As applications and accomplishments of the Primary Care Behavioral Health (PCBH) model proliferate (Reiter, Dobmeyer & Hunter, 2018), possible contributions of a family systems perspective in this arena seem conspicuously absent. Understandably, population health priorities such as accessibility, high productivity, and brief, team-based episodic care may leave little time for systemic formulations of problem maintenance or interventions that target social units and processes beyond the patient. Here we describe an adaptation of strategic-systemic family consultation (FAMCON), originally developed as a specialty approach for change-resistant health and behavior problems (Rohrbaugh & Shoham, 2011, 2017), to primary care. Stepped FAMCON complements the pragmatic, time-efficient PCBH model by reserving family involvement for complaints that do not respond to first-line individual-focused medical or behavioral interventions. This generalist approach addresses behavioral aspects of chronic medical conditions (e.g., non-adherence to diabetes regimen, unexplained physical symptoms) as well as persisting behavioral complaints (e.g., depression, anxiety, SUD). It also (a) formulates problem maintenance, including helper involvement, in a systemic framework not dependent on psychiatric diagnosis; (b) optimizes indirect (non-prescriptive) behavioral intervention framed as assessment; (c) leverages PCP influence to promote patient/family engagement and adherence to behavioral interventions; and (e) enhances response to post-consultation follow-on procedures, including evidence-based individual interventions. FAMCON embodies the systemic themes of circularity (locating problems in current cycles of interaction), context (looking beyond the patient), and pattern interruption (breaking problem-maintaining cycles), with key constructs including ironic processes (when ‘solutions’ maintain problems), symptom-system fit (when problems stabilize relationships), and communal coping (when ‘we-ness’ facilitates change). Procedures include a warm handoff meeting with PCP and systemic BHC followed by 30-60 minutes with BHC; an assessment phase consisting of 1-4 BHC meetings with patient and family members; an opinion/feedback session incorporating observations and recommendations, both medical and behavioral; and a PRN follow-up phase adjusting strategies and tactics to patient/family response. During the assessment phase, with indirect intervention framed as assessment, the BHC remains overtly neutral about behavior change, offering no direct suggestions or advice prior to the opinion/feedback session with the PCP. In addition to highlighting exportable clinical tools (e.g., social network interview; family engagement scripts; communal coping intervention; assessment and opinion planning templates), we discuss promises and pitfalls of stepped FAMCON in light of recent pilot work by first author MR in the rural Virginia primary care practice of third author CM.
- Identify gaps in knowledge regarding family-focused assessment and intervention methods in primary care.
- Describe systemic patterns of problem maintenance, including ironic processes and symptom-system fit, and the role of communal coping in clinical change.
- Describe stepped FAMCON assessment and intervention approaches for primary care complaints that do not respond to first-line medical and behavioral interventions focused on the individual patient.