Upon entering psychiatry residency, I was immediately engaging with families of patients. I hoped to serve them well, but I feared that, at times, failure was all I could offer. I recall one particular failure vividly. I had just come on service at our inpatient psychiatry unit. One of my new patients was ready for discharge—my colleague had provided me with a summary of his stay to date, and my attending said he would take care of the interview. The 22-year-old patient had been admitted for a manic episode, his fourth in a year. When I met the patient, I was struck that he appeared to have ongoing mania, albeit slightly attenuated. I was concerned that the plan for discharge was a bit premature, but it was my first day meeting him and my attending seemed confident in the plan. I received a call from the patient’s aunt later that day. She said, “My nephew came home, destroyed the house, and took off. Why did you discharge him? Couldn’t you see he was still sick?” I stumbled through an attempt at an explanation. I suggested bringing him back to the emergency room—“He won’t come willingly.” I suggested calling emergency services—“They never do anything.” I suggested pursuing an order of detention through the probate courts—“Isn’t that your job?” Her exasperation was palpable, as was my guilt. She hung up on me. The patient was readmitted later that week.

In caring for patients with serious mental illnesses, such as schizophrenia and bipolar disorder, I quickly realized the key role families play in the care of their loved ones. They do everything they can to ensure patients take their medications and attend their appointments. They provide for the patient’s basic needs, housing them indefinitely or paying for an apartment, taking them grocery shopping, and encouraging basic hygiene. They are the first line of defense against decompensation; they often have to watch as their loved one gets sick, waiting for them to be “sick enough” for intervention. They have to decide when to call for help. They take responsibility for the patient’s care upon discharge from the hospital. They take guardianship and in doing so become responsible for making all decisions for their loved one. They suffer the pain of watching their loved ones repeat a cycle of decompensation and hospitalization. They worry what will happen to their loved one when they are gone.

I have profound respect for the families of patients with serious mental illness. Psychiatry often has too little to give them. Psychiatric medications have limitations in terms of both efficacy and tolerability. The residential options for patients with serious mental illness are limited and difficult to access when available. Decreased average length of stay and inadequate number of hospital beds limit adequate acute treatment of serious mental illness. Stringent legal requirements for involuntary care often require patients to decompensate to the point of crisis before intervention can occur. I experience the realities of these failures as the psychiatrist delivering the bad news. “I’m sorry, he doesn’t qualify for a nursing home and the group home won’t take him back.” “I’m sorry, the medication may not help with his apathy or cognitive impairment.” “I’m sorry, he meets criteria for discharge even though he won’t accept medication.” “I’m sorry, he doesn’t meet criteria for admission…yet.” “I’m sorry.”

As a young psychiatrist, I acknowledge the complex historical realities and systemic factors that contribute to these failures. Despite these failures, there is hope. I have had the good fortune to be exposed to creative evidence-based approaches to serious mental illness, such as assertive community treatment (ACT) teams, assisted outpatient treatment, and first episode psychosis clinics, that provide more efficacious care for patients and their families. Advocacy efforts to increase access to psychiatric professionals and address laws that restrict access to treatment provide hope for systemic change. The Clubhouse model directly responds to the needs of people with serious mental illness, offering opportunities for employment and friendship. Exposure to ACT teams, the Clubhouse model, and advocacy opportunities during residency are essential to promote more effective collaboration with families.

Residents sometimes receive mixed messages about the role of families when attendings, staff, or other residents complain or criticize family members who are “too involved” or who make reasonable requests that the system simply cannot accommodate. Residents should instead be taught that families are a critical element of care for patients with serious mental illness; assessing the nature and quality of family relationships should be a standard part of evaluation. Residents should practice routinely engaging families in the care of their loved ones by holding family meetings, providing updates during hospitalization, and seeking to understand family dynamics that may influence treatment. It is easy to focus on the failures enumerated above; my hope is ultimately rooted in the tireless efforts of families to care for their loved ones with serious mental illness. I aspire to help them do so successfully.