informal, taking place during the daily routine of the institution. They are not systematized, do not have a specific objective and are characterized by a great deal of anxiety.²¹ During the present study, we investigated these daily contacts by means of interviews with psychologists and psychiatrists. We tried to find out how the contacts are established, which are the difficulties, which are the results and which are the demands resulting from them.

Method

We aimed at covering the several divisions of IPUB, including psychiatric emergency room, outpatient clinics and hospital wards. Therefore, 15 professionals were interviewed: six psychiatric medical residents (R), four psychiatrists (M) and five psychologists (P). We focused our study on professionals who provide individual care to psychiatric patients with the purpose of finding out how they integrate the family in a treatment model that is oriented to the individual. Professionals such as nurses, social workers and family therapists, who received diverse training, directly deal with the patient's family. Therefore, we concluded that they have a more continual contact with the families. Due to that reason, we focused on the physicians and psychologists' point of view with the purpose of finding out about the way they keep in contact with relatives in spite of not having been trained for that task.

The interviews were planned based on a semi-structured questionnaire and were made by the first author at the institution according to the availability of each professional. All interviews were recorded upon the interviewees' approval. The interviewees' names were not disclosed. All interviewees accepted participating in the present study and signed a written consent form. With the purpose of testing the questionnaire, we made two pilot-interviews. Both of them were included in our analysis. Thereafter, the questionnaire was approved and did not need any changes.

We used a qualitative method, and the interviews underwent content analysis²² after being transcribed. Hence, we extracted fragments of the interviews, grouping the answers according to the following topics that comprised the nucleuses of meaning: contact with the family, objectives of the contacts, results, obstacles, advantages, necessity of providing care to the family, and referrals. The interviewees' statements depict the daily routine and several typical situations of a psychiatric hospital, revealing the presence of the family, the need of providing care to the family and keeping in contact with family members.

The present study was approved by the Research Ethics Committee of IPUB/UFRJ. All interviewees signed a written consent form.

Results and discussion

Contacts with the family

Before systematizing a specific treatment, it is necessary to define when the contact with the family takes place, trying to promote the implementation of a service that includes relatives according to the professionals' practices. Initially, the interviewees reported two different situations upon contact with the family: due to the severity of the case and to the length of stay in the psychiatric institution, which, in case of a long hospital stay, can dismiss the family, considering it unable to deal with the patient.

It's a very severe patient, schizophrenic (...) a situation the family has difficulty to deal with. At the end of every visit, I see them as well. (R1)

Patients that have been in hospital for a long time (...) we are working hard to get in touch with the families. (M1)

When there is a severe case, it is important that the family visit the institution, even when the patients are adults. On the other hand, when treating children and adolescents, the presence of the family is constant, which makes the contact with the family much frequent. However, such intimacy is considered a risk. The health professional must refer the family to other mental health services, so that the family members' treatment is independent from the patient's treatment.

For example, this adolescent I'm seeing... I'm constantly in touch with his mother to check, collect some data and check how he is doing. I referred her to another type of psychotherapeutic care to avoid confounding with his treatment environment, to prevent her from bringing her own issues. (P5)

In addition to severity, the following interviewee highlights the importance of taking advantage of the family presence, mainly during the first medical visit.

When the patients come here for the first time, they usually come with a family member. (...) then we make the first interview in the presence of the relative, and some of them come along for the next visits. (M4)

At psychiatric emergency room and hospital wards, the family seeks help to deal with critical situations. As time goes by, however, family members withdraw, become complacent and consider themselves unable to deal with the patient. Emergency situations are described as those in which the family gets more involved and, as a consequence, during these moments there is contact with health professionals.

At the emergency room, I get to meet the families all the time. (...) it's as if the families provide information on the patients and after that we do something to them and, as if by magic, we return them to their families. (R2)

During hospital stay, there are two different moments when the family is usually contacted. The first one is related to the professionals' need of knowing more about their patients' history at admission. The second situation takes place when the patient is discharged and he/she must be returned to the family. These are two specific moments, since they are not meetings complying with a routine of systematic care. Professionals' contact with the families usually does not make them feel as part of the treatment process. On one hand, the family transfers the responsibility to the hospital, exempting itself. On the other hand, the hospital leads the family to withdraw.

I believe we often get in touch with the family to talk about the patient's history and then... we call them when the patient is discharged. I think we take very little advantage of the family presence on a daily basis. (M1)

It is possible that casual meetings may take place at IPUB, which evidences the family's attempt to keep in touch with the health professional. In this case, the report of psychologists reinforces the need of separating the patient's treatment from the family members' care, being careful to avoid mixing both treatments, which is considered harmful.

I met with three families today: one mother, who I referred to psychotherapy; a wife, who attended two sessions with me and I referred to another therapist; and a patient's mother called me.(P1)

In the psychiatric institution, it is common that therapy sessions are invaded by family members. Psychologists seem to be more concerned about this, although psychiatrists also feel bothered by that.

It happens that a mother brings her daughter to the session and wants to get into the office before the daughter does to check on her case, to invade her daughter's treatment environment. (P4)

Psychologists also point out that it is important to be in contact with the family during the most difficult moments. For instance, when there is need of bringing the patient back to treatment, trying to know how the family understands this process.

With my patients, once in a while, I talk to the mother or the father when there are greater difficulties. (...) In these moments we contact the family to see how we can bring this patient back to treatment, to check how this family is doing. (P2)

Objectives of the contacts

In spite of emphasizing the need of contact, objectives are not used as a manner of systematizing the care provided to the families: Anyway, the objectives enable us to identify the results.

Based on the interviewees' report, the main objectives of contacting the families are listed below:

- To make the family participate in the treatment:

(...) A hospitalized patient (...) and the mother provides us with her impressions on her daughter, she sees her improvement. I think she realizes she can deal with that. (...) let her participate because, in fact, it's that person that will take care of the patient afterwards. (M1)

- To find out about the patient's history, getting information from the family at the same time as preparing the family and offering guidance on how to deal with different situations involving the psychiatric disorder:

To get information, to discharge and also to have contact with the purpose of preparing and helping the family to deal with the situation. (M5)

Guidance, to help with medication. (...) When there is need of hospitalization, if we have a strong bond with the family, it's easier for them to accept the procedure. For the family to accept and also agree with it, trusting us... (M3)

— To get to know the family's dynamics and the relatives' understanding of the psychiatric disorder:

We basically need to understand how this family works. (...) to understand the patient's functioning, for instance, regarding his mother, father, or sister. (P3)

To get to know the family. (...) I believe you need to know the environment where the patient lives because I think it makes all the difference. (R2)

— To understand the severity of the case and the family's distant attitude:

There is no guilt. I try to understand both sides (describing the distance between a daughter and her sick mother). And then, by getting to know their history, I was informed that that patient did not raise her daughter. Her daughter was raised by the neighbors. She doesn't have any bond with her mother and she has two young children, and when the patient, the children's grandmother, has a crisis, she does things such as forgetting to turn off the gas stove. (...) Then, I think we see the situation from a different perspective. I can understand that this mother did not raise her daughter because she was sick, while her own daughter is involved in the whole situation, and she is not able to understand it. (M2)

Results of the contacts

The results of the contact with the families are not motivating because the difficulties still seem to surpass the benefits. However, according to the interviewees, it is important to insist. In spite of the difficulty of reaching good results, the family is necessary to achieve good results with the psychiatric treatment according to the patient's own perspective. In addition, the family promotes treatment adherence because of the alliances established and due to the collaboration achieved during these contacts.

In most cases, it establishes deeper bonds. I believe that the patient gets more involved. (P3)

Therefore, being in contact with the family makes family members feel supported and facilitates treatment, even though the result is not as relevant as it could be expected.

In the short-term, you can't achieve great results, but I think that there are benefits. I even believe that the family feels supported at least. The family members know that there is someone they can count on if they need it. They know you can understand their problem. Then, I think that somehow this must really change things. (M2)

Obstacles

The interviewees describe the main obstacles when trying to keep in touch with the families.

— The therapist's omnipotence that makes the family withdraws.

I think that this happens when you believe that you can, in terms of therapeutic resources, completely solve that patient's problem, instead of thinking that his problem is part of a family structure. Or, when you see the family members as elements that are not part of the therapeutic resources. (M1)

— The unpredictable involvement of several issues, touching the family in a way they cannot tolerate:

The family gets shaken up, sure, and then they withdraw, and depending on the type of patient, the patient also quits treatment because he/she was very motivated by the family. (P4)

— When the family is a negative influence on the patient by preventing contact or even making it impossible. In the first example, the wife's interference is seen as harmful, since she makes threats, saying that she will tell their children a secret. The therapist's work, however, provides a therapeutic environment to the patient and his children. In the second example, the family's lack of ability to deal with the problem is highlighted, which impairs the hospitalization process and the discharge.

And then he decided, after starting therapy, to tell that to his children. Then, the result is completely different from what the wife expected, since she thought that their children would be upset; but they accepted it and are very involved in the treatment. They are willing to do family therapy. (P5)

When we have inpatients, it's difficult for the family to be tolerant towards the patient. (...) If the family was a little more patient and tolerant, it would be possible to keep the patient at home. (R3)

Psychologists tend to blame the families for the obstacles. On the other hand, psychiatrists tend to see themselves and the service as the main obstacles.

— The family becomes an obstacle when it questions the result and/or the need of treatment and certain techniques, interfering and disturbing:

We are trying to convince this mother to come to the family meetings. We have called her up several times, but she never comes, and when she comes, she doesn't let her daughter talk. In short, there is this lack of connection. Then, the mother, instead of helping, ends up disturbing. (P4)

— Lack of support, both emotional and financial, and the family's social situation are obstacles that together create an overload for the relatives and make contact more difficult:

I think that is the lack of support from the family. Because I believe that the family gets very worn out here and we have something to offer to that family. It's something difficult to do. (R2)

The family has transportation problems (they don't have the money for bus passes). They have real problems. (M2)

- When the family transfers the responsibility of taking care of its sick member to the hospital, contact is a conflicting factor in the relationship between professionals and family members:

Here at IPUB, as a resident, I have seen many patients who were discharged and the relatives didn't want to take them home, they didn't agree with discharge because they wanted the patient to stay longer, or because of the severe social problems that the family wanted to abandon. The patient didn't have a home to return to. Then they wanted to leave him here. (R6)

Advantages

The advantages of keeping in contact with the family are related to meeting the above mentioned objectives and to the attempt of achieving good results for the treatment as described by the interviewees:

- Family is necessary for any person; keeping in contact avoids breaking the patient's bonds:

We need to form bonds, without bonds we are not ourselves. Bonds are a small part of our history. I'm sure that if we allow the patient to choose, he/she will go back to his/her family. The problem occurs if we isolate the patient from his/her family and, because of hospitalization, it might happen. (M1)

- To be in contact enables the establishment of alliances that result in the participation of the family, leading to good treatment results:

The family must be informed, not about what takes place during the sessions, but how the patient is doing. We need to be able to work as a team. (P4)

- There is a change in the professionals' perception of the family, broadening the way they see treatment:

I believe it's very important for the patient. Because I believe we should not rely only on medication. (...) There are many patients whose biggest problem is the family rather than the medication they take. (R4)

- The contact allows meeting the objectives, such as providing guidance and engaging the family in the treatment:

It consists in information about the emotional difficulties, how the family can help, explaining that the patient is not in that situation because he/she wants to. This is very helpful in the family environment, and it's useful for the treatment. (R3)

Need of providing care to the family

The interviewees also notice that the family needs specific care focused on learning how to deal with the disease and on the emotional difficulties of family members. Interviewees mentioned some of the reasons why families need care:

- Due to its importance in the patient's life and the characteristics of its dynamics and relational history. Therefore, the family should receive guidance.

Sure... it's the way the system works... it's more complicated when you work only with the patient because the whole family dynamics is sick. (P2)

The mother... the parents, I think they get too puzzled, they had a strong need of denying, even when the kid was here in hospital, because the kid used drugs, and they started saying that all his problems were related to drugs, and I had to be very emphatic several times. I had to talk to the father and the mother. (R1)

- Because families have multiple problems:

Yes. Because if we think about the problem from a broad point of view, we see the whole family, we have that old story of the tip of the iceberg. The patients seeks treatment and then you realize that there are several aspects of that family that are not working as they should, that are not flowing well.(P1)

- Because the expectations they had about their child, who got sick, were not matched:

It's difficult for the mother to admit that her son has schizophrenia. I think parents project a set of expectations onto their children, which is perfectly normal, and it's very difficult for the mother to admit that her child has a severe disease. I think parents need a lot of support. (R2)

Referrals

In face of the need of offering specific health care to families, interviewees report on the cases they usually refer to family therapy or to another type of service.

- When they refer people to family therapy, they not always have information about the treatment results and, therefore, the referral is controversial. The family has a high degree of complications, since it usually has a long history of emotional and relational conflicts, which discourages referrals. However, therapy can help patients to return to their homes:

Another case that I referred is a patient who has a very aggressive father. His parents are separated. It's also a very complicated family. The father spanks his son, who is 24, and they also ended up dropping out because they can never come all together, either the mother or the father does not come. (M2)

Actually, I think that we have very little contact with family therapy. (...) I believe it's difficult to assess therapy results; I can recall a severe case that is very difficult to analyze in terms of improvement, but the few sessions they attended may have helped. Then they stopped coming, but it helped them to receive the patient at home. I remember another situation when I saw the family members and it helped the patient to return home. (M1)

- There is preference for group therapy referral:

I think it's interesting for the family to participate in sessions with other families (in the group), for them to know how other mothers deal with it. I believe it's very good. (P3)

I used to refer more people to group therapy. People are able to exchange their experiences. It's more effective than referring to family therapy. I prefer this. I prefer groups of family members. (M3)

- In addition to the family group, there is also preference for individual therapy referral:

I prefer referring to individual therapy. I usually refer to the family group so that the person can see how she/he feels, but I also offer the individual therapy and then I let them decide what they prefer. (...) I have seen mothers, fathers, relatives who attend group sessions and feel very comfortable, but I think that I generally refer to individual therapy. (P1)

- Families are usually referred to family therapy when the family members "are very disruptive," interfering with the patient's treatment, but there is constant lack of motivation:

I usually do it (...) when I realize that the family is getting in the way a lot... I think it's important that this family is referred to family therapy. (P2)

It seems that the family doesn't have much motivation. At least, in most cases, I couldn't make the family to provide great support to the patient. (R5)

Conclusion

During the course and treatment of the psychiatric disease, the patient's family often suffers due to the absence of care mechanisms that should be delivered by several mental health professionals. We were surprised by the interviewees' effort to contact and work with their patients' families. There are more methods used to get in touch with the families than we could suppose. In the daily routine of the institution, the health professional who is closer to the patient usually provides the family with information and some recommendations that serve as support for relatives during the treatment. The contact may continue as occasional conversations, which are intense and informal at the same time, or it can even include family therapy. Between these two options, there are countless possibilities of contact.

However, there is a gap in the field of mental health services. The reason for such a gap can be understood when we become aware of the conflicts between the patient and his/her family, the professionals' prejudice and the lack of professional training. After understanding these issues, it is possible to implement a service that provides care to the families. The obstacles of such implementation are also related to the organizational characteristics of the institution. Therefore, even though this type of care is expected to be delivered according to the psychiatric reformation, if specific care mechanisms are not created, the family suffers due to the lack of care. Thus, data analysis enables us to identify four thematic areas that should be discussed:

1) Family's inability and overload. Such negative aspects can start being corrected since the first contact between the family and the institution;

2) Variety of types of care offered to the family, adapting them to each case, instead of offering just one option, such as referral to family therapy;

3) Systematization of a method to keep the family well-informed, according to the specific characteristics of each case, which may reduced the family's inability and overload;

4) Development of strategies to increase the family's participation with the purpose of establishing an alliance with the psychiatric institution, at the same time as the family members receive care.

Before defining that the care provided to the family has been efficient or not, it is necessary to analyze the type of contact that has been made with the families. There is not only one model that can be adopted. There are many models to be considered and developed based on the daily routine and experience of the health professionals involved. The identification of the topics described above enables us to visualize possible manners to implement a systematized service that might undergo a later investigation of its effectiveness. Hence, the objectives mentioned by the interviewees can be implemented and the results can be discussed.

Providing care to the family is an important resource to promote the patient's hospital discharge. After all, the treatment will continue in the environment where this patient lives, including the familial environment. Parents who take care of psychiatric patients are exposed to a heavy load of stress, with negative results for their health, which may need to be treated. The impact can be reduced by therapeutic interventions, social support network and community support. This can decrease the load of the contact with health services, helping family members to interact and manage the daily life of patients, strengthening the partnership between family and institution. Therefore, stressful factors can be reduced and the the quality of life of the people involved can be improved.

In fact, the family plays an important role in the patient's hospitalization; it influences treatment, recovery and hospital discharge, but this role can be even more important. With the need of participating in the treatment, it is necessary to interfere with the environment where the patient lives, developing strategies so that the family takes part at the same time as it receives attention and care.

The professionals we interviewed keep in contact with the families despite all obstacles they find along the way. When professionals become aware of their limitations, there is a tendency to refer those families that are more emotionally intense and/or have more conflicts to family therapy. Even though, the effectiveness of this approach is controversial. As a consequence, the referral seems more like an urgent need in face of the unbearable situation than the recommendation of a specific approach that relates mental disorder and family/social relationship.

Systematization and record of the care provided, showing the presence of the family in the psychiatric institution, make it possible to conduct studies that enable to demonstrate the effectiveness of the interventions proposed, from informal contact to family therapy. Thus, a field focused on the interpersonal relationship to understand mental health and mental disorder can be strengthen. Discussing obstacles, advantages and objectives of the contact with the family, it is possible to define a routine in which such contacts are not a source of stress for all those involved and become an important resource in the care delivered to the psychiatric patient. In addition, the family may need to receive specific care, and the first professionals who deal with the family will be prepared to make pertinent referrals based on the availability of specialized environments to listen to the family members. After all, a long path must be traveled in order to achieve systematization of a service focused on the psychiatric patient's family. This systematization starts to be implemented when we consider the several methods of contact used during the daily routine of the psychiatric institution.

Acknowledgements

The authors thank FAPERJ for the scholarship granted to the associate researcher Edna Ponciano during 2005 and 2006.

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Publication Dates

• Publication in this collection
  24 Aug 2009
• Date of issue
  2009

History

• Accepted
  10 Mar 2008
• Received
  18 Jan 2008