Bogdan de Barbaro
Between the psychiatric diagnosis and the "family diagnosis"  77
Summary
If the idea of the bio-psycho-social model is not to be merely a concept on paper, the family dimension must be taken into account in every clinical diagnosis and concept of treatment. The example of schizophrenia illustrates the advantages and problems this entails. Accommodation of the family context has clear benefits: it enables a more thorough understanding of the patient and creates the foundation for action to reduce the risk of relapse. It is therefore strange and worthy of reflection that despite the effectiveness of psychoeducation, it is not a part of the canon of treatment: on the one hand families are not always invited to co-operate, and on the other they often refuse the offer of co-operation themselves. In this situation the relationship between the psychiatrist and the patient's family needs analysing, in particular their mutual - and often subconscious - emotions and prejudices, for these can create the beginnings of a dysfunctional "vicious circle" and cause the entrenchment on both sides of attitudes preventing the conclusion of a therapy contract. How to break this impasse and help to create a positive team? Paradoxically, the potential for therapy is greater when - especially at the start of the treatment process - the psychiatrist is "capable of not knowing" and is prepared to listen to the perspective of the members of the patient's family without prejudice and to take a close interest in the "family's story". Only once the psychiatrist has heard and accepted the family's perspective can they together deconstruct the elements of the "family's story" that contribute to the problem and together seek changes for the better. Unlikely as it may  seem, this may prove a considerable challenge to the psychiatrist, who is accustomed to controlling the therapeutic situation through his psychiatric theory and diagnosis, his psychiatric language and his psychiatric institution. The above issue is part of a more universal dilemma: how far does the psychiatrist's "linguistic power" extend and when is it beneficial to that therapy to share that power with the patient and his family?