In honor of Family Caregiver’s Month, Therapy Times’ staff writer, Bob Stott, sat down with Clarissa Smith, PhD, MAR, OTR/L, a Birmingham, Ala.-based therapist, to discuss the role of today’s family caregivers in the therapeutic process, and how encouraging a strong cooperative relationship between therapist and caregiver can result in dramatic improvements in patient health.


Therapy Times: What are some of the patient management problems that can arise in the interaction between caregiver and therapist?

Clarissa Smith: It is the primary role of the therapist to be clear on all instructions to the patient or caregiver despite the setting whether outpatient, home health or a skilled nursing environment. In many cases problems arise when therapists prejudge a situation or circumstance prior to spending time to really understand the role of the family caregiver and their historical context.

Since we know that communication is a two-channel approach, (three, with the patient), it is imperative that the following therapist understands:
Cultural implications for the family member, tone of voice and non-verbal language. Be sure that the family member can read and write, if not, modify the plan to indicate clear verbiage. Any education to a caregiver should involve no more than two to three steps if one is to ensure carryover to the patient.
Breakdown can occur if adequate demonstration of the task is not sufficient. This could interfere with the initial physician’s recommendations. For example, partial weight bearing of a right hip means about 50 percent to a therapist. What does it mean to the caregiver? It is always best to allow them to watch you complete a task first several times; they are to return demonstrate it using the visual, verbal, and written forms. It has been my experience that most therapists are in too big of a rush to do it right. Therapists can be held liable for inadequate family caregiver education.


TT: Do power struggles ever occur over the progression of medical decisions concerning the patient? If so, why?

Smith: Power struggles and control of one’s decisions can be a conflict factor especially between physician’s, family caregivers and patients. If a patient is competent, I believe he or she should have the ultimate decision-making power, even if it is not in his or her own best interest.

Physicians and therapists are providing a service to the patient, not the other way around. Therapists and physicians are to help the patient make good choices about their care, but the ultimate decision is the patient’s whether good or bad. The role of the therapist is a supportive one, and that’s why the word “therapy” means “to heal.”

Therapists are healing agents, not conflict agents. We should never act as though we have the answers to all of our patient’s woes. In fact, family caregivers will actually resent the notion, and will quickly exert their power and influence over the situation. Therapists must know when to draw the line when giving advice that really should be a family’s decision.


TT: Do you have any experience with an overbearing caregiver or physician? Is there a non-confrontational resolution to this problem?

Smith: Of course there is. One cannot run from conflict. It has been my experience that since the physician wrote the therapy orders for the patient and not the caregiver, ethically, we must do what is best for the patient first. We should always remain calm and listen to what the family caregiver is saying because after all, they know the patient best.

An overbearing caregiver is a sign of stress, burnout, a desire for control and probably a need for respite. Therapists should seek to harmonize the therapeutic process or treatment with education to the patient and caregiver; otherwise you are wasting your time. In other words, if the family caregiver views you as the lone ranger and antagonist, you have already lost.

You must win the family caregiver over by using the following conflict resolutions techniques:

• Speak in a low and calm tone.
• Be quick to listen, slow to speak.
• Acknowledge their efforts and praise them for what they are doing to help the patient. They are often underappreciated and over criticized.
• Find out the root of the problem. If it is a matter of personality, switch therapists. 
• Focus on the plan of care and orders from the physician. I, typically, say that the doctor has written orders for me to work on this or that, so this lends me true credibility. 
• Finally, focus on the patient. Do what’s best for him or her by educating a controlling person every step of the way. Save your sarcastic comments and keep them to yourself. Family caregivers don’t need any more stress.

TT: If a caregiver has a problem with the therapy regimen, how should they approach the physician?

Smith: The very first thing a family caregiver should do if they have a problem with a therapy regimen is to first discuss it with the therapist. It is always best to put your concerns in writing. A therapist who is responsible for administering the treatment should never be left out in the dark about what is going on with the patient. If this is not discussed with the therapist first, a violation of trust automatically occurs which can, ultimately, affect the immediate and future therapeutic relationship.

The therapist should have the opportunity to clarify any orders or treatment regimens with the physician first, so that there will be a team effort.

If this does not resolve the issue, the family caregiver should write down his or her concerns with the regimen (after discussing with the therapist) and contact the doctor for clarification not accusation. Family caregivers must understand that health care professionals can become paranoid if even hinting at the notion of lack of knowledge, competence or ignorance about a treatment.

Family caregivers should ask questions if in doubt, and they have a right to speak and speak out, but do it in a manner does not jeopardize the license of the professional. It’s the method, not the act itself. A family member who has a relationship with the patient’s doctor needs clarification at times because they are often overwhelmed and overburdened.

Physicians sometimes lack great communication skills and are not always clear on the goal of the regimen, so the family caregiver as the patient’s advocate should contact the physician if that will put his or her mind at ease.


TT: If the physician has a qualm with the caregiver’s treatment at home, how should they approach the therapy regimen, how should they approach the caregiver?

Smith: The physician should always seek to communicate in a clear, direct, and concise manner. Depending on the severity of the complaint, the physician should ask questions first, not make assumptions. A clear understanding of the problem is a great place to start. A physician should stick with the “who,” “what,” “when,” “where” and “how’s” of a situation before assuming a deliberate or innocent actions.

The number one problem with caregivers and physician is lack of communication on the family caregiver’s level. Speaking on a sixth- and ninth-grade level without degrading someone takes skill. The ability to take medical terms to the layperson takes skill, and most physicians care and spend the time necessary to explain things.


TT: Is an over-sympathetic caregiver problematic to continued therapy, whether at home or at the facility?

Smith: Once again, what is the relationship between the family caregiver and the patient? What is their history together? Is the caregiver experiencing guilt, shame, doubt and regret? It is true that a caregiver who works against the therapeutic healing and independence process can interfere with function of the patient?

Striking the balance is best, and it is possible for the therapist to use the family caregiver in a supportive but encouraging role, in lieu of a sympathetic one. I believe we need the word empathy instead of sympathy. Changing the pattern and relationship of the family caregiver and patient should not be a goal, just know when to foster encouragement and maximal level of functioning on your part.

You cannot control the behavior of another; you can only educate how your treatment is helping the patient to the caregiver, and give tips about their approach to care. When possible, even educate about the disease process and how it affects function such as falls, balance, cognitive status and levels of independence.


TT: Are there tips you could suggest for mending relations between caregiver and physician?

Smith: Yes, there are several tips for mending the relationship between caregiver and physician?

• The physician should recognize that the family caregiver is acting on behalf of the loved one and as an advocate.
• The physician should be down to earth in communications and show genuine concern for both the caregiver and patient; after all, without the care of the caregiver, the patient’s health and well-being will be affected.
• The physician should have open communication with the family caregiver about their loved ones (of course, with confidentiality rules for HPPA).
• The burden on the physician to improve communications because it is the family caregiver who knows most about their loved one. Physicians should foster appreciation for the family caregiver who is the primary person to carry out his or her instructions, especially when it comes to medications, levels of care, supervision, assistance with ADLs and other functional mobility/personal care matters.
• If there is a trust issue between the physician and the caregiver, the chances of follow-through with the treatment regimen is limited if not absent. So a tip would be to listen, listen, listen some more to the caregiver.
• Both the family caregiver and the physician need an open door policy. It bothers family caregivers when they fail to return calls in a timely manner or if at all. Trust is violated and the family caregivers feel as though she or she does not care about their loved one.
• Family caregivers need to follow the physician’s advice to the best of their ability or seek another one if communication is such a problem. When in person, the two should look at each other when speaking instead of writing and walking while communicating. Nonverbal messages go a long way with family caregivers and they either usually trust a physician or not, typically, no gray area.
• Family caregivers can improve physician relationships on their part by being organized, having the medication list, side effects, communicate falls and functional abilities clearly. Take the list of problems or concerns to the doctor’s office and check them off as they are answered. If in doubt by a physician, the family member should check it out. It is best to ask too many questions than not enough.
• Finally, all healthcare professionals including physicians should take courses in cultural diversity. Older persons of varying races often communicate differently depending upon their trust, background, and the historical context. For example, an older black female patient will communicate differently with her physician than with her minister or preacher. Intimidation and paranoia about the system are factors to consider let alone trust. Each patient and family member should be treated as humanly unique and as individuals with the intent to improve the lives of others.

    – Bob Stott is a staff writer for Therapy Times. Questions and comments should be directed to bstott@therapytimes.com.