An interview with Kristin Beville, LICSW, MPH
We asked Kristin Beville, Director of the McLean Hospital Department of Social Work, about the challenges that families and caregivers face when a loved one lives with hard-to-treat depression, how they can manage emotions and expectations, and how they can be effective partners in care.
Q: How would you describe the state of a family caregiver when an adult in their family has not had an adequate response to depression treatment and comes to McLean Hospital for assessment and treatment? What kinds of emotions are common?
McLean Hospital is a specialty psychiatric hospital that provides an array of evaluation and treatment services including clinical treatment of depression for those who have not had a sufficient response to prior treatment. Many of our patients and their families have already been dealing with depression for a significant period and have already undergone a range of treatment approaches including individual therapy, multiple medication trials, ECT/TMS, and even residential treatment.
Families and caregivers with a loved one who has hard to treat depression often describe feeling
• hopeless about the likelihood of their loved one getting well
• overwhelmed by all that they need to do while also worrying about their loved one’s wellbeing
• angry about the challenges of the U.S. mental health system, the barriers to accessing insurance-based treatment options, and the lack of effective treatments to help their loved one
• worried about the possibility of suicide, given their loved one’s ongoing depression.
It can be especially difficult for families and caregivers when someone they love and care for so much is struggling with depression. Their loved one might not leave the house, or even the bed, for days at a time. It can also feel frightening being unsure how to help. Many families and caregivers feel terrified at the potential lack of response to new treatment approaches, wondering if their loved one will get better and concerned that anything they do to try to be supportive could make things worse. Worrying can be extremely draining, so not only are caregivers and families emotionally vulnerable, but their energy and physical health may be affected as well.
Q: What professional supports might a family caregiver expect from a hospital or treatment facility? What should they be asking for from the hospital/facility to help them cope and provide constructive support to their loved one?
Here at McLean Hospital, providing compassionate care and respect to both our patients and their families and caregivers is one of our values. Every person who comes to McLean Hospital (and presumably everywhere else) for inpatient treatment is assigned a social worker. The social worker works within a multidisciplinary team and acts as a liaison to help develop treatment plans and provide psychoeducation and support for families and caregivers. If your loved one is receiving inpatient treatment, assuming they have authorized us to talk with you about their diagnosis and treatment, it is fair for you to expect regular updates on your loved one’s response to treatment. Social workers can also help to facilitate a meeting with the treatment team to review the treatment plan as well as explore aftercare recommendations and options. The social worker can also help families and caregivers identify resources in the community for their own support and educational needs.
Social workers are here to support a loved one’s family and caregivers just as much as our patients. Communicating with the social worker about your concerns and recognizing your important place in your loved one’s treatment and wellbeing is an important element to everyone’s health and wellbeing. There are times, for some reasons, that your loved one may choose not to provide permission for communication to occur between you and your loved one’s social worker. Many families understandably feel great distress at being excluded from treatment decisions. Know that you are not alone. There are many wonderful resources in the community to help support you through these times and to help you move forward and prepare for supporting your loved one following their hospital discharge.
Q: People experiencing hard-to-treat depression often have a sense of hopelessness, believe that treatment efforts are futile, and lack a sense of self-worth that would motivate them to be active participants in their own care. What are constructive ways that family caregivers can support and be partners in care for their loved ones with hard-to-treat depression?
Caregivers who have a family member in crisis mode often want to jump into problem-solving mode. This puts family members and caregivers in a difficult position and different role other than being the loving supportive person that your loved one needs, particularly if there is a disagreement about treatment. Family members and caregivers need to guide their loved ones to their professional team while focusing on providing support and validation for what they are going through.
Unremitting depression is disheartening and can cause some families to believe that their loved one is not doing everything they could be doing to get better or even wonder if their loved one really wants to get better. Families should continue to educate themselves about treatment options and be prepared to ask questions and support their loved one in advocating for the treatment that is the best fit for their loved one. This would be a good time for families and the treatment team to come together for a treatment review to discuss and consider which treatment has worked in what ways, what hasn’t worked, and what options have and haven’t been tried. It can be helpful for everyone to be included in the same discussion and have an agreed-upon plan moving forward.
This is also a good time for families and caregivers to remember that they should have their own supports (e.g., someone to drive carpool, someone to pick up some groceries, etc.), including their own self-care plan and therapist.
Q: What are things that families can do to stay united and hopeful when a loved one has hard-to-treat depression? Is there anything to do differently than when a loved one has earlier-in-treatment depression?
I encourage families to pursue family therapy as a way for everyone to get support and learn how to improve communication skills, learn other skills like validation, and be more transparent about feelings and concerns. It’s really important to learn how to be honest about feelings and set healthy boundaries within relationships. It can be difficult to set and enforce boundaries, but not doing so can result in resentment and fracture family relationships. I also encourage individual family members to seek out support groups and also seek out their own individual therapy. Having your own therapist (and any other needed treatment) gives you an outlet to address your own self-care needs, with the result that you can be more present for your loved one, providing validation and support.
Q: What else is important about the role of families/family caregivers when an adult is living with hard-to-treat depression?
Please take care of yourself, learn to create and enforce healthy boundaries, and be sure to tend to your own physical as well as emotional needs.
Kristin W. Beville, LICSW, MPH, is the Director of Social Work and the Social Work Training and Education program at McLean Hospital in Belmont, MA. She is also the hospital’s Civil Rights Officer. Ms. Beville is currently a member of the National Association of Social Workers-Massachusetts Board of Directors. From 2018-2019, she served as a member on the statewide Section 35 Commission regarding involuntary inpatient treatment for substance use disorders under Governor Charlie Baker. Ms. Beville has advanced training in clinical supervision, mentalization-based therapy, and family therapy. She approaches her clinical and leadership responsibilities by utilizing the knowledge base of both social work and public health to raise awareness through advocacy, decreasing stigma and debunking myths about mental health, enhancing preventive services within the community, training and mentoring younger clinical social workers, and delivering empirically-validated treatments for individuals and families.