Family Interventions In Mental Health 9780335243938, 0335243932, 9780335243945

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Withnell & Murphy PB

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“Withnell and Murphy provide a structured and comprehensive resource for the mental health professional who seeks practical strategies that will empower families to engage with challenging issues, maintain the balance between stress management and recovery and build the foundations of lasting relationships.” Niall McLaughlin, Senior Lecturer, Mental Health Nursing, Canterbury Christ Church University, UK

t is rare that people live in the absence of family, friends or other social support networks, so working with families and staging effective family interventions is an important and logical aspect of promoting recovery in mental health nursing.

This book is a comprehensive and accessible guide that will help you to incorporate families more fully into the care of individuals with mental health needs. The authors carefully introduce the concept of family interventions before going on to demonstrate its practical application, offering examples from practice and also potential barriers to implementation. Key features of this book include: ● ● ● ●

Case studies of real family work Examples and practical tools to use in practice Aims and learning outcomes for each chapter Questions at the end of each chapter to enhance self assessment and reflection

Neil Withnell is a Mental Health Nurse and Senior Lecturer in Mental Health Nursing at the University of Salford, UK. Neil Murphy is a Mental Health Nurse and Lecturer in Mental Health Nursing at the University of Salford, UK. Cover design Hybert Design • www.hybertdesign.com

www.openup.co.uk

WITHNELL & MURPHY

Family Interventions in Mental Health will be an invaluable tool for both mental health students and qualified practitioners. It will also be relevant to social workers and occupational therapists working in mental health settings or the community.

Family Interventions in Mental Health

Family Interventions in Mental Health

Family

●

Interventions in Mental Health

NeilW NeilM

I T H N E L L U R P H Y

Family Interventions in Mental Health

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Family Interventions in Mental Health NEIL WITHNELL AND NEIL MURPHY

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Open University Press McGraw-Hill Education McGraw-Hill House Shoppenhangers Road Maidenhead Berkshire England SL6 2QL email: [email protected] world wide web: www.openup.co.uk

and Two Penn Plaza, New York, NY 10121–2289, USA First published 2012 Copyright © Neil Withnell and Neil Murphy, 2010 All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher or a licence from the Copyright Licensing Agency Limited. Details of such licences (for reprographic reproduction) may be obtained from the Copyright Licensing Agency Ltd of Saffron House, 6–10 Kirby Street, London EC1N 8TS. A catalogue record of this book is available from the British Library ISBN-13: 978-0-33-524393-8 (pb) ISBN-10: 0-33-524393-2 (pb) eISBN: 978-0-33-524394-5 Library of Congress Cataloging-in-Publication Data CIP data applied for Typesetting and e-book compilations by RefineCatch Limited, Bungay, Suffolk Printed in the UK by Bell & Bain Ltd, Glasgow Fictitious names of companies, products, people, characters and/or data that may be used herein (in case studies or in examples) are not intended to represent any real individual, company, product or event.

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“Family Interventions in Mental Health Nursing is an essential addition to a growing body of literature … The authors’ consideration of the barriers to implementation in contemporary practice will … provide points of clarity in the search for solutions. This scholarly yet highly accessible book will appeal to a wide variety of practitioners from those at the very beginning of their careers to those experienced in delivering or teaching family interventions on a day to day basis.” Paula Kennedy, Senior Lecturer in Mental Health Nursing, Liverpool John Moores University, UK

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Contents

List of figures List of tables About the authors Preface Acknowledgements

ix x xi xii xv

PART 1 The context of family interventions

1

1 Introduction to family interventions

3

2 The evidence for family interventions

7

3 What are family interventions?

15

4 Theories of family intervention

22

5 Key concepts in family intervention

26

PART 2 Application in practice

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35

6 Dealing with the practicalities

37

7 Developing skills for family intervention

41

8 Engaging families

52

9 Assessment and family intervention

61

10 Formulation in family intervention

72

11 The role of education in family intervention

82

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CONTENTS

12 Communication skills for families

89

13 Stress management for families

98

14 Problem solving for families

108

PART 3 Examples in practice

115

Introduction to Part 3

117

15 Getting started

119

16 The family with education needs

124

17 The family with communication needs

129

18 The family with stress management needs

135

19 The family with complicated problem solving needs

140

20 The family with a service user who refuses to engage

146

PART 4

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Evaluation and the way forward

151

21 Where now?

153

22 The barriers to implementation

159

23 Researching family interventions

169

Glossary References Index

178 182 189

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Figures

3.1 5.1 5.2 9.1 9.2 10.1 10.2 12.1 13.1 13.2 13.3 13.4 14.1 19.1 22.1

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Crystal ball gazing The Yerkes–Dodson law Stress–vulnerability model Basic genogram Sociogram Algorithm for family work formulation A formulation for Raymond Stress management assessment grid A stimulus–response example Another stimulus–response example Shared formulation Shared formulation in practice Structure for problem solving Structure for problem solving Conceptualization of Lewin’s force field analysis for family interventions

20 30 32 64 65 77 78 96 99 100 104 105 109 143 160

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Tables

2.1 6.1 7.1 9.1 9.2 12.1 12.2 13.1 14.1 15.1 15.2 21.1 23.1 23.2 23.3

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Why family interventions should be used Advantages and disadvantages of various settings Self-assessment of skills Assessment tools Items of the KGV (Version 6.2) Pros and cons for communication work with families OFFER structure Stress situation monitoring form Problems and needs Reflection Developmental plan Relapse prevention protocol Research methods and themes Useful journal articles Action plan

9 39 49 66 68 92 97 103 111 123 123 155 174 176 177

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About the authors

Neil Withnell, MSc is a Registered Mental Health Nurse and Senior Lecturer at the University of Salford. He is currently Programme Leader for the Diploma in Nursing/ BSc Ordinary Degree (RN Mental Health) and his background is in acute mental health nursing. Neil Murphy, MSc is a Registered Mental Health Nurse and Lecturer at the University of Salford. He is currently Programme Leader for the post-qualifying BSc (Hons) Degree in Therapeutic Interventions and his background is in community mental health nursing.

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Preface

As mental health practitioners, we find that family contact is an integral part of the work we carry out with our service users. We rarely see people who live without any family, friends or other social support networks. These various support groups will be considered as suitable to receive family interventions over the course of this book. While the relevance of family is clear, a formalized approach to working with families is often not promoted. There is a large, and growing, body of research and evidence, emphasizing the need for mental health practitioners to offer family interventions. The fact that this research is not routinely incorporated into working practices has been acknowledged, but not fully explored. We aim to address some of the issues which prevent more widespread use of family interventions by identifying some of the obstacles that sometimes prevent even those specifically trained in family interventions from putting this into practice. We will also give a clearer perspective for those who wish to use these vital skills in their everyday practice. While this book does not replace the need for training in the use of family interventions, it can be used to complement such training, and/or as an introduction to the subject. Our enthusiasm for family interventions is derived from many years of working in mental health and witnessing the benefits, for service users and service providers, of effective family interventions.

The format of the book The book comprises four parts. Part 1 contains five chapters that set the scene for family interventions. Chapter 1 introduces you to family interventions. Chapter 2 focuses on the available evidence for family interventions. Chapter 3 discusses what we mean by family interventions. Chapter 4 outlines some of the existing approaches to family interventions. Chapter 5 explores several key concepts in family interventions. Part 2 contains nine chapters that take you through the application of family interventions in practice. Chapter 6 outlines some of the practicalities that need to be considered prior to commencing family intervention work. Chapter 7 explores the

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PREFACE

xiii

skills required to carry out family interventions. Chapter 8 gives tips on how to engage with family members. Chapter 9 identifies the need for assessment. Chapter 10 focuses on formulation. Chapter 11 explores the use of education. Chapter 12 discusses communication skills within families. Chapter 13 identifies stress management. Chapter 14 looks at problem solving. Part 3 contains six chapters outlining examples in practice. Chapters 15–20 focus on working with families and we provide examples of how to get started, education needs, communication needs, stress management needs, problem solving needs, and a scenario of a family with a service user who refuses to engage. Part 4 contains three chapters. Chapters 21–22 focus on the barriers to the implementation of family interventions and discuss the way forward in these circumstances. Finally, Chapter 23 outlines research potential within family interventions. The book can be used as a reference tool and the contents pages will direct you to the chapters you may need in relation to particular situations within your own practice. Read in its entirety, the book provides a structured approach to family interventions, underpinned by evidence-based research. All of the chapters in parts 1, 2 and 4 commence with sections titled ‘Aim’ and ‘Learning outcomes’. These sections outline what you will come to understand from reading the chapter. There are five questions at the end of each chapter; these are designed to make you feel more confident with the subject matter, and encourage you to continue to develop your knowledge of family interventions.

Who is this book for? If you are training in mental health, you will find this book useful in introducing the concepts that surround family interventions, and the book should act as a framework for further training and development once you are qualified. Qualified practitioners will also benefit from the broader concepts which are discussed throughout the book. Understanding the relevance of and need for family interventions, will (we hope) engender a willingness to work more proactively with family members in a skilled and knowledgeable manner.

Notes on terminology There are many terms in use for the people who are in receipt of mental health services. These terms include patient, client, consumer and survivor. While we acknowledge this, and recognize that individuals would prefer to be called by their own name, we use the term service user throughout this book. Similarly we use the term family member when we discuss the people involved with the service user. Although this may include carers, neighbours and distant relations, we acknowledge that any person who has a significant amount of contact with the service user can potentially be addressed as a family member. We use the term family worker when we discuss the role of the professional involved in family work. Throughout this book we refer to health care policies and websites. These policies and web addresses were correct at the time of writing, but please be aware

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xiv

PREFACE

that they may not remain current. We would like to encourage you to use your initiative and to ascertain what is current. There is a glossary of terms at the back of the book. This glossary contains words that are given in bold at their first occurrence in the book, and provides an explanation of their meaning; this is not necessarily a dictionary definition.

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Acknowledgements

We would like to thank the service users and family members we have worked with over many years. This experience has been invaluable in both the desire to want to write this book, and in parts of the content. We would like to thank everyone at Open University Press and McGraw-Hill Education, for their support and guidance in putting this book together. Finally, we would also like to thank our own families: families are important, and without their support, writing this book would not have been possible.

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PART 1 The context of family interventions

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1 Introduction to family interventions

Aim The aim of this chapter is to start to explore the history and development of family interventions, with related evidence for mental health practice.

Learning outcomes By the end of this chapter you will be able to:

• • • •

identify the historical work surrounding family work articulate the effects of family blaming describe the emergent theme of expressed emotion detail some key factors related to legislation and the need for family-orientated therapy.

Introduction It would not be unreasonable to expect that any person experiencing serious mental health difficulties would receive care and support from family members, and that being at home in a familiar environment would be the ideal place to receive this care and support. Unfortunately this is not always the case, and in reality many people experiencing mental illness are treated in hospitals. It is generally accepted that family members, and carers, often feel unable to help. They can feel stressed through being with their relative 24 hours a day, often witnessing behaviours and symptoms which are difficult to understand. They experience a variety of emotions and distress because they are with their relative, largely without a break. This includes general stress, anxiety and a fear of what may happen, and frequently guilt. Alongside these emotions the family member may experience financial difficulties, as going out to work may not be possible with the constraints of providing supervision and care. There are often restrictions on

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THE CONTEXT OF FAMILY INTERVENTIONS

social activities and disruption for siblings and other family members. This also has an effect on an individual’s physical and mental well-being. It is thought that carers are twice as likely to have mental health problems if they provide a substantial level of care to someone with a mental illness (Department of Health 1999).

A brief look back through the history The involvement of family in the care of mental illness has been somewhat curtailed. Although the family has traditionally cared for mentally unwell members of society for many years, the transition from family-based care to institutional care became the norm. As it became evident that people experiencing mental health symptoms needed treatment, the early treatment of mental illness subjected the sufferer to an ‘asylum’ with little thought to the family members. In the early years, there was the view that mental illness was caused by the family, and the notion of family blaming (Johnstone 1999). For many years people suffering from mental illness were isolated from society and placed in large institutions. Alongside this isolation was the combined prejudiced view of society. It is well documented that people with a diagnosis of schizophrenia (in particular) experience discrimination and stigmatization (Sayce 2000). While attempts to reduce this are ongoing, it is an added burden for both the sufferer and family members. At the beginning of the twentieth century a small French town of Ainay-leChâteau became a setting that did not isolate individuals with mental illness but rather welcomed them with open arms. In this rural town ‘mentally ill men’ were welcomed as part of the family (family colony). These men (lodgers) lived everyday lives with ordinary families (foster parents), and even held down jobs. This setting provided invaluable social insights into the effects of family involvement and has been documented as part of a four-year ethnographic study by Denise Jodelet (1991). This particular study highlights the importance of ‘family’ involvement, and the benefits that support and care can provide. In 1948 Henry Richardson explored the importance of family care in the recovery from both physical and mental health difficulties. His book Patients have Families is well regarded as a significant step forward and is seen as a contributing factor to the development of systemic family therapy. Systemic family therapy is very effective and is supported by evidence. This approach is based on the idea that the problem lies within the whole family and not one single individual. We highlight this but acknowledge that this is a very different approach to family interventions. The most significant piece of work that can be regarded as paving the way forward for family interventions was carried out in the 1950s. George Brown (a medical sociologist) and colleagues began to study the outcomes of relocating longterm mentally ill people into community settings (Brown et al. 1958). The results focused on the environment that patients were discharged to. Interestingly patients who were discharged to family homes fared far worse (in terms of relapse and readmission to hospital) compared to those who lived on their own or in a supportive

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INTRODUCTION TO FAMILY INTERVENTIONS

5

residential setting. Those who were discharged to hostels, where there was little warmth and support, experienced the worst outcomes. Further work carried out in the 1960s and 1970s (Brown et al. 1962; Brown et al. 1972) led to the development of the now very familiar term expressed emotion, which we discuss further in Chapters 2 and 3. The significance of social inclusion gathered pace in the 1980s with increasing recognition by the government. The advent of ‘community care’ was outlined in what was referred to as the Griffiths Report (Griffiths 1988), which emphasized the benefits of maintaining individuals in their own homes. In 1989 came the publication of the White Paper Caring for People: Community Care in the Next Decade and Beyond (Department of Health and Department of Social Security 1989). This was added to in 1990 by the National Health Service and Community Care Act (Great Britain 1990). The introduction of the National Service Frameworks in the 1990s included a framework for mental health. Within this framework is recognition that carers’ needs should be met (Department of Health 1999). This was further enforced in 2004 with the publication of the Carers (Equal Opportunities) Act (Department of Health 2004a). Further to this came the National Institute of Clinical Excellence (NICE) guideline recommending that family interventions be offered to all families where a family member has experienced schizophrenia (NICE 2002).

Family interventions From the development of expressed emotion came the recognition that work needed to be carried out with family members that would ultimately reduce their stress, increase understanding and, importantly, benefit the individual experiencing the symptoms of mental illness. Work by Leff et al. (1982) was significant and seen as a vital piece of research in kick-starting a whole wave of studies which attempted to determine how effective interventions with families could be. The studies have strengthened the evidence base for family interventions and outlined the effectiveness of this approach. When you also add the potential financial savings to services (as high as 27 per cent: Tarrier et al. 1991) it only strengthens the need for family interventions to be offered as part of everyday practice. However, despite the need for family interventions, they are certainly not offered in many mental health services. There are a few notable exceptions: in Bath (Smith and Velleman 2002), Somerset (Stanbridge et al. 2003) and the work of the Meriden family programme in the West Midlands (www.meridenfamilyprogramme.com). There has been a considerable push to develop training courses across Britain and this is leading to a significant number of trained therapists, yet despite this training professionals are not carrying out family interventions. Why is this? It may be that services do not recognize the benefits or do not have the available resources. It may be that family members do not want this intervention. It may be that therapists feel they do not have the support to carry out the work. Whatever the reasons, the benefits cannot be ignored and mental health services need to look at the barriers to the implementation of family interventions. This is addressed further in Chapter 22.

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6

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What constitutes a family? ‘What constitutes a family?’ is a question that is often asked. In our experience colleagues have sometimes stated that they cannot carry out any family work because the service user does not have a family. Colleagues often state that the service user has only a partner and there are no other family members. We hear experienced staff say that they would like to carry out family work, but family members are always out at work, or are not available when the service user is visited. It would be ideal if every service user had a mother, a father, a brother and a sister who were willing to engage in family work – in reality this is not the case. This is often one of the difficulties in starting family interventions, as it is perceived that any family work can be offered only if there are several family members involved, and that they are all available at the same time. If we broaden our view and look more widely, and actually ascertain who the service user spends time with over the course of a week, we can include those who spend a significant amount of time with the service user. This could include grandparents, aunts, uncles and people who are not actually related. Carers are often included in family intervention work, as they spend a large amount of time with the service user. A significant amount of time could be regarded as a minimum of 35 hours per week (5 hours per day) though we are not prescriptive in this. We feel that regular contact and awareness of the service user’s illness are significant.

Summary

• • • • •

Family members experience a range of emotions as a result of witnessing often difficult behaviours from their relative. An individual with mental illness should be treated in a familiar environment, if at all possible. Family interventions are beneficial to both the family members and the individual experiencing mental health difficulties. Family interventions are cost effective. Any person who has significant contact with the service user can be considered as a ‘family member’.

Questions 1 2 3 4 5

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Who carried out the research in the French family colony? Geographically, which areas carry out family interventions? When was the National Health Service and Community Care Act first published? What is ‘family blaming’? Why are family interventions not routinely offered?

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2 The evidence for family interventions

Aim The aim of this chapter is to detail relevant influences and evidence that underpin the development of family intervention in clinical practice.

Learning outcomes By the end of this chapter you will be able to:

• • • • • •

understand the evidence base for family interventions establish the impact that different styles of communication have on participants in family intervention detail the drivers for the use of family intervention describe the importance of family members undertaking family intervention articulate a rationale for the use of family intervention in practice start to explore whether family intervention is truly evidence based.

Introduction Before we start to explore the evidence for family interventions, we briefly review what sort of evidence we feel is influential in relation to the area. Rather than just relying on laboratory-type evidence, we felt the need to focus on practice-related evidence where possible. This would enable us to explore the engagement in a praxis construct. This would involve the competing demands on practitioners to complete not only the basic administrative and team-related work, but also the demand of family members and service users. Addressing these demands can create a sense of overwhelming dread, perhaps due to another way of working. We choose to look at it as a model that can influence everyday practice, rather than seeing it as something to be feared. Evidence-based practice and whether family interventions are evidence based are not necessarily definitively answered in this chapter. We would like you to be able to

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think about this question, and then ask yourself the question, are family interventions evidence based, and if so in what way, using the information we have provided? Restricting the evidence to this small section would be a form of reductionism in approach, and we prefer to thread the information throughout the book so as to add to the sense of praxis. Not that we fail to offer information for the support that it is, but ultimately we need to address the questions below (and those in subsequent chapters) to see if family interventions could be so described. For family interventions to be viewed as evidence-based practice they would need to address the following: G G G

Is family intervention based on best available evidence? This evidence will need to have a research base. Research would need to be of such a quality to have addressed the issues of rigour and reliability and be systematic and controlled.

To partially address the question you may want to look at databases such as the Cochrane and Campbell centres for information. You could also consider the drivers from government and the evidence it uses to support the need; another area could be the National Institute for Health and Clinical Excellence (NICE). Whichever you look to, you may be swayed by the need to adhere to the gold standards of evidence (meta-analysis, randomized controlled study, systematic reviews), yet for practitioner research, frequently this information seems distanced from the practicalities of the work to be undertaken. More often case study and experiential accounts seem more grounded and applicable to skills development. Ultimately what you find important in addressing whether family interventions are evidence based or not is, on a superficial level, down to what you and your service are willing to accept as evidence. If you are trying to present a case for introducing family interventions, you will need to consider all of the above and not be exclusive. We offer some thoughts as to why family interventions should be used in all services, with mentally ill people at the centre. There is a high level of confidence concerning the utility of family interventions, especially when considering the evidence base presented by Pilling et al. (2002) and Pharoah et al. (2010). Pilling et al. (2002) completed a meta-analysis involving 1467 patients, in 18 family intervention trials. They concluded that although improvements were made, some decline over time occurred. They cast doubt over some of the information they used as there were differing methods of intervention and differing groups of clients. With this in mind they still suggested that family interventions ‘had clear preventative effects on the outcomes of psychotic relapse and readmission’ (Pilling et al. 2002: 763), and that family intervention should be offered to families of people with a diagnosis of schizophrenia. Pilling et al. (2002) identified some important markers for why family interventions should be used. The evidence they examined is summarized into themes in Table 2.1. The Pharoah et al. (2010) Cochrane Collaboration concluded that family intervention could reduce the frequency of relapse and the need for hospitalization. The information was of interest for people with schizophrenia, clinicians and policy

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Table 2.1 Why family interventions should be used Category

Outcome

• Relapse • Readmission to hospital • Suicide

• Reduction in relapse rates • Reduction in readmission • No increase in the rates for those involved in family interventions

• Compliance with treatment • No real difference with other treatments • Burden • Reduced level of burden • Compliance with medication • Improved compliance with medication regime makers. They did suggest some caution over the findings as much of the evidence they reviewed had poor methodological quality. To move on, there is a need to look at the historical perspectives that have influenced the development of family interventions. It is fine that we have such eminent and authoritative evidence, but conceptualizing the information needs more detail. The issue of relapse has probably become a marker for success or failure in the eyes of lay people and professionals. There is clear evidence that family members do have a role in the identification and relapse of mental illness (studies by Brown et al. 1962; Goldstein and Doane 1982; UCLA projects by Goldstein 1987). This role needs to be understood from a variety of perspectives in order to find a positive way forward and avoid an age-old default of blaming the family for all the problems that a service user presents with. Throughout the book the theme of expressed emotion and stress vulnerability will be detailed and linked to different aspects of education and therapy. The fact that a great deal of research has gone into the issue of expressed emotion cannot be ignored and should be discussed as a factor in why we need family interventions. To say that this is the main factor in relapse would be naive and exploration of affective style and communication deviance will be discussed in later chapters. We need to accept that prior to a service user coming to the attention of a mental health service, there have been many life experiences and attempts by the individual and their family to remediate problems, solve dilemmas and make sense of something that seems to make no sense. The manner in which this is done varies according to the problems and the family members. They have generally adapted styles of coping and communication to address the difficulties they perceived. This may have led to the development of new behaviours and risk taking by the family in order to resolve conflict or attempt to make sense of bizarre and frightening allegations. Unfortunately many families conclude (with or without the help of services) that they are to blame for the illness, and find it difficult to relinquish this blame. Blame and ultimately labels can be attached to families and even individual members. All too commonly families can feel rounded on and that their actions are scrutinized by people who have nothing to do with their family. This can lead to polarizing views and inharmonious relationships with service providers. The introduction of mental health services may inadvertently introduce a paradox that leaves relatives confused and at time paralysed, ultimately reinforcing

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the blame. Sometimes a little bit of knowledge from pre-registration courses can lead to poor conclusions, and well-meaning throwaway statements can lead to long-lasting conflicts and upset. The paradox often comes from well-meaning service providers who through a limited knowledge of the influence that a family have on illness suggest that the family are not to blame for the service user’s illness yet if they changed the way they all behaved to the service user, they could have averted a relapse. Herein lies the initial reason for why family intervention needs to be explored in this book. We hope to increase the body of information available for all levels of service provider in order to help them to avoid creating damaging conflicts before therapy has even started.

Expressed emotion Although expressed emotion is discussed in detail in other sections, we need to look at the components at this point in order to offer a cogent argument for why we need family interventions. If we accept the details suggested by Vaughn and Leff (1976) that expressed emotion has three distinct components, hostility, criticism and emotional overinvolvement, and that families can fall into categories of high expressed emotion (exhibiting many factors related to the components) and low expressed emotion (exhibiting few if any factors related to the components), then we can start to see a tangible thread for help that may need to be given to support the family. It is generally accepted that families who are viewed as having high expressed emotion have a higher relapse rate than the low expressed emotion families and that as the amount of contact time increases with such families, so does the chance of relapse (Kavanagh 1992). Acceptance that expressed emotion is an important theme in family work must not be lost and the addressing of it can become the rationale for family interventions.

Compounding influences Mental health workers with many years’ experience see trends come and go. If we are not careful, family interventions may be seen as a trend and this would be unfortunate. The development of the opinion that families had a role in the development of mental health emerged from the work of Bateson et al. (1956) and the discussion of ‘double-bind’ (where one message conflicts and invalidates a subsequent one). An example of this could be seen in a parent’s interaction with a child. A mother says that she loves her child while showing disapproval. The child is unable to comment upon this due to the dependency on her. Although anecdotally discredited as unresearchable by Abeles (1976), the work of Koopmans (1997) argues for the theory to be revisited due to the narrow focus of past attempts to understand the influence on children who developed schizophrenia. Family relationships were further explored, especially ones where ‘strife’ existed. Lidz and Fleck (1985) identified competition and hostility in families and looked at situations where the ideas of one parent were not addressed by a passive other. The importance of these studies is in the fact that the factors highlighted started before the

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THE EVIDENCE FOR FAMILY INTERVENTIONS

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birth of the service user. Therefore they could not have been a consequence of the behaviour of the service user. This unfortunately raises the issue of blame again, but care is needed by mental health workers. Blind acceptance of such ideas could lead to altered practice and scapegoating of families or family members. Our understanding of the factors identified gives us the opportunity to focus on tangible themes for therapeutic interventions. Just because the family worked in this way does not mean that they have done anything deliberate in order to cause harm to the service user. The fact that families have been identified as significant was highlighted only through the development of the illness. Many families with this pattern of behaviour have probably never come to the attention of mental health services.

Drivers The move of mental health services from hospital to community has gathered pace since the mid-1990s. The involvement of mental health workers and family members has become more commonplace yet limited help is offered. Predominantly help is singled out for the service user and the family are left to deal with the aftermath. Over recent years the government has made moves for families to be both recognized and included in the decision-making process. The advent of the carer’s assessment (Department of Health 1999) and the highlighting of what constitutes a good carer’s assessment (Department of Health 2007) raised the profile and rights of the family. Hand in hand with the increased rights is the demand for better services and a say in the way care is provided. Organizations such as Rethink (a UK charity) are at the forefront of moves to make services more transparent and collaborative. Implementation of guidelines published by the National Institute for Health and Clinical Excellence (2002, 2009) cover a range of treatments and services. Family interventions have become part of the guidance for working with people who experience schizophrenia (NICE 2002, 2009). NICE guidelines at this point argued that family interventions should be offered to 100 per cent of families where a family member has experienced an episode of schizophrenia. More recently NICE has developed a shared learning database with the Meriden Family Programme whose aim is to help services implement family interventions so service users and their families receive evidence-based care and support. The access to online information is an important part of this but only one part.

Service user and family involvement It is laudable that we promote the importance of the family, but we must not lose sight of the service user in all this. At some time in the future the service user may become so unwell that hospitalization may be considered. The family will need to know their rights and in particular the ‘nearest relative’. This person can apply for a service user to be detained or discharged under a section of the Mental Health Act (Department of Health 1983). Such decisions are never easy and families can feel disempowered at times with the merry-go-round of doctors and mental health professionals offering

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advice. What is clear is that families need an impartial advocate to support them. More importantly they need to have the knowledge to help them make sensitive decisions and not become scapegoated for their opinions. The families have a pivotal role at crisis times and their inclusion is imperative. For family interventions, it is at times like this when the family see the gaps in their knowledge and the need for family interventions is raised. Commonly referrals for family interventions are made when a service user has been admitted to hospital. Families are generally more receptive to support when their relative is (or has been) in hospital, and the important message that family interventions need to convey is often better received at these times. It is in these situations where knowledge of working with families and the understanding of issues such as expressed emotion and stress vulnerability are paramount. Understanding the crisis that has potentially precipitated admission to hospital and the need for both tact and diplomacy both go without saying, but appreciation of the events and the understanding that the family placed on them is vital. Care is needed not to overinquire yet you need to exude a level of interest. It is at these times that it becomes clear what could potentially be the families’ opinion about mental illness and their immediate needs become identifiable. At times families develop a tolerance of abnormal behaviour and accommodate this. What seems unacceptable to the outside eye may not be to those exposed to the thoughts and behaviours for a prolonged period. Care is needed not to demean the coping strategies and isolate families with their attempts to cope. Although risks need to be taken to accommodate some adaptive strategies, preservation of the relationship is important. After all it is important that the interests of the service do not detract from the lifestyle that the service user and their family may want. The preservation of the family relationships is an aim of family interventions as well as working together with the service user and family to improve their functioning on all levels. This functioning will need to encompass social skills, problem solving and education about the illness (to name but a few). If this aim is made transparent and the relation with service providers made collaborative the quality of life of the family and service user may improve. The improvement of quality of life issues will need to be measured and this may involve the use of a standardized tool such as the Manchester Short Assessment of Quality of Life (MANSA) (Priebe et al. 1999) in order to identify and quantify elements of life that may need improvement. The baseline measurement made at the outset can influence any joint programme of care and act as a future measure for improvement or deterioration. Another important factor is the overt design that the family intervention takes. The main crux lies in the domain of the service user and the family members engaging in treatment and having a say about what this may look like. Engaging in treatment and understanding principles such as normalization will allow them to make choices and take risks on their terms. The risk taking may include tolerating a level of illness that the service user and family accept, and could involve the notion that the service user may not be symptom free. The level and form of symptoms will be discussed in later chapters but will be established by the family worker being knowledgeable about various forms of assessment scales and having positive interpersonal skills. The family worker will need to

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understand key skills of discourse including counselling-type skills in order to develop core skills (see Box 2.1).

Box 2.1 Core Skills needed for family workers Carl Rogers (1951) advocated the following core interpersonal skills:

• • • • • •

showing acceptance being genuine having some form of empathic understanding having a level of congruence having unconditional positive regard listening and responding.

These core skills may help the flow of interchanges of communication and help the worker to deal with elements of resistance. Showing understanding and being genuine may seem to be basic skills; however, being able to demonstrate these attributes needs constant attention and vigilance. The complicating factor in this is that the worker needs to use the skills in conjunction with assessment scales while trying to maintain a flow that addresses the concerns and agenda set at the outset (this will be discussed further in later chapters). It would also set precedence for the underpinning style of interchange. The introduction of family interventions may be the first time that the service user and the family have had exposure to mental health workers. There is anecdotal evidence that getting it right first time may improve the prognosis for the service user. This is an underpinning ideology for the introduction of Early Intervention Teams.

Summary

• • • • • • • •

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Blame is an issue that can be felt by family members who have been insensitively worked with. Expressed emotion is a possible factor for relapse. Expressed emotion is affected in high expressed emotion families by increased contact. The issue of double-bind should not be automatically ignored. NICE guidelines argue that family interventions should be offered to 100 per cent of families where a member experiences schizophrenia. Care is needed not to scapegoat families for the illness and to blame them for coping strategies. Accept that families do not necessarily work as family workers do and may have skewed views of mental illness and coping strategies. The use of core skills will enable workers to ease the process of communication but there is a need to accommodate the style to ensure that assessment is addressed.

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Questions 1 2 3 4 5

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Name three components of expressed emotion. What is a double-bind? What rights does the nearest relative have in relation to the Mental Health Act 1983? Improving functioning will need the exploration of which factors? What factors do family interventions try to address at the outset?

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3 What are family interventions?

Aim The aim of this chapter is to position family intervention within the community, and detail the impact of expressed emotion on functioning.

Learning outcomes By the end of this chapter you will be able to: G

G G G

highlight the impact of government decisions on the families of people with a mental illness understand the concept and constituent parts of expressed emotion describe the notion of burden identify the need to understand and address expressed emotion.

Context (drivers and environment) The heightened involvement of families in the care of mentally ill relatives was directly affected by the decision to close large mental health units and move the residents back into the communities they came from. This has been an ongoing process since the early 1960s in Britain, and more recently under the auspices of ‘Care in the Community’. The deinstitutionalization talked about by Barton (1976) gathered a head of steam under the 1980s Conservative government with its attempt to mirror the events happening in Italy with Psychiatrica democratica. It was, however, not as visionary as Franco Basaglia, nor nearly as radical (see Box 3.1). The consequential structure may be sceptically viewed as a cost-cutting strategy and an opportunity to address a decaying and somewhat out-of-date system of care. This led to the breaking up of older large institutions and the implementation of resettlement of people who had lived in the large institutions for many years. Resettlement was a term generally used to operationally move people back to

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Box 3.1 Franco Basaglia Franco Basaglia was a prime mover in the enactment of Law 180 in Italy which effectively introduced the move from segregation of mentally ill people in large institutions to rehabilitation within society. In essence it moved to close mental hospitals and replace them with a community-based service.

their host district and transfer care and costs to that district. Many moved back to families, which worked well with the government ethos of family unity and responsibility. What it did do inadvertently was to refocus the care of mentally ill people back on to the family and loved ones and away from a purely segregated medicalized approach. In truth the closures had been going on for some time before these moves but at a very slow pace. Service users were moving out of hospital but limited expectations were placed on family members to care for the service user. Research had found throughout the 1960s and early 1970s that people who were discharged tended to return to hospital more quickly if they had moved back to the family home. This was finally confirmed by the seminal work of Brown et al. (1972) and their article where they identified that people with schizophrenia who were from high expressed emotion families (hostility, criticism and emotional overinvolvement) relapsed more often than people with families of low expressed emotion. This issue was largely missed by practitioners and policy makers. Therefore the opportunity to start to address family problems and the focus of therapeutic relationships and problem solving was not undertaken. Instead the focus moved onto the service user with symptoms. More efforts were put into the biological side of psychiatry and the engagement of families into a partnership with services was a rare event. The focus moved onto closing hospitals and rewarding the health authorities with a dowry for each person moved out of a hospital bed and returned to a community placement. Families were somewhat usurped into the caring role.

Community care and expressed emotion The move to a more community care focus clearly placed more emphasis on family support. The family became a key element in the support for people with mental health problems, especially longer-term mental health problems (Barrowclough 2003). This role is emphasized in the people who have just been diagnosed as mentally ill (first episode) with up to 60 per cent of these people returning to live with a family (Gibbons et al. 1984). Families who adopted the carer role clearly experienced change in the relationships between themselves and the service user, but also each other. The role they adopted (either paternalistic or nurturing) was never going to be easy. It could come at a level of cost that they could not potentially see at the outset. The level of stress that families in this situation found themselves under could be problematic (two-thirds of family members experience stress due to the role of caring for the mentally ill person: Barrowclough et al. 1996).

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The access to a hospital bed was reduced and more emphasis was placed on the family. Under-resourced community services responded by redeploying staff who had traditionally worked in institutions into community care work. These staff were often without the necessary skills to construct meaningful relationships between family and services. This new era of mental health care started to show what effects the movement of service users back to families was having. It unearthed more information that demonstrated the collision course that service users sometimes encountered with families and reinforced the evidence base of the theory related to expressed emotion. Expressed emotion is defined by Butzlaff and Hooley (1998: 547) as ‘a measure of the family environment that is based on how the relatives of a psychiatric patient spontaneously talk about the patient’. Expressed emotion was believed to have a variety of components; developed by the work of Vaughn and Leff (1976), three distinct components, hostility, criticism and emotional overinvolvement, were identified. This presents a frame to view family discourse and functioning. We now explore the Vaughn and Leff (1976) components in a little more detail.

Hostility When related to the disorder of the service user, hostility is seen in the form of blame. Commonly the family perceive the service user as being in some form of control over the path that the illness takes. At times the service user is held accountable and the level of blame is focused due to a perception of them not wanting to get better. Brewin et al. (1991) identify that where such hostility exists, families have a great deal of difficulty problem solving as the illness is the cause of most of the difficulties.

Criticism Criticism can be a combination of hostility and emotional overinvolvement. The tone and content of discourse is commonly seen as disapproving or rejecting of the service user. Vaughn and Leff (1976) presented it as a ‘clear statement of resentment’.

Emotional overinvolvement Family members will often blame themselves for the illness the service user has and will become overly involved with them. The service user is removed from responsibility and the family member will often argue that the service user has no control over the illness. This can become overbearing and the service user can at times be almost pitied. In some ways this could be seen as passive dismissal of service user opinion, and is not far away from the earlier two elements of expressed emotion.

Measurement of expressed emotion In research, measurement of expressed emotion is generally achieved using the Camberwell Family Interview Scale (Brown and Rutter 1966); however, this is a

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research tool that is not widely available for copyright reasons. The measure of expressed emotion can be subjectively observed by careful analysis of the discourse within a family and the exploration of the tone and content of the interchanges about the service user. Commonly the family worker will get a feeling that the relative is intolerant of the service user’s feelings, leaving them in a position of dealing with their own illness and the criticism of others who are potentially there to help them. High expressed emotion families tend to be quite narrow in their appreciation of the service user’s feelings and show signs of the factors highlighted before. They focus on the service user in an accusatory fashion, suggesting that they are often not trying hard enough and not controlling their illness. Criticism is almost seen as a way to drive change in the service user. The criticism is aimed not only at the illness but also at idiosyncrasies of the service user, and is therefore personalized. Low expressed emotion families tend to sympathize more and accept that the service user has limited control over their illness. Criticism is still there at times but is less pointed and personal. The difference in family expressed emotion level is argued by Weisman et al. (1998) to be due to the education level of the family and the general acceptance of the illness. Care is needed not to ignore the service user in all this and to ensure that they are not passive recipients of the criticism aimed at them by families. The effects are detailed later in this chapter, but the limited work that has been completed on the appraisal that service users make on criticism aimed at them is summed up by Cutting et al. (2006). They suggest that service user sensitivity to criticism was linked to stress. If a service user was aware and could identify expressed emotion issues in an ‘influential other’ and they had awareness of their own sensitivity to criticism, then they could predict potential stressful events. Such stressful events are commonly involved in relapse.

Why is it important to know if expressed emotion is present in the families I work with? Exposure of clinicians to families is becoming more commonplace. In the past the focus was only on the service user, and family members, maybe through fear of embarrassment, avoided contact with psychiatric services if at all possible. Contact that does occur is usually fuelled by the service user’s relative voicing concerns. Such interchanges should not be taken as read as a sign of high expressed emotion. In fact the interchange may adopt various roles for the participants and the initial encounters may give a false perspective on what is actually going on. The issue of interviewer effect and the disparity in power perceived by the relative may have an impact on what and how things are said. Regular contact with the family members with the service user present will start to give you more of an idea about how the service user is perceived and spoken to. Care is needed not to jump to conclusions on the evidence of one meeting. Service user report and exploration of familial beliefs about the illness can aid a better awareness of the level of expressed emotion.

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If expressed emotion is present at high levels, it is clearly linked to relapse of the service user (Vaughn and Leff 1976; Kavanagh 1992; Butzlaff and Hooley 1998). Other factors such as medication adherence have been looked at in relation to relapse. Medication still remains a first-line treatment in the UK for people with schizophrenia. It has been argued that adherence is needed for recovery, with poor compliance related to relapse (Gray et al. 2002). Families can have a positive influence on medication adherence (Mari and Streiner 1994) and expressed emotion does have an influence on compliance (Sellwood et al. 2003); these are important factors when working with families and identifying the level of expressed emotion. Another important element that needs to be explored is the amount of face-toface contact that the family and the service user have. In our own studies and research we try to avoid the pinning down of the amount of face-to-face contact and tend to hone in on the importance and impact of the carer on the service user. We believe that the amount of face-to-face time that relatives and the service user have is important, but we do not see it with the same level of importance as Vaughn and Leff (1976) did in their work. We perhaps pragmatically accept that we cannot truly understand the impact that short periods of time can have on relationships, but we do feel that some relatively limited face-to-face contact can cause upset and lasting damage in relationships. We also believe that when we look at the narratives that ensue, we can see that minor incidents can have a lasting impact on the understanding family members and service users have of the social world in which they live. This has a consequence on the relationships developed and the actions of each. Vaughn and Leff (1976) found that the longer the time of face-to-face contact, the more frequent the relapse. In their study they focused on the relapse rates within nine months of 128 individuals diagnosed with schizophrenia. Of this group 71 were assessed as being in low expressed emotion households and 57 from high expressed emotion households. Within the high expressed emotion households, there was a significant increase in relapse rates for those individuals who had face-toface contacts with family members over 35 hours per week (almost 70 per cent). This moves the discussion on to the effects of living with a person with a mental illness.

Burden It is accepted that over 80 per cent of people (friends and family) involved with someone with schizophrenia will experience some form of emotional or practical burden (Magliano et al. 2002). This burden presents as a loss in something or an unwanted change created by the presentation of the illness. This can lead to an altered level of quality of life for the carer causing changes in social activities and psychological distress (McDonell et al. 2003). It is unclear from research if the burden experienced is worse when overt positive or negative symptoms exist or when a mixture of both are present. What has to be accepted is that the presence of psychological illness leads to a level of upset and perceived heightening of a sense of burden in the carers. Provencher and Mueser (1997) identified that subjective burden (distress caused by disturbing behaviours) was related to both positive and negative symptoms. Objective burden (negative

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consequences caused by the reaction to the illness such as stress in the home) was related only to negative symptoms. When inability to control negative symptoms existed, carers reported higher levels of objective burden. The term ‘burden’ is somewhat pejorative as it suggests that the service user is a hindrance or problem to the family. The use of this term, although widely accepted now, still raises concerns about blame and that the service user is seen as a burden, therefore they are to blame for what is going on. This causal relationship we feel is reinforced by the term and is armoured by the view of burden being quantifiable in terms of objective and subjective measures. The identification of the specific areas where the service user has caused the family to miss out will only heighten difference and frustration. If not handled sensitively, blame and retribution can ensue. Although we use it in this chapter, we do not like the term ‘burden’, but we use it to represent the research and identification of themes found to cause problems for the family. Conversely the term ‘expressed emotion’ offers the alternative view that the families are to blame for the illness. If we accept that objective burden is a measurable disruption to the household caused by the service user’s reaction to illness, and accept that subjective burden is distress felt by the carer caused by the service user’s illness (hence reliant on objective burden), then we need to pose the questions shown in Figure 3.1 to establish legitimacy.

Figure 3.1 Crystal ball gazing (adaptation of themes identified from practice and the influence of George Szmukler 1996).

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This legitimacy is difficult to establish due to the variations in outcomes of life stresses or events. Therefore we find that families start to speculate over potential changes caused by the service user and their illness to their life and lifestyle. This ultimately leads to the circular argument of blame and the causal relationship of when anything goes wrong the default position becomes the service user and their illness.

Summary

• • • • • • •

Evidence produced by Brown and colleagues in the 1960s and early 1970s identified that people discharged tended to return to hospital more quickly if they had moved back to the family home. Families became a key element in the support for people with mental health problems, especially longer-term mental health problems and people first diagnosed with schizophrenia. Two-thirds of family members experience stress due to the role of caring for the mentally ill person. Families where hostility exists have a great deal of difficulty problem solving as the illness is seen as the cause of most of the difficulties. The presence of high expressed emotion can lead to the increased risk of relapse. Families can have a positive influence on medication adherence, and expressed emotion has an influence on compliance with such medication. Burden causes a loss in something created by the presentation of the illness, leading to altered level of quality of life. This leads to changes in social activities and causes psychological distress.

Questions 1 2 3 4 5

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The movement of people from mental health units into community care used which example from Italy? What are the components of expressed emotion? What tool can be used to measure expressed emotion in families? Define ‘burden’. What types of burden are there?

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4 Theories of family intervention

Aim The aim of this chapter is to outline the various theories of family interventions.

Learning outcomes By the end of this chapter you will be able to:

• • •

understand the key theories of family interventions describe the stages of behavioural family therapy start to identify the key components used within family intervention.

Introduction As family intervention work gathered pace in the 1980s, many professionals attempted to try out various formats to ascertain which would be more beneficial. There was no doubt that family interventions were successful (in lowering expressed emotion, reducing distress, reducing relapse and improving social functioning), yet which approach would be more effective? This chapter looks at some of the approaches that have been taken. The following list of approaches is not exhaustive but should give you an insight into the effectiveness of the various approaches to family work.

Behavioural family therapy Falloon and colleagues (Falloon et al. 1985; Falloon 1988) have been instrumental in developing behaviourally focused family work. Falloon and colleagues developed behavioural family therapy and found great success in this type of approach. Behavioural family therapy is a systematic and structured approach to single-family intervention. In behavioural family therapy there are six clear phases.

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• • • • • •

23

The first phase is concerned with collaboration or what they term ‘connecting with the family’. This phase is vital in developing working relationships and defining the importance of the family members in treatment. The second phase covers the assessment of the service user and family members. The third phase concerns the education of family members; it is argued that family members need specific information about the illness, and treatment of the illness. The fourth phase focuses on communication skills training, encouraging the family members to communicate effectively with a minimum amount of stress. The fifth phase focuses on problem solving training, the aim being to allow the family to work together in solving problems and being able to achieve goals. Finally, there is the termination phase. On average 15–30 sessions will take place, with the frequency reducing as the family start to work together, with an emphasis on regular family meetings without family workers being present.

The work of Falloon and colleagues was taken forward with the development of the Meriden Family Work Programme (www.meridenfamilyprogramme.com). Set up in 1998 one of the programme’s aims is to train clinical staff, service users and carers in the skills needed to work effectively with families. To date, the programme has trained over 2600 therapists in behavioural family therapy, and over 130 trainers/supervisors within the West Midlands area. Another, and vital, aim of the programme is to ensure that those trained are then able to implement the interventions by addressing some of the barriers that prevent family work from happening.

Multiple family group treatment McFarlane and colleagues (McFarlane et al. 1995; McFarlane 2004) carried out research into multiple family group treatment. In this approach families are first identified and then offered educational workshops, where clinicians present information about mental illness and the treatment of illness. This education is then followed up by regular meetings of multiple family groups, with the emphasis on family members developing relationships that are not centred on mental illness and family members sharing their experiences. Following this, problem solving groups are formed. McFarlane and colleagues’ research yielded excellent results compared to single family group psychoeducation, and is extremely cost-effective as many family members can be seen together.

A constructional approach Barrowclough and Tarrier (1997) provide a constructional approach to family work based on a cognitive behavioural framework. In this approach great emphasis is placed on the assessment of the problems. The service user and all family members undergo a thorough assessment. The approach identifies various assessment tools specifically designed for the assessment of relatives. Within the assessment the strengths of the

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family unit are gathered, rather than the focus being on the areas for intervention. Ultimately a thorough assessment provides the family workers with a broad picture of both the service user’s illness and the responses of each family member. This allows the family workers to ascertain how individual family members cope with problems associated with the illness. The assessments can take a great deal of time as each family member is assessed individually; therefore, the approach recommends the use of co-working to enable two workers to share the assessments. This approach allows family workers the opportunity to feed back to the family how well they are doing and promotes a strong collaborative process. From the assessment a formulation is drawn up and this is then fed back to all family members. Here family members are able to gain information from all the assessments and this frequently opens up the issues that are often unsaid. Interventions are then focused around education of the family members, the reduction of stress and helping families to promote the well-being of the service user. The thorough assessment enables the appropriate use of education and stress management as this has been identified via the assessment tools. Their approach also looks at the monitoring of early warning signs, advocating that the prevention of relapse is a vital area on which to focus. The approach is expected to take place over a nine-month period of time, on average, recognizing that some families respond more quickly, and some may take longer. The interventions derive from a large-scale research study of a family intervention programme in the Salford District Health Authority. This took place between 1982 and 1987 and showed favourable results in terms of relapse rates and improved social functioning (Tarrier et al. 1988, 1989).

Family work model Kuipers et al. (2002) offer a therapeutic approach that combines drug treatment in conjunction with family work. Their ‘family work model’ consists of a psychoeducational component followed by a structured family approach, again with an emphasis on cognitive behavioural therapy. The psychoeducational component consists of three components – an education programme, family sessions in the home and a relatives’ group. Their ‘model’ covers the importance of engagement of the family, and highlights the difficulty between working as a family worker and being a guest in a family’s home. Their approach discusses the importance of co-therapy and psychoeducation. They place a significant emphasis on improving communication between family members and highlight the importance of communication training. They promote the use of problem solving skills and also propose the running of a relatives group alongside the family work. As with any cognitive behavioural type intervention, the use of homework is important in this approach. Homework allows the family members the opportunity to try out what has been discussed in the sessions, without the family worker’s involvement. This is important as the family members need to continue to work together long after the sessions have finished.

An integrated family work model Smith et al. (2007) have developed an integrated family work model, based on a symptom-led approach. The model covers the assessment and needs of the service

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user and the family members. Their approach focuses on everyone’s strengths and they recognize the importance of independence and working at the family’s own pace. They propose a family meeting, an emphasis on education, coping strategy enhancement and problem solving. Finally they look at evaluation, and the offer of booster sessions if needed. They rightly promote the notion that family work must be individualized.

Summary

• • • • •

There are various approaches to family intervention. Success has been found in all of the approaches. There are various stages in behavioural family therapy. Working with single family units or multiple family groups has found similar success. Many of the approaches share common components within family intervention work.

Questions 1 2 3 4 5

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How many phases are there in behavioural family therapy? Who coined the ‘family work model’? Who worked with multiple family units? Who developed the constructional approach? What interventions were common in all these approaches?

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5 Key concepts in family intervention

Aim The aim of this chapter is to explore the key components of family interventions.

Learning outcomes By the end of this chapter you will be able to:

• • •

list the key components used within family intervention articulate a rationale for the use of each component present an argument to support the need for family intervention.

Introduction There is clear evidence that family interventions are effective and that various approaches have produced successful results. Yet, which components are most effective? It is clear from Chapter 4 that the approaches to family intervention were all different, though closer inspection does highlight the inclusion of key components in the delivery of the interventions. This chapter will draw on some of those key components in more detail.

Engagement It is vital that the approach to family work is seen as a positive approach and that family members are actively involved in the work. This cannot be done without the engagement of all family members. Often it is clear that several family members do not wish to engage with the process as they feel that they are not the ones needing any help. Blame is often attributed to the service user with the illness and family members struggle to understand why they need to be involved. Engagement with the family members is an important step, and one that should not be rushed. As with all of the approaches listed previously, the initial stage of engagement is a very important step.

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When engaging with a family, you need to be clear from the outset. You are entering into a group of people who have been together for a considerable number of years and you have to work hard to gain their trust: this may not be easy. A clear and open channel of communication is vital; they will want you to be honest and understanding of their situation. A clear rationale as to why you are there is needed. You will need to be open as to what your involvement will be, how long or how often you will be there, what is expected from them, who else may be involved, will they all have to be in the house at the same time each week, etc. This needs to be clearly explained as early as possible in order to gain their interest and engagement. You will be entering a household of people who will have formed their own family boundaries. A boundary in its simplest meaning is a barrier. The family will have developed their own boundaries over a number of years and these boundaries will be formed between all the individuals within the family. These will be ‘rules’ that the family will adhere to: how to address each other, what subjects are permissible to discuss (and what are not), and the use of swearing, etc. They will also have developed rules between themselves and the outside world; family ‘secrets’ that must not be broken, personal issues that are not for open discussion, etc. When engaging with a family, it is important to be aware that these boundaries exist. We do not ask that you completely understand what the boundaries consist of, but that you take this into account. An open and clear communication system is vital in this instance.

Co-working We advocate working in pairs where possible. This presents not only some positive aspects of family working, but also some potentially negative ones. On the positive side it means that there is an opportunity to share the assessment process and each family worker can assist with the assessment of different members of the family on completion of the Relative Assessment Interview (RAI) (Barrowclough and Tarrier 1997) and Knowledge About Schizophrenia Interview (KASI) (Barrowclough et al. 1987) scales. It also provides what Kuipers et al. (2002) advocate: a chance to model joint working and a cooperative approach. We would argue that it further provides the family workers with the chance to explore and utilize each other’s skills. This can enable skill development. After all we are not all masters of every skill, and this opportunity can give you the chance to see how others manage families, while also picking up on microskills in negotiation. The verbal communication and observational aspects of co-working give the family worker the chance to reflect on their own skills and try out newer ones, while having an observer to offer feedback on practice. In a way this heralds one of the dilemmas that can also ensue. No one is necessarily going to tell you that you did really well when in fact you made several errors. Co-working can be stressful and can feel as though you are on trial at times. This should be embraced as this is the form of live support that many family workers need to maintain and further develop their skills. Complacency when co-working has not been used can be a problem. If no one is there to advise you on your clinical skills, then it can be difficult to raise self-awareness to a level where self-clinical analysis can

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happen. Even when recording sessions, small details can be missed and when working with a large family, the sessions can become tiring and less well managed. Trust and the forming of alliances is another part of co-working, however, and working as a team with a clear objective is essential. For some co-workers, a clear script is used until confidence and trust are achieved. Once these are gained, more conceptual approaches and less defined roles can be used. Care is needed though to ensure that there is still a lead family worker and a co-worker. When working with a variety of families, the changing of role is advisable so as to aid skill development and feedback. We have always planned the sessions ahead; even with experience we do not neglect this element. Care is needed not to become too overconfident, and to ensure we have specific roles with each family. Discussing the content of the session shortly after a session enables accurate evaluation and detailed note keeping. Individuals will not have seen all that went on in the session and the sharing of information can point out deficiencies in action and skills to be developed. This also means that if a session was particularly stressful, support is on hand to examine some of the reasons for this. Just because a session became stressful should not mean that the family worker blames themselves. Careful re-evaluation of what went on is needed; if working alone, this can be a major shortfall.

Assessment Assessment is a must. Without an accurate assessment the whole intervention can go wrong. Although all the approaches that we have alluded to do not identify the assessment phase in their work, we feel that an accurate assessment is of particular importance. If we do not ascertain where to target the intervention, the intervention cannot possibly be of any benefit. There are many assessment tools that are available that will assist you within the assessment process. For the assessment of the service user, these include the KGV (Krawiecka et al. 1977) and the Brief Psychiatric Rating Scale (Overall and Gorham 1962). For the assessment of family members, there are the Family Questionnaire (Barrowclough and Tarrier 1997), the Relative Assessment Interview (Barrowclough and Tarrier 1997) and the Knowledge About Schizophrenia Interview (Barrowclough et al. 1987). For the assessment of everyone, there is the General Health Questionnaire (Goldberg and Williams 1988) and the Manchester Short Assessment of Quality of Life scale (Priebe et al. 1999). These are just some of the assessment tools that are available and we discuss them further in Chapter 9. What we strongly advise you to do is assess, assess, and assess a bit more!

Formulation Psychological formulations are central to the science and practice of cognitive behavioural interventions (Persons 1989). Formulations are more than simple enumerations of problems and cognitive processes. They are designed to provide a framework for understanding and explaining the mechanisms and processes underlying the

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observed problem in a particular case (Persons 1993). Developing collaborative cognitive behavioural formulations with service users with psychosis may be difficult (Kingdon and Turkington 1994). Individualized case formulations can be highly complex and change as the family worker gathers new information about the service user (Brewin 1988). Both the complexity and the changing nature of formulations may present difficulties for psychotic service users, who frequently demonstrate deficits in abstract reasoning, mental flexibility and comprehension (David and Cutting 1994). Information gathered from the assessments and ongoing information gathering enable both parties to create a shared understanding of the links between thoughts, feelings and behaviour, and as such provides a ‘map’ of the problem that helps to decide in which area interventions should be targeted (Persons 1989). Formulations are extremely important in family interventions. They take many forms and can vary from being highly complex in providing a complete overview, or extremely simplified providing a mini-formulation of particular problems (Persons 1989). We would argue that a formulation is vital in family interventions, and note that of the approaches identified there is only one reference to formulation, in the Barrowclough and Tarrier approach. We discuss formulation further in Chapter 10.

Education Of the approaches that we have covered, a common intervention throughout has been the use of education for family members. Some of the approaches are very structured compared to the others, yet they all note the importance of providing education regarding the illness and treatments available. Covering education ensures that all those involved in the therapy have a shared understanding of what they are dealing with. Education is a key component in family work. It is often surprising the limited amount of knowledge that the service user and family members have, regarding mental illness, treatments and resources available. What is also evident is that many family members have incorrect views on mental illness, and this is often as a result of finding out information from friends, or, more commonly, the internet. From our experience the sharing of clear and accurate information yields good results. We discuss education in further detail in Chapter 11.

Communication skills Several of the approaches have identified that disturbed patterns of communication can hinder any work and that this must be addressed. Communication is often a major area on which to focus the main components of family intervention. You might expect that families would communicate effectively; in our experience this is often not the case. It is important to look at how and why family members communicate, and to further explore what is said. Just to sit and listen to a conversation between family members can garner a great deal of understanding as to how the family function together. You might expect that members of a family would be polite, courteous and thoughtful of what (and how) they communicate with each other, yet it is often eyeopening to listen to some of the conversations. We need to remember that the family

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members may respect and love one another, but in a situation of high expressed emotion and intense pressure things are often said that may be out of character. There are many barriers and interesting communication patterns within families, and gaining an understanding of how this impacts on their day-to-day functioning is a key area on which to focus. Working with families to enhance their communication skills is an effective component of any family work and we discuss communication skills in more depth in Chapter 12.

Stress management Again, stress management was not common throughout the approaches, which we find a little surprising. Stress is a term that was originally used by Selye (1956) to describe the pressure that is experienced by an individual in response to the demands of everyday life. Although we all need stress (as without this we could not experience a sense of achievement) our ability to cope with this stress is compromised if we are under an amount of pressure that is far greater than what is considered ‘normal’. In this sense we could argue that being in a family with a service user with mental illness, and the possible high expressed emotion, is not normal, and will place demands on each family member. It is important to understand stress and to try to identify what is the underlying cause of stress within the family. It is useful to have an understanding of how a certain level of stress can improve performance, yet as this stress increases, performance gradually deteriorates. This can be seen in Figure 5.1 (based on Yerkes and Dodson 1908). As we can see from Figure 5.1, the way that stress affects people is highlighted at three key points: A, B and C. Point A refers to a low level (or no) motivation. Here there is low performance and low stress. Point B shows there is an increased level of performance and a fair amount of stress. At this point self-reward is achieved. At point C stress is increasing, leading to performance starting to depreciate.

Figure 5.1 The Yerkes–Dodson law.

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If we add the issue of vulnerability in here, we can see how important the emphasis is on stress management as an intervention. Everyone is vulnerable to the development of symptoms of a mental illness, some more so than others. Vulnerability is seen as related to genetics and acquired in nature. If there is mental illness in the family, you are more vulnerable than someone with no family history. Acquired vulnerability relates to the experience of life; this could be the interactions that we have during our adolescent years and significant life events. The main significant life events can be seen in Box 5.1, which ranks events in the order of potential severity (adapted from the work of Ambelas 1987).

Box 5.1 Ranking of life events 1 2 3 4 5 6 7 8 9 10

Death of a child Death of a spouse Imprisonment Death of a close family member Serious financial difficulty Miscarriage Appearance in court for serious offence(s) Failure of own business Marital separation Unwanted pregnancy

As we can see there are various reasons why we become susceptible to the development of mental illness. Add to this the component of stress and there can be seen a relationship between stress and vulnerability. Zubin and Spring (1977) looked further into this relationship and developed the stress–vulnerability model shown in Figure 5.2. As we can see in this straightforward model, everyone is prone to vulnerability, and the higher the vulnerability the relatively small the amount of stress that is required to place you over the curve, and create the potential for becoming unwell. A low level of vulnerability requires a higher level of stress to place you over the curve. Either way, keeping the level of stress to a minimum could keep you under the curve (well). We have to be mindful that everyone is unique and therefore a high level of vulnerability does not always equate to mental illness, otherwise there would be millions more people with a mental health diagnosis. We discuss the management of stress further in Chapter 13.

Problem solving Further to the need to manage the amount of stress is the requirement to focus on problem solving. This is best looked at once stress management techniques have been used, as the families will have started to look at coping strategies, and will be aware of some of their problems.

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Figure 5.2 Stress–vulnerability model.

Problem solving is a very common cognitive behavioural method of intervention (Hawton and Kirk 1998). This involves the identification of a problem, considering possible solutions, looking at the advantages and disadvantages of each solution, deciding which solution is most workable and discussing and deciding on what steps need to be taken. All families encounter ‘problems’ yet may not really know how to deal with them. Families have their own unique ways of dealing with problems, and in most cases this is usually effective. However, by adding in the situation of a person with a mental illness, and a high level of expressed emotion, the family’s ability to solve problems is usually compromised. Families can take years to perfect problem solving, yet when under considerable pressure this problem solving ability diminishes. The family members respond to solving problems through knee-jerk reactions, rather than positive problem solving. This can lead to burnout, which we discuss later in the book. By incorporating this problem solving approach, families will often feel that they are then equipped to deal with many types of difficulties that they encounter. We discuss problem solving in more depth in Chapter 14.

Relapse prevention Relapse prevention is not an area that many family intervention studies have addressed, and it is one that we feel is often overlooked. Often a fear for family members is that some difficulties will return, and that they will not know how to deal with these difficulties. Smith et al. (2007) do cover booster sessions, and Barrowclough and Tarrier (1997) address the identification of early warning signs in their approach. The relapse prevention approach that we recommend stems from the work of Birchwood et al. (2000). Their work on early warning signs is well regarded and is a straightforward approach to the identification of a relapse signature and the development of a relapse drill.

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In our experience we have found the use of a simple traffic-light approach to relapse prevention works well, and it is well received by service users and family members. We discuss relapse prevention in further detail in Chapter 21.

Summary

• • • • • • • •

Of the approaches used, there are common components within the interventions. Remember, assess, assess and assess some more. Assessment is vital. Education is seen as a vital ingredient in all family intervention approaches. Communication skills are required for families to work together effectively. Formulations are useful to the family members, as they help the family to understand what is happening. Families will undoubtedly experience stress. Problem solving is a common method of intervention, and we recommend this is started after stress management has been conducted. Relapse prevention work can be useful in family intervention.

Questions 1 2 3 4 5

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What is a formulation? Name the key components of family intervention. Who are the authors of the stress–vulnerability model? What is problem solving? Why offer relapse work?

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PART 2 Application in practice

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6 Dealing with the practicalities

Aim The aim of this chapter is to outline some of the challenges that we often face when starting to carry out family interventions.

Learning outcomes By the end of this chapter you will be able to:

• •

understand the need for careful consideration and planning of family intervention work articulate some key practicalities that need to be addressed.

Introduction It is a useful starting point to consider the practicalities of any family intervention work. Careful consideration of all the pertinent issues is vital, as this gives the family workers a balanced starting point. This chapter highlights some of the considerations requiring attention prior to carrying out any family work. Planning ahead is essential; addressing these issues earlier in the process will promote engagement and success.

Who should we offer family interventions to? In an ideal world the answer to the question ‘Who should we offer family interventions to?’ would be ‘To every family member who cares for someone with a mental illness’. However, in reality this cannot be the case. Many family members cope extremely well with the difficulties of caring for a service user and this should be acknowledged. There are many family members who do not want any involvement, and it would be extremely difficult to try to persuade these members to become involved. To offer a service where family interventions are not needed is an ineffective use of limited resources. Acknowledging where family interventions are not needed

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allows us to prioritize and this in turn results in better outcomes. It is worth explaining to all family members that the family intervention work can continue without their involvement, and they are always welcome to attend. We have found that this works well, and the benefits seen by other family members encourage involvement.

Should the service user be involved? Again, in an ideal world, the answer to the question ‘Should the service user be involved?’ would be ‘Yes’. The direct involvement of the service user can be pivotal, as ultimately they will benefit from the outcomes of the family work. The service user can be regarded as the key component in the family work, and they are in a good position to discuss their own symptoms and experiences of living with a mental illness. It is recognized that effective interventions involve the service user in at least some of the meetings (Fadden 1998). However, the focus is on the family members, and in reality family work can be carried out without the involvement of the service user (Smith et al. 2007). If this is the case, it is vital that the service user is approached and is able to give permission to discuss any issues pertaining to their illness. Care should be taken not to divulge any confidential issues that the service user may not want sharing with family members. We believe that it is essential that the service user is involved because there are positive outcomes when the service user is included in the work.

When to carry out family interventions We are often asked at what point family interventions should be offered. Should this be when the service user is unwell? Should this be when everything is going well? Or should this be when the service user and family are asking for help and support? The answer is all of the above. If the service user is unwell, this may be causing a great deal of stress to family members, and it may be the ideal time to carry out some family work. If the service user is well, again this may be an ideal time to address any issues that cause anxiety, and with the service user being well, they could be actively involved. If the family members and service user ask for family intervention, again this will be ideal, as not only are they wanting support (and are more likely to engage), but also they are positive about the notion of family intervention, and feel that it will help.

Where to carry out family interventions The setting for family intervention work is important. Careful consideration as to the venue and time is necessary in order to increase the likelihood that family members will engage in the intervention. A location near to a family home can be much better than an office that is miles away. It is often necessary to make appointments outside of normal 9–5 working hours, as family members will have jobs too. They may need to arrange for childcare, and transport may prove difficult. A family home is a good place, but interruptions (television being on, dog barking, telephone calls) often occur, and the less formal surroundings of a family home make the family members relax and they may revert to the routine of the household (putting the

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Table 6.1 Advantages and disadvantages of various settings Venue

Advantages

Disadvantages

Family’s own home

•

Familiar environment, family members will feel more relaxed No need to travel No need to arrange childcare Increased possibility of engagement

• •

Helpful if service user is an inpatient More formal to enable clear structure May be felt to be more formal and therapy-like

•

More formal to enable clear structure Neutral ground for family workers and family members

•

• • • Ward environment

• • •

Community-based setting e.g. general practitioner (GP) surgery, health centre

• •

•

• •

•

Less formal structure Family members might revert to own home routine Family members behave differently in the presence of the family workers

Travel arrangements for family members Ward can be disruptive May be felt to be more formal and therapy-like Travel and childcare arrangements for family members May feel stigmatized if living locally and being seen in community setting with mental health services

washing on, chatting about their day, etc.). Table 6.1 outlines the advantages and disadvantages of various settings. It is important to visit the home at least once to get a feeling of the surroundings in which members see each other as a family (Barrowclough and Tarrier 1997). You also need to consider the arrangement of the room that is to be used. The seating arrangements, in particular, need to be thought through, to enable an environment that is conducive to appropriate discussion and effective communication. The family worker and co-worker should not sit together, as this can be seen as very directive, and may affect the flow of open conversation. It can also promote a sense of division between the service user and family members and the professionals. Care needs to be taken when planning sessions to minimize disruption and also to ensure that any working out-of-hours policy is followed. If the session takes place in the evening, there should be a strategy or protocol for confirming that the family workers have finished and are safe.

How to start family interventions Even highly experienced practitioners will be wary of starting work that they have not carried out before. Working with a service user and family members can be extremely

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difficult and challenging, and the worker needs to be comfortable and confident in their approach. We address this further in the book, but we also advocate the use of co-working when engaging in family interventions. The support and sharing of work by two workers can make the family work seem less daunting and has the advantage of facilitating peer supervision in the process. It is a useful starting point to set ground rules (Kuipers et al. 2002). This involves allowing the family members to make suggestions that are agreeable to all. An agreement that respect is maintained and that everyone present is allowed the opportunity to openly discuss issues should be accepted. The rules for one person to speak at a time and confidentiality to be maintained are necessary, to enable progress to be achieved. It is also useful to discuss, and agree, what will happen if someone is not present, which inevitably will happen.

Summary

• • • • • •

Before starting with any family intervention work, consideration needs to be given to practical issues. All family members should be encouraged to become involved. The involvement of the service user should be maintained, although family work can continue without the service user’s involvement. The service user should be approached to give consent to discuss any personal issues. There are advantages and disadvantages for different venues, and care should be taken with this in mind. Ground rules are important, to enable the family work to be beneficial.

Questions 1 2 3 4 5

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Explain why the service user should be involved. Should family intervention work be started when a service user is in hospital? Give three examples of the types of venue that are available for family work. List three advantages and disadvantages of these venues. What ground rules should be considered prior to starting family work?

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7 Developing skills for family intervention

Aim The aim of this chapter is to outline the key practitioner skills needed for effective family interventions.

Learning outcomes By the end of this chapter you will be able to:

• • •

understand the use of skills, such as Socratic questioning, within family intervention describe the variety of skills implemented within family intervention sessions explore case scenarios and identify the need for self-assessment of own skills.

Introduction This chapter covers what we feel are the main skills required for successful work with families. The list of skills covered is by no means exhaustive; rather it is the skills we feel are most appropriate. There are many excellent texts written on skills, and we advise that you become familiar with some of these texts. Working with families is challenging and fundamentally requires a caring approach. A caring approach is acquired by developing trust, hope and confidence with those with whom you are working (Benner 1984). Practitioners should ensure that the individual and family members are able to see these essential qualities in order for the family work to succeed. In order to gain trust it is vital that you are completely honest throughout. If you arrange an appointment for a specific time, ensure that you are there at the right time. It takes a long while for the development of trust, so be clear with your intentions from the start. The family will hope that you will be able to help them. It is important that this hope is rewarded with small but significant changes. A quick way to instil hope is to

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find a quick solution to an area of concern. This could be giving some clear information or guidance with medication etc. Confidence is a skill that comes with both experience and knowledge. By having a good all-round knowledge of mental health diagnoses and treatments, you will be able to demonstrate a positive and confident approach to family work. The more experience with family work the greater the confidence – so keep working with families. Alongside caring comes compassion. Compassion involves being open to the suffering of both yourself and others (Gilbert 2005). The desire to appreciate the suffering of others and to work towards relieving this suffering is a quality that is fundamental to working with those in mental health.

Therapeutic relationships Hildegard Peplau (1952) was instrumental in recognizing the importance of the therapeutic relationship. In mental health you are dealing with very personal issues and a vital skill is that of forming, maintaining and ending the relationship. In order to develop a therapeutic relationship, a range of skills is needed. Carl Rogers (1951) promoted client-centred work and recognized the importance of the therapeutic relationship. His core principles are:

• • •

empathetic understanding – being sensitive to other people’s feelings genuineness – being aware of one’s own feelings, and being honest and open unconditional positive regard – being accepting of everyone, and recognizing that everyone has the right to receive respect and care.

Rogers (1951) was instrumental in recognizing the importance of the person in their care. His approach emphasizes that the individual is an ‘expert’ on their own problems, and that the role of practitioners is in guiding them to explore their own feelings, usually through reflection. Similar themes to Rogers’ work are incorporated by Gerard Egan (2002), whose work also looked at core principles (support, challenge and empathy) but he argues that the conditions are not sufficient in themselves. He acknowledges that problem solving is also required.

Interpersonal skills Ultimately interpersonal skills are the skills with which we communicate. Below are a list of several of these essential skills, but the list is not exhaustive. We draw your attention to other texts that primarily focus on key communication skills.

•

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Active listening – in establishing a therapeutic relationship we need to be aware of our own non-verbal communication. Service users and family members will be aware of the level of interest from practitioners and a lot can be seen via the nonverbal communication that we display. Maintaining an appropriate level of eye contact (not too little, not too much), being open and relaxed and facing the

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• • •

43

family members is vital. Without this you will struggle to maintain engagement with the family. Asking open questions – open questions are different from closed questions that require a yes or no answer. An open question invites a considered and deeper response. Reflecting – this demonstrates clear understanding, and shows that you are listening. Clarifying – this means checking out that you have all the necessary and correct information.

Socratic questions and guided discovery Socrates was a famous Greek philosopher (470–399 BC ) who educated his pupils by asking them questions. This approach encouraged the pupils to look more deeply into the questioning and made them explore ideas in greater depth. Greenberger and Padesky (1995) took this further to highlight the importance of guided discovery whereby the practitioner asks a series of open-ended questions that ‘guides’ the individual to ‘discover’ answers for themselves. This is much more effective than the practitioner giving the answers. In family intervention this is a relevant skill, but it takes a lot of practice and skill to master. Examples of Socratic questions are given in Box 7.1.

Box 7.1 Socratic questions What exactly does this mean? Can you give me an example? Can you rephrase that, please? What would happen if . . .? Can you give me an example of that? What alternative ways of looking at this are there? Then what would happen?

Specific session management skills Working with families within a time-limited framework requires good sessionmanagement skills. You are working with the family for approximately one hour per week, over a relatively short period of time. It is vital that this one-hour session is productive. Practitioners who regularly attend meetings, or who even chair meetings, will see the benefits of a properly facilitated meeting. Family members will often wish to discuss many issues; this could be a particular bad day, difficulties with the understanding of symptoms, questions from the last

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session or even general difficulties with household bills etc. While it is important to respond to the family’s concerns, you have to be mindful that you are there to carry out specific family work. For the specific skills detailed below, we give short examples with Peter and his parents as a family (see Box 7.2). The specific skills are:

• • • • •

setting an agenda involving everyone dealing with conflict collaborating setting homework.

Box 7.2

Peter and his family

Peter is 25 years of age with a diagnosis of schizophrenia, following an illness while studying at university four years ago. He is currently being treated with large doses of antipsychotic medication, the side effects of which make him drowsy. Peter lives with his mother (Ingrid, 51, a civil servant) and his father (Donald, 54, an accountant). There is constant friction in the household as Peter finds it extremely difficult to get out of bed in the morning.

Setting an agenda Agenda setting is a vital component of family intervention. Agenda setting requires you to ensure that you gain the most benefits from the session, and discuss items of priority.You have to be skilful in ensuring that both the family members and you place items on the agenda. Once you have agreed what will be discussed, it is important that each item is given sufficient time. It is useful to be open and to allow everyone to agree on how long to spend on each item. Inevitably there will be the situation where you may not have covered every item, so in this case you must be clear that any items not covered will be first on the agenda for the next session. Keeping to task and maintaining the focus on key issues is the foundation of a successful session. Example of setting an agenda An explanation of the role and structure of agenda setting is explored with the whole family for the first time. Family worker: Thank you for all attending this session today. You all have had time to consider taking part in family intervention and agreed to do so when we first met. Is that still the case? Mother: Yes, I certainly have but I am wondering how often we will need to meet as I need to get time off work.

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Family worker: Well, that would be something we can discuss together, but just before we discuss that, is everyone in agreement that you want to continue with family intervention? Father and son (Peter) both agree . . . Family worker: OK, in order to explore what you want to discuss within the sessions, the first thing we do in family intervention is to set an agenda. This is used to structure the time together and give you all time to offer things that you would like to discuss, and for me to also offer items for discussion. We can then decide which items we should explore together in order to get the most benefit from the time available. What I will do is write down the issue of how frequently we should meet, and on which day and at what time. Are there any other items that you want to put onto the agenda?

Involving everyone Involving everyone requires you to be mindful that all family members (and the service user) are included in the session. This is often a difficult skill, and the use of a co-worker will help to ensure that this happens. At certain points in the session it is helpful to ask the co-worker to summarize what has been covered and confirm that everyone is happy with this. Asking each individual member to add anything before moving on will ensure that, even if certain members seem quiet, their input is valued. Example of involving everyone This example illustrates the use of a co-worker to summarize what has been discussed. Family worker: Thank you all for your input. I will ask my colleague to summarize where we are up to. Co-worker: Yes, thank you. So, just to sum up what has been discussed here today. There seems to be a situation when Peter does not get out of bed for a certain time. This then leads to arguments between everyone. Would you all agree that this is correct? Mother: Yes, that is true. Co-worker: And do you [Father] agree that this is the case? Father: Well, now you put it like this, I feel that it is. Co-worker: And Peter, do you feel that this is a true account of what is happening? Peter: Yes, I feel that when I cannot get up, then this causes a great deal of arguing.

Dealing with conflict Dealing with conflict is an area that nobody wishes to experience but is nonetheless a vital skill. You will be discussing difficult situations and this will bring up certain emotions. It is imperative that the session flows well, and that any conflict is addressed and the family move on.

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Example of dealing with conflict This example concerns the issue of Peter being unable to get out of bed. Father: He’s always lying in bed, he’s lazy. Mother: No, he is not. It’s the tablets that make him tired. Family worker: It seems that this is an area that we all could look at, and discuss in more detail. Peter, do you agree that this needs addressing? Peter: Yes, I’m not lazy, he thinks I am. Family worker: OK, do we all agree that we can discuss this further? Mother: Yes, definitely. Father: Yes. This issue of dealing with conflict (and problem solving) is acknowledged as a strength within the family.

Collaborating Collaborating is considered by us to be the most important skill within the sessions. The ultimate aim of family intervention is to equip the family to be able to apply techniques within their everyday lives, which enable them to function as a family. Therefore, everyone working towards this in a purposeful way requires good working relationships. Example of collaborating The example is working on the same issue, of Peter being unable to get out of bed at a certain time. Co-worker: So, to summarize. You all feel that you will try and look at how you react if Peter is not out of bed by 9 o’clock? Mother: Yes, I will be careful not to argue. Peter: Yes, I will try to get up, but sometimes I just can’t. Co-worker: And you [Father]? Father: Yes, it does cause arguments, but I will try and look at how I react. I know he does not do it on purpose, but it drives me mad. Family worker: Great, so we all agree to try this approach? It is then acknowledged that Peter and his parents are working together.

Setting homework Homework – it is widely accepted that family intervention does not just happen within the one-hour session and that the skills and benefits seen in the session need to continue on a day-to-day basis. It is the purpose of family intervention work to equip the family members with all the necessary ‘tools’ to enable them to continue

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functioning at an optimum level long after the family intervention work has finished. Therefore the setting of homework (or between-sessions tasks) is needed (Beck et al. 1979). We feel that homework is an essential component of family intervention work, because not only does it test out the work completed in session, but also it measures motivation to change. As a practitioner you need to carefully select appropriate work to be carried out when you are not there. On setting this homework (collaboratively) you need to ensure that the family members feel that they can achieve what has been agreed. Within the next session it is important that this work is then discussed, looking at what went well, and the outcome of any intervention set. Example of setting homework In this example the family worker suggests some homework for the family. Family worker: One of the things we agreed at the outset was that we would conclude with some tasks for the next time we met. From today is there anything that you feel you may need to do? Father: I suppose I should look at how I react to Peter when I speak about getting out of bed. Mother: Well, that might be because he is stressing you out! Family worker: Well, perhaps one of the things you will need to try to do is to write down some of the ways that you react to Peter when he does not get out of bed, and how that feels for you. Do you feel that you could do something similar, Peter, in writing down how it feels when your father starts to shout? This information then becomes an item on the agenda for the next sessions. Feedback is given on what the family had found and then explored in more detail.

Ten essential shared capabilities In 2004 the Department of Health published the ten essential shared capabilities (ESC) for mental health practitioners. This publication followed consultation with service users, carers and practitioners and highlights the key capabilities that all mental health practitioners should possess (Department of Health 2004b). It is heartening to see the mention of families and carers in nearly all of the ten capabilities, with the only exception being ESC10, which is regarding personal development. As practitioners these ten capabilities are of great importance, and should be demonstrated by anyone working within the mental health arena. The ten essential shared capabilities can be found in Box 7.3.

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Box 7.3 Ten essential shared capabilities 1 Working in Partnership. Developing and maintaining constructive working relationships with service users, carers, families, colleagues, lay people and wider community networks. Working positively with any tensions created by conflicts of interest or aspiration that may arise between the partners in care. 2 Respecting Diversity. Working in partnership with service users, carers, families and colleagues to provide care and interventions that not only make a positive difference but also do so in ways that respect and value diversity including age, race, culture, disability, gender, spirituality and sexuality. 3 Practising Ethically. Recognising the rights and aspirations of service users and their families, acknowledging power differentials and minimising them whenever possible. Providing treatment and care that is accountable to service users and carers within the boundaries prescribed by national (professional), legal and local codes of ethical practice. 4 Challenging Inequality. Addressing the causes and consequences of stigma, discrimination, social inequality and exclusion on service users, carers and mental health services. Creating, developing or maintaining valued social roles for people in the communities they come from. 5 Promoting Recovery. Working in partnership to provide care and treatment that enables service users and carers to tackle mental health problems with hope and optimism and to work towards a valued lifestyle within and beyond the limits of any mental health problem. 6 Identifying People’s Needs and Strengths. Working in partnership to gather information to agree health and social care needs in the context of the preferred lifestyle and aspirations of service users, their families, carers and friends. 7 Providing Service User Centred Care. Negotiating achievable and meaningful goals; primarily from the perspective of service users and their families. Influencing and seeking the means to achieve these goals and clarifying the responsibilities of the people who will provide any help that is needed, including systematically evaluating outcomes and achievements. 8 Making a Difference. Facilitating access to and delivering the best quality, evidence-based, values-based health and social care interventions to meet the needs and aspirations of service users and their families and carers. 9 Promoting Safety and Positive Risk Taking. Empowering the person to decide the level of risk they are prepared to take with their health and safety. This includes working with the tension between promoting safety and positive risk taking, including assessing and dealing with possible risks for service users, carers, family members, and the wider public. 10 Personal Development and Learning. Keeping up-to-date with changes in practice and participating in life-long learning, personal and professional development for one’s self and colleagues through supervision, appraisal and reflective practice. Source: Department of Health 2004b

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Further skills As family intervention work is based on a cognitive behavioural therapy (CBT) approach, it is worth looking at the checklists and rating scales that are used for those practitioners who undertake CBT training. The THORN initiative trainees were assessed by using the Schizophrenia Family Work Scale (Devane et al. 1998). Trainees in CBT are routinely assessed through the Cognitive Therapy Scale (revised) (Blackburn et al. 2001). We recommend that you review these assessment tools, for further skills development.

Assess yourself All of these skills require a great deal of experience and practice. Self-awareness of your own skills, strengths and weaknesses is a good starting point. Being aware of your strengths (and limitations) allows you to pay particular attention to areas for development. This awareness is helpful when co-working in family intervention work. Working alongside another practitioner enables the two of you to work towards your particular strengths and fosters a close working relationship. Table 7.1 allows you to self-assess where you feel that your skills are lacking or need improvement. Please take a few minutes to look at the selfassessment and honestly answer each question. You could also list your strengths and weaknesses.

Practice makes perfect With any skill it is beneficial to practise, practise and practise some more. This is best achieved through role-playing in a safe setting, which allows you to test out your skills in a supportive environment, and has the added benefit of the views and feedback from colleagues. Box 7.4 highlights the opportunities for role-play.

Table 7.1 Self-assessment of skills How would you rate yourself on the following?

• Confidence • Ability to collaborate • Keeping to task • Ability to form relationships • Session management skills • Interpersonal skills Strengths Weaknesses

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Box 7.4 Practice scenarios for role-play In order to develop your skills it is useful to practise in a safe setting. It is extremely beneficial to role-play situations that you may encounter in family work. In groups of four (or more if possible), take turns to be the family worker, the co-worker, the service user and the parent. Any additional people can role-play other family members. Imagine situations that you may encounter, and role-play the various parts. It is ideal if you are able to capture the session by recording it. This allows you to watch the recording, and pause at key points in order to discuss what went well, what could be improved, etc.

Various roles Within family intervention work you will be undertaking various roles. These include the roles of educator, facilitator, problem solver and modeller.

•

• •

•

The educator role requires the skill of carefully and considerately sharing information in a clear and understandable manner. The sharing of this information must be clearly communicated and at a level appropriate for the needs of the family members. The facilitator role fundamentally has the necessity for good management-type skills. Being able to carefully and skilfully conduct the sessions takes a great deal of practice. The problem solver role requires a considerable amount of skills in being able to understand what is the underlying problem, and then to suggest possible solutions to the problem. This is not an easy role as families often feel that what you see as a problem is indeed wrong. The modeller role requires the skill of being able to display attitudes and behaviours that you require from the family members. You are modelling the attitude and the behaviour that you feel the family members should be displaying.

All of these roles are discussed in further depth in later chapters.

Summary

• • • •

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There are many skills that are required for successful family intervention work. A caring approach is a must, and this encompasses many qualities. Setting an agenda is important in order to gain the most from the family intervention sessions. Setting homework is important to enable the service user and family members to try out what has been discussed within the sessions.

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• • • •

51

Collaborating is vital, because you need to work together. You will undoubtedly already possess many of the skills needed, and others you will gain with experience. Self-assessment is an important area.You need to be aware of your own skills, and any areas for development. Role-playing will enhance skills development, and allow you to look back and critique your own skills. If possible it is worth recording practice scenarios.

Questions 1 2 3 4 5

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What does caring encompass? Can you name three interpersonal skills? What specific skills are needed to manage sessions? Can you name any of the ten essential shared capabilities? Where would you look for further skills?

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8 Engaging families

Aim The aim of this chapter is to explore the variety of ways that engagement can be employed in family intervention, and identify any obstacles.

Learning outcomes By the end of this chapter you will be able to:

• • •

detail a rationale for engagement with family members describe the benefits, and risks, associated with engagement in family intervention identify the steps that could aid engagement and getting started with family intervention.

Introduction Engagement is probably one of the main stumbling blocks encountered in therapy. It involves not only getting the family involved but also keeping them involved. Many family workers often assume that once the family members are engaged, that will continue throughout the time together. This chapter explores the issue of engaging families in more detail.

Engagement dilemmas Engagement can be seen by novice workers as a given. The family will agree to see them and therapy will happen. Next, work will continue, and then therapy will end. Some families will engage and work in a focused way that will make the therapy pretty straightforward. Others may not engage in such a seamless manner and the family worker should question why this is. Some family workers ignore this presentation and plough on regardless, while others explore the reasons why.

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The main problem with carrying on regardless may be that the family members start to drop out of sessions and then disengage. Dealing with the situation and exploring the reasons can be problematic. For family workers who are not very experienced or who have skills that are limited, it can feel that the family members in question are not trying. The consequence of this assumption could be that the workers cast a level of blame for the family problems onto those members and use this as a justification for any breakdown in communications. Further assumptions about dysfunction and the level of expressed emotion will invariably follow. This could lead to the family feeling to blame for what has happened and could create divisions within the family about both therapy and the service user’s illness profile. Care is needed not to imply blame; if the family workers start to feel that this may be happening, reflection on the approach and strategies will be needed. Deeper consideration about bounded rationality and the level of second order intelligence must be looked at (see Boxes 8.1 and 8.2).

Box 8.1 Bounded rationality Bounded rationality assumes that humans are not completely rational in their decision-making and that this can be adaptive. For example, it may have greater utility to make a decision on less information rather than expend time and energy on accumulating more information of marginal utility. Source: Gigerenzer et al. 1999

Box 8.2 Second order intelligence – the programmed intelligence It is what you were trained or conditioned to do. It is your mechanical mind or cultural conditioning. Self-consciousness is often helpful during any professional training, and then the behaviour becomes automatic. Examples:

• • •

Stop at red lights when you are driving – go when it turns green. Solve maths problems accurately. Follow the rules of grammar in your local language. Source: based on http://thirdorderintelligence.com/what/what.htm

A knee-jerk reaction may be to become ‘stricter’ to the process of family work and potentially change the flow and relationships established. This in itself can be problematic. It is important that if engagement is being compromised by a rigid adherence to process, then at some time a decision is needed as to when to move on and not to become difficult to the family. This is not arguing that the process is not important, rather that it can be worked on as you progress from some simplistic work if that maintains the involvement of the family.

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Non-engagement The family members not engaging is often an excuse used by family workers when they struggle to start off the process of family intervention work. Not engaging can be a damning label and the reasons for non-engagement are complex and should be explored. Meeting with the family and developing a working relationship presents the first hurdle – the positive notion that everyone will want to work with the family workers. This is not necessarily the case, as Kuipers et al. (2002: 13) point out: ‘It is very likely that a family will be reluctant to engage in treatment. There may be a history of unhelpful previous professional contact, actual or perceived’. The history may be nothing to do with the people involved on this occasion, but if previous contact with the service had occurred, and been negative, then there is a possibility that their reluctance may be legitimate.

Steps to engagement Developing a therapeutic alliance (as with a service user) is an important first step. The understanding of the structured nature of family intervention and need for all parties to be involved lends itself to the Bordin (1979) notion, that three key components are needed in the relationship – goals, bonds and tasks. These are mutually constructed in the form of: G G

G

the sharing of goals across the family the recognition of tasks that each person will need to do in the relationship that will develop the development of an attachment bond between them.

Falloon et al. (1993) argued that for any intervention programme to work, each member of the family will need to have commitment to the process and will need to aim to attain their own personal goals through the process. The risks of engaging are listed in Box 8.3.

Box 8.3 Risks of engaging

• • • • • • •

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The therapy may cause an upset to the present coping strategies. The family members may feel blamed for the problems. It may take effort and time to engage, and this is only the start. The service user may become too stressed and relapse. Therapy can get into the cycle of going through the motions and realistically the family are not that committed: the question is ‘What are we doing here?’ Undue pressure on family members: ‘If I don’t take part then it will look like I am not interested.’ Ultimately there can be a fear of change.

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Engagement starts very early on and is an ongoing process. As indicated in earlier chapters, engaging is usually started at the point of a crisis. Contact with the family workers is commonly measured by chance encounters and by non-traditional contact (Kuipers et al. 2002). The brief contact when seen on a ward or a telephone call handled by the family worker all add to the benefits of engagement. Naivety concerning engagement, believing that this starts only when we want it to, needs to be challenged. If family members have seen the workers, and already started to form some ideas about them, this may influence future contact. They may have preconceived ideas about the treatment process and may have hidden agendas between individual members of the family. To say that engagement is simple is not true. In later chapters the themes of assessment are discussed but at this point it only needs to be said that the assessment process itself can be an engaging process as well as a cathartic one.

Aims of engagement One of the main aims of the process of engagement is to offer a positive view of the rationale and aim of therapy. The engagement process, although at times potentially strained, if persevered with and flexible, can set the ball rolling in therapy. Much of the fact finding about each other is done in the initial interchanges between family members and workers. Much of what transpires is assessing each other informally and testing out the level of trust that each can place on the other. Trust should not be expected and needs to be earned. Trust cannot be established purely on professional status. Regardless of who you are, you must not make assumptions about the family trusting you. A tolerant and flexible approach is needed early on as in the forming stages of any therapy individuals that have their own agenda eventually play their hands. This may be in the form of not turning up or being deliberately disruptive. The management of these situations can lead to continued therapeutic work or the end of it. We do not suggest that you should be at the beck and call of the family, merely that you remain tolerant of others at the outset. Remember they are taking the risks in this therapy and you are a facilitator. At preliminary meetings, informality can ease engagement, but structure and process will need to be discussed and be evident. Occasionally one of the workers may know the family well, which can be a positive and a negative thing for therapy. Care is needed not to make assumptions or to be overly friendly as this may affect the way the family work within sessions. It may also negate the influence of the other worker and lead to messages being missed by one of them.

Identification of barriers Initial stages of engagement need to identify barriers to therapy and especially to the workers. It is better to sort out differences in opinion and any worries that exist early on. Ensuring that this is done is important as when they appear again later, they may affect the flow of the work being completed or bring into question the efficacy of the work completed. Tackling barriers and conflicts at the outset are important. Expecting them to just go away is naive. Clarity of the process and the need for knowing what has happened in the past will lead to the work not falling foul of

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historical or personal dislikes. Repeated mistakes in this regard will lead to disengagement. There will come a point with some families where their ambivalence to family work becomes so obvious that the workers may have to accept that therapy at this time for this family is something that is not going to work. What is important is that the workers have explored some of the most pertinent issues:

• • • •

What are the barriers perceived by the family? What are their fears for therapy? Is it something to do with what the workers have said or offered? If they change their minds at a later date, can they still access help?

It needs to be said that family work is not for all families. If the family does not want to do the work, then at least leave them with the opportunity for contact in the future. Some families are difficult to engage at the outset, never return calls or avoid contact, even though they initially showed interest in the therapy. The workers, as already discussed, should not lightly concede that the family do not want to work; with busy and tight schedules of therapeutic work it may feel like an easy option to accept, but this should be avoided. Before giving up the workers need to have reflected on their attempts to engage the family and answered some of the following questions (abridged from Kuipers et al. 2002):

• • • •

Did the family workers send out individual letters to each person offering a timed and dated meeting to discuss therapy? Is a request for the family to contact the workers to confirm attendance attached? Did they try to contact the members by telephone to check they had received the letter and were attending? Is there someone the family trusts, other than the family workers, who might act as an intermediary for the family to discuss the work further and explore ambivalence?

These are important issues that need to be addressed. Careful planning and having an agreed portfolio of the process that can be adopted is necessary. These attempts to engage the family may have a partial effect. Sometimes at the outset only a couple of the identified family members attend. The others may, for their own reasons, avoid or not want to commit to the work. Efforts should still be made with those not attending to keep them up to date as far as possible and leave the door open for them to attend at a later date. With time this could become more difficult. Other family members may start to drop out of the sessions after showing interest and attending. These members should be contacted and asked politely why they are having problems attending. It could be something very simple like work commitments and a change to the timing and venue of the meeting could be considered. When only part of the family unit are engaged in the therapeutic work, it needs to be said that the outcome may not be as effective. However, the work should still

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continue. It is important that the work is not stopped for a couple of people who cannot make the meetings. Others can try to keep them up to date, but as before this may be problematic and difficult. If the service user is the person who is avoiding the meetings, then you need to explore why. This may be due to a relapse or a misperception regarding the work. It may be that the service user feels totally overwhelmed by the work. Whatever the reason they should be encouraged to attend and any perceived difficulties can be openly addressed. It could be a simple misunderstanding or something as serious as a conflict or actual fear of a relative. This will draw into question the assessments completed at the outset and reinforce the need to have accurate and detailed assessments of all the people to be involved. Although the assessments are discussed later in the book, it is an opportune moment to discuss the assessment of the service users, and then relate this to the issue of engagement. The need to assess symptoms leads to the use of a symptom rating scale. We generally use the KGV (Krawiecka et al. 1977) as a starting point. We prefer any workers who are working with the service user at the time to complete the assessments with us as it is generally a more comfortable atmosphere and one where the service user may feel less on trial and potentially more able to talk freely. Using a symptom rating scale gives the opportunity to establish a baseline of symptoms prior to therapy. This can then be contextualized with life events and perceptions regarding understanding related to treatment and family reaction. The KGV (Krawiecka et al. 1977) is our preferred choice because of the timeframe of one month for symptom assessment and the detail it enters into. The KGV is explored in further detail in Chapter 9.

Assessment effect on engagement The effect can be several fold on the issues related to engagement. The service user completing the KGV (or similar symptom rating scale) may be experiencing such an interview for the first time. Although quite time-consuming (in some cases), the level of detail and opportunity to elaborate on specific questions may never have been offered in the past. The process can be quite cathartic and also educative. Symptoms that are discussed show a level of interest in the service user possibly not shown before. The time and detail of questions being used can help to establish a bond between the interviewer and service user. Many of the service users we complete the KGV with suggest that we are taking them seriously and although not always liking the questions, they can understand the need to follow the process. Some indicated to us that they didn’t realize that some of the symptoms we elicited together were actual symptoms and others were able to feel a sense of relief by telling it all. Much of the engagement comes from the sharing of personal information and the need for the interviewer to display humanistic qualities. Paraphrasing and offering some personal feelings of the interviewer are essential. In one interview we conducted we asked about visual hallucinations. Family worker: Have you experienced any unusual visual experiences recently? Shelly: In what way?

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Family worker: Things you have seen that you are aware that others have not been able to see. Shelly: I did see blood running down the wall last night. I told Graham [her husband] that I had seen this and he said that he couldn’t see anything and to stop looking. At first I thought he may have killed someone upstairs and it was their blood and he didn’t want me to find out, but I realized that we had been out all day together and this could not have been the case. Family worker: This must have been very frightening for you. Shelly: Well it was and I kept thinking about it, but dared not to look again while he was there. Family worker: Well, if I was seeing that I probably would have felt anxious and wondered as you did where it had come from. But I would have probably had to have had another look. Shelly: I did after about 30 minutes when Graham went to make me a cup of tea, but it had gone. Family worker: How do you account for this? Shelly: I don’t really know. I suppose it could have been an illusion but it was bright red and running down the wall. It certainly looked real. Family worker: Has this happened before? Here the narrative demonstrates how the interviewer showed interest and concern using his own feelings as though he had been present. This is not allowed to detract from the flow of the interview, however, and he quickly (when appropriate) refocuses on the frequency of the hallucination. The feedback from the service user was very positive and this information was used in the larger family sessions for education elements about symptoms and for exploration of how family members may have felt when seeing something like this themselves. It led to a greater understanding of the distressing symptoms and why at times the service user spoke and behaved the way she did. It led to a strengthening of the bonds between the members and continued attendance by all those present. The maintaining of family members’ attendance is a consistent problem, as stated earlier. Exploration of potential barriers is an important component of the maintenance of therapy. There are four key elements discussed below. Some of these were explored eloquently by Kuipers et al. (2002) and we have expanded on their themes and advice following our many years of practice and adoption of our way of facing such dilemmas.

1. In the past the family or family member had a bad experience with service providers It is important for the family workers to explore past contact on an individual level and then on a group level. Contextualizing what happened is needed and then examining how this may influence the person’s belief about therapy and commitment. It is a fine balance of washing your hands of problems and casting blame on to others compared to accepting that as workers you are part of the system, but not necessarily in tune with the decisions that were made before. After all it has to be accepted that decisions were made for a reason and that in hindsight the same decisions may not be

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made again. Listening and showing understanding of the level of upset or even anger may help to show that you are sympathetic but unable to change what went on through their eyes. Acknowledging what happened is a first step; identifying if it will happen again needs to be looked at. It is important not to say that this would never happen again as you have control of only your actions and not of others. At a later time this could be looked at through the problem solving sessions and a strategy adopted.

2. Unattainable expectations for therapy Commonly some family members put all their eggs in one basket and engage for a short time, or until a time when their expectations are not being met. Clear messages about what therapy is about and what it may attain should be given. Care is needed not to get people’s hopes up about major changes and participants should be informed that effort and commitment is needed for anything to alter. Exploration of the history and the level of expectation, and why they need such a level, should be entered into. Setting unrealistic goals will ultimately cause problems for the family member and then the service user. Realignment is needed but careful monitoring for changes in the expectations is warranted. Often a member will agree to realign expectations but insidiously move the boundaries towards their original expectation, only to feel that therapy has not met what they wanted. Refocusing onto the service user and the changes made may help.

3. Underlying mental health problems with other family members Sometimes other family members will have underlying mental health problems and these may create a distraction to the original focus of therapy.Therapy should continue but time out to deal with the other issues may be needed for that individual. The impact that their illness has, and having multiple members with mental health issues, needs to be investigated as to the impact on the family structure, decision-making and functioning. Signposting for help and adhering to the process of therapy is important to present the consistency for all concerned. Care is needed for workers to reflect on what was happening and whether therapy could continue in its present form with multiple problems being presented.

4. Inability to accept that change is happening Inevitably, change can be very slow and family members do not see change happening. At times like these, returning to the baseline results of assessments can remediate the problem. There are, however, some family members who may want change in a more immediate and substantial form. They may need to have time with the workers exploring what change is and how it can be very slow. Highlighting the changes made will often derive only some short-term relief. Repeated questioning and returning to this theme may be something that has to be accepted and reiterating the changes by the workers made. Care is needed not to allow these people to become ostracized by the rest of the family or become so dominant that they affect the continuation of therapy. Management of such events is an intrinsic skill that is developed with time.

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Getting started Once all the contacts have been made and those who want to attend have made it clear then the first full session can start. This will involve the establishment of (in front of all parties) the goals of the therapy, the role of the workers, touching on expectations of participants and how the sessions and therapy will be conducted (a case study in Chapter 15 addresses some of these themes). This is a good time to reassess commitment but an expectation has already been made that through attendance they want to take part. The lead worker can usually offer some opening comments in order to get things going in the large group: It’s great to see you all and I must thank you for your time already given in order to get to this point. I will need to just go over a few themes that are important about the therapy. We will also be happy to answer any questions that you have and clarify anything that you are unsure about in the therapy. Asking questions is important as if you are unclear about something then if you keep quiet you may never get the answer and this would be both a shame and present a gap in your knowledge and understanding. I will just outline the themes of the therapy . . . Does anyone have any questions? This presents the position of getting going with therapy and the issue of engagement needs continual monitoring throughout the time together.

Summary

• • • •

Engagement is an ongoing process and is an essential component of family work. Care is needed not to take it for granted that everyone will want to participate. You will need to look at the ways that you work and have been trained to ensure that you are not making assumptions and are working with the issues raised by the family. Assessment can help to engage the family but awareness of what the family want and their own personal expectations can lead to the therapy remaining a fairly bespoke experience.

Questions 1 2 3 4 5

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Identify four key barriers to engagement. What are the key components of developing a therapeutic alliance with the family? What is to be gained in using a symptoms rating scale with the service user? What skills do you believe you will need to possess to engage a family in therapy? What risks might the family perceive when engaging in therapy?

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9 Assessment and family intervention

Aim The aim of this chapter is to introduce you to assessment of the service user and family members.

Learning outcomes By the end of this chapter you will be able to:

• • •

understand the rationale for assessment describe a range of assessment techniques applicable to family intervention be able to list, and detail, specific assessment tools currently in use, and available for use, in family intervention work.

Introduction This chapter looks at the nature of assessment and introduces the use of a timeline, genogram and sociogram, and a few of the many assessment tools that are available. We can think of assessment as the foundations for building a house – the foundations provide a structure for the remainder of the house, and are crucial to the success of the building. Similarly the assessment process provides a structure for the intervention, and is a crucial stage, because without an accurate assessment the intervention could be totally ineffective. The assessment stage is a vital stage and as such should not be rushed. We appreciate that the assessment process can be extremely time-consuming and, at times, frustrating (you feel that you know what needs doing and want to get in there to put things right) but taking your time and working through the assessment can also be rewarding. It is surprising how often the assessment can be seen as an intervention in itself. Discussing issues in a calm and inquisitive way can be extremely cathartic and we have regularly seen family members alter their behaviour and their approach just by asking questions that promote a certain response. We would argue

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that assessment in itself is a form of intervention and we have seen many positive changes within the assessment stage. When starting to work with a family, often one of the first thoughts is ‘How am I possibly going to carry out an assessment of all these family members?’ This can be daunting, and time is often limited. However, the National Institute for Health and Clinical Excellence (2009) guidelines on schizophrenia advocate that family intervention should be offered to all families (of people who have schizophrenia) with treatment lasting between three months and a year, and including at least ten sessions. This puts things into perspective, and acknowledges that family intervention is important and should not be rushed. Time should therefore be available to carry out meaningful and appropriate assessments. Prior to assessment the first question you should ask is ‘What am I assessing?’ This avoids the temptation to gather myriad assessment tools, without considering this first question. It is tempting to fill out a range of tools – tools that you have just come across, tools that you have heard about and tools that you ‘feel’ you should complete. However, the purpose is not to use as many tools as possible, but to consider what information you need. What do you wish to assess? What do you want to know? Why are you carrying out an assessment? This question is fundamental. Try to remember the analogy of the house foundations. As Chapter 8 outlined the importance of engagement, you are aware of assessment being part of the engagement process. Assessment can be extremely personal and you are asking some very difficult questions that may bring out a plethora of memories and emotions. Sometimes you may find that people respond in very emotional ways – at times they may feel that you are being critical and challenging how they respond to situations. You need to remember that they have done their upmost in caring for their relative, and praise should be given for this.You are not just focusing on what needs to be done, but you are also highlighting strengths and resources within the family, to build upon. It is important to see the service user and all members of the family initially, in order to explain the purpose of assessment, and to answer any questions that may arise. You then need to explain that assessments will be carried out individually, and give a clear rationale for this. Once you are clear about the purpose of the assessment, you need to decide which particular assessment tools may be useful to you. Assessment tools are useful, but do not replace the skill of asking appropriate questions in a calm and considered way. The use of closed and open-ended questions is a skill that is developed over time and we must not forget the use of non-verbal skills. By observing the non-verbal and verbal responses we can ascertain a great deal of information.

Timeline A timeline is a chronological account of a service user and family history related to development, milestones and critical incidents. We advocate that one is completed as part of the assessment of the service user. A timeline will allow everyone to identify significant times when incidents or events occurred and for them to be unpacked and explored for thoughts, feelings, emotions and behaviour.

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The simplest way to construct a timeline is by taking a large piece of paper and, with the service user, working through the years. As information is added it can be verified and discussed. Extra information can be added to as time goes on. A timeline will be an important aid to the case conceptualization for everyone. An example is included below of a partially developed one for 19-year-old Paul. Timeline of Paul aged 19. 0

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4

Mother and father separate. Moves in with grandparents. Grandfather a heavy drinker and at times violent to grandmother.

5

First school.

6

Mother takes out of school following domestic violence in the family home and relocates to Bristol.

8

Sees child psychologist following violent incidents in reaction to difficulty in accepting authority. Mother has new boyfriend who seems fine. Hates school and has no friends.

11

Moves to new school. Disruptive behaviour and bullying of other school attendees. Detained by police for drinking alcohol in a public place.

11.5

Juvenile court remands to special unit in Middlesex. Moved out of family home. Didn’t like it. Wanted to stay at home. Mum’s boyfriend leaves as he can take no more of his disruptive behaviour.

12

Takes cannabis for first time. Quickly moved on to ‘E’s and glue. Had first trip which frightened him.

14

Started hearing others saying they were going to get him. Pre-emptive attack on fellow detainee with a knife. Moved to local adolescent secure unit. Put on drugs that made him feel odd (olanzapine).

16

Released from hospital. No educational achievements and no true friends. Mental health staff just want to drug me up. Angry with system.

17

Moved into looked after children unit. Met Jason and Petra. Mother has never visited him throughout. Did get letters from grandmother occasionally.

18

Angry and threatening about father and fellow resident and housing department. Medication increased. Paul sees it as a punishment.

19

Involved with community mental health team. Awaiting accommodation. Does not trust the mental health services.

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The use of the timeline has been invaluable for service users who have had difficulty in narrating stories and has provided them with some structure to ‘hang’ events and emotions on. They present the family workers with information that can be used throughout future sessions. One of the main advantages of timelines is that they can be updated and added to whenever the family member, service user or family worker feels necessary.

Genogram Another useful tool for assessment is the use of genograms. These are pictorial representations of the family structure and details. Figure 9.1 is a basic genogram for Paul.

Figure 9.1 Basic genogram.

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Sociogram Another useful tool for assessment of the family is the sociogram. This in many ways is similar to the genogram, yet it helps the worker to explore with the service user those who are important in their life and the contacts made. A sociogram presents the opportunity to highlight who the service user likes to work with, or not. A sociogram further adds to the genogram by allowing the separation of groups from the service user. Figure 9.2 is an example of a sociogram for Paul. Relationships with Paul are quite clear in that part of the extended family do not get on with him and, other than specific family members, the only positive relationship is with friends (Jason and Petra) from the looked after children’s unit. Paul does not have a positive relationship with services or the housing department.

Figure 9.2 Sociogram.

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Assessment tools Assessment tools are widely available and plentiful. There are tools that assess symptoms, side effects, responses, general health, quality of life, knowledge, and so on. There are tools that can be completed by the individual, by an observer and by the interviewer. There are tools that can be completed in a few minutes and some that can take several hours. What is important is that the right tool is chosen for its own merits and that it addresses what you need to know. There are assessment tools for the service user and also for the family members. Here we will look at some of the more commonly used assessment tools, and the ones with which we are more familiar. As stated earlier, this list is by no means comprehensive. Table 9.1 highlights the tools that we will discuss.

Manchester Short Assessment of Quality of Life (MANSA) The MANSA (Priebe et al. 1999) is a relatively quick and easy-to-use assessment scale that focuses on the service user’s quality of life. This fits well within the concepts of wellness and recovery and is useful for the service user to complete without the need for a practitioner asking questions. The scale asks for some very personal information and individuals may find it difficult to disclose personal details; yet, with the practitioner’s support, this can be an area on which to develop the therapeutic relationship. You will find that over time the individual will feel more comfortable in completing the scale. The scale comprises 16 questions that the service user completes using a Likert scale to rate his or her satisfaction within a number of areas. These cover health, work, financial situation, leisure, social life, safety, living situation and family situation. There are no right or wrong answers as the response is purely from the service user’s view point, assessing perceived quality of life at the time of completion. The advantage of the scale is that the results are compared over time; this is useful for monitoring progress.

Social Functioning Scale (SFS) The SFS (Birchwood et al. 1990) is a useful scale in that it focuses on the family members responding to questions concerning the service user. As the name suggests, Table 9.1

Assessment tools

Assessment tool for the service user

Assessment tool for family members

Manchester Short Assessment of Quality of Life (MANSA) Social Functioning Scale (SFS) Krawiecka, Goldberg and Vaughn (KGV)

Family Questionnaire (FQ)

Brief Psychiatric Rating Scale (BPRS) Psychotic Symptom Rating Scales (PSYRATS)

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Relative Assessment Interview (RAI) Knowledge About Schizophrenia Interview (KASI) General Health Questionnaire (GHQ) Family Member Interview (FMI)

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the focus is on the functioning of the service user in various social situations. There are seven areas on which the scale focuses: 1 2 3 4 5 6 7

Social engagement and/or withdrawal Interpersonal behaviour Pro-social activities Recreation activities Independence in living skills (competence) Independence in living skills (performance) Employment.

Note that the scores generated will be compared to the standard deviation of a similar population. This can help the service user to understand where their level of functioning exists with the similar population, not the general one. The scale is widely used and the answers can be useful in determining interventions. As with the MANSA the SFS is a very useful scale for monitoring progress.

Krawiecka, Goldberg and Vaughn (KGV) There are a variety of modified versions available since the original KGV was published in 1977. Version 6.2 (Lancashire 1998) is the one we are most familiar with, and we feel that service users work well with this. Ultimately the choice is yours. This is a 14-item scale (see Table 9.2) that adopts two general methodological approaches. The first six items (1–6) are assessed using a semi-structured interview and are rated against a set of descriptors over the last month. The final ratings (7–14) are observational and are rated on the interview currently being conducted. The format involves (in items 1–6) specific questions that have to be asked. These are in bold typeface; supplementary questions are provided to clarify any meaning or doubt caused by ambiguity about the answer in order to rate against the rating scale. The rating scale compares the service user’s descriptions of the symptoms to a set of ratings with a score of 0–4 specific to the item in question. Generally the 0 score relates to no evidence and the 4 relates to significant or severe levels of symptomatology of the item. The total score can be arrived at by adding the score of items 1–13. The total score for the assessment of positive symptoms sub-score is calculated by summing the score of items 2, 5 and 11. The total score for the assessment of negative symptoms sub-score is found by summing the score of items 7, 10 and 12. Finally the affective symptoms sub-score can be seen by summing the score of items 1, 3 and 4. In addition to this, advice is offered for anxiety, depressed mood and elevation of mood. Here the levels of frequency, duration, subjective severity and control are established over the last month of the specific item. For delusions the interviewer is asked to focus on the level of preoccupation existing and level of conviction to this item. Finally for the hallucination item the interviewer is encouraged to establish the frequency of hallucinations but also if the

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Table 9.2

Items of the KGV (Version 6.2)

Item number

Symptom

1 2 3 4 5 6 7 8 9 10 11

Anxiety Depression Suicidal thoughts/behaviours Elevation of mood Hallucinations Delusions Flattened affect Incongruous affect Overactivity Psychomotor retardation Abnormal speech

12 13 14

Poverty of speech Abnormal movements Accuracy of assessment

auditory and visual hallucinations are true hallucinations or pseudo-hallucinations (see Box 9.1).

Box 9.1 True and pseudo-hallucinations True auditory hallucinations are heard outside of the person’s mind (either somewhere in the room, outside the building or part of the body). Pseudo-auditory hallucinations are heard in the person’s mind or in their head. True visual hallucinations have all the qualities of being real: solid, 3D, in colour and could be mobile. Pseudo-visual hallucinations lack what is offered for true visual hallucinations with them commonly being flat and without colour. You should also categorize flashes of light and spots before the eyes in this category. Source: Lancashire 1998

Care is needed in the use of this tool as commonly service users present conflicting information that contradicts what was said earlier in the interview. This should still be scored as it presents and there is an opportunity to score the ambiguities in the final item. Some symptoms may be caused by medication (restlessness). The interviewer needs to score this item as the service user presents and not make allowances for the medication. Notes should be made throughout the interview in order to supplement the information being gathered. This will help the interviewer with what Lancashire (1998) refers to as nature and content of elicited and observed symptoms for future reference.

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Brief Psychiatric Rating Scale (BPRS) The BPRS (Overall and Gorham 1962) is a well-validated measure of general symptoms. Originally developed in 1962, the scale contained 16 symptoms; it has been further developed (Ventura et al. 1993) and now contains 24 symptom constructs. The scale consists of direct questions, ranging from not present to extremely severe, measured on a seven-point Likert scale. The BPRS is a scale commonly seen in research papers, but is also used in a variety of community mental health teams in the North West of England. These teams advocate its efficacy in the work that they complete. As with the KGV, the BPRS is a useful global tool, though much quicker to administer.

Psychotic Symptom Rating Scales (PSYRATS) The PSYRATS (Haddock et al. 1999) is a semi-structured interview that consists of two subscales that measure dimensions of auditory hallucinations and delusions. For auditory hallucinations, the service user is asked questions on eleven areas:

• • • • • • • • • • •

Item 1: Frequency Item 2: Duration Item 3: Location Item 4: Loudness Item 5: Beliefs Re Origin of Voices Item 6: Amount of Negative Content of Voices Item 7: Degree of Negative Content Item 8: Amount of Distress Item 9: Intensity of Distress Item 10: Disruption to Life Caused by Voices Item 11: Controllability of Voices

For delusions, the service user is asked questions on six areas:

• • • • • •

Item 1: Amount of Preoccupation with Delusions Item 2: Duration of Preoccupation with Delusions Item 3: Conviction Item 4: Amount of Distress Item 5: Intensity of Distress Item 6: Disruption to Life Caused by Beliefs

All items are scored on a scale of 0–4, with 0 being no problem, to 4 being maximum severity. The PSYRATS is a useful validated assessment tool that is used widely.

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Family Questionnaire (FQ) The FQ (Barrowclough and Tarrier 1997) is a self-report measure, completed by family members in their own time. The questionnaire is a checklist of 49 areas, each measured on three five-point scales. The first is how often the behaviour or symptoms occur, the second scale asks the relatives to rate their concern with this behaviour or symptom, and the final scale focuses on the relatives’ ability to cope. This questionnaire is quick and easy to use and is of great benefit in highlighting strengths and current coping strategies. This paves the way for interventions that assist the family members with their coping strategies.

Relative Assessment Interview (RAI) The RAI (Barrowclough and Tarrier 1997) is a global assessment tool that elicits problems, strengths and needs. It is an interview schedule that allows the interviewer the opportunity to ask questions in a relaxed and comfortable manner. The interview is semi-structured with specific areas to target, yet allows the family members the benefits of being able to discuss situations in greater depth, which is often lacking in many assessment tools. There are five content areas in the RAI. These include background information, psychiatric history of the individual, current problems or symptoms, relationships between family members and general information about the relative. This tool can be completed with each family member separately; while this can be time-consuming we would advise that it is worthwhile spending the time.

Knowledge About Schizophrenia Interview (KASI) The KASI (Barrowclough et al. 1987) is an interview schedule specifically developed to ascertain relatives’ knowledge, beliefs and attitudes about schizophrenia. The interview takes between 10 and 30 minutes, and is completed with each individual family member. The interview takes the form of a conversation and focuses on six key areas. These are diagnosis, symptomatology, aetiology, medication, course and prognosis, and management. The results can be used to form the basis of an educational package; the interview can then be used to determine the effectiveness of the package. Although the interview was designed to be used with those with a diagnosis of schizophrenia, we would argue that the interview can be adapted for any mental health problem. Commonly, this scale is adapted for people with bipolar and unipolar illness.

General Health Questionnaire (GHQ) The GHQ (Goldberg and Williams 1988) is a questionnaire that purely focuses on the relatives’ general health. This questionnaire elicits the relatives’ current situation and how this differs from their ‘usual’ state of health. The questionnaire highlights the difficulties of caring for an individual and the impact that this may have. The 28-item questionnaire consists of four dimensions: somatic symptoms, anxiety symptoms, social functioning, and symptoms of depression. The questionnaire

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is quick to complete and the results can enable the family member to seek further support as necessary.

Family Member Interview (FMI) The FMI (Falloon et al. 1993) is a semi-structured interview which ascertains information concerning goals, problems and the problem solving functions of every family member. The FMI consists of six particular areas: 1 2 3 4 5 6

Background information Knowledge of service user’s diagnosis Coping and burden Reinforcement survey Personal goals Other problems.

The six areas are fairly flexible but provide a clear approach to how the family members are coping.

Summary

• • • • • • • •

Assessment is vital; it can be seen as the foundation on which to build. We must take time with assessments; do not rush this important stage. The use of a timeline, genogram and sociogram aids the assessment process. Assessments in themselves can be considered as part of the intervention. It is important to assess all family members as well as the individual. There are many assessment tools available, yet it is important to consider what it is that you want to assess. Assessment tools are designed to assess the individual, as well as the family members, and care should be taken when discussing this. You must give a clear rationale. Assessment tools are useful for monitoring progress over a period of time as they provide a clear baseline of information.

Questions 1 2 3 4 5

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Why is assessment important? What do you need to assess? NICE guidelines recommend how many family intervention (FI) sessions? Name two tools for assessing the service user. Name two tools for assessing family members.

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10 Formulation in family intervention

Aim The aim of this chapter is to present you with the opportunity to examine the use of behavioural and cognitive behavioural formulation, and also to consider how this might fit within your own case work.

Learning outcomes By the end of this chapter you will be able to:

• •

understand the need for formulation in family intervention work describe the process of formulation.

Introduction In many books and manuals the issue of formulation is commonly dealt with under the area of problem identification and management. We feel that it really needs to be looked at on its own as in practice it is one of the main areas that workers struggle to articulate and consequently find difficulty in working towards a case formulation and conceptualization model. ‘Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about the causes and maintaining factors that inform interventions’ (Kuyken 2006: 13). Kuyken (2006) went on to argue that this can be applied for the presenting issues of couples and families. Within this chapter we encourage various ways of looking at formulation, but keep the presentation of Raymond’s family as a constant (Box 10.1).

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Box 10.1 Raymond and his family Raymond is a 42-year-old man who lives at home with his parents. He has been diagnosed as experiencing a schizoaffective type disorder that is characterized by blunted emotions, low mood and persistent dissociation. It was felt prior to him taking medication that he was deluded, believing that he was someone very special and that everyone was being nasty to him in order to stop him getting to his destiny, but there is limited evidence of this in his current presentation. Raymond is isolative and, following a recent incident with a family member, he eats in his room. He becomes aggressive on approach around meal times and his conversation is negative about his abilities. At times he refuses to discuss his thoughts in detail and his family reported, at these times, that he will act out of character. An example was following a difficult session with a care coordinator; he left the home in the early hours and headed into the city. He was picked up by the police when he was seen walking in a residential area at night. He had been asked what he was doing by a police officer but was unable to articulate a reason. They took him to the family home where his mother dealt with the officers. Throughout his life he has felt ‘singled out’ as in school he was regarded as being different and not to be trusted by the other children. He was shy and did not make many friends. The school teachers said he was clumsy, and nicknamed him ‘dropsy’. Although Raymond laughed about this, the comments upset him greatly and he would spend time in his room crying. If his parents tried to comfort him he could become aggressive towards them. He sees himself as different.

Initial formulation may be regarded as being like a synopsis of how it is. For Raymond this may take the form of the description in Box 10.2. Box 10.2 Initial formulation for Raymond Raymond is a 42-year-old man who has been diagnosed with a schizoaffective disorder and lives with his parents. He has become more isolative over time and has a history of problems in dealing with stress. He doesn’t talk openly about his feelings and shows his emotions often through aggression. Commonly there is a lack of understanding of the causal link between his thinking and actions. This has culminated in him behaving oddly, like walking the streets at night, and having no explanation when approached by the police. He feels he is different and is conscious of people watching him. He has in the past expressed that he is a special person, but never elaborated on why. If pressed for explanations he will isolate himself. A coping strategy he has adopted is to avoid situations where others may watch him doing something.

This does seem similar to the description in Box 10.1 but draws together some of the general themes that describe Raymond’s actions, beliefs and where possible feelings and emotions. It provides a working narrative to start to understand how events and actions may be linked.

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How does a worker progress in understanding formulation? At the outset this chapter sets out to explain what case formulation is and its uses in family work. The model adopted follows Persons’ (1989) simplistic but usable presentation. She argued that case formulation conceptualized problems on two levels:

• •

overt difficulties: real life events such as depression and getting on with others underlying psychological mechanisms: often irrational beliefs about self such as ‘If I say something I will cause him to relapse’.

The overt difficulties can be looked at in two ways:

• •

on a macrolevel: can be described in the person’s or family’s terms on a microlevel: can be looked at in reference to thoughts, behaviours and emotions, which can demonstrate the irrational and sometimes maladaptive mechanisms.

Our understanding through experience is that there is commonly a relationship between the microlevel items. Persons (1989) argued that if a problem existed in one of the microlevel items, there is a likelihood that a problem will exist in the others, supporting our observation. It can also be then argued that if a change in one of the same components occurred then there may be a change in the others; in behavioural terms this would relate to generalization. The focus of the therapy is commonly related to cognitions related to the service user’s illness or pertaining to their consequential behaviour and emotions. This therefore links closely with cognitive behaviour therapy and the notion forwarded by Beck (1976) that altering the thinking related to an event can lead to a change in the mood generated. We have to acknowledge though (coming from a behaviour therapy background) that there has always been an interest in the behaviour causing resultant symptoms of that behaviour. Although this may seem overly simplistic and Skinner-like in theory (work related to behavioural activation which is related to operant conditioning (Skinner 1965), encouraging behaviour that activates action and discouraging behaviour that doesn’t), it can have positive results with individuals. Therefore we would argue that both cognitive and behavioural therapy should be utilized within the work undertaken with families – the cognitive components working towards a change in the schemas held related to the illness and the behavioural components activating change and modification of actions. This does in some way suggest that we believe that the family presentation is an interrelated presentation of behaviours, cognitions and emotions that are in some way interdependent on each other. Therefore addressing this pragmatic use of cognitive and behavioural interventions is warranted. In family work the aim is similar to individual work, to identify the predisposing, triggering and maintenance factors related to the presentation. Adrian Wells (1997) argues this for formulations related to anxiety, yet we see utility in a wider perspective when linked to contextual events and working as far as possible in the ‘here and now’. Getting a grip on the problems being experienced and their related beliefs can help to identify the impact. Looking historically into the use of formulation, Beck (1976)

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related them to beliefs and assumptions leading to vulnerability and symptoms. Behaviourists looked at the antecedents of the behaviour and then the consequences. All views have a utility and for inexperienced staff the behavioural approach is a good starting point to start to understand some of the interrelatedness of events. The more cognitive approach of Beck (1976) aids the worker in establishing vulnerabilities created when simple behavioural approaches have extinguished some actions, and supports the impact of cognitions on behaviour with uncontrolled variables appearing and having a disastrous effect on someone felt to be improving.

What can formulation offer the family worker? Persons (1989) would advocate that:

• • • • •

Formulation can act as a guide for the choice of interventions. It allows the family worker to present their understanding of what is going on, related to the cognitions, behaviour and emotion. It can aid the family worker in assisting the service user to identify risky situations and the way they manifest. It can be the conduit for strategies aimed at problem solving. It can help the family worker to understand resistance and offer structure for collaboration and intervention.

Where do you start? No formulation is any good unless there has been some assessment (in our view and echoing Persons 1989) of the overt problems and the underlying mechanisms. This should enable the parties involved to establish a list of problems that therapy will start to address by proposing the nature and impact that the problems have on the functioning of the individual and family. The formulation is a first stab at suggesting ‘Is this how it is?’ and the resultant engagement of the family into a collaborative relationship which permits challenge and realignment of the said formulation. This should then present an agreed hypothesis that will become the focus of the section of work undertaken. Along with this is a need to adopt a link with collaborative empiricism so that the experience of the problems can be truly understood and the context of its presentation aired. This is further endorsed by Garety et al. (2008), who suggested that the work would need to focus on one family problem at a time utilizing the formulation arrived at as the family understood it.

Behavioural formulations As indicated before, behavioural formulations exist in identifying the behaviours that have become problematic and the antecedent and consequences of the behaviour. Exploration of the coping strategies employed should be looked at but care is needed not to negate any attempt to cope nor cast blame for human frailties in the face of the problem. As in Chapter 8 it was made clear that disengagement could occur if blame is inferred.

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To use the simplified approach, the next section will look at a case formulation utilizing the ‘ABC’ (antecedent, behaviour, consequence) approach. Raymond who lives with his mother and father identified that his parents would annoy him and he would become angry and shout at them. The parents were asked to establish when the shouting began in an attempt to identify any antecedents. They were also asked to note what happened afterwards to establish any consequences of the action. Contextualizing the events became quite interesting as the only time they were able to identify that Raymond shouted at them was when they called him for a meal. In response to the call Raymond would enter into a shouting rage, which cast beliefs that they were trying to make him into an old person who just did as they were told.They went on to report that after such an outburst, his mother took his food up to his room on a tray and left it at his door. They noted that the food was quickly collected and always eaten. On review it became clear that Raymond’s shouting was serving to generate a positive outcome for him. The exploration was entered into about what Raymond disliked about eating with others and why he was willing to become so angry with the family he loves in order to eat his food in his room on his own. The intervention in a behavioural way needed to address the situation and one specific way of addressing it was identified: exploration of how the consequence, which was positive, could be diminished in personal value to Raymond in place of the original request. This would then negate the need for him to become angry and shout at his parents. The family identified that Raymond never suggested what he wanted to eat, nor became involved in any preparation. They began to utilize time when he was in the room to ask his opinion regarding food and prepare snacks that could be presented immediately in that room. This reduced the opportunity for eating in his room alone and gave the chance to explore further why he had adopted this behaviour.

A more cognitive formulation Revisiting the issue of Raymond eating in his room alone, exploration of the trigger was made. The main issue was focused on Raymond eating food in front of others. A while ago, according to the family, the family would eat together.They accepted that Raymond did eat quite messily, probably due to excessive salivation caused as a side effect of his medication and a tremor when trying to exert some fine control over implements. His mother reflected in a conversation that one day Raymond had been called for his lunch. He came to the table and found his Uncle Wilf and his wife were to eat with the family. They had no idea regarding the side effects of Raymond’s medication and Wilf was rather critical of poor table etiquette. Raymond spilt food on his shirt. Wilf remarked that he needed to slow down and show respect for the meal presented by Raymond’s mother. This led to Raymond feeling more stress and becoming a little more agitated. He knocked over a glass and was called stupid by Wilf. No one challenged Wilf or tried to support Raymond. He left the table while listening to derisory comments from Wilf of ‘Are you not even going to clean up your mess?’ Raymond in a discussion at a later date was able to see that he had always been a bit clumsy. At school he was unable to coordinate his hands to catch a cricket ball and was mocked by what he called the sporty types. He was commonly singled out by

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teachers when passing books around. He vividly remembered them saying, ‘Don’t give it to Raymond, he’ll only drop it!’ They also nicknamed him ‘dropsy’. He consequently avoided handling things or performing delicate tasks in front of others. He never had an issue with his parents until this event with Uncle Wilf in their presence. He was able to see that the clumsiness affected his life in other ways. Another limiting effect was that he applied only for work that he could do unsupervised and quickly found that he was unable to gain employment and became something of a loner who avoided others. He could see that his action of not taking a chance of allowing anyone else to see him eating, by eating alone, protected him from potential criticism. Probably the easiest way to represent this information would be to use a simplistic algorithm, (Figure 10.1), like the one used by Blackburn et al. (2006) for people with a depressive problem. Although not centrally located to families this algorithm does fit very well with family work related to how the people fit within the family and the disapproval and attempts to please others, as well as the freedom to be one’s self and be unique within the family. These principles link with what Alford and Gerrity (1995) view as the understanding of personality in depressed people: sociotropy and autonomy. In Figure 10.2, a model is presented as a means of trying to understand the way that everything fits together for Raymond.

Figure 10.1 Algorithm for family work formulation (modification of presentation of the cognitive model for depression by Blackburn et al. 2006).

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Figure 10.2 A formulation for Raymond.

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You can see how this was used in the case of Raymond. What you need to do is to start to think about your own clinical work and try to apply this format to a family that you are working with and identify the discrete elements. However, this addresses only part of what is needed for a family formulation, but it is a good starting point. Persons (1989) proposed a formulation template that would move the above approach on another step and start to identify more clearly some of the external factors involved in the presentation. She presented a conceptual framework in the format shown in Box 10.3.

Box 10.3 Case formulation (Persons 1989) Identifying information: Chief complaint: Problem list: 1 2 3 4 5 Hypothesized mechanism: Relation of mechanism to problem: Precipitants of current problems: Origins of the central problem: Treatment plan: Predicted obstacles: Source: Persons (1989: 53)

Each of these elements will now be looked at in a little more depth in Box 10.4.

Box 10.4 A case formulation for Raymond Identifying information: This is the sometimes vague details offered by the family about what is happening that they feel is related to the need for family interventions. Chief complaint: What is it that the family members believe is the main problem? Careful attention may be needed to the words used and the way they phrase the complaint. Problem list: The need to create a detailed list is important. Rarely (if at all) does a family present with just one problem. Difficulties can appear when families have difficulty or are reluctant to develop a list. Common worker strategies can be focused on the rationale for such a list and perhaps agreeing to do it together.

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Many of the problems will appear in vague subjective ways which may need the worker to aid the person proposing the problem to focus it onto the core themes of behaviour, thoughts and emotions. Hypothesized mechanism: The worker will need to test out a theory that could account for the problems on the problem list. This may at first be related to an underlying mechanism in the way the family function when under stress or be related to the present coping strategies. Relation of mechanism to problem: The worker will need to explain how this proposed mechanism relates to the problems on the problem list. Precipitants of current problems: The next stage will involve the worker exploring how the mechanism could be responsible for the presenting problems. Origins of the central problem: Looking at the family and service user history will help the worker hypothesize about the origins of the problem. Treatment plan: This is the collaboratively arrived at set of measures to address the problems identified earlier which will need to include some notion of structure for the sessions and the use of homework. It will need to have focus on what the family feel needs to be addressed and indicate responsibilities and the way in which it will achieve the personal aims of the individuals. Predicted obstacles: Establishment of any predictable future obstacles needs to be discussed and identified. They may be commitments but they may be in the way that individuals relate to each other. Whatever the obstacle it will need to be identified and where possible addressed. Source: Persons (1989: 53)

Returning to Raymond, it is clear that the formulation explains some of the connections between what has happened to him and the impact on his thoughts and behaviour. The formulation goes on to indicate some developmental factors and early experiences that have shaped his presentation. The structuring of this information can prove beneficial for both Raymond and his family. Care is needed not to allow it to be a method to cast blame on others and abdicate responsibility for trying to make a change. There is a need to emphasize the importance that this is a working formulation and that this can be reviewed as time moves on.

Summary

• • • • •

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The use of a formulation is an important component of family intervention. Formulation conceptualizes problems on two levels. An accurate formulation will assist the family worker in the choice of intervention. Formulation follows on from assessment. There are behavioural and cognitive formulations.

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•

81

A formulation helps the service user and family members to understand what is happening.

Questions 1 2 3 4 5

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How does Persons (1989) conceptualize case formulation? In the Blackburn et al. (2006) cognitive model for depression, what areas of the formulation are not necessarily shared with others? How do you feel that the issue of formulation fits with the terms sociotropy and autonomy? Why does the approach need to adopt a link with collaborative empiricism? In what two ways does behavioural activation (which is related to operant conditioning) work?

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11 The role of education in family intervention

Aim The aim of this chapter is to introduce you to the need for education in family interventions, within the society we live in.

Learning outcomes By the end of this chapter you will be able to:

• • •

understand the importance of education in family interventions describe the practitioner skills for education giving in family interventions identify common sources of information used for educational information about mental illness and family interventions.

Introduction As we highlighted in Chapter 9, the purpose of assessment is to elicit (among other things) the knowledge within the family setting. The Knowledge About Schizophrenia Interview (KASI) can be adapted to ascertain knowledge, beliefs and understanding about any mental health problem, and, as is often the case, education is a vital intervention. While some would argue that education is not an intervention, we feel that the giving of information concerning a person’s illness can help the individual and family members develop a greater understanding of mental illness. This also serves the purpose of allaying any misconceptions that people invariably have surrounding mental illness (Fadden 1998). The media are important sources of information regarding mental health for lay people and professionals alike (Wahl 1997). The media include television, film, books, newspapers and the internet. However, the media portrayal of mental illness is not usually a positive (or accurate) one, and yet many people will develop their views according to what they hear on television and read in the newspapers.

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For example, within the medium of television there are many incidences of those with a mental illness being referred to as ‘crackpot’, ‘a sad little psycho’, ‘basket case’, ‘where did you get her from, care in the community?’ (Shift 2010). Newspapers are similar in their depiction and this is epitomized by headlines such as ‘care in the community mental patients kill 34 people’ (Daily Express, 17 August 1994), which create an illusion that violence and mental illness are synonymous. The changing face of media is evident when complaints are made. The loss of a ‘national treasure’ in the story by The Sun newspaper was headlined ‘Bonkers Bruno Locked Up’. This was very quickly replaced by ‘Sad Bruno in Mental Home’ (Cook 2003), following complaints from readers and mental health campaigners. The complaints that rolled in concerning the story led to the then editor of The Sun, Rebekah Wade, agreeing to undertake some mental health awareness training. The unfortunate theme here is that someone who can yield such power and influence did not consider the consequences of what was published. Editors, film makers and authors need to be aware of the impact that stories have on the opinion of those reading them. A simple example of this is a Rethink (2007) study, which identified that of a survey of 67 Members of Parliament (MPs) 42 per cent of the MPs said that for them, some of their information about mental illness came from newspapers and 19 per cent of MPs from the television. Although not that high a percentage, it is a demonstration of how the media influence the views of those people elected to govern and to make the laws that affect mentally ill people. Education is not simply about the giving of information concerning diagnosis; we also see the benefits in providing education for the use of family intervention. Explaining what the purpose of family intervention is, and the perceived benefits and structure, can be of great significance, not only to engagement, but also to instil hope. In our experience the explanation at the beginning of therapy is paramount to the success of family intervention. A criticism of psychoeducation (used in family interventions work) is that it may be somewhat unnecessary, and the argument that family members are ‘experts’ and know everything concerning the diagnosis should be respected; after all they have lived with it for many years. However, we would counter this by advocating that if relatives’ understanding (or misunderstanding) is properly assessed, this would highlight areas to target. Indeed, the research to date emphasizes the importance of education as an effective component of family intervention.

Efficacy The available textbooks for family intervention all highlight the importance of family education, particularly for those with a relative with a diagnosis of schizophrenia. Many of the research studies also discuss the importance of education as a vital component of family work. Dixon et al. (2000) found that the efficacy of family psychoeducation remains compelling. Pitschel-Walz et al. (2001) argue that psychoeducational family treatments are essential in the management of schizophrenia. Bustillo et al. (2001) advocate that psychoeducational family intervention should be made available to the majority of those persons

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suffering with schizophrenia. There are many more research studies to back this up, but we draw your attention to just a few to illustrate the importance of family education.

Before you start The most important question to ask yourself is ‘Why am I providing education?’ This question may sound fairly simple, but it is a question that you need to consider. The alternative question would be ‘What will happen if I don’t provide education?’ As we have alluded to the notion that education is vital, you may be wondering why these questions need to be asked. We highlight these questions to ensure that you are clear as to the purpose of education. There is an element of risk involved in carrying on, and you need to carefully consider the risks involved. Following on from the assessment, it should be clear if there are gaps in knowledge within the family members (some possibly more than others). It may be that the family are very aware of the diagnosis, symptoms, prognosis, medication, etc.; sometimes maybe one member is more aware than others. However, you could be giving information that can be difficult to accept, and understand. Therefore, how you pitch the information should be sensitive to the level of current understanding, and the level of comprehension, as you provide more information (see Box 11.1).

Box 11.1 A case example One day we were working with a family and provided some information in the form of a leaflet (from a very reputable source). The leaflet was left with the parents of a teenage boy. On the next visit we asked about the leaflet and were surprised at the reaction. Both parents became quite angry as they felt that the leaflet was basically telling them that they were to blame for their son’s illness. This was extremely difficult for them to comprehend and had an obvious impact on the collaborative relationship. We then had to clarify what the leaflet was explaining, yet this undoubtedly made the future work somewhat uncomfortable.

So what is the purpose of education? Education can generally be seen as addressing the knowledge or lack of it in relation to the service user’s mental health problems. Education also starts to address the key themes related to stress that all family members may be experiencing. Falloon et al. (1993) argued that education needed to focus on the following:

• •

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establishing a working relationship (therefore be related to engagement and participation in family work) improving understanding (both of what the workers are trying to do and in relation to the illness and stress created because of the illness)

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providing a reason for treatment (including each person’s role) presenting knowledge and coping strategies (ongoing process that can unearth misperceptions and gently correct them) finding ways to enhance self-management (seeing the members as the experts and underlining the major contributions they all can play).

In the next section we acknowledge that Falloon et al. (1993) provided some key headings that summarize the process extremely well. We have utilized the headings and some of the themes to discuss the issue of education in more detail.

How to provide the information How to provide information will be developed further in the case chapters but as indicated earlier, the atmosphere that exists is an important starting point. Look at the place where you meet with the family and the content chosen to try to get the messages over in a way that involves and does not ostracize the members. Making the message too complicated can lead to problems as can being too simplistic. Experience will enable you to best judge this and using the readily available information can help in the early stages. As you become more experienced, you will be able to modify the approach and address the family needs with more confidence. The difficulty can be that all family members are not necessarily able to understand the information in the same way or at the same speed. Regular checking may be needed and there may be an opportunity to use knowledgeable members to help to deliver the understanding. Care is needed though as this can be divisive and may in some circumstances lead to resentment from some and a feeling of ‘not being good enough’ from others. Relating the information to the service user’s problems or needs is a must. Information that is too general may confuse and dilute the session. Involvement of the service user to try to explain how they felt, or reference to symptoms, can contextualize the information and enhance the impact. It can also help family members to see that each member has a different opinion on the symptoms and coping strategies. This will lead to healthy discussions that are pertinent to the process. Family worker questions and information are carefully provided so as not to be too didactic. Feedback should be sought and may need to be challenged as in some circumstances the family members may answer how they think the family worker wishes them to answer rather than honestly.

Timing Getting a group of people together for a meeting at the same time can be very problematic. In our experience we have generally been the most flexible and offered outof-hours work. This was usually because the family members were working and the venue for most of our work has either been the family home or a health centre where rooms were available only in the evenings. The regularity and duration need to be established and this is negotiable between the family workers and the family members.

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Family worker skills Knowledge is important: the family worker will need to be up to date with information on a variety of illnesses and treatments. This will need to be backed up with evidence but the family worker needs the confidence to modify the information for a range of audiences. Preparation for difficult questions is a must. Many families will ask quite abstract or odd questions. We remember one family member asking us, ‘So this stuff he keeps going on about . . . you know the aliens! It is all a lie. Isn’t it?’ Another was quite clearly confused by some educational material: ‘Well, since that information you gave us on genetics we’ve decided to make sure he has his own knife and fork, and only uses his own cups and plate . . . we don’t want any of us coming down with it!’ These sorts of misunderstandings became apparent only on the feedback sessions following the education sessions. Clearly the work completed in the sessions and the establishment of understanding had not been rigorous enough. There is a point though where rigour in establishing understanding may cause embarrassment or create a division between the family worker and the family members. This highlights the process of conveying the facts in an understandable and systematic manner that will allow the family worker to establish understanding as they progress. It will also allow for situations where family members will not accept some information and allow this to be challenged in a timely way. Once again (as indicated earlier in the book), tact is needed so as not to negate or ridicule opinion.

Content What is and what is not included depends on the family members. The content needs to be understandable and usable; too much detail may turn people’s attention off, too little may leave them confused. Likely stumbling blocks are generally that the family worker either overestimates or underestimates the family’s ability to grasp facts and contextualize them. Leaving them with some work to do will check on commitment and also help to amend the content level at the following sessions. Preparation for all eventualities, however, will be needed by the family worker. The content can become a good medium for exploring present and past symptomatology. It can also be the first point where early warning signs of illness markers are identified and noted in the family sessions.

Some sources of information The internet was developed in the 1970s and following on from this the World Wide Web came into existence in the late 1980s. As the web has developed and become more available, it is unusual in the current era for families not to have access to this resource. Common terms in everyday speech now seem to relate to social networking sites, and although this may be more prevalent in the younger generation, it is fairly safe to say that the majority of people are aware of the existence of Google. On a regular basis we hear nursing students saying they will ‘Google it’ when we ask them where they will gather their information from. This causes us a great deal of concern. Although there are many excellent websites available, there are also websites that are fairly inaccurate (see Box 11.2).

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Box 11.2 Example of a google search When we typed in ‘What is Schizophrenia’ into Google Result: over 7½ million sites found When ‘Family Interventions’ was typed into Google Result: 54,700 sites found Confused! You would be confused if you didn’t know what you were looking for. The hits for family intervention included family interventions for schizophrenia, family therapy, family violence, etc.

If it is clear that there are gaps in knowledge, it is vital that the education provided is both accurate and appropriate. Although it is difficult to ascertain a family member’s level of knowledge, it would become clear from an accurate assessment as to where the gaps lie. This may be the symptoms of the illness, the effects of the medication, treatment options and so on. It may also be worthwhile asking the family what information they would like. Once this has been established, the issue then arises of where to find the information. We would point you in the direction of the major reputable sites, for example, Department of Health (www.rbwm.gov.uk/web/social_publications_mental-health. htm), Royal College of Psychiatry (www.rcpsych.ac.uk/mentalhealthinfoforall.aspx), MIND (www.mind.org.uk/help/information_and_advice), etc. We would advise caution for sites that are not widely known. Once you are clear and have found some information, you need to adapt this to your family. We would advise careful reading to ensure the wording is pitched at the right level and is easy to understand. In mental health there is an awful lot of jargon, and, while this is known by professionals, it is not widely understood by everyone. The best advice we can give would be to reword any information that you feel is appropriate and adapt it to meet the needs of the family. Look back at the assessment and try to ensure that you address what the family deficits are. Tailor-make the information so that it addresses what the family need.

Cultural issues While information is widely available, it is important to consider cultural issues. A good understanding of the culture of the family unit that you are working with is important. Consider what the family views are concerning mental illness. In some cultures, for example, depression is not recognized. Some cultures view the experience of hearing voices very differently to others.

Summary

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Education is a vital intervention in family work.

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The Knowledge About Schizophrenia Interview (KASI) can be adapted to any mental illness. The assessment of family members’ knowledge must be carried out carefully, and their needs must be addressed when providing information. Be careful with the amount of information that is available. The internet has many unreliable sites. Always carefully read and adapt the information to the family needs. Be mindful of cultural issues.

Questions 1 2 3 4 5

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Why is education important? What two questions should you consider, prior to providing education? How would you provide information to a service user and family members? Why is a good knowledge base important? Why consider cultural issues?

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12 Communication skills for families

Aim The aim of this chapter is to introduce you to how communication can occur in families, and how this can be improved.

Learning outcomes By the end of this chapter you will be able to:

• • •

understand the importance of communication in family interventions, and how poor communication can present problems detail an approach of enhancing communication in family intervention, using a structured process identify the link between an accurate assessment of communication skills and the progress made within the family.

Introduction Later in the book we look at interpretations influenced by Lazarus and Folkman (1984) related to the stress and associated appraisal following problems in communication, but here we draw attention to some of the models developed to aid understanding of communication. The early work of Lasswell (1948) is useful in understanding the communication process for families and we feel important in helping family workers to conceptualize the communication process in therapy. Underpinning his model, Lasswell (1948) argued that communication had intent to affect the receiver’s behaviour and can be represented as follows: the person sending the message (communicator) conveys the message (verbal or non-verbal) to another person (the receiver); this message is received and then an effect or reaction occurs. This aids the understanding of what happens during communication but not necessarily how it happens. In family work we like to think that communication is made for a purpose. This purpose could be one of attempting to persuade another in

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some way to accept their opinion. This involves the person sending the message by means of a medium (action or statement) for another person or receiver to interpret. The purpose could be a personal driver or a moral one. It could be sent in order to get over a point of view or to demonstrate reaction to what is happening either now or in the past. Ultimately the message is sent with the intention of creating some change in the receiver that may generate action or opinion. In an attempt to explain this further we turn to the Shannon and Weaver (1949) model to address the process of communication that can help our understanding of how it happens. Sender–message–channel–receiver is regarded as the process of how a message is initially sent through a channel, then the message is received and interpreted. On the surface, this appears fine, and is pertinent when we consider that members of the family pass information or opinions on in a variety of ways and ensure that the message is received. Although appearing logical, the process when applied to families is fundamentally flawed. The process works well for understanding things like the transit of goods from one place to another. If that was all that was needed, this model would suffice. The problem with families is that there is a message attached and a meaning which needs to be understood, and there is a relationship between the people involved. Many family messages are coded for the receiver to understand. They may be produced in a way that meaning could be ambiguous and lead to misunderstanding or confusion. The problems with communication in families are that messages may be sent for one purpose, but interpreted for another. Add to this the mix of personality and mental illness with someone in conflict and you have a recipe for chaos. The content (message) is important, as this is where Shannon and Weaver (1949) would argue that the meaning is, but the channel (family member) can amend this and the receiver (another family member) has their own understanding. This could be dependent on experience, attitude or expectation. The assumption that the message will be uniformly understood is where problems may start to emerge. The risk of making assumptions about communication is an area that family work needs to address to ensure that the communication medium is uniformly understood and the language used is unambiguous and clear. For example, if a mother says that her mentally ill son is lazy, could other members of the family interpret this differently? The answer to this will be in the detail and the common language that is used within the family setting. Understanding of communication could be better represented by the mass communication work of Wilbur Schramm (1954). His work allows you to appreciate that understanding and coding or decoding of the message occurs. In families, the fields of experience can be wider than just the message, and may be what Schramm (1954) referred to as connotative, or understanding based on emotional or evaluative personal experience. This differs from the more mechanistic (or denotative) meanings common to most people. This explanation allows the family worker the opportunity, if needed, to explain not only how different people may interpret the same information in a different way but also how the expectations of a message can be made about a message to the

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family. That is, that the message was felt to have the same meaning to all, but each understood it in their own way.

Communication deviance The common language used can (as has been seen in the section on expressed emotion) be important in the exacerbation of symptoms and the presentation of illness. Like expressed emotion, the theme of communication deviance warrants some discussion. Stone et al. (2004) argued that communication deviance was where a family had problems in maintaining attention and meaning. The problem with this is that the service user is exposed to contradictory or conflicting approaches from the communication used within their family environment. Wynne and Singer (1963) found this in some families where schizophrenia was evident, and argued that it may have something to do with the development of the illness in family members. Nugter et al. (1997: 199) argued that when a ‘speaker had a high level of communication deviance, a listener has difficulty in comprehending and visualizing what the speaker is trying to say’. This deviance was related to family history of schizophrenic disorders within family members. Subotnik et al. (2002: 719) argued that this subclinical thought disorder expressed in speech ‘may be an indicator of genetic vulnerability for the illness’. This incidentally fits well with the psychoeducation section and the values related to the stress–vulnerability model (Zubin and Spring 1977) and the evidence found by Brown et al. (1962) of the influence that families may have on the re-emergence of symptoms. These arguments are something you may start to identify in the communication patterns that exist in the families that you are working with. But what about it? The crux of the matter is that the communication patterns may have an effect on the presentation of illness but that there may also be other elements of mental illness existent in the families that has gone undetected or untreated. Earlier chapters have shown the importance of affective style. This is relevant here as it helps with the conceptualization of communication. Affective style refers to language that is critical, guilt inducing or intrusive (Doane et al. 1981). This adds a complicating factor to the rapidly clouding mix. What are the differences between expressed emotion, communication deviance and affective styles? Well, to most there is little, and most are referred to as expressed emotion by family workers. The subtle difference is in the way that the affective style can exist without the evidence for expressed emotion. Although not necessarily a component of expressed emotion, they are more descriptive in expressing what is happening and infer the need to explore more about family history and treatment relating to mental health.

Mixed meaning In family communication it must be accepted that the listener may well misinterpret what the message was intended to represent and you may want to explore how the manner in which messages are sent can cause this. This may lead on to educational elements related to mental health issues, but may also be more simplistic and explained purely by the way things are said and the level of emotion experienced at the time and

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about the issue. Each person will have their own way of communicating and it is not the practitioner’s place to make people speak in a different way or use technical language. Instead the focus should be on making them understand that sometimes what is said may not come over as intended and that someone’s reaction may not be a personal slight but more of a reaction to how they have interpreted what they thought had been said. By introducing sessions where this can be identified and remedies explored, the level of stress within the family may reduce and the clarity of communication improve. This will enable the family members to understand each other better and to increase their own self-awareness of how people can negatively or positively react to what they say. This level of self-awareness is what the family worker will be striving for. We cannot make people say nice things all the time but we can help them to understand the consequences and why they may want to say the things they do.

Why would we look at conducting communication sessions with families? Table 12.1 offers some of the potential pros and cons for communication work with families, as discussed by Falloon et al. (1993). Addressing these factors, especially the cons, is important in any therapeutic work. With families the problems lie with the number of individuals being involved at any time. A further problem may be that the less confident members find it hard to talk openly and they may remain quiet despite having something positive to say or something that is a real dilemma for them. This can lead to internal conflict and a potentially dissonant experience as the sessions progress.

Dissonance Dissonance (the word itself implies conflict or inconsistency) is a communication theory detailed by Leon Festinger (1957) which involves the holding of incompatible beliefs at the same time, creating a feeling of disharmony. An example may be a family

Table 12.1 Pros and cons for communication work with families

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Pros

Cons

Enhance the communication between family members Reduce stress Improve coping Share personal goals Request a change in style of communication Can express pleasant and unpleasant feelings Opportunity to listen and identify where you are

Flag up difficulties that may seem insurmountable Open up old wounds Highlight the lack of progress over the years even with professional help Provide opportunities for individuals to try to impose their values on the rest Focus purely on negative aspects instead of positive ones Create unhealthy risk taking by increasing optimism outside of the expectation Misinterpretation of information and misidentification of values leading to perceived bias towards individuals

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member who constantly feels that medication is poisonous and that the service user should not take it, but never voices this. The service user who lives with them and is under the family member’s supervision continues to take the medication and is generally well with this regime of treatment. Medication is once again discussed in a positive light and the family member feels compelled to go along with what is going on as others are happy, yet they feel disturbed by the decisions. They experience the turmoil of being unhappy with this, yet happy that the service user is well. They avoid talking about medication due to the fear of letting slip their beliefs and go along with the present regime. Unearthing true beliefs is important as this family member is experiencing a great deal of internal stress caused by their inability to communicate their true feelings. In time these feelings may become apparent but this in itself may present a new problem when the opinion surfaces as this will commonly be at a time when crisis or relapse occurs and can be seen as unhelpful and divisive. Many people continue to harbour hidden beliefs so as not to appear ‘smug’ and self-righteous at a time when support and compassion is needed. They carry on in an inharmonious way with whatever happens and their true beliefs remain hidden.

Underpinning approaches Positive reinforcement is encouraged throughout. We tend to try to ignore negative comments and allow family members who are becoming more confident to challenge them. The process of change will take time and there will be no real eureka moment, but a gradual change to something more reasonable. Care is needed not to allow the family worker’s expectations to take hold and influence the therapy that goes on. Understanding of the variety of communication styles that are present is needed and encouragement of honesty important. Support and the use of individual sessions for family members to voice opinions outside of the main group may be needed. This may provide the family member with the confidence to voice their true beliefs and then aid the progression of treatment without the fear of new beliefs emerging at a time when it could only be counterproductive. Assessment of interpersonal skills related to communication is one way forward. Care is needed as many tools for this suggest that interpersonal skills are either passive, assertive or aggressive. The value of knowing this is really related to the family group you are working with and may create tension and discussion about how things can appear different to how they actually are. Assessment tools may also anger or ostracize some members who identify themselves with a tool as aggressive when they do not think they are. One easy method is to simply get the family together and observe them talking. Notice is taken of how they express feelings and make requests, also if they listen to others and appear interested. Interaction needs to be focused on positive elements and on what they do well rather than on what they didn’t do so well. If communication is proving difficult, the opportunity presents for the family worker to model the use of communication in a role-play type scenario. The more real life the better, but care is needed not to negate past efforts and suggest either a lack of trying or inability to

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command simple skills. As discussed earlier in the book, tact and diplomacy are important.

Typical behavioural sessions Falloon et al. (1993) focused on the process and set out a family behavioural communication package. This is loosely adopted here, but we (having amended our practice over the years) use only some elements. The package we developed involves the following activities:

• • • • • • •

The family workers identify and personalize the communication strengths of family members. The family workers explore these in a session and establish if everyone can see them and how they feel about trying them (each person will need their strengths identifying). The family will identify a list of scenarios that they feel demonstrates where the family communication is lacking and this will be role-played. The family will run through the scenario and the family workers will avoid interfering where possible. The family will explore the fidelity of the scenario, and then if needed the role-play will be repeated. Once the scenario is as it is felt it should be, the family worker will ask one of the members to make a request, be it positive or negative depending on the role-play. Feedback from family members is then gained and each member asked to practise the skill for next time.

A colleague of ours was immensely talented at this and really aided us in the development of the process. He engaged us in addressing initial cynicism and helped us to see the value of such an approach. A good example he demonstrated was that although it may seem simple and at times awkward to you to suggest some communication skills, you need to run it past the family as all are different. Also each family functions on a different level and care is needed not to introduce your values and use this as a yardstick for moving on. Grounding yourself in how the family function or do not function is important.

Assessment of communication For any communication package you will need some assessment of the family’s communication skills. This, as hinted at earlier, needs some focus and the exploration of strengths and contextual information related to things said (both the words and the way) is important. We advocate the emphasis that Falloon et al. (1993) made towards pleasant and unpleasant statements. Figure 12.1 is an example of a grid that can be used to collect such information. The rationale for this is to identify communication deviancy and critical comments. It also, on a positive note, gives the opportunity to

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identify the positive coping strategies used in communication. We advocate, as in many cognitively orientated approaches, the use of Kipling’s six honest men to aid the contextual content (Box 12.1).

Box 12.1 Kipling’s six honest men I KEEP six honest serving-men (They taught me all I knew); Their names are What and Why and When And How and Where and Who. I send them over land and sea, I send them east and west; But after they have worked for me, I give them all a rest. I let them rest from nine till five, For I am busy then, As well as breakfast, lunch, and tea, For they are hungry men. But different folk have different views; I know a person small— She keeps ten million serving-men, Who get no rest at all! She sends’em abroad on her own affairs, From the second she opens her eyes— One million Hows, two million Wheres, And seven million Whys!

Clearly the use of the six terms – who, what, where, when, why and how (www. kipling.org.uk/poems_serving.htm) – engages the family in recording the presentation of communication patterns in detail. It also provides the opportunity to elicit emotion and impact. Use of the grid (Figure 12.1) will enable everyone to report and a comparison of the completed grids should highlight similar trends and events that cause problems. This information can also be useful for stress management and the problem solving sessions. From this, discussion about the content can begin and extracts can be taken, indicating themes related to what was felt to be pleasant or unpleasant and the impact it had on feelings. Identified statements can become the core information used in communication sessions and exploration of the context can lead the family to identify how they are communicating currently and how this is interpreted. Care is needed not to allow the sessions to hone in on one person and make them the core of the discussion. This may well drive them away and the family work could simply end.

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Figure 12.1 Stress management assessment grid.

Some basic rules At this point it must be said that the sessions will need some structure and some basic rules. The structure will remain quite constant, using agendas and a collaborative approach utilizing feedback and understanding. Concepts continue to be explored in a guided discovery fashion with emphasis on behavioural and cognitive behavioural skills to formulate and create related homework. The core themes of any experiments need to be behavioural in principle and addressed by each family member accordingly. Within the sessions we advocate the approach adopted by Kuipers et al. (2002). They assert, as do many other family workers and therapies, that the participants need ground rules. These provide an important safety net for participants but they must not be too rigid so as to become restrictive. We use the acronym OFFER to structure communication sessions (see Table 12.2).

Summary

• • •

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Apart from the rules that need adhering to, the theme of communication is a necessary element in any family intervention package. There needs to be an understanding of how and why we communicate. Communication skills also involve sharing treatment themes with other elements of family intervention in order to enable family members to utilize the skills and pick them up quickly.

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Table 12.2 OFFER structure Common rules for family intervention Rationale One person speaking at a time

Often (especially when conversation is animated) people talk over each other and the messages are lost

Focus the conversation

Remaining on one theme at a time allows the opportunity to explore it in depth without distraction and understand each person’s point of view

Fairness

If the participants start talking about people instead of to them, it can leave a feeling of isolation and this can become a habit that reinforces it

Enabling all

Allow people to speak and be heard: this can be achieved by a combination of the above

Respect for opinion

Each should have the opportunity to talk and sharing this equally where possible is important

• •

•

Having communication skills avoids having to learn technical skills for different treatment sessions and engages family members in an approach that has some utility in the continued challenge of living with mental illness. Self-awareness and examining the comments that are made, sometimes without thinking, can be cathartic but also upsetting. Sometimes self-image is one of kindness and thoughtfulness, yet when we explore what we say to loved ones we find that this may not be the case. Support and tact may be needed to maintain people in the work and a clear method of working can help to keep people moving forward with optimism.

Questions 1 2 3 4 5

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What may be a problem with the use of the Shannon and Weaver (1949) model for explaining communication? What are Kipling’s six honest men? What does the acronym OFFER mean? Identify five pros for the use of communication in family intervention. What part does dissonance play in family intervention?

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13 Stress management for families

Aim The aim of this chapter is to introduce you to the importance of stress and stress management in family interventions, providing a process for implementation.

Learning outcomes By the end of this chapter you will be able to: G G G

understand the importance of stress management in family interventions describe an approach to stress management in family interventions detail the need for the adoption of a specific model of stress management, such as the transaction model of stress.

Introduction This chapter focuses on the importance that stress, and in particular the management of stress, plays within family intervention. Part of the management of stress involves the effective use of communication, and the ability to problem solve; these are addressed within other chapters.

What is stress? At one time or another almost everyone will experience stress. Stress may be defined as an individual’s response to threat (Falloon et al. 1993). The key word in this definition is the word ‘individual’. We all perceive stress in different ways, and in this sense what one person deems stressful may not be the same for others. Stress can arise from both positive and negative situations. For example, promotion at work (positive) can bring with it extra responsibility causing more stress. Not having enough money to pay bills (negative) also carries an increased amount of stress.

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Stress can be subcategorized into ambient stress and life event stress. Ambient stress relates to what we experience in our everyday lives – the stress of living. The general routine of going to work, paying bills, bringing up children, and studying for exams are all part of life. These situations cause stress in themselves. Life events also carry a significant amount of stress; the death of a relative, partner or child carries with it a large amount of stress. Divorce, moving house and redundancy carry what is regarded as smaller amounts of stress in the ranking of stress (Ambelas 1987), though are still stressful events in themselves. The threat can be regarded as the stimulus that causes a response.

Let us take the example of a first appointment with the mental health team. The stimulus is meeting someone from the mental health team for the first time (in this example a life event). The response includes both the physiological and the psychological components to the interview. If we look at the example in Figure 13.1, an interview is a stressful event. It is appropriate to feel nervous, for your heart rate to increase and to experience a dry mouth. You will feel nervous at the thought of what is expected, what to say, and what they will do with this information. With regards to stress, the key area is the level of stress and how well you deal with the stress. Let us look at the same example but with a very different response (Figure 13.2). In this example it is clear that this individual will undoubtedly experience an increased level of stress. Following this stimulus and response definition comes a need to process the situation, how to deal with the situation, and what adjustments need to be made.

Figure 13.1 A stimulus–response example.

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Figure 13.2 Another stimulus–response example.

Lazarus and Folkman (1984) took this ‘model’ further and developed the transactional model of stress. They viewed the interactions and adjustments to the transactions and looked more deeply into how we appraise situations. Their work focused on cognitive appraisal (which they see as a two-way process), primary appraisal and secondary appraisal. Primary appraisal refers to how an individual appraises a situation – irrelevant, benign-positive, or stressful. An example could be a cancellation of the train service for the following day when you had agreed to attend the family meeting. This could be irrelevant if you do not use the train or are able to get to the meeting in another way. This could be seen as benign-positive if you regard this as a meeting that you didn’t really need to make, but felt that it was merely a show of interest. This could be seen as stressful if you felt attendance was important and that you have to attend. Secondary appraisal occurs at the same time as primary appraisal; this is when we consider what can be done to manage the situation, by looking at how we cope with the situation. This considers options and resources available to us. This leads to either a perceived ability to cope (positive stress), or a perceived inability to cope (negative stress). With the example above you could consider alternative ways of getting to the meeting, whether that is a lift from a friend or family member or getting a taxi, although still stressful. This could also be negative stress if you feel you cannot get there under any means.

Stress and vulnerability Exploring the relationship of stress and illness necessitates a conceptual shift in that stress not only makes you think and feel differently, but also can make you vulnerable and susceptible to certain forms of illness. There has been a wealth of literature surrounding stress and vulnerability, with a significant proportion focusing on stress–vulnerability models (Zubin and Spring 1977; Neuchterlein 1987). These models clearly identify that we all have a vulnerability to developing a mental illness, and that vulnerability on its own may not lead to illness. However, if we add a significant amount of stress to this vulnerability, the risks increase greatly.

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Family intervention Stress can be experienced by both the service user with a mental illness and the family members, as a result of living with the service user. It is important in family intervention to acknowledge the stress on the service user. The stress of having a mental illness, taking medication, attending appointments and having professionals to visit can all affect the individual. We acknowledge this and urge you to make every effort to address stress with the service user, whether that involves asking for medication to be reviewed, offering education sessions or focusing on developing effective coping strategies. The focus here will be on working with the family members, recognizing that if stress is managed with the family members it will greatly benefit the service user. The stress encountered by family members tends to be as a result of the observed behaviour of the service user, causing a stress response. This response (in our experience) is usually negative. How a relative appraises and responds to the situation or behaviour is extremely important. Therefore the techniques that need to be employed consist of eradicating the behaviour of the service user, or managing the response of the family member. As we have stated, it is beneficial to look at ways of eradicating the behaviour of the service user, though this may not always work. The targeted intervention is in managing how the family members respond to the stimulus. Stress management techniques have been well documented over the years. We recognize the breadth of written work on this subject and will apply this to family intervention work with mental health. The primary aim of stress management is to work on the tensions that the family members are experiencing. The rationale is that when people are highly stressed their capacity for effective problem solving is reduced or they may be more likely to exhibit high expressed emotion coping responses or deviant communication patterns. By looking at reducing stress we may reduce the burden of care. It is important to acknowledge the problems that family members have to cope with. They are living in stressful situations 24 hours a day, often without a break, and we need to be mindful of this. This underlines the importance of the reaction of family members in determining stress responses. The stimulus in most cases is the mental illness itself, and the consequences of the illness. The response is the family members’ attempt to cope with the situation. If they become unable to cope, or attempts at coping fail, stress responses become apparent. It is important to highlight that family members are not to be regarded as bad at coping, rather that they are presented with exceptional demands on their ability to cope (Barrowclough and Tarrier 1997). The steps for effective stress management include assessment, education, identification, formulation, intervention and evaluation.

Assessment Throughout this book we advocate the importance of assessment, and this is no exception when focusing on stress management.

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In Chapter 9 on assessment we identified the use of several of the many assessment tools available. The assessments (for example the RAI) will undoubtedly have identified many problem areas that in themselves are causing a great deal of stress. Here you need to ensure that you are familiar with the information that was accumulated throughout the assessment and that you have identified areas on which to concentrate. However, as we say, assess, assess and assess some more, so you have the opportunity to explore in full any areas that you feel need further clarification.

Education Chapter 11 highlights the importance and benefits of education within the family setting. Here we advise you to provide education concerning the role that stress plays in maintaining the problems and difficulties that the family members are experiencing. We have found in our experience that a session that explains the stress– vulnerability model is extremely rewarding. The family members like to hear you explain to them that they are not always to blame, and that stress is often unavoidable, but that with some careful and considered approaches this whole situation can be improved. Everyone has their own views on what stress is, yet everyone manages stress in very different ways. Exploration of the variety of ways that people react to stress and how each of them in the family do so can be educational and yet at times cathartic.

Identification Following assessment, work needs to be done to ascertain what the main problem areas are. You may have identified many areas, you may have identified none. What is important is that you work collaboratively on this. The family members and you may have differing opinions on what is causing stress, and it is vital that you work together. This often takes careful and considered skill in using the information available from the assessment. You may want to undertake some further assessment to ensure that you have identified the right areas to target. In this case a simple form could be used. Table 13.1 identifies a useful tool for gathering information. Let us consider Kipling’s six honest men mentioned in Chapter 12 when we looked at the types of questions to ask (who, what, where, when, why and how: www. kipling.org.uk/poems_serving.htm). Table 13.1 gives an example of a stress situation monitoring form. Although quite simple, the form could yield a lot of information if completed accurately. As with any forms that you ask family members to complete, you need to ensure that they are happy to do this and understand what is being asked. For example, consider the questions asking what were your thoughts, feelings and behaviours. Although this may seem straightforward to some, it may not be clear for all. Many people struggle to identify their thoughts, yet can easily identify feelings. Steps should be taken to ensure that all family members know what is expected, and what the purpose of completing this form is. You may need to adapt this to suit the particular family that you are working with.

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Table 13.1 Stress situation monitoring form 1

Day Date Time (When)

2

Where were you? Who was there? What exactly happened?

3

What were your thoughts? What were your feelings? What were your behaviours? Why do you think this happened? How do you think this could be avoided?

Formulation After gathering the information and having identified the main problem areas, a shared formulation is the next step. Chapter 10 has identified how to conduct a formulation, and Figure 13.3 shows an example of a formulation based on stress management. We can see from Figure 13.3 that the situation or critical incident that the service user experiences leads onto thoughts, feelings, physiology and then the behaviour. This behaviour triggers the situation for the family member, and a so-called vicious circle ensues. Figure 13.4 gives an example of this in practice. Although simplistic, this gives you an understanding of how stressful a situation can be. It is crucial to share a formulation like this with all family members (including the service user) as this highlights how situations like this can be construed. If you relate this one situation to several situations, it makes it easy to understand why stress management is important. Consider a self-assessment test; thinking of a family you are presently involved with, try to look at a couple of their problems and how they create stressful situations that the family have to work with. Also explore a situation you may have been involved in and start to unpack a practice-related situation that caused you stress. Look at your

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thoughts, feelings and emotions. Being honest about yourself can help you to understand what it may be like for the participants of your family interventions work.

Interventions There are various interventions available for the management of stress. Inevitably, the accurate assessment and formulation go some way to helping the family members understand what is happening, and this alone can be seen as an intervention. If family members can see how certain responses and behaviours cause stress, they often alter some of these behaviours. An accurate assessment is the key. Following this there is the need to address what is causing the stress. If we look back at the stimulus–response model, we need to either modify the stimulus or change the response, or maybe intervene in both. We list below eight of the interventions that we have used.

Figure 13.3 Shared formulation.

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2

3

4

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Distraction – a very useful way of coping with a particularly stressful behaviour. It is usual within families for family members to become angry and embroiled in difficult behaviours. This behaviour is sometimes as a result of the illness and by not responding and doing something else, the family member will be able to manage the situation better. Education – a beneficial intervention. Providing information regarding the illness, and that this may be the cause of the troublesome behaviour, often reassures the family members. Altering the response – simply looking at alternative responses to behaviours can be extremely helpful. Changing a negative, and often angry, response is often rewarding. Communication – a clear and open discussion about problems is cathartic in itself. This allows all family members to have their say, and fosters clear communication channels.

Figure 13.4 Shared formulation in practice.

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7

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Problem solving – developing a solution to a problem. This can be spending time doing other activities that the family members used to enjoy. Reappraisal – looking at the behaviour of individuals within the family and alternative ways of seeing situations, by ‘changing the way individuals think’. This is an extremely beneficial intervention. Anxiety management – providing anxiety management techniques to family members allows them to be able to implement strategies that help them deal with stressful situations. Professional help – occasionally there has been the case of having to refer family members for further assessment. Stress manifests in many ways, and can sometimes be as a result of mental health difficulties.

As mentioned earlier, this list is not exhaustive, but does represent a selection of a few of the interventions that we have successfully used.

Evaluation Once interventions have been agreed, the next step is to evaluate whether the techniques employed were of use. There is no point in setting interventions if we do not address their effectiveness within the next few sessions. It is possible that the interventions were not of benefit, or that family members were unable to carry them out. Again it is helpful for the family members to record this for discussion in session. A form that may be of use is outlined in Box 13.1.

Box 13.1 Evaluation form 1.

What was the situation or behaviour?

2.

What was your response?

3.

How did you feel?

4.

Were you able to cope?

5.

Do you feel this response was helpful?

This is a useful measure to ascertain if the response enabled the family member to feel less stressful about the situation or behaviour. If the response was useful, and left the family member feeling able to cope, this can be applied to other situations.

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Summary

• • • • • •

Stress is encountered by us all in our everyday lives. Stress is often common in families who live with mental illness. It is important to recognize that family members are not to be regarded as bad at coping, but that they have been presented with exceptional demands on their ability to cope. A careful and thorough assessment is vital. A shared formulation enables the family members to understand what is happening within the family. There are many interventions available to reduce stress, and a flexible approach is needed.

Questions 1 2 3 4 5

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What is a definition of stress? Can you explain the difference between ambient stress and life event stress? What is the transactional model of stress? Why is a formulation important? Name three possible interventions for the management of stress.

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14 Problem solving for families

Aim The aim of this chapter is to introduce you to the importance of problem solving in family interventions, and the structure required for clinical implementation.

Learning outcomes By the end of this chapter you will be able to:

• • •

understand the benefits of problem solving in family interventions describe the process of problem solving in family interventions identify the importance of understanding needs in family interventions.

Introduction In this chapter we encourage you to reassess where you are up to with a family you are working with, and explore if the steps taken before focusing on problem solving have generated a working relationship within the family and if the previous sessions have started to elicit problems that need addressing. Problems may not all be necessarily related to mental illness. Families are exposed to a variety of events that in turn lead on to problems that are then responded to. Life has many stressors and all families live with a level of stress that is present in all others in society. The unexpectedly large bill drops through the letter box, someone has difficulty in getting to work because the bus was late or they overslept, and they had limited time to prepare for something. These ambient stressors in most families are coped with in a variety of ways, but where a major mental illness is evident they may not be as manageable. The impact of stress on a family may appear to be on one member: Ross who is 17 years old coming home and telling his mother that his girlfriend is pregnant, or Joanne who has been married for ten years finding out her husband

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has been having an affair and is leaving her. The impact is not just one way. The impact is experienced by all the family members and the reaction is uniquely different. Therefore aside from the mental health problems that one member of the family you are working with is experiencing, there may be other stressors that are creating problems for other members of the family to manage as well. As we have already discussed, stress can play a major part in the emergence of mental illness symptoms, and a service user’s vulnerability may place them in a risky position when ambient stressors are added to the stress of illness. The longer the stress goes on, the more demands are placed on the service user and family coping strategies. We advocate that this intervention should preferably start only after stress management work has been generally completed. This is so that the family have started to develop coping strategies and are starting to work as a family that understands some of their problems caused by issues related to life and illness, and their interpretation and reaction. Problem solving, or not, is unique to all families. Every family will have its own way of dealing with or avoiding stress and problems. Problem solving may seem a simple suggestion, but one that families have limited structures or abilities to conduct when distracted by illness. We feel that although artificial, families will need what Falloon et al. (1993) argued for, that is to be trained to problem solve. We acknowledge Falloon’s six-step approach, and believe that without this, problem solving would have remained responsive instead of planned. Through years of use we have slightly modified it to fit with the demands of casework experienced by us. We prefer the structure outlined in Figure 14.1. Rather than entering into a workshop style approach, we advocate that problem solving be blended into the sessions and the emergent themes for family difficulty embedded into the model. The model we use is a common one seen in much of therapy, with our interpretation of the detail in the steps. We continue as in other sessions to utilize agendas, giving feedback, exploring the meaning and feelings behind what is said and generating some homework to be completed for the next session.

Figure 14.1 Structure for problem solving.

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Defining the problem The focus of this approach involves identification of some core information:

• • •

problem list family strengths family needs.

This is an important step that will need the family to define the problems. The family worker should not intervene too much and create further problems. As the family is encouraged to identify their own problems and structure strategies to deal with them, it will enhance the chance of them sticking with it if things get difficult. The reason behind this is that they have investment in their own work and are less likely to give up and blame the family worker for not knowing the family and its problems well. The generation of a problem list will need some encouragement to move on from the traditional negative view related to medication, the service and the service user not trying. The family worker encourages everyone to offer suggestions (regardless of how odd they seem). An example is seen below: Family worker: OK, if we can write all the suggestions down first and then look in more detail later, we can all have a chance to voice what problems exist. Anne: I feel I do all the work in the home. John: No way, you think you do. Anne: Well, what do you do? Family worker: Before we move away from what we are trying to do, what do you think the problem is with this, Anne? Anne: Well, John will just sit there all day and never make cups of tea, clear his plate, or do any tidying. John: That is so wrong. Family worker: John, Anne is starting to identify some problems that she feels exist. She is narrowing down what she said before into smaller clearer themes. At present we are just gathering together what you feel are problems. These are things we will go back to once we have gathered what you feel are the problems. What would you like writing down as problems from this then? The family worker has to maintain some control of the process of gathering a problem list. Remaining calm and focused is important. Being calm, clear in the information given, and firm if necessary are skills required. Generating problems is a risky part of family work and can lead to heightened emotions and sometimes anger. As can be seen by the example, simple remarks can irk some people, and a need to challenge and modify should be acknowledged. Reminding everyone of the process should help in this situation. If the session descends into chaotic back biting and anger, the family worker needs to exert control. The family worker may need to stop everyone talking and

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refocus on the task. It has unfortunately been our experience where we have had to halt a session and reconvene later in the week due to persistent negativity by one family member. After a break the family member may apologize for their behaviour and want to voice why they had reacted in this way. This needs managing and redirecting to the generation of a problem list. The family worker could then acknowledge the strength of the family member in being honest enough to admit that they were wrong in some way. This will be one of the themes added to the next part of the defining sessions. The process of gathering problems and then narrowing them into discrete issues goes on until there are only re-emergent problems. The family worker can then start to elicit the strengths of the family. To get the ball rolling, the worker can identify that the family were able to see the problems and narrow them into clearer problems. An ability to work together and contribute and listen can be offered. However, this should be offered only if the family are having problems getting started. As with the problems, the strengths are listed and these may well be some of the coping strategies that are used to deal with the problems in the future. Sometimes it is not the skills that are missing to help someone to deal with a problem, more so the identification that it is a problem and the opportunity to intervene. Identification of needs is the final part of defining a problem. This is an area where most family members and practitioners seem to have problems expressing themselves. Most identify that a need is something that the service user requires. Well, yes, but what do they require and why? Most of the contextualizing has already been done when using Kipling’s six honest men. So what is a need? Before explaining you should examine your own interpretation of what a need is. In Table 14.1, we have highlighted some problems for you, just like in a care plan. All you have to do is identify the need. We acknowledge that this was an unrealistic exercise but we hope it was one you found useful, trying to answer and elicit needs. Needs are individual and this really sets them aside for a collaborative inclusive approach that uses the person’s own words and experiences. It once again presents the individual as the expert as they are the one who is experiencing the problems and who knows what limitations are caused by these problems. Herein lies the answer as to what a need is. The need is simply, ‘If the service user or family didn’t have the particular problem, then what would they be doing?’ Revisit Table 14.1 and try to think of service users who you may have worked with who experienced similar problems. Although hypothetical, try to identify potential needs. This process is an important part of family work as this can be one where the family start to gel together and have joint needs and understand that they may have some solutions as well. Table 14.1 Problems and needs Problem

Need

Hearing voices Intolerant of people asking questions Constantly lying in bed

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The impact of narrowing the focus onto needs must not be underestimated. When unpacked it can cause sadness in a sort of grief way. It can generate blame and anger as to why it was not seen before or why someone never helped before.

Potential difficulties with eliciting problems As with any therapeutic intervention that uncaps emotions, anger can follow. Generally, having someone from outside of the family present can be enough to subdue anger and perhaps mitigate reactions. However, this may not be enough and some assessment of why the anger emerged is needed. Revisiting the rules, is everyone being listened to? Getting an opportunity to voice concerns and opinions? Addressing each other by name rather than in the third person? If so, diffusion by the family worker may be needed and often simply exploring why they are so cross can lead to unearthing misunderstandings or even longstanding bias that you may have thought was dealt with before. This discussion may then lead on to a new problem for the family to discuss. Ultimately the family worker will need to maintain control throughout. It is an easy place to lose the focus and for the family to descend into ‘one-upmanship’ and to try to score points against each other. The family worker should refocus on the purpose of the therapy, setting aside family differences and then working on them. A worrying way that families may begin to cope is to use the family worker’s arrival as an invitation to voice anger and express negative views. In our experience some family members are not so engaged outside of sessions but suddenly become vocal and use the presence of someone from outside the family to voice potentially hurtful thoughts. This must be managed and the family worker may well have to face the family member with their behaviour and express the fact that this behaviour is not tolerable in sessions. Once again reframing (Kuipers et al. 2002) this into strengths (e.g. that the person feels so strongly to bring the issue up in front of the family) is a strategy worth exploring to turn it into something constructive. It is important that everyone is given an equal amount of time to talk. If all else fails, the service user can negotiate time to speak outside of the session, but only with the family’s permission. Care is needed as this may be a coping strategy by family members to test out negative feelings and to avoid engagement in family work.

Consider possible solutions Here brainstorming as advocated by Falloon et al. (1993) is needed and with everyone involved if possible. Families sometimes find it hard to think outside of what has been suggested for treatment or safe solutions. The family worker needs to engage the members in an innovative approach where their suggestions can be noted and this all adds to the pool of possible solutions. It is a good point at which to identify potential goals for the family intervention. If the family do struggle to come up with solutions, the family worker may well need to offer some. This needs to be contextualized and may require the family worker to model answers depending on how the family may see things. Take care not to negate or belittle. As with most people, when we are asked to do something and find it difficult, we can be a little sensitive, so tact is required.

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The family worker should reaffirm that the relatives have strengths and can help each other to achieve change. A list of possible solutions for the problems will be generated. This is then explored in more depth in the next stage.

Advantages and disadvantages to each solution Within the family group each solution can be looked at in practical terms. The advantages and disadvantages are noted in order to be able to prioritize a plan of action. This can be commonly started as a theme for homework for all family members. Each member is given a copy of the problems identified and the list of possible solutions. For the next session they are tasked to deal with the various advantages and disadvantages of the possible solutions. These can be discussed and as before, control may be needed. Suggestions need to be heard and respect for each other’s opinion ensured. A general consensus will be needed and also careful consideration as to whether the family are addressing the problem and associated need. Identification of the strengths within the family that will make the solution workable can be entered into.

Which is the most workable? Working together needs to be encouraged here. Joint decision making and agreement on a solution that all feel comfortable with is warranted. As before, a list can be generated which is then prioritized. Care is required as differing affinity for solutions may sabotage some. Agreement to move with one approach is needed and the decision rests solely with the family. They have to decide what to do and how. This moves gently on to the final stage.

Steps needed to achieve The structuring of the steps needed to achieve the solution will explore potential barriers and the things that may make it happen. These modulators are important in any family work. If the family go into something being aware of them, they are more likely to see pitfalls in a less catastrophic way. Being the architect of the plan can have some rewards as it is they who ultimately will cause the change. Family worker: How well do you feel that you are doing in relation to the need to feel like you have a role in the family? John: Well, I still struggle to get motivated but Anne is encouraging me and not necessarily doing everything for me. She will, in a nice way, say things like ‘Moving your plates made me less grumpy!’ Family worker: In what way? John: Well, she says that it is something less that she has to do and this means that she can do something for herself. It also stops the arguments about me making a mess. It made me notice when I put them in the sink that the back garden needed tidying. She asked if I could help. It does make me feel that I am more involved in what is going on in the house.

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The family worker throughout was merely the facilitator of proceedings. The completion of this should improve self-esteem in the family and provide a more cohesive understanding and approach to handling problems. It places the family in the position of focusing on the positives for therapy and their involvement in it. It should give them the confidence to plan for the future and a tried and tested method of problem solving. Breaking the process into steps presents an opportunity for the family to run through what will be done, when it will be needed and how each has a role. This running through can allow for fine tuning and trouble shooting of misunderstandings. It can also give the family the chance to use what Falloon et al. (1993) relate to as rehearsal. This can be done in the safety of the session and feedback from all can tighten up any problem areas.

Future sessions Reviewing the work completed and the giving of feedback can maintain the momentum of the family to tackle problems. As problems are dealt with, the need for more general goal identification becomes more pressing. What was done well and what could be used in future can be explored. A look at how the family are generally coping and revisiting the generalization principles discussed earlier will be made. A checking of coping strategies and identification of future perceived problems can highlight where the family feel they are on the continuum of therapy. Skills acquired or identified and a better understanding of each person’s role can lead to a more harmonious family.

Summary

• • • •

The process of problem solving can be a real chance to energize a family and also get them to sort out problems and provide them with the skills for the future. Being aware of the risks associated is important and handling conflict may be needed. Remembering the structure of the sessions and keeping the themes used in other sessions can create a consistency of approach that the family starts to identify with and use themselves. Having a simplistic model lends itself to being used; more so when change is a consequence.

Questions 1 2 3 4 5

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How might a family worker handle conflict in a session? What elements are needed to structure a problem solving package? Identify the three core information themes for problem solving. What is a need? How can the identification of needs help in a collaborative working relationship?

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PART 3 Examples in practice

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Introduction to Part 3

The chapters in Part 3 are case examples of a representation of live work that was conducted with families. The names have all been changed and some key identifiers altered. They are presented in this form so they can be used for training purposes and for use as vignettes for continued professional development. The structure of the chapters includes a description of the family and each member, the current problems and some questions for you to think about. The case example will not answer these questions as there is generally no one true answer but will focus purely on one area of family intervention. The family intervention section for each chapter will focus on one of the following: education, communication, stress management, problem solving or relapse prevention. Examples of assessment tools will be included. For all the cases, a referral and some engagement rationale has already been completed and the therapy does not necessarily follow on immediately after the description. We anticipate that the cases will pose many questions for you, and that you will identify your own preferred way of completing the work. The suggestions remain only as suggestions, and these were reactions to what was happening at that time for the family. They were, however, actions taken at that time and place and under the direction of the particular family. As you read the chapters it will become clear to you that a cognitive approach is adopted throughout and that due to pressures of prioritization, the same format would not be adopted. It needs to be made transparent that although we advocate a systematic process that follows the same practical process, at times this needs to be changed due to the presentation on the day. Agendas were used in all the sessions in order to establish some structure and familiarity for participants. The general skills of feedback, use of understanding and collaboration are apparent. You will need to think about the pacing of the sessions and the introduction of themes and strategies. When reading the chapters you will probably feel that something else could, or should, have been done. This is a positive aspect that requires you to identify why you would think this and how it may become inherent in your own practice.

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Attempts are made to derive service user and family member perspectives and the use of guided discovery and mini formulation clarifies this through focusing on cognitions and the reactions of the family members and service user. This allows you to consider what needs to change and how this could be developed. Homework was used, especially for self-monitoring, but also for other reasons. Once again you should consider what else could have been done. We discuss some assessment tools, and these do vary. The use of a breadth of assessments is practical, but consistent use with one family is advocated.

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15 Getting started

Box 15.1 Annemarie and Bernard’s story Annemarie is a 40-year-old woman who was first diagnosed with schizoaffective-type disorder at age 22. She had recently become aggressive and believed her husband, Bernard (46), was having an affair with someone at work. She believed the woman was called Alison, and that this had been going on for a year or so. She says that she hears him talking to Alison on the telephone when she is out of the room, and has confronted him, but been met with denial. Annemarie and Bernard have been married for seven years. Bernard knew a little about her past mental health problems and believed she had suffered with depression. He himself had experienced this when his first wife and daughter had been killed in a car accident. Annemarie had a good education and had a first-class honours degree in media studies. She had never had a relationship with a man until Bernard, who she met through a friend. Bernard was concerned about Annemarie’s health as she made lots of accusations that he said were untrue, but no amount of trying to prove he was not doing what she thought ever seemed to have any lasting effect. Bernard had taken Annemarie to their GP, who had first directed them to Relate (a marriage guidance service), but one of the counsellors suspected something else and asked them to attend the Accident and Emergency department to be assessed by the liaison team. Her rationale was that Annemarie was starting to make threats of wanting to kill Alison, even though Bernard neither knew nor worked with someone called Alison.

First contact The first contact is commonly the most anxiety provoking time for all those involved. For the family, there is the situation of having yet another group of professionals involved and potentially casting doubt on the previous professionals’ ability to cause

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change and reinforcing that the family were still unable to sort it out. For the workers, there is the anticipation of what will be said and how you will cope. Annemarie had been in the service for approximately seven months before being referred to our team. She had been seeing a psychiatrist and receiving home visits from a social worker who worked with a local community mental health team. The social worker had read one of our referral forms and given the family a copy of a flier that explained what the family interventions team did. Both Annemarie and Bernard agreed that they needed to do something as they seemed to be unable to talk and spend time together. They still loved each other but could not understand what was going on. The community mental health team had tried to engage them in some psychoeducation work but this seemed to fall flat as Annemarie and Bernard then disagreed about who was actually ill. Bernard had become quite stressed with the relationship and had seen his GP about this. He continued to work and Annemarie remained as a housewife. They wanted to sort things out between themselves but perhaps both felt that they were unable to conceptualize what was happening, and what had happened. The social worker had suggested that they were both strong characters and that due to the presence of a psychotic-type illness, a lack of progress from standard care, the evidence of an increased level of burden (as described by Provencher and Mueser 1997) and both individuals wanting to take part in the work, that family interventions should be offered (Falloon et al. 1993).

Offer of a meeting A letter was sent to the family members explaining who the family intervention workers were, their contact details and when they could visit. They also attached the reasons for the referral (which should have been discussed with them). A request was made in the letter asking them to contact the workers if the date was acceptable and that the visit would not take place unless confirmation was received. Although the family responded, the workers followed this up with a telephone call a couple of days before the due date to ensure that the visit was still wanted.

Explanation of therapy Preliminary meetings need to be organized for the workers first to meet the family and then to establish times to complete the assessments. It needed to be made clear that the assessment stage was only the start and that rushing into therapy might not be beneficial. Although both were keen to start, from the outset Annemarie wanted to explore Bernard’s infidelity. We made it clear that this may well be discussed at a later point, but at the present time we were just discussing the process. We elicited that Annemarie had canvassed every worker she had encountered about this, and had never (in her opinion) received a satisfactory answer. Although deflecting the issue, it would need to be noted and could be explored in the assessment interviews. The use of a standardized type of explanation was seen in Chapter 8 (here slightly modified for the family in question):

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It’s great to see you both and I must thank you for your time already given with your workers in order to get to this point. I will need to just go over a few themes that are important about the therapy. We will also be happy to answer any questions that you have and clarify anything that you are unsure about in the therapy. Asking questions is important as if you are unclear about something then if you keep quiet you may never get the answer and this would be both a shame and present a gap in your knowledge and understanding. I will just outline the themes of the therapy . . . Does anyone have any questions before I start? This rationale we believe focuses the family and gives permission to comment. We also believe that without the use of rationales for this, and then subsequent assessments, the collaborative elements of therapy are lost. We actively encourage families to feed back if they feel we have made it clear or not, as this will help hone and continually aid our skills at offering rationales. The structure was discussed and potential duration of therapy was estimated (Kuipers et al. 2002). So just let me make sure we all are aware of what we are agreeing to. Once the assessments are completed we shall meet weekly for the following four weeks and then review the frequency, as Bernard you will be becoming very busy at work around that time and are unable to make a firm commitment to weekly work over the Christmas period? We shall meet for one hour in the family home and anticipate that the duration of therapy will be approximately nine months, but this could be slightly shorter or longer depending on progress. The range of assessment interviews and the conduct required of all parties was examined. Bernard, as we have discussed we will use a variety of assessment tools, Relative Assessment Interview being the main one. This will take up to a couple of hours to complete and will involve exploring your understanding of the events around the illness and your opinion about how it appeared and some of the things affecting it. For you, Annemarie, we will complete the KGV assessment which is a symptoms rating scale that looks at your symptoms over the last month. When we start the work together we would prefer if each of you respect the other’s comments and avoid unduly negative and disparaging comments. If you let the person speak it would be appreciated. Accept that whatever you say may be challenged but please avoid personalizing comments and if we feel that at any time the sessions are becoming too heated, we may ask for a break.

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Agreement was made that they wanted to engage in the process. The theme of engagement started from the first meeting. Remembering the themes discussed in Chapter 8 and the potential barriers needed to be considered, this led to the workers simply exploring the contacts that the family had had with mental health services and their relationships. They explored some of the risks related to engagement and expectations. Checking of details and agreeing the time, duration and setting of the meetings was an important element, together with the right to cancel meetings and the conduct of all parties that embraced respect and allowing each to have their say.

Sharing of information It was made clear that the information provided at the assessments would be used to formulate an understanding of the problems. It was also made clear that each person knew when the assessments were being conducted and that they were completed solely with that person. Dates for contacts were made with venue and time, and the date for the formulation meeting agreed. Discussion about disclosing information to the referring team and psychiatrist was also made. A final point was to agree that even though they had agreed to commence therapy, if they decided to cease, this would be respected, but the workers might want to know why they were unable to continue.

Getting on with the work Although the process was agreed and the therapy timetable established, Annemarie decided not to start at this point. She said that Bernard would manipulate the workers and that she would be brow-beaten into accepting his view. No attempt to engage her into therapy was fruitful at this stage, but the door was proverbially left open for future work. This she took up some five months later, but the process outlined above was entered into again so as to maintain the standard of care.

Reflections We offer here what our reflections were on this case (Table 15.1). In the rest of the chapter we want you to reflect on what you might have done or would do in the case offered.

Developmental plan (three things to take away) From your practices identify scenarios where you have encountered a similar theme to this one (Table 15.2). We have used this account to demonstrate that even when you think everything is set and ready to go, it may be cut short. Also, if you do present a professional approach and leave the decisions with the family, they often come back and engage in therapy. The following chapters are case studies which are intervention specific and we ask you to reflect and look at your own development, just like we did in this case example.

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Table 15.1 Reflection What skills did you identify?

How were they used?

How could you use them?

1. Negotiation

Initially in trying to sort out contacts for assessment

Placing ownership of the contacts onto the family. Giving them some control over the timescale and the pace of the therapy in the initial stages

2. Disclosure of personal opinion

In response to personal information that was emotive

When discussing personal information, where appropriate how that may have made us feel. This heightens the normalizing side of therapy and emphasizes that we are human as well with feelings. Care is needed as and when to offer this. Much initially lay with ‘I suppose if that happened to me I would feel worried and upset!’

3. Collaborative working

Allowing the family to lead the process of therapy

Working to an agenda and in a collaborative way gives the family the opportunity to get some of their questions on the discussion board. Working with their issues should further engage them and help to establish their coping strategies

Table 15.2 Developmental plan What happened?

What did you do?

What would you do differently?

1. Initial interview seemed to go well, yet they then cancelled.

Followed the set process and allowed the family the chance to voice opinions

Explore what might Potentially detailing the cause one or both of positive nature of therapy and them not to engage in less about the commitment more detail instead of collectively

2. Families initially Ensured that the declining contact contacts and process had been followed

3. Family wanted to start therapy after initially declining

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Ask each family member in more detail as to what elements they felt unsure about and try to explore how this could be overcome

Re-ran the process Nothing to do with used with all the process, but families perhaps establish what had changed for them to be able to engage now

What do you need to learn/ develop?

Perhaps the way the information was presented. Maybe we over emphasized the negative components and dwelled less on how the process had helped others Not feeling like we may have done something wrong or have said something that caused the initial decline. Accept that family interventions is not for everyone, and that the choice is the family’s and not ours

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16 The family with education needs

Box 16.1 Adam and Sylvia’s story Adam is a 21-year-old man who was first diagnosed with schizophrenia at age 18. He had become withdrawn and believed his mother was trying to poison him. He experiences auditory hallucinations that repeatedly tell him that he is being watched by a secret organization and that his mother Sylvia is part of the same organization. Adam had left school with a range of GCSE and A level qualifications and was regarded as very bright. He was to go to university but became ill prior to the commencement of his course. Sylvia believed that she was to blame for his illness as she said that she was instrumental in the breakup of her marriage when Adam was 16. This had caused a great deal of stress and she had often confided in Adam about her upset and anger towards his father. She believes Adam should be better by now and that the drugs he is taking are not working. Sylvia feels Adam is not trying hard enough and that his thoughts about her poisoning him are a fantasy of his mind. Adam and Sylvia, although living in the same house, spend only short periods of time together. Adam tends to be in his room and surfs the internet at all hours of the day. Sylvia no longer works and spends her time doing housework and visiting friends. She does prepare food for Adam but he rarely eats anything. She becomes annoyed if she returns home to find that he has left her food and cooked something else. She accepts he has been ill.

Assessment – Adam Adam had completed the KGV (Krawiecka et al. 1977) and the PSYRATS (Haddock et al. 1999). From the questions asked he reported hearing voices (mainly a woman’s voice that could be his mother’s sister). The voice generally lasted about ten minutes and would occur two or three times per day. The content of the voice was a commentary about what ‘she’ (he implied his mother) had planned to do to him. At these times he became anxious and hypervigilant about the content of the voice. He

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admitted to discreetly watching his mother and when she was out of the home searching her room for evidence to support the threats of the voices. He said he had found lots of evidence but was not willing to share it with us. He admitted to surfing the internet for an organization called ‘EST’. He said that she was a member of this esoteric organization and that they could collectively affect his mind. He believed that the drugs made him more susceptible to their influences and that he didn’t always take the medication as prescribed due to this. At times he was incongruent and had a fixed stare that could make you feel uncomfortable. He denied any suicidality or mood disturbances. He felt that the voice was there to help him stay out of the influence of this organization. (It must be added at this point that ‘EST’ is a real organization that is shrouded in some secrecy; it is otherwise known as the Esoteric School of Theosophy.)

Assessment – Sylvia Sylvia had completed the Family Questionnaire (Barrowclough and Tarrier 1997), the Relative Assessment Interview (Barrowclough and Tarrier 1997) and the Knowledge About Schizophrenia Interview (Barrowclough et al. 1987). From these assessments it was clear that she believed that she was in some way to blame for her son’s illness. Sylvia thought that the only answer was to find the right drugs to help him. Sylvia accepted that the anxiety made him worse and consequently avoided contact with him at certain times. She did admit to arguing with him about his thoughts and medication. She felt he needed to stop messing about on the computer and get a job as this would focus his mind away from all the rubbish the internet was feeding him. She acknowledged that she paid the bills in the home and that Adam gave her money, from his benefits, towards them. This included the internet provider. She was aware of him watching her at times but did not disclose any awareness of how frequent this was, nor was she aware that he was searching the home for evidence against her. She said he was always ‘going on about EST’ but didn’t know who they were. She knew about his voice hearing and wondered if he was taking illicit drugs. She didn’t feel threatened by him but constantly thought of what his life could have been like if he hadn’t become ill. Sylvia said Adam did have contact with his father but this was over the internet as he had moved to Portsmouth following the breakup of the marriage. She had a few close friends but had not told them the details of Adam’s illness. She admitted feeling guilty about the trail of events surrounding Adam. She owned up to feeling very alone with Adam and that she could not talk to anyone else as she knew of no one going through what she was.

Questions 1 2 3

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What other assessments do you feel we need to do, if any? Listing the key points from the information, establish what Sylvia may find helpful. If you feel Adam’s delusional state may have some factual basis, how would you change (or would you change) your approach?

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Suggestions For this chapter we focus only on the education component of family intervention. As it says in Alice’s Adventures inWonderland, ‘begin at the beginning and go on to the end: then stop’ (Carroll 1992: 143). A methodical approach in this case is quite important as there are many distracters. Some factors may usurp the process suggested earlier but in this instance we are to focus on the education component. Ask yourself some more questions: are there any apparent gaps in Sylvia’s knowledge about Adam’s illness? Who has provided her with the information she has? What is it that she feels is wrong with Adam? These questions are important to answer as there may be knowledge already there that is correct but she is making the choice to view things the way she wants. Alternatively she may have incorrect or partial knowledge that may be distorting her view. Beck and Young (1980) suggested that pinpointing the problems helps to focus the therapy and is initially a ‘trial and error’ process. However, establishing the understanding that she currently has and sticking with that for the time period may be necessary. Remember that no one likes being told they are wrong. Tact and sensitivity are the order of the day in this case (this may be through not only what is said but also the tone of the voice and the frequency of family worker speech). Exploring where she got the information from and the interpretation she has made on this information may shape how you are going to proceed. It has to be acknowledged that overassessing will possibly drive the family member away. Underassessing may mean that you start to make false assumptions that they know what is going on when they don’t. It is a fine line.

Education sessions If you look at one of the assessments completed with Sylvia, the Knowledge About Schizophrenia Interview (Barrowclough et al. 1987), there is a core focus on some themes important in psychoeducation. 1 2 3 4 5 6

Diagnosis Symptomatology Aetiology Medication Prognosis Management.

These themes need further exploration and checking on Sylvia’s understanding by looking at the answers she gave for the following questions: 1.4 What do you understand by the diagnosis schizophrenia? Do you think it is: (a) Having a minor nervous condition, or having been ‘overdoing it’ lately?

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(b) A severe mental illness which can affect all aspects of a person’s life? (c) Other? (a stress-related illness) For (a) and (b) Sylvia replied that she ‘didn’t know’. For (c) she answered ‘yes’. 2.3 Do you think Adam could help or control: (a) The voices he hears? (b) The suspiciousness (of him watching you in the home)? (c) The checking of his food? For (a) and (b) Sylvia said she ‘didn’t know’. For (c) she felt that he could control it. 5.2 Which of the following do you think are likely to make Adam worse, or bring his problems back? (a) Having nothing to do? (b) Stressful life problems (e.g. moving house, getting divorced)? (c) Being pushed and nagged by the family at home? (d) Not taking his tablets or injections? For (a), (b) and (c) Sylvia answered ‘yes’. For (d) she justified a ‘don’t know’ with the statement that ‘they have never found the right drug yet, so until they do he will never take them correctly’. 6.1 Do you think there is anything you can do to help Adam’s schizophrenia? To this she simply answered ‘no’. Many psychoeducation sessions would merely provide some literature on the illness that Adam has, and the medication presently taken. This is a dangerous process if done haphazardly. Any information provided will need to have been read thoroughly and considered as to whether the content is too jargonized or simplistic. One method the family worker used was to provide the literature and to work through it in the sessions. This provided a comfortable and safe environment to openly discuss things that Sylvia was unsure of and to answer her questions. Her key question remained about his diagnosis and whether all of his suspicious behaviour was illness. As you can see from her answers, there were several important areas where knowledge was absent. As Adam was in the session with her, he was at times able to contextualize some of the information and to offer insights into his experiences. Although initially Sylvia accused us of siding with Adam, with his contextualization she quickly started to see some of the things she admitted to not wanting to see, mainly that her son who was very bright had a potentially long-term illness. Although not comfortable with this, Adam accepted this statement, but was still sceptical about the role of EST. Having read the literature we provided for them, both Sylvia and Adam could see similarities to his experiences and those listed. Both were able to see that perhaps the need to talk about the illness and symptoms may be beneficial. Getting started is the important theme here. Accepting that nothing will necessarily go without a hitch is apparent. It was always going to be difficult as

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Adam was clearly suspicious of his mother and the family workers, and Sylvia of the workers’ intentions. On reflection the education session went quite well but we had misjudged Sylvia’s concerns about our intentions. This had not come out in the interviews which we had conducted with her prior to the sessions. Another feature that hadn’t come out in the earlier sessions with Adam was acceptance of some of his symptoms as illness. The family workers clearly felt that prior to starting that he believed that they were potentially part of a conspiracy with his mother and that he was not ill. You will enter a lot of family work with a level of anxiety as you may think you have many answers but when you put people together in a room they often speak and act in an unexpected way.

Reflection Reflect on three things from the scenario. What skills did you identify?

How were they used?

How could you use them?

e.g. engagement 1. 2. 3.

Developmental plan (three things to take away) From your practices identify scenarios where you have encountered a similar theme to this one. What happened?

What did you do?

What would you do differently?

What do you need to learn/develop?

1. 2. 3.

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17 The family with communication needs

Box 17.1 Amanda, Stuart and Elaine’s story Amanda is a 35-year-old woman who has been diagnosed with schizophrenia for over ten years. She has an alcohol problem, but has recently become abstinent. Stuart and Elaine (her parents) have retired, both having worked for the Inland Revenue. They had hoped to have moved away from the local area and resettled in the country to enjoy their retirement and pursue their love of walking and having a smallholding. Since the onset of Amanda’s illness ten years ago, Stuart has always avoided contact with professionals. He is reported by Elaine to be angry at the lack of progress and does not believe that Amanda tries hard enough to deal with her symptoms. He is often quite disparaging about her and rarely offers anything more than a critical comment to her. Elaine feels she needs to protect Amanda from Stuart at times and will often go behind his back and help her out financially. This caused a great deal of unrest when Elaine gave her a substantial amount of money for a deposit for a flat and Amanda went on a binge drinking session. All the money was spent and Amanda was admitted to hospital with a recurrence of catatonic-type symptoms. Her self-care and dietary intake ceased and she became mute. Stuart could see only that she had brought it on herself and that she needed to be told how she was ruining all their lives.

Assessment – Amanda Amanda had been assessed in the Accident and Emergency department and admitted to a ward. She was assessed both by the senior house officer and the ward staff. A member of ward staff who had completed a psychosocial interventions course attempted to complete the Brief Psychiatric Rating Scale (Overall and Gorham

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1962), but with limited outcome. The staff member went on to discuss home life with Amanda’s parents as Amanda was unable to contribute at this time. The staff member immediately noticed a tension between them all and felt a level of conflict in their understanding of the illness. Amanda was given neuroleptic drugs and developed side effects, which included becoming a little restless and hypersalivating. It was difficult to assess the more subtle side effects and these were detected only due to the overt nature of them. The accuracy of the assessments remained unclear; when working with the family the staff had hoped to identify idiosyncratic behaviours that they could use as markers for progress. This was not forthcoming as Stuart would bring his wife to visit but sit in his car for the duration of Elaine’s time spent with Amanda. Amanda at this stage needed encouragement to self-care, eat and address her daily needs. The consultant had considered electroconvulsive therapy (ECT) and the use of nasogastric feeds if her condition did not improve quickly.

Assessment – Stuart Stuart came over as a forceful man who was quite concrete in his thinking. At this stage he did not want to complete any formal assessments, but did agree to a discussion around the Relative Assessment Interview (Barrowclough and Tarrier 1997). He admitted to believing that he felt mental illness and alcohol dependence were a weakness. However, he did drink alcohol and it transpired that his grandmother had been admitted to a mental health unit for many months in his teens. He said the family never talked about it but she was looked after by his grandfather and never attended any family get-togethers. He had read a lot about mental illness and in particular schizophrenia. He understood that stress could be linked to relapse and that the use of alcohol could have a detrimental effect on Amanda’s health. He was clear that she had wasted her opportunities in life and blamed her for a string of failed relationships and poor choice of potential partners. He focused on her drinking as the cause of her problems. He admitted to being critical of her but felt that it was because he didn’t want her to break down again – something he acknowledged had failed in this instance. He felt guilty about how he had acted and we became concerned about his mental health. We felt that there were potentially some depressive symptoms being shown but Stuart was adamant that he was well.

Assessment – Elaine Elaine engaged in talking freely and was keen to become involved in assessments. We completed the RAI (Barrowclough and Tarrier 1997) with her and identified many differences to the assessment completed with Stuart. Elaine was more flexible in her thinking patterns and accepted that Amanda’s illness was probably a consequence of mental illness being in the family and stress. She openly admitted that her view of mental illness was that it was normal but said that her approach was to try to wrap Amanda up and protect her. She openly argued with Stuart and would go against his wishes to help Amanda.

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Elaine said that she may appear to be going along with Stuart in front of Amanda at times, but once he had left the conversation, she would retract what she had said in his presence. She acknowledged that she did this to ‘keep the peace’, but sometimes Amanda seemed confused. She was concerned about Amanda’s drinking and that she never came to them to say that she might not feel too good. She understood the illness process and the symptoms but when she saw them she would try to introduce alternative conversations as she felt this would distract Amanda from the illness. She saw Amanda’s illness as a brain chemical imbalance, something she said she had either been told or read. She did admit to feeling helpless when Amanda was catatonic and that her not eating was not due to thoughts of being poisoned, more so that she had become totally absorbed in another world. Elaine said that she and Stuart would help in whatever way they could but found professionals in the past had been dismissive and at times accusatory towards them.

Questions 1 2 3 4

What strengths do you feel the family members have? What problems do you feel the family are having? What problems are there in their communication style? What would you prioritize as an action other than education?

Suggestions For this chapter we focus only on communication strategies. Some families . . . communicate well, but others show disturbed patterns of communication which hinder useful work with them. (Kuipers et al. 2002: 30) The family are already adopting dysfunctional coping strategies and in particular Stuart is wary about the professionals’ actions. Care is needed not to drive wedges between them and to avoid further perceived blame. In this instance it is accepted that one of the main factors needed is to start to establish some communication channels. At present that is difficult with Amanda, but work with the parents could start. It is not always possible to get everyone together for sessions and some creative thinking may be needed to at least bring the family together in its approach. In this instance the family workers agreed to meet just with Stuart and Elaine away from the hospital. Amanda was advised of this. This was felt necessary as Stuart was clearly uncomfortable with something at the hospital and was not engaging with anyone there. Some time would be needed by the workers prior to the session in order to work through what was going to be done and to have a clear path and potential contingencies should resistance be met. The family workers would need to develop a rapport and address what Beck and Young (1980) saw as a desirable strategy for a

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cognitive therapist – the ability to balance the structure, being careful to address being imposing and too directive.

Communication sessions (initial) For the sessions the family workers wanted to adopt the more overt behavioural style of communication work used by Ian Falloon. The family workers were aware of the need to engage both Stuart and Elaine in the sessions and allow an equal flow. The family workers were concerned that the work may seem overly simplistic and a little demeaning, creating a distance between the family’s expectations and their own. Prior to the session in a planning meeting, the family workers had considered simple scenario role-plays to help Stuart and Elaine to connect their styles of communication and the potential interpretation. This was felt at this time to be potentially dangerous as it could look like a blame exercise that focused on their deficits and that they were to blame for any consequences. The family workers agreed to structure the sessions and use guided discovery to try to enable each of them to explore what the meaning was behind the way they communicated. It was important not to allow dominance of time by one person and an equal balance if possible was needed between the workers talking and listening. Exploration of potential consequences to the present coping strategy was engaged in, as illustrated here: Stuart: Everything I do seems to cause problems. Family worker: Why might you say this? Stuart: Even when I know I am right I seem to come over all wrong. Family worker: Do you have an example? Stuart: The staff on the ward think I wind her up. Elaine says that I don’t try. Family worker: How do you see what you are doing in reaction to . . .? Stuart: I know it seems pig-headed but what else could I do? Family worker: What does Elaine suggest? Stuart: That I put things behind me and think about Amanda. Family worker: What will this mean that you do? It is becoming clear that Stuart is realizing (potentially before this conversation) that he needs to alter the way he is dealing with the situation. He is clearly unhappy and has heard what others have said, but he has not changed. This time gave him the opportunity to reappraise his actions and show others that he was listening to them. There are some problems when working with someone who at the outset appears to be obstructive. It is a common mistake when co-workers are used that family workers can be felt by some to ‘gang up’ on individuals and create the assumption of feelings of dislike of individuals which becomes a distracter in the sessions. Clear roles and planning were needed in order to maintain the direction of the sessions and establish equity between them. One aim was to set an agenda that looked at the way the family talked about difficulties but was sensitive enough and directional for where the conversation should go. The workers needed to give Stuart time to take the lead and talk about instances he had encountered and how he had coped.

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The focus moved on to a careful exploration of how Stuart and Elaine felt they had communicated their feelings and how these had matched with the reactions of others. Although at the outset Stuart seemed quiet and not really comfortable, he did listen and talk. Elaine was very open and admitted to feeling like a mediator between Stuart and Amanda at times. There was a sense she felt empowered to make some accusations about Stuart and his impact on Amanda. Management of this was paramount as this could have led to the disintegration of the session almost before the family workers had started. The workers needed to make careful interjections, getting Elaine to reframe the things she was saying. She was able to reframe her thoughts into an opinion being based on what she had seen and that was due to Stuart’s apparent lack of openness about how he felt about the difficulties they were having. It became clear that Stuart was worried about Amanda and that about 50 per cent of the time he was careful about what he said to her. Initially Elaine found this difficult to accept, but using similar reframing allowed Stuart to articulate what he meant. He was able to say that he didn’t deliberately go out of his way to be critical, nor appear angry. Much of his apparent brittleness was due to his feelings of being unable to cope with the stress of Amanda being ill and his lack of control over what he said. He had become concerned that he was driving her away and that he was to blame for arguments, therefore it was better he didn’t visit the ward so that he could not make comments which could potentially lead to further blame or guilt. This was the start of them talking more openly and explaining some of the meanings behind what Stuart said. This forum enabled him to start to clarify what he meant and probe some of his assumptions that underpinned his thinking. It also started to help to see the consequences in a new light. Although not totally cathartic the sessions allowed each of them to make a start on talking and listening and setting themselves goals for future sessions.

Reflection Reflect on three things from the scenario. What skills did you identify?

How were they used?

How could you use them?

e.g. reframing 1. 2. 3.

Developmental plan (three things to take away) From your practices identify scenarios where you have encountered a similar theme to this one.

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What happened?

What did you do?

What would you do differently?

What do you need to learn/develop?

1. 2. 3.

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18 The family with stress management needs

Box 18.1 Roger, Susan, Stephen and Michelle’s story Roger is a 28-year-old man who has a diagnosis of drug-induced psychosis. He has continued to use cannabis for over 12 years and has experimented with many other drugs including cocaine and legal highs. Susan (49), Roger’s mother, suffers from bouts of depression and has had treatment in hospital under a section of the Mental Health Act 1983. She did complete a degree in education and taught at a local primary school, where she met Stephen (50), who is also a teacher. Stephen himself says he suffers with his nerves and is at present on sick leave from work due to stress. Michelle (15) is still at school and is revising for her GCSEs. Over the last three months she has found that her family life has become very different from when she was young. Michelle’s parents rarely leave the home and often do not shop for food. Roger regularly gets ‘stoned’ and for days acts in a suspicious manner. He has made accusations to her that she is the child of an angel and that her parents are impostors. She finds this very difficult to deal with and has found it hard to concentrate at school and on her revision. Her form tutor has written a letter to her parents about this but they have not responded. Roger has recently stolen some money from his mother and used her credit card to withdraw a large amount of money. He left the home for three weeks and didn’t tell anyone where he was. The police were involved and his social worker was informed. He returned in a dishevelled state, but apparently mentally no different from when he left.

Assessment – Roger Roger has had intermittent contact with various services. He has drifted from the substance misuse service to secondary mental health services, never really engaging with anyone. He has been repeatedly arrested by the police for drug-related crime and has only recently returned home following a binge.

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He was assessed using the CAGE-AID (Brown and Rounds 1995) and the KGV (Krawiecka et al. 1977) over a couple of sessions. The CAGE-AID identified (on subsequent discussion) that he was quite angry about people criticizing him for his drug use. He felt he was an adult and should be left to do what he wanted. He did say that he felt strange at times and had some thoughts about impostors replacing his parents; these were thoughts he had all the time and they slipped out when he was ‘stoned’. This information was explored more in the KGV (delusions section). Roger believed that everything was especially designed for him to fail. He felt that he was under surveillance and that his sister was someone very special who had to be monitored. He said that the stealing from his parents to get drugs was part of his searching for answers, as when he was stoned he could see things more clearly about the conspiracy that was going on.

Assessment – Susan Susan completed a Health Questionnaire Screen (locally agreed non-validated tool) and was assessed using the Family Members Interview (Falloon et al. 1993). Susan found the level of burden created by Roger’s drug use unbearable at times. She admitted to isolating herself and drinking alcohol and using prescription drugs throughout the day. At times she had come into conflict with her GP when she requested repeat prescriptions too early. She was clearly in distress but was receiving no support at present. The family workers broached the question of whether she wanted help for her problems but she declined. She did say that the last time someone was involved, they had told her to throw Roger out as this was the source of all her problems. She then cancelled all contacts with this worker. The workers discussed talking with the GP about a medication review, which she agreed to go to.

Assessment – Stephen As with Susan, we completed the Health Questionnaire Screen (locally agreed nonvalidated tool) and the Family Members Interview (Falloon et al. 1993). Stephen found it difficult to concentrate throughout the discussions. He was clearly anxious and fidgety. He said he disliked conflict and that Roger was unwell but ‘not a bad lad’. He didn’t understand about Roger’s mental health problems as a diagnosis nor the effects of his drugs misuse, other than that Roger became more intense and upset his mother and sister. At times Stephen appeared distracted and his communication disjointed. He was unsure why we were asked to be involved and linked it to the police following up Roger’s stealing and his going missing. He was involved with a counsellor at his GP’s service and was seeing her weekly. He was taking prescribed medication for a depressive or stress-related problem. He felt that the whole thing was overwhelming him.

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Assessment – Michelle With the consent of her parents we interviewed Michelle and used the Family Members Interview (Falloon et al. 1993). She was very angry with the whole family. She felt she was being let down at a vital time of her life. She felt Roger was not ill and that his constant use of drugs was ‘scrambling his brains’. She felt her parents were pathetic and weak. She was frustrated that they couldn’t do the simple things in life, like keeping a good home and getting Roger away from her. She admitted that in school some girls had been pushing her about and commenting on her parents. One girl’s sister went to a school where her father taught. Others asked her for drugs. She could only see that Roger was incumbent and that he was ruining her life. She wanted to do well as she planned in the future to go to university and get away from the home.

Questions 1 2 3 4

Where should you start with the family interventions? What protocol or policies (where you work) will you need to consult for you to interview Michelle? What other assessments would you want to complete with each family member (if any)? What potential problems do you envisage with working with this family?

Suggestions For this chapter we focus only on the stress-related work conducted. Stress in families can be viewed as the relationship between the stimulus and the response. The stimulus creates the situation which is appraised by family members. This primary appraisal can be seen as either a threat or not. Clearly the use of positive coping strategies would potentially lead to an appraisal of no threat. If not, the perceived threat generates a secondary appraisal that can also be looked at in a new light of whether the family member believes they are able to cope. This can either lead to a positive coping strategy or a negative one that creates negative stress and further reactions. Let us take the situation of Roger using illicit drugs, and apply this to the transaction model of stress (Lazarus and Folkman 1984).The event (use of drugs) is appraised primarily. If there was no threat perceived, there would be no stress. However, in Roger’s case, the family members perceive there to be a threat because he could be irritable and start to accuse the family of being impostors.This then leads to a secondary appraisal, in which the family members perceive the situation as either manageable or not. If they felt that they could not deal with this situation, they would start to argue with Roger and this is viewed as a negative appraisal and causes ‘negative stress’. Alternatively, the family members could see this situation in different way. They could take the view that Roger’s accusations are a result of his drug use, and that he is not being personal. This is more of a positive reaction and their reaction would enable them to give him time and space and not to argue with him. Although this is still a stressful situation, they are dealing with it as a ‘positive stress’.

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Families need to be carefully managed: they are not necessarily bad at coping with situations, but have many different levels of stress to cope with. This must be acknowledged by the family workers, and a tactful approach is required, especially when helping the family members to develop a shared understanding. A stress point became apparent in one of the meetings. Roger: I like doing drugs. Just every time I do my family seem to go off on one! They say you’re talking rubbish and . . . well, they won’t listen. Family worker: What do you want them to do? Roger: This is it; I want to tell them about how I see things but cannot do this without drugs. Family worker: Have you been using drugs today? Roger: No. Family worker: Do you want to use some of the time now to tell them things? Michelle: He’s not going to tell us we are all aliens or something. He is not stoned so he’ll lead you along to believe that there is nothing wrong. Roger: I want to say that I feel that you seem odd to me! Different! Not like you used to be. Co-worker: Stephen, you seem to be upset by this. Stephen: Well, I am. I don’t think he is a bad lad, and the drugs mess up his head. Michelle: Here we go . . . Dad protecting his favourite son! He always protects him no matter what he says. Family worker: I hear what you are saying, but can we just clarify with Roger what is different and odd? The emphasis here was to maintain the flow of the conversation, to acknowledge Stephen and Michelle but to try to avoid dismissing the remarks. These would be addressed as the session went on. It is apparent that Roger feels that he is not heard in the home and needs to use drugs to get by. The focus of the session is to initially focus on Roger and then to help the family to find some way of coping with the interpretations of Roger’s communication. This level of stress could have an adverse effect on the family’s own health. While the stress levels remain high, so the ability to problem solve remains stifled. Hence the family continue to function in their present way. The sessions that followed aimed to further develop what the family identified as their understanding of stress. The use of normalizing and the fact that it can be difficult to live with someone who used drugs and expressed such thoughts had to be acknowledged. The effect that the family’s level of stress was having on Roger was also explored. Stephen later added that when everything seemed to be going well in the home, Roger seemed less troubled. This was an important observation that became part of aiding the sharing of their understanding of stress. This was used to develop a mini formulation that could underpin some of the work: Roger uses drugs and talks about people being replaced by impostors. This makes Michelle angry and makes Mum go to bed. She feels anxious and down. Stephen tries to arbitrate and Michelle feels that he is taking Roger’s

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side and that he cares more for him than her. Roger picks up on the stress and continues to use drugs. The family workers noted the disagreements and explored hypothetical situations in order to help the family to identify how they attributed behaviours and managed situations. With this family, as with many others, the use of self-monitoring forms to derive further meanings were used and the collaborative approaches were adopted to identify and to prioritize intervention. The range of interventions is discussed earlier in the book but it would be useful for you to consider which way you would now move forward in this case and the sort of interventions you may want to use. The key skills that the family workers used were a consistently positive approach and a systematic way of addressing the stressors. Time was invested into ensuring that the details were accurate and that the contextual factors were accounted for. Understanding animosity and dealing with conflict are part of the process. Careful management and avoiding scapegoating and ostracizing people are needed.

Reflection Reflect on three things from the scenario. What skills did you identify?

How were they used?

How could you use them?

e.g. systematic approach 1. 2. 3.

Developmental plan (three things to take away) From your practices identify scenarios where you have encountered a similar theme to this one. What happened?

What did you do?

What would you do differently?

What do you need to learn/develop?

1.

2. 3.

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19 The family with complicated problem solving needs

Box 19.1 Alice, David and Mary’s story Alice is a 34-year-old woman who was recently diagnosed with a schizotypal illness. This is characterized by her belief that a man (named Simon) was in love with her and that they would run away together and live happily. In fact she had never met Simon and her accounts of contact with him are limited to events where someone rings the doorbell. The person inside is delayed in answering and when they do, there is no one there. She says that it must have been him and that he must have been called away by his office. David (father, 62) is a retired plumber. He is frustrated by Alice’s talk. He finds himself openly calling her mental and screaming at her to grow up and get a real man. Alice infuriates him even more when she responds that ‘just because you have no love in your life should not stop others from finding it!’ Mary (mother, 61) is a housewife; she rarely comments to either of them and finds a coping strategy of letting them argue. She was diagnosed with ovarian cancer ten years ago and underwent many surgical procedures. She still has follow-up appointments with her cancer specialist and has recently found a breast lump. She started a course of chemotherapy and has lost much of her hair; she experiences long periods of tiredness. She openly admits that she feels she may die in the next few years, but this is only her opinion. Alice was arrested last week by the police. She was accused of a breach of the peace. She had called at a house 20 miles from her own with a bunch of flowers and argued with a woman who answered the door. She said that the woman’s husband (Simon) and Alice were leaving and they were to set up home together. The woman had attacked Alice and had called the police. Neither of the people Alice had visited had ever met her, but the husband was called Simon.

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Assessment – Alice Initially Alice was assessed by her care coordinator at home using the KGV (Krawiecka et al. 1977). She appeared to engage well with the process and didn’t seem guarded or hold back on how she felt. The observational elements suggested that she was a little incongruent and had pressure of speech. The more specific elements of the semi-structured interview highlighted an elevation of mood and delusional beliefs, scoring 3 and 4 respectively on the items. Alice seemed perplexed that the trail of events (related to her visiting Simon’s house) had not turned out how she envisaged. She dismissed it by saying that he was not the real Simon and that she now knew where he was. She openly spoke about the forging of a relationship and how much they loved each other. Exploration of her family’s attitude to her behaviour and beliefs caused some anger. She became irritated that they could not see things from her point of view and that they were unhappy, so they tried to make her unhappy. She dismissed her mother’s illness as stress. The cause she felt was her father, who had too much time on his hands and had become an interfering old man. The PSYRATS (Haddock et al. 1999) was used to further explore her delusions. It became clear that she thought about Simon most of the day and that the only distress she experienced was when others challenged her about him or referred to her as ‘mental’. She showed no insight in particular when the item of disruption to her life was explored.

Assessment – David David was assessed with the Family Member Interview (Falloon et al. 1993). David was able to speak about the symptoms Alice had and the medication she was supposed to take. The main area of concern came from the ‘coping and burden’ section. He honestly said that he couldn’t understand her. He said she would not see reason and although she was ill, there should be some semblance of insight that her actions were going to get her and the family into trouble. He did say that he had goals but they did not include Alice, and that a typical day involved an argument between him and her, with Mary staying out of the way, so as not to stress. He could only see that Alice could end up hurt and could go off with anyone who wanted to take advantage of her. This was reported as not being an isolated incident. He had seen this behaviour from her as a child in various ways, each time ending in her being hurt. More recently he had seen her on the internet and had seen letters she had been sending out to various addresses, but all to ‘Simon’.

Assessment – Mary As with David we completed the Family Member Interview (Falloon et al. 1993). Like David, Mary found Alice’s behaviour stressful. She was not as negative and said she deliberately avoided confrontation. She said that when Alice and David started arguing, she felt unwell and deliberately went out of the room. This was not because she didn’t care about or love them, but that it upset her so much that

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she found that the pains she had from her illness escalated. She did not tell them this. She consequently spends most of her time in her room and rarely spends time with both of them together. She finds it easier just to see them alone. Her main focus was Alice’s arrest and impending court case. Mary was aware that her illness was not helped by stress, but that she needed to support Alice. Mary understood about Alice’s illness and the medication and effects it should have. She felt that Alice probably was not taking it as she experienced side effects initially (restlessness and ‘drooling’). Mary knew that these had been present for a long time and that they had gone away. She was unaware that Alice had changed medication (it later transpired that Alice had not gone to her last outpatient’s appointment with her psychiatrist).

Questions 1 2 3 4

What are the most immediate things that are needed for this family? What problems do you feel the family are having? What problems are there in their communication or stress management style? What would you prioritize as an action in the present circumstances?

Suggestions For this chapter we focus only on the problem solving element of the treatment package. Although the family seem to understand a lot about the illness and its treatment, it should not be taken for granted that they do not have any misconceptions or faulty understandings. The way that they communicate is clearly problematic and the levels of stress very high for all. The difficulty is that they have not started to address the impending court case, nor how they are reacting to each other. The issue of Alice not taking medication and avoiding her psychiatrist is concerning, but realistically a level of initial problem solving was needed quickly. While in the police cells she had been seen by the Mentally Disordered Offenders (MDO)/Court Diversion Team, who were concerned about the impact the events would have on her mental health. They had to acknowledge that her actions placed her in a vulnerable position, and her wishes were that they were not involved. They did say that they would support her in court, but Alice wanted no contact as she felt she had done nothing wrong. There were no strong grounds to detain her in hospital, but the team members were liaising with her care coordinator. After much discussion the family workers felt that they needed to act quite pragmatically at first and address the key problem of the court case and Alice’s unwillingness to accept help. The initial sessions moved quickly into identifying a problem list from all parties and looking for solutions (no matter how odd). Care was needed as Mary was feeling unwell but wanted to be involved and a level of management was anticipated between David and Alice due to their conflicts. The family workers attempted to use a structured practical yet collaborative approach in the session. The situation of high levels of stress and conflict clearly

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Figure 19.1 Structure for problem solving.

led to the family not problem solving. The general aim of the session was to get the family to recognize problems facing them in the short term and collectively look at the resources they had to tackle them by gaining some control. This should reduce some of the stress presently experienced as well. A list was drawn up which included clear definitions of each item. Figure 19.1 illustrates the stages used in the session.

Defining the problem There were many problems discussed and noted, but the court case was top of the family list. Although she believed she had done nothing wrong, Alice was aware she would appear in court and this frightened her.

Consider possible solutions The solutions they discussed involved:

• • • • • • • • • •

Running away Not turning up Getting the psychiatrist to write a supportive letter saying Alice was ill Speaking to Simon’s family and getting them to drop the charges Asking the court if the case could go ahead without Alice Liaising with the MDO/Court Diversion Team Getting a session with a local solicitor (free 30-minute consultation) Going as a family to support each other David going with Alice or Mary going with Alice Asking the care coordinator to go along.

While the list was not totally comprehensive, the family did start to see that there were errors in just arguing. They seemed to change profile and work together. There were issues with David commenting on Alice’s suggestion about running away or not

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turning up, but clear boundaries were discussed before and equity of opinion and suggestion was agreed.

Advantages and disadvantages to each solution It was made clear that this needed to be done once all solutions had been exhausted. The real consequences were identified as avoidance, and time restrictions for getting supportive letters and a local solicitor to help. The family felt that the MDO/Court Diversion Team could be contacted for advice. Although they had rejected the team, they felt they should accept this option and the decision was a family one and not Alice’s solely. The advantage of this was that at least the MDO team had been to court before (none of the family had been) and the team could at least advise them of what should happen. Further, it would clarify if everything that should have happened to Alice while in custody did follow the rights of a vulnerable adult. A decision as to whether either parent would go was left, but they agreed that one parent would go. Both offered to go and this was to be left up to Alice.

Which is the most workable? The family had all the details of the MDO/Court Diversion Team. They were clear in what they wanted to ask and the support they needed. They also thought that they would liaise with the psychiatrist and care coordinator. An air of calm seemed to permeate once a decision was made. Whether this was the right or wrong decision would only be found when trying to implement it. This emphasizes the process of involvement and making own decisions more important than what was right or wrong, with hindsight.

Steps needed to achieve The family allocated Alice with the action to speak to the MDO/Court Diversion Team, with the proviso that David could step in if she was having difficulty. They were going to initially ask for them to meet up and go through the procedure. Next they would talk about consequences and longer-term ramifications should things go wrong for Alice.

Reflection Reflect on three things from the scenario. What skills did you identify?

How were they used?

How could you use them?

e.g. flexibility 1. 2.

3.

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Developmental plan (three things to take away) From your practices identify scenarios where you have encountered a similar theme to this one. What happened?

What did you do?

What would you do differently?

What do you need to learn/develop?

1.

2.

3.

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20 The family with a service user who refuses to engage

Box 20.1 Iram, Muhammed, Razia and Tariq’s story Iram is a 35-year-old woman who has a diagnosis of bipolar disorder. She is a qualified pharmacist and with her brother, Tariq (32), she co-owns a local chemist shop on the high street. She has been reported to the pharmacists’ governing body for a string of mistakes with medication and she is at present advised not to practise. Her brother, who is also a pharmacist has taken over the running of the shop alone. Muhammed (father, 66) is a local general practitioner and still works. He has seen this all before and can see a pattern of events linked to her elevation in mood. He finds that when problems start he is contacted and generally has to try to sort out any difficulties. Both Iram and Tariq still live in the family home. Razia (mother, 66) is a housewife. She speaks little English and has spent long periods of time at home in Pakistan. The family say very little about her and tend to ignore her when professionals have called at the family home. One professional who spoke Malwai (dialect of Punjabi) said she made little sense and kept saying ‘Iram needing the Jinn removing from her’. This was understandable from a cultural perspective but it was the changes in dialect and the threatening tone that concerned the worker. Iram is taking Lithium Carbonate, and a small dose of amisulpride. She is not consistent with self-administration and the family, although concerned about her not taking her drugs, seem to have done little to address it. She has been found surfing the internet and her father was contacted by her bank as a guarantor for a new mortgage she was proposing to use to buy a clothes shop.

Assessments – Iram Iram has been involved with mental health services for many years, as have her family. The family workers were asked to revisit the family due to this relapse. The assessments she had completed in the past consisted of the KGV (Krawiecka et al. 1977) and mood-related scales such as the Hospital Anxiety and Depression Scale (Zigmond

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and Snaith 1983). At present her mood was elevated and she was demonstrating limited insight. As this was seen as a crisis by both the family and the involved secondary mental health team, the family workers were asked for a limited input to address the present problem. The family workers soon found that Iram’s mood had been elevated for over three weeks and that she had refused to take any medication. She had been staying up late at night and eating very little. She detailed a plan to buy a shop and develop a network of similar shops throughout the North West of England. When asked about her experience in such ventures, she became angry and accused the family workers of a lack of vision. She had problems concentrating and interjected with a variety of tangential topics. The issue of medication was discussed but she said she no longer needed it as she was perfectly well and that we sounded like her parents. When we asked how they had dealt with the issues, she said that both her mother and father had hit her recently when she had spoken about not taking medication, and her mother had tried to conceal it in her food. Her father had also shouted at her and said he would send her out of the family home if she continued to do bad things.

Assessment – Muhammed Muhammed was convinced that Iram needed to be admitted to hospital. He had spoken to her psychiatrist, who had requested the meeting with the family workers. Muhammed was not impressed that his demands were not being met in the way he wanted. He felt she needed detainment (something that Iram’s GP wanted to avoid) and then medication. He was angry with the services provided and was not keen on the meeting as he had to rearrange an appointment at his surgery. The time and date, however, had been checked with him and accepted. He was angry that she had put his name forward as a guarantor for a mortgage, and that the other family members had not tried to resolve the problems that Iram was experiencing. Although understandably frustrated with another relapse in her mental state, he was phlegmatic about the consequences of what he proposed. He said he disagreed with her GP’s assertion that detainment might create more lasting psychological damage, and that she was not detainable at present.

Assessment – Razia The family workers had taken an interpreter with them on the visit, but Razia was said to be out of the country. This was seen as quite odd as the workers had asked who would be present at the meeting and were advised she would be there by the secondary mental health team.

Assessment – Tariq Tariq was quite aloof about the meeting. He said that his father knew best and those services should listen to him. He said that his sister was meddling in finances again and that his mother was unable to supervise her well enough at home. He was unhappy

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as he had closed his shop for the meeting and was anticipating Iram being detained by the police. It was clear that Tariq and his father had similar views on a coping strategy and had not looked at any alternatives. He said that aside from when he came home from work, he had limited contact with her. In fact he thought up until the last couple of days she was well. He felt her mood had been raised but nothing out of the realms of what he had experienced before. His main concern was that Iram might spend lots of money and this could affect the family finances for the future.

Questions 1 2 3 4

What are the main problems that the family are experiencing? What alternatives are there for the family, in regard to family work? What crisis work could the family be engaged in? What would the family need to do in the future in relation to helping Iram?

Suggestions The first focus of family work could look to establish the catalyst for the present crisis. Pinpointing such events can be difficult but should be engaged in as this can lead to a better understanding of the context of the crisis and the initial attempt to cope with it. The next focus would be establishing their present coping strategies. We have already seen that both mother and father had resorted to (reported, not proven) violence in order to try to get Iram to go along with their wishes for her to take medication. This particular issue could not be ignored and needed some exploration. We should note that the family workers had to make an alert under the interagency vulnerable adults policy. They put in place a protection plan, which worked in tandem with the ensuing family intervention. If this continued, there might be an escalation or this might become default behaviour when faced with similar situations in the future. The family workers will need to identify a package of interventions that can be introduced as a maintenance package. This could then become part of any future relapse prevention plan that the family agree to. We are mindful of the need to focus your attention on the earlier questions. One of the alternatives that could be used would be to use the argument by Falloon et al. (1993) of focusing on:

• • •

precipitating factors exacerbating factors prodromal signs (Falloon et al. 1993: 145).

In this case the family workers felt that they needed to address the violence at the outset. It was necessary to address the issue as a matter of urgency, primarily to establish if Iram had suffered any injuries but also to explore if this was a coping strategy used

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in response to the catalyst of her refusing to take her medication. The other reason was to establish the safety of the home for her. We needed to assess when the violence occurred. This would, we hoped, lead to a discussion where future coping strategies could be identified for inclusion in any treatment package. Iram said that both her father and mother had hit her, but she understood their frustration with her. She did say that they still treated her as a little girl. She couldn’t remember how many times it had occurred but she said it was whenever she didn’t do what they wanted. Muhammed said that he was not proud of hitting her but he needed her to understand the consequences of her actions. Her mother was becoming ill with the stress of her daughter’s behaviour and this needed to stop. He accepted that he should not have done it. Family members do get frustrated with other family members, and anger can be a natural consequence. Often showing a level of anger can be helpful in indicating how frustrated someone has become and can sometimes help in resolving problems. However, it can easily move from anger to violence if not checked. Tariq said he was unaware of such events and felt that it was inexcusable, regardless of how Iram was behaving. He felt that his father should have focused on his mother’s illness and addressed that instead of directing his anger at Iram. Tariq said there could be no amount of provocation that would mitigate these events. He accused his father of assault and said that he should be ashamed. The family workers felt that they needed to intervene at this stage as emotions were beginning to run high. If left unchecked the situation might have become more heated with personalized blaming, and a potential for aggression or even violence. Although this could still occur, it was prudent to at least give the family the opportunity to reflect on what was said and take a short break. If left to continue, the potential of destructive, personalized accusations and possibly future relationship affecting comments or actions could have occurred. On the spur of the moment people can become angry and say things that they might later regret in the heat of the discourse. Giving a short break might help to reduce emotions in some cases, but you should be aware that in others it can cement feelings, and the call to intervene is based on experience and knowledge of the family dynamics and individuals. This highlights the need for accurate and detailed assessments of individual family members. It also raises the issue of iatrogenic factors caused by family interventions (situations and events that would not have occurred if not for service intervention). Muhammed was shaken at his son’s remarks and acknowledged that perhaps he should have asked for help earlier as his wife had been unable to cope with Iram being up in the night and her incessant talking. He felt that the catalyst was not the medication but the effect her behaviour was having on others. He felt that when his wife became so upset that she wanted to go to her brother in Pakistan, it was the final straw. He saw himself as having to cope while working and that he didn’t want to burden Tariq with the problems. The honesty and humility of this seemed to register with the family. Tariq said that his father should have made him aware and he would have helped. It was clear that a level of anger and upset still existed, but Tariq remained fairly composed and chose his words carefully in venting his thoughts and feelings. This section highlighted the need to identify problems early and to access help. Sharing problems with family members may lead to a sharing of the burden (and

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potentially acting out of character). The specific behaviour that created the violence was not as it was first thought, not taking medication, but could have been a consequence of Iram’s behaviour of not taking medication. In later sessions the family outlined an agreement of how Iram could have control of her medication and how they could challenge her if her behaviour became erratic. Following the first crisis, Iram resumed taking medication (albeit initially sporadically) saying that if it caused such upset she might as well do it. Although this was not the understanding the family workers wanted, it did address the concerns of the family and the secondary mental health teams.

Reflection Reflect on three things from the scenario. What skills did you identify?

How were they used?

How could you use them?

e.g. focusing on precipitating events 1. 2.

3.

Developmental plan (three things to take away) From your practices identify scenarios where you have encountered a similar theme to this one. What happened?

What did you do?

What would you do differently?

What do you need to learn/ develop?

1.

2.

3.

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PART 4 Evaluation and the way forward

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21 Where now?

Aim The aim of this chapter is to introduce you to the steps to take following family interventions.

Learning outcomes By the end of this chapter you will be able to.

• • •

understand the importance of relapse work describe the process of relapse work, using a traffic-light approach identify and detail the problems associated with burnout in practice.

Introduction The completion of family intervention is rewarding; it is good to feel that you have helped a family overcome some difficulties. By working with the family over a period of (sometimes) many months it is often difficult to let go and allow the family to carry on without you. Families will sometimes feel that they need your continuing support, but, if you have been able to start to disengage from the therapeutic relationship, the point has to come where they go it alone. That is not to say that you have totally discharged them and that they cannot access support in the future, but rather, you have acknowledged that they are able to continue to function without your regular visits. In this chapter we focus on what to do once family work is coming to an end. This is often a difficult time and needs a careful and considered approach. As family members start to feel that their situation is improving, they often worry that at some point they might return to how things were, that is, they start to fear relapse. This fear of relapse needs open discussion and some planning. The use of relapse prevention and booster sessions will aid this process, and potentially help them to develop skills for life in relation to coping strategies. It will also identify potential problems in

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practice and the way that they interpret fears. Careful management will lead to family members developing skills and problem solving further.

Relapse prevention Relapse is generally defined by the emergence, or exacerbation, of symptoms, usually preceded by changes in functioning up to four weeks prior to the event (American Psychiatric Association 1994). Therefore, relapse prevention interventions should focus on identifying, monitoring and acting on these subtle changes as soon as possible. This period prior to relapse is known as the ‘prodromal period’, and is characterized by changes in the person’s mood, behaviour and thoughts (Knight 2002). There is a growing body of evidence supporting the idea that identifying and monitoring an individual’s prodromal signs, and establishing appropriate action plans in the event of them occurring, can help to prevent relapse, or at least reduce the impact of the experience. It also increases the individual’s sense of control over their prodromal signs (Knight 2002). A relapse can mean different things to different people, whether it is the return of troublesome symptoms or the admission to hospital. The feelings of becoming ‘unwell’ again are very distressing to both the individual and the family. Relapse prevention is crucial as it may increase control over the illness, reduce feelings of hopelessness, and increase understanding of the illness. Although relapse prevention work is not seen as a vital ingredient in family work, we feel that addressing this issue is important. We have seen through our own clinical work that if relapse prevention is discussed, family members are happy to work on this approach. It seems right that families will not want to return to how things used to be, and that by considering steps to try to avoid a relapse (or catch symptoms earlier) then it is likely the situation at home will not be as distressing. When working with a family using a relapse prevention approach it is first important to try to gather everyone’s views on what constitutes a relapse. Working with the family to try to ascertain the early warning signs (Birchwood et al. 2000) of a possible relapse is crucial so that measures can be put in place if these signs are seen. It is useful to introduce the idea that relapse could possibly be prevented by learning to identify these early warning signs, and then to address these signs as early as possible. This is achieved by looking back at the most recent episode of illness and attempting to identify any noticeable changes in thoughts, feelings and behaviour. This is often difficult to do, as everyone tends to struggle discussing their thoughts and feelings, so a useful technique is to try to focus on particular events. This may be a birthday, an important televised event, anniversary, etc. It is easier to tag thoughts, feelings and behaviours to the event. For those families who struggle to identify thoughts, feelings and behaviours, the 55 card-sort exercise (Birchwood et al. 2000) serves as useful prompts. These are very helpful to use in practice, but it is advisable to ask the family members if there are others. Once early warning signs are identified, you move on to discussing potential interventions. These interventions could be employing successful coping strategies, medication review, appointment with a psychiatrist, support from other professionals, etc.

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Next you draw up a plan with the family, identifying the early warning signs and pathways for support. All family members have a copy of the plan and can use this if they notice any subtle changes. We advocate the use of a traffic-light system. This allows everyone involved to see areas of concern, and what steps are needed to address any changes in symptoms or presentation. An example of this can be seen in Table 21.1, which identifies the colours of a traffic light. Table 21.1 Relapse prevention protocol Name: Care coordinator: Consultant: GP: Out of hours team: GREEN LIGHT

Feeling much the same as usual

• being able to go out • enjoying activities • sleeping well • feeling able to relax AMBER LIGHT

Start to notice things are not going as well as usual

Implement strategies as planned

• take medication as prescribed

• go out regularly Read through plan. You may want to talk to someone

• feeling anxious or restless • try to go out for a short while only, build on this • feeling overwhelmed • behavioural experiment • acting a little suspiciously explanations to • feeling like I cannot trust others • alternative events • avoiding crowded areas • talk to care coordinator RED LIGHT

You feel that you can’t manage

Get help from someone you trust

• going 2–3 nights without sleep • contact care coordinator • not going out or seeing people • outpatient appointment with consultant in 2–3 days • not doing any activities • out of hours team, if at • losing interest in everything weekend or evening • behaving coldly to other people • thinking that others can read my mind

• thinking people are talking about me

• thinking people are against me • feeling aggressive

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Example – Raymond in Chapter 10 As we saw in Chapter 10, it is evident that Raymond gets angry towards his parents, and that this mostly stems from his experience of meal times. This culminated in Raymond shouting at his parents. Once this had been addressed, and ways of coping with this had been agreed, then all should be well. However, if Raymond started shouting for no apparent reason, it could be said that this was an early warning sign of him becoming unwell again. It is therefore beneficial to intervene at this point, before this particular behaviour escalates. Here a plan of intervention would be useful. This could be an agreed strategy – for example, responding to Raymond in a calm way and trying to identify if there is something that is making him angry. There could be a need to look at recent behaviour of others, for example have the parents been confrontational in any way? Relapse prevention would be built on through the use of booster sessions where we would be able to explore adherence to the model and fine-tune the detail of the relapse signatures. Over the next couple of sections we explore the use of booster sessions and potential problems attached to family work.

Booster sessions When considering disengaging from the family work, families can often feel that they might struggle without your support. We feel it is appropriate to offer the family booster sessions. This could mean arranging to visit the family within an agreed timeframe (three months for example) or offering the family the option of them contacting you in case of any difficulties, worries, or just to see how things are going. We have found that the offer of booster sessions serves as a safety-net and that the family might not take you up on the offer. However, the knowledge that this is available serves as an intervention in itself. If the agreement is to have a booster session (or two), this session should be just that. You are not restarting any family work, but merely looking at refocusing on what has been achieved. The family may just need you to be there to confirm that they are doing everything right, or just seeking clarification on a disagreement. It is worth remembering that the focus of family intervention is about the family having all the necessary skills to deal with situations, so, with this in mind, that should be maintained. Allow the family to disclose the reason for the booster session, and reflect back their concerns. This will allow them to problem solve for themselves. Your role in this situation is purely as a facilitator, enabling the family to agree a way forward.

Burnout issues While working with families is highly rewarding, it is also extremely challenging and stressful. Working in a high expressed emotion environment, often outside of normal work hours, will be stressful. Families will demand a lot of your time and support and this takes its toll. We advocate the importance of co-working as much as possible. Co-working has many advantages. Not only does this serve the purpose of peer support in therapy,

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but also acts as support outside of the work. Co-working allows both family workers to share the workload, in particular the assessments of all family members, and to intervene as necessary. Leading a family intervention session requires a lot of knowledge and skill, and this is enhanced by experience. A lead worker will ensure that the family members stick to the agenda, where the co-worker will focus on what is being said, and summarize as needed. A good co-worker can take off a lot of the pressure from the lead worker, and take over as necessary (if the lead is getting stuck for example). Having two practitioners also allows the family workers to model helpful ways of communicating to the family members. Outside of the sessions both family workers are then able to discuss what happened in session, to ensure they are approaching the family in the most beneficial way. They are able to share ideas, share their views, and most importantly, let off steam. This is necessary to avoid the build-up of stress. To have an effective working relationship, both workers need to be able to trust each other. This is a foundation on which to build the working relationship. At certain points within the family intervention work, lead workers may find their confidence lacking. This is where their co-worker can step in and take over, allowing the sessions to continue and the lead worker to gather their thoughts. Without this trust the relationship can be strained, and you will find that the family workers may compete with each other. This is not helpful, nor the intention of family work. Supervision from a qualified and experienced therapist is necessary. When working in family interventions you need to ensure that you are gaining support and advice from somebody more experienced than yourself. Being able to openly discuss how you feel the therapy is going from somebody who is not directly involved is rewarding.You can discuss your frustrations, your successes, and even your confusion as to what to do next. If you are able to record your sessions (ensuring that you have gained informed consent from all the family members and followed the local health trust policy on recording), this serves as a useful format for supervision. This recording could be used to ‘score’ your skills, discuss particular areas of concern, or to identify any difficulties in the session. You could discuss the use of the two family workers (lead and co-worker) and identify potential strategies for future sessions. Group supervision could also be used. If there are sufficient practitioners engaged in family intervention work, this approach is extremely beneficial. The group supervision session could ‘mirror’ a typical family intervention session.You can set an agenda, ensuring items are given priority.You then focus on discussing and reflecting thoughts and feelings, and develop a plan of action or homework. This is a highly rewarding approach to take, as more input often reaps more ideas and support.

Problems in practice There could be many difficulties encountered in family intervention work. This could take the form of family members not turning up for the sessions, family members becoming aggressive, family members colluding, etc. Undoubtedly the safety of yourself is of importance, and you should ensure that all risks are identified and managed prior to staring any family intervention work.

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While every attempt is made to try to avoid these particular events from happening, ultimately you may be faced with these obstacles in family intervention work. Seek guidance and support with these obstacles, which could be seen as a challenge; this in itself makes the situation more positive, we all like a challenge!

Summary

• • • • •

It is worth looking at carrying out relapse prevention work with the family, to address issues that may arise as early as possible. Always offer the use of booster sessions, even if the family do not take up this offer. This allows the family to feel supported, and that they have a safety-net. Co-working has many advantages in family intervention. This includes support, sharing the workload, and sharing ideas. Supervision is needed in family intervention work. Discussing issues with a qualified and experienced supervisor allows you to develop your own skills and knowledge. If possible, group supervision is advantageous. This could ‘mirror’ the family intervention session.

Questions 1 2 3 4 5

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What is relapse? Can you name two advantages of booster sessions? What are the benefits of co-working? Why is supervision important? Can you name any potential problems in practice?

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22 The barriers to implementation

Aim The aim of this chapter is to introduce you to the present and future potential barriers for the implementation of family interventions into practice.

Learning outcomes By the end of this chapter you will be able to:

• • • •

detail some of the specific barriers that could make the implementation of family interventions into practice difficult describe potential solutions to the existing barriers identify the importance of addressing the barriers to implementation of family interventions decide if family interventions are evidence based after all.

Introduction In this chapter we explore not only some of the obvious barriers to implementing family interventions, but also some of the less obvious ones. The chapter attempts to make you consider where your organization sits in this respect and consider what you may need to do. Some of the factors you may wish to explore involve the issue of change and the drivers for change. This was alluded to earlier in the book but will need to be developed further in this chapter. Ultimately we need to identify the drivers and resisters for change (Lewin 1952). Figure 22.1 examines some of the important factors but avoids, at this point, identifying if they are drivers or resisters. It is important to acknowledge that the factors implicit in maintaining the status quo (no change) are in this case the same factors involved in creating the change. Every service and team will be different with slightly different drivers and resisters, but generally the same themes causing problems.

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Figure 22.1 Conceptualization of Lewin’s force field analysis for family interventions.

Later in this chapter we consider if the implementation of family interventions is a positive change. First, we discuss each of the drivers and resisters and accept that in your service, there may be different details related to the main theme. We keep the narrative to a maximum of three key points, not because there are no others, merely to demonstrate some of the thinking needed to start to get you to analyse your service and identify the barriers.

Is family intervention unique in having barriers to implementation? It has to be accepted that even though evidence and policy stipulate implementation of specific actions, commonly this is not played out in the real world. The naivety of those believing that ‘because the government say so . . . therefore it will be happening’ must be challenged. There are many problems with implementing any policy or guidance, more so in respect of guidance, as it is not necessarily as eagerly implemented due to a lack of local policing and a need to report back to government on its implementation results. One would therefore be led to conclude that policy must be implemented, and everything should be written in this form. Guidelines are commonly utilized around the world to try to introduce a standardized practice that increases the health of the population and leads to a measurable

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change generated by those people implementing it. The policies and guidelines in health care are commonly evidence based, therefore one would assume readily implementable by the staff. If this were the case one would further assume that the health of those the staff serve would improve and any inequalities in service be addressed. This is unfortunately not the case. We will just offer some brief examples of such problems and then go on to indicate why policy or guidelines may not be implemented. Grol (2001) inspected a ten-year period of time (and over 70 evidence-based guidelines) related to dissemination and implementation of evidence to health care in the Netherlands. While he found that awareness and knowledge was (according to his assessment) high, the implementation was variable. The variation was not necessarily uniform and varied from guideline to guideline and physician to physician. The average implementation was approximately 67 per cent for the set guidelines in this period of time. The NHS Centre for Review and Dissemination (1999) found that passive dissemination probably had little effect on behaviour change and therefore implementation of guidelines. It found that there were many factors related to this but that the more complex the guideline, the fewer adherences were found. It did argue that they were ‘more likely to be effective if they took account of local circumstances, were disseminated by active educational interventions and were implemented using patient-specific reminders’ (NHS Centre for Review and Dissemination 1999: 4). Hence the argument it offers is that they are not implemented effectively. In the United States, McGlynn et al. (2003) examined the health records of over 6000 people who had access to health care. All files were assessed for compliance with agreed procedures or guidelines. They found that there was a variance between people depending on their presenting problems. Overall they found that the people in the study received only about 55 per cent of the care that was recommended. For family intervention, Fadden (1997) comments that of a training programme for family interventions, 86 people were trained. Of these on follow-up 40 per cent of the families seen were seen by only 8 per cent of the participants. The inference here is that of those who are trained in family intervention, few actually use the skills in practice. The Healthcare Commission and the Commission for Social Care Inspection (since April 2009, the Care Quality Commission) (2007) in a joint review of community mental health services in England (2005–2006) collected data from 7500 people. Over the time period shown they identified that only 53 per cent of them had received family interventions. The guidelines were present in the health trusts and the finding was that the implementation at local level was poor. Surprisingly it was found that this audit was potentially the first practice service audit completed in some areas. Murphy and Withnell (2011), using a very small sample of students completing a family interventions course, tried to establish if the training the students had received and implemented during the course continued afterwards. We found that although each person still felt that they possessed the skills to conduct family interventions three months after completion of the course, the opportunity to do so in practice was not there once the course finished. What is of importance here is that each of these

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students commenced the course having access to families for the requirements of the course work and the express support of their line mangers in the health care setting. Further the family intervention was seen as important to the service, and was sufficient to provide financial support to the students to complete the necessary elements. Yet once the skills were achieved and practitioners found to be competent for clinical practice, barriers were placed in the way of the students in utilizing them. The next section of this chapter explores some of the elements felt by us to be important in relation to the barriers to implementation of family interventions in clinical practice.

Service users Common barriers for the service users have tended to be related to insight into what family interventions were about. Service users have been sceptical about the package that has suddenly appeared and is advocated as a treatment option. The fact that it works in a very different way from other treatment options used in the past must appear confusing. That the service user will need to engage in the treatment with their family and also detail possibly personal information related to them for the first time is regarded as risky by some. Questions are common from service users about the rationale for talking with family members and gaining information in regard of their illness. The illness or treatment can be another barrier as service users can find the sessional work stressful and have on occasions relapsed. Combined with this is a refusal to engage due to delusions or beliefs about the treatment or even a family member. Confidentiality is a regular concern. Service users may have thoughts or have said things in the past that they have never disclosed and fear the possibility of it coming out, in particular when it relates to a family member or someone close. The risk of family members changing their opinion of the service user is too great for some to take part and the fear of a slip of information getting out is too great a chance to take.

Families Faith in the service can be at a low ebb in some cases as the case work has been going on for many years with limited improvement or even change. In the past, for various reasons, families may have felt isolated and in some cases ostracized by services. Faith in a change of approach will not be immediate and may take more than one attempt to engage. The past may have instilled too many barriers for change, but efforts still need to be made. Feeling managed and blamed is a regular complaint about poorly managed family intervention sessions. As indicated earlier in the book, tact and diplomacy are paramount, care not to negate or blame is important. This is a common error in the outset and in particular in the psychoeducation elements. Similarly with service users, engagement can be problematic. Just accepting change after many years of seeming to battle against the odds and perceptions about a service that did not listen or communicate with you can be too big a step in one go.

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Commitment to someone else’s agenda and changing routine may be anxiety provoking. Raising personal or sensitive issues that are generally managed by avoidance could be overly optimistically embarked upon. To some, to have the limited control they have developed over some symptoms challenged has led to them dropping out or just not attending.

Attitude of staff Practitioners trained in family interventions, when introduced to an existing mental health team, could potentially create an ‘us and them’ situation. This would require sensitive and supportive management in order that all practitioners continue to feel valued and willing to draw upon each other’s skills and experience. Such collaborative working provides an ideal basis for the introduction of family interventions. Perceived priorities may be different for individual members of staff and those prioritising family interventions may come into conflict with practitioners whose knowledge of this approach is limited. It has been found that staff returning to their original teams after training had difficulty implementing family interventions in practice. Commonly the staff returning with the skills, when found not to be utilizing them, used excuses (Fadden 2006) of having difficulty in finding time for family interventions and the demands of their caseload getting in the way of implementation. Perhaps a lack of guidance or permission may be present. Family intervention training is commonly found as part of a BSc (degree) or MSc (masters) course, and students opt for modules that are clinically related as this can be completed with minimum change to caseload and workload. Training is available, however, and as indicated above, it is not sufficiently implemented into routine practice after completion of the course. The risks of change can be too great a step to take for some staff. To turn around on the practice to which you have devoted time and effort can psychologically negate years of experience in some eyes. To endorse something that you did in a training course and then find little support for it in the health trust takes a lot of courage and, as will be highlighted later, a great deal of support. Ultimately some staff revert to type and go back to the way they worked prior to completing a training course or adopt the default practices of a department due to reasons highlighted by Murphy (2007) and many others (lack of perceived support and continued supervision of family interventions to encourage and maintain implementation and skills). This area will be explored a little more in the ethos section. This apparent battle that staff can feel they are engaged in can, as Michie et al. (2007) found, create a level of self-doubt and then difficulty in making time to carry out interventions. Commonly the family intervention trainee member of staff is the odd man out in a team and can consequently feel increasingly isolated.

Managers As with the staff, the managers need to amend their service perceived priorities. The problems can be related to commissioned practice and the ‘numbers game’ of visits.

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Rigid adherence to service protocols that do not include family interventions make the chance of any family intervention trained person implementing what they have both learned, and experienced, very difficult. Understanding of what family interventions are about could well be where the problems lie. Implementing NICE (2009) guidance and utilizing evidence-based practice could be seen as a ‘square peg in a round hole’ to some managers. Implementing something for the future versus now is too great a risk. Not to meet the targets can lead to loss of staff and threats from higher management to the authority of the managers. This invidious position we would not wish on anyone. Senior management need to take a stance on adhering to NICE and other evidence-based guidance in commissioning family interventions into routine practice. Fadden (2006) found that, for some services, family interventions were seen as an optional extra that was not measured as an outcome by teams. We do have to say that we have seen some managers tying to implement family interventions and other specialized services in mental health teams, and although having the passion and wish to do so, finding it hard in the face of competing demands of changing service protocols and crisis. Managers are not inherently obstructive. They have a service to run and although they are consciously able to see the value of family interventions do, we believe, take the wrong option at times. They do not necessarily stop staff from conducting family interventions, but rather make other things more of a priority, making implementation difficult. This is not through a lack of vision, more so through a need to demonstrate practice that is measured and uniformly audited, something that Fadden (2006) found as a barrier.

Ethos of service The ethos of the service and how this fits within family intervention, and then how this fits with meeting targets, is an overarching dilemma to any service. The way that services are configured and audited can drive and develop a service delivery agenda. If a service constantly changes approaches to meet local and national directives, the ethos underpinning why the service exists can become lost to the integral elements – such as the staff. This can lead to meeting targets becoming the priority as opposed to the service users becoming priority. Objectifying the work in this way rules out originality and creativity leading to dispassionate implementation and reacting to need from a small menu instead of identifying need and creatively engaging with it. Traditionally the focus has been aimed at the service user, now family interventions argues for a shift to include the family as well. Much of the work that mental health practitioners engage in is argued to be service user centred and increasingly families are not included due to fears of breaching confidentiality. Measures are needed to embrace the whole rather than just the parts and arrive at a protocol that subsumes the values of family interventions from the outset of care instead of an optional extra bolted on at the end (if at all). However, if the staff have no awareness of family interventions or the valuable contribution it can make to care, then how can they be criticized for not introducing it? As Fadden (2006) identified, a lack of skills within teams is a barrier for family interventions.

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We have a long history of working in and with community mental health teams. Such teams are seen as secondary services that work with people who are potentially experiencing longer-term problems, and who have been assessed by others, treated and then referred on to the teams. It still amazes us that such teams have been increasingly drawn into crisis intervention work when a crisis intervention team exists. Yet why? This duplication of roles and move to the exciting crisis arena was never at the heart of the ethos of any secondary mental health team. Not sticking to role and doing what the teams are good at are challenged by this move. It begs the question why have a crisis service at all if other teams are doing the same work? We are uncertain where the manipulation is coming from but we are sure that this expansion moves it into conflict with its traditional role. This will make it difficult to conduct effective family interventions and in many cases the term ‘family interventions’ will never be mentioned or even thought of. The cornerstones of care, inclusion and value-based practice, are not always given the recognition that they deserve. A more business type short-term measurable practice base with limited skill implementation is being used, so as to demonstrate completion of short-term interventions. This means that work such as family interventions may be used, but split into shortterm discrete units of care, commonly never addressing the full remit of a family interventions package. The underpinning values of teams could potentially be eroded and creativity and novel practice are being made difficult to implement. Many will disagree with our opinion, and we hope that they do. But a challenge here is to look at the service you work with and explore what the ethos of the service is and if it is still truly placing the service user at the centre. Further, is there still room for creativity in the use of family interventions?

The role of universities in promoting family interventions When we explored pre-registration programmes, there was a dearth of evidence of family interventions being taught in universities at this level. Student nurses, social workers and other health care practitioners should understand not only the importance of families, but also that there are alternative ways of treating someone other than by medication. The need for skills other than risk management and observation should be recognized. It has to be accepted that even if the skills and knowledge related to family interventions were given via universities that it may well not happen in practice. The universities are in a market-led commodity field, and courses are driven by people willing to enrol. Uptake of family interventions in post-qualifying courses is low, but sufficient. These numbers would be increased if awareness of the values and evidence of family interventions was more widespread. At present it is seen as almost a ‘loss leader’ in supermarket speak, but one that everyone knows is essential. Investment in pre-registration courses for nurses, social workers and other allied health services is required. There is a need to generate a market, not for the universities, but for shaping practice and improving the evidence-based practice engaged on in the health care setting.

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Government As indicated earlier, the guidance provided by government may not be being implemented and the ways in which implementation is measured is potentially not robust enough to demonstrate not only the offering of family intervention, but also the process and implementation as highlighted in our book. This could be addressed with more detailed audit of skill, not just for family interventions. Changing demands can hinder development and implementation as they replace directives that have commonly had little time to demonstrate efficacy and rely on a short-sighted view of what improvement means. For services to implement family interventions and longer term therapies they need to creatively look at what guidelines are being suggested and look at how the therapies can meet some of those discrete elements. Without this, family interventions will be difficult to implement and therefore the general public will be offered a limited service when being told that they are getting an up-to-date evidence-based service. The use of independent audit would be welcome as self-audit related to guidance implementation can be fraught with bias. The real question hinges on the availability of funding. Money is provided but this is not ring-fenced for anything specific such as family interventions. Money is available for the local providers to implement services they feel their local population need and they are told to implement NICE guidance based on national need. Although the government is not asking for trusts to set up family intervention teams, it is asking for this to be conducted. We feel that the trusts who have set up family intervention teams are forward thinking and progressive, but need to be wary of a centralized national driving force, demanding local services that may not be needed. This was epitomized by the blanket way that Assertive Outreach Teams (in secondary mental health teams) were developed. It became clear that the local population did not match the estimated national criteria for dependency, and hence teams were either under-used or forced to take clients that did not match the criteria set out in the initial guidelines in order to fulfil their quota. Consequently many are now being disbanded and staff reabsorbed into the secondary mental health teams. This is an example of how a centralized national driving force can result in negative outcomes if not based on reliable evidence concerning need and efficacy. We believe that family interventions should be delivered by all mental health workers and taught as core skills. Through lack of use the skills may become a little jaded, therefore short courses and refreshers, or joint working as we have outlined, could be beneficial. This would help mental health services to adhere to the available guidance and implement what we see as evidence-based practice. The guidance for family interventions is that providers should ‘Offer family intervention to all families of people with schizophrenia who live with or are in close contact with the service user. This can be started either during the acute phase or later, including in inpatient settings’ (NICE 2009: 309). The question is, though, what does the government mean by family interventions? Trusts will continue to report on the guidance, but how does the government know what is being implemented and the quality of that intervention? After all, family interventions may

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take the form of liaising with the family once or having ten sessions over a period of several months. But to take the government on their guidance it needs only to be offered.

Is family intervention a positive change for service providers? Family intervention can be seen as a positive change only if certain service-led provisions are made. Most importantly, that the training of staff is supported and the model of family interventions implemented and uniformly used. Adhering to the process is important and the continued support through supervision a necessity for change. The evidence suggests that families who engage in the family intervention work better together, spend less time in hospital and are generally less of a burden on services. Understanding this and running with it will mean a change to services as we see them at present, but one which is truly not that far away. A common theme that services look to is whether the users are satisfied with the service provided. If this was to include the family as well, especially in relation to treatment offered to them, family interventions would have a place cemented in practice. The underpinning theory of family interventions is related to CBT and behavioural therapy. These skills are applicable to many situations, but are also evidence based and auditable. It is easy to measure something that has an evidence base and protocol for use. Trying to measure vague follow-up of service users and the use of psychodynamic procedures is difficult. The more practical and structured approach endorsed by family interventions lends itself to being audited and establishing if it has a value to the service providers and users. The implementation of family interventions can drive an inclusive approach. The family members have always been carers, and unpaid ones at that. Family interventions present them with the skills not only to care better, but also to see change and feel part of the process of change.

Summary

• • • • • • • •

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There are barriers that exist for the implementation of family interventions. Although guidelines exist, these are not necessarily implemented as part of routine practice. There is evidence that those trained in family interventions do not always implement what they have learnt upon completion of the training. Confidentiality is of concern for the service user. Engagement is a potential barrier, both for the service user and the family members. Staff attitudes can be challenging and deter the family worker. Managers are under pressure to meet targets, and this ‘priority’ can be a barrier. Family interventions have a strong evidence base and can therefore be audited.

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Questions 1 2 3 4 5

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What staff attitudes were found to be a barrier to implementing family interventions? What themes were suggested to aid implementation of guidelines? What barriers are identified in relation to service users for engaging in family interventions? Why could the ethos of the service affect implementation? Why may policies not always be implemented?

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23 Researching family interventions

Aims This chapter does not attempt to present a definitive ‘how to conduct research’ in family interventions. The aim of this chapter is to raise some questions and highlight the potential for research in practice by using simplistic examples which we hope will make you consider how you could conduct a research project in your own clinical area.

Learning outcomes By the end of this chapter you will be able to:

• • •

understand that anyone can conduct research in practice articulate a process of practice research detail different approaches to constructing a basic research proposal.

Introduction Throughout the book we have attempted to get you to look at your past, current and future practice. We believe that there is still a glaring omission in the content of this book and one that many practitioners either seem to find difficult to undertake, or are frightened at the prospect of– research. Although having many protocols and potential rules, if you can get over any latent fears, we believe it can be both rewarding and developmental.

Conducting research McCormack (2009: 31) cites Plato: ‘those who know and do not act and those who act and do not know’. This relates to the stereotype of researchers knowing but not necessarily acting and practitioners acting but not necessarily knowing. We argue that this separation needs challenging and that practitioners should be both acting and knowing; there is one particular way to achieve this, which is through research.

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If you conduct research in the clinical area, you will need ethical approval and some support from your management team. But research should not be avoided just because there are a few hoops to jump through. It is a sad fact that clinical research seems to be less frequently undertaken as NHS ethics committees and universities have tighter protocols and time limits for studies. Unfortunately this is seen as a negative point for research and has become a commonly commented upon reason for not conducting any research. The problem has been inadvertently escalated by academics in response to these factors and now for many students, reviewing services and research proposal preparation have replaced the standard dissertation research element of degree and masters programmes. Many courses require students to complete research proposals as part of the assessment criteria. These proposals are often at a standard that could be submitted to an ethics committee. Many, however, never get sent.

Elements of research From a personal perspective any form of research needs to have novel elements but to adhere to convention. The student needs to achieve an element of praxis and to be developmental. The conventions we ascribe to have some structural components and also some basic philosophical ones too. Although accepting the notions of paradigms in research, we prefer to simplify where possible, but believe that each person conducting research should (if a novice) have some supervision and appreciate the impact of their actions of conducting research. Understanding the ontological, epistemological and axiological issues related to any generated piece is a basic requisite. Do not, however, allow yourself to be put off by these terms or start to infer that a new language is needed for research. To understand what is known, what is known about the known and the value may be a more simplistic way of putting it. However, when you read research these may be the terms you see and you need to get used to understanding and using them. By reading research you will be starting to find presentations you favour and styles that you feel more accustomed to. This may be linking to your own personal profile of the way you like evidence to be presented and what you feel is a good way to present evidence to others. This is inextricably linked to your own beliefs and the sort of style of research you may want to conduct. The problem is which style do you feel reflects your belief and how does that style affect the studies you may do and the methodology?

What type of researcher am I? We suppose a question you may have is, how will I know what sort of a researcher I am? This is a complicated and sometimes variable ‘meal’.You may start off believing that you are a positivist, constructivist, pragmatist or even a phenomenologist. This is important, but it will become apparent to you when you start to explore what you feel is evidence. In the earlier chapters we deliberately left the question of whether family interventions are evidence based or not. Ask yourself the question, is there an evidence base and what did you believe made up that evidence? This is the first stage

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for you to unpack what sort of research leanings you may actually have. If you found that you felt comfortable with facts and figures, that could imply one thing. If you prefered the personal accounts and narrative, this could mean another. If you appreciated the blend of both and the drawing together of one form leading onto another, this could lead to another implication. The act of looking back on the area in question in this way may lean you to the notion of reflexivity where you are in this element the centre of the research, and raising your level of awareness. Understanding that you are generating ideas for research and that you may be involved in the research as a player could to some be off-putting, but to others exciting. We are probably quite pragmatic in our understanding of research. We do have a leaning to specific methodologies, but feel that William James (2007) and his description of Papini’s (an Italian pragmatist) assertion is an inspiration for constructing a view. In a hotel you have a corridor. Behind each door you could have a different person with a different perspective on how to resolve or answer questions, but they all had only one practical way into and out of their rooms. They had to go out of their doors and down the corridor. This allows each person the liberty of looking at a problem how they like, but in that hotel there was only one practical way of going and telling others about the way they would deal with the particular problem. Consequently the pragmatist among us can afford themselves a multitude of views on how to address a question or a research dilemma, but will rely on what best suits to order and structure it. Therefore we all need to walk down the corridor. This may seem a little aside from clinical work, but it highlights the fact that you need to reflect and look at how you both presently problem solve and what path you choose to structure the outcome. The structures you are choosing may well have a research element: literature searching, experimenting with interventions, controlling variables and evaluating the change (if any). This in some ways links to both practice and the education you completed for the qualification(s) you possess. In past studies you may have undertaken research-related modules and as a consequence possess the skills to develop (although potentially latent) a proposal. Or possibly you have the potential to do so, but perhaps you are too apprehensive to contemplate ever doing so. Much of your clinical practice may well be with service users, but will involve the service users’ families. As you have seen on reading the earlier chapters, these families are the melting pot for what works and doesn’t work in regard to care. Families are also an oasis for researchers as they generate so many potential studies and present you with a wide range of ways to consider how to conduct a study. Once awareness of this is uncapped, you will start to see the opportunity for becoming a practice researcher. Think about a service user and their family. Then consider either what happened with them or is happening with them. Ask yourself these questions:

• • • •

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What have I done in their case? Considering the way I did it, would I either like to do it with another family or could I do it again? What did I do and is there any evidence to support why I did it that way? What made it either work or not and how was it for all the participants?

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Answering these questions will lead to the generation of further questions, but this might mean that as an individual you step out of your own comfort zone, and enter into the fearful unknown, searching for answers that you suspect you have little or no control over, otherwise you may believe that you would have addressed them already. In essence, the answers will probably present you with further questions and necessitate you generating more detail. The way the detail is gathered is up to you and will unwittingly have started you on the research pathway. What has started to happen is that you have set out on a journey to address questions and then modified and honed them into some format that is addressable. This might uncover some evidence related to your practice, identified rational and irrational answers, presented scenarios that may excite or concern you but ultimately begun a venture into questioning and hypothesizing about remedies to the questions found. The following section will explore three simplistic ways to start to structure a research proposal to continue the journey you have just commenced, and hopefully quell some of the anxiety pangs of conducting research in practice. If we simplistically look at research for family interventions in the following three terms,

• • •

qualitative quantitative mixed methods,

then we can start to envisage how to move on from what you do in practice into some research. From the casework you have you will be able to generate lots of questions that the work and its process has raised in your mind. The reflexivity exercise you embarked on is probably as Titchen et al. (2007) would suggest – illuminating and a unique experience. The questions have to be looked at more carefully and not merely hung on some hook in the back of your mind. Generating questions is the first true step we feel in deciding whether you need to research the matter at hand. As indicated it is all too often the case that nothing is ever done with these questions.

Actions We advocate that you should jot the thoughts down and become practised at generating a clinical log. This can have great personal use, not only for research but also for clinical issue identification for clinical supervision. We accept that at first the questions you generate may not look like research questions but may with exploration become so. The generation of questions is commonly completed in response to something missing or unexpected in practice, and reflects something at that moment in time that needs attention. Unfortunately it is a common occurrence that the thoughts are lost and nothing ever happens to that ‘gem’ of a question. The discussion with both self and with others about the question may change the words ever so slightly and although reflecting, consideration may require some further

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amendments to be made more purposeful. This will create what Creswell (2003) argues to be the central intent and the thing that you want to do in the study and what you want out of it. Depending on your personal allegiance to established paradigms, this will depend on how the statement is constructed and the words used. Basically you will find that you are moving from the ideas into some way of viewing how the thing you want to do can be done and the use of such things to practise. In global terms the questions established will influence the boundaries of research. We can see that for ease of understanding at this point there will be a need to move the questions on and establish a methodology and a way of collecting the data. The interpretation will depend on how and what data you actually collected and wanted to collect. But before looking at this, let us just focus on the where and what could be collected. In qualitative terms it could be usual to set the research in a natural setting and utilize emergent themes from the people involved. These could be thoughts, actions or just experiences in families. Ultimately you will generate a picture of what is going on. In quantitative studies you could structure the statement more formally and consider the variables present and then consider comparison. You may find that there is an order in which the variables occur. The identification of independent variables in family work often relates to outcomes of actions of families and their members. They may also relate to what the service has done (treatment) and the change undergone. In mixed methods you will need to consider both qualitative and quantitative components and could explore the experiences that families have during treatment and the outcome as a consequence. Generating any of the above will lead to a revisiting of the initial thoughts and questions and then a restructuring of those thoughts and questions into research questions. To try to help you conceptualize some key themes we have produced Table 23.1, which outlines the uses of the research approach chosen for some of the themes that would be needed. These themes emanate from the work of Cresswell (2003) and are presented in a table form for ease of comparison. Looking at Table 23.1, it will become obvious what personal style of research you will adopt when considering families. Narrowing the simplistic process down allows you to conceptualize whether and how to basically structure a study. We deliberately avoid using jargon and have written the chapter as simply as possible. This we believe should allow you (if unfamiliar with the terms) to see that your interpretation of how to answer a question and the structures you would adopt have some basis in the research process.

Implementation If we move on and look at how this could be done, we can see that in a qualitative study, for example, you could engage the family in exploring their experiences with living with an illness. This could be developed by identifying personal stories and narrative accounts of the experiences. The production of trends and themes will allow the production of some analysis on the study and then lead onto the opportunity of

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Table 23.1 Research methods and themes Theme to be addressed

Qualitative

Questions and hypothesis

• State the questions (the main • The question shapes the study and the

Theoretical considerations

• Issues that are thought to be

Methods

Quantitative

one and then any supplementary ones) • In the narrative, the verbs used • tend to include explore, describe, report, understand or discover important • Whether the researcher positions themselves in the study • Is there a causal theory? • Ultimately the design

hypothesis is used to propose and predict the outcome Commonly the question will focus the study onto the hypothesis of comparing or experimenting

• Testing out theories and repeated •

measures Deductive

• What the qualitative study has • Maybe an experiment that is being in the form of characteristics • Researcher’s role • Use of purposeful sampling • Data collection procedures (could be observations, interviews, reading of documents, etc.) • How the data will be analysed and any interpretations • Representation of the data and the generation of themes

looked at for impact • Will have a purpose and a rationale • Will specify the population and the sample to be used • Commonly random samples • Explain any tests of instruments used • Outline the variable and the way the data will be analysed • Produce a clear plan and potentially use statistical data to emphasize the outcome(s)

Mixed methods

• Here the use of the purpose statement will generally suffice as it needs to have both qualitative and quantitative elements in the questions used

• Can be deductive and inductive towards theory

• What mixed methods is and why it is being used

• Identify the challenges posed • Will data be collected sequentially or concurrently?

• The sample and an explanation for it • How the data will be analysed and how this then relates to the chosen strategy

• Adopt representations dependent on the phase of the study; qualitative/ quantitative

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proposals for change or simple reflections of events. Either way this will allow you to generate a rich in-depth account of the novel experiences. In quantitative studies, for example, the families could be engaged in testing out the impact of a change on behaviour and measuring the outcome. The analysis could be statistical with variables being manipulated or maintained. Comparison to other families that are engaged in the same experiment can be made. Clear statements of impact and on prediction in the future may be made. With mixed methods, for example, the introduction of concurrent or sequential designs can allow the family to potentially follow either a phase of collecting data (quantitatively and qualitatively), in one phase (concurrently), or over two phases (sequentially). The kind of process could involve the concurrent measurement of attitude in a structured measurable way and an interview (semi-structured or unstructured) exploring the consequences of such on the family members. The sequential method may utilize quantitative or qualitative measures but the latter would be dependent on the results of the former.

Research and family interventions Regardless of the style of research, there is a need for research related to family interventions. In their reviews of the research Pharoah et al. (2010) and Berry and Haddock (2008) found a considerable amount of evidence for the practice, but what seemed to be limited evidence of it being conducted in practice and researched for development. We would advocate that case studies and narrative accounts can be produced to raise questions and demonstrate family interventions in practice. As we saw earlier in the book, organizations such as Meriden (and others) are exemplars of what can happen, but they can present only a limited amount of evidence that will build the evidence base for family interventions. We hope that you may be among the next group of people to take up the challenge and start to add to the body of evidence for family interventions and be developmental in moving it on to another level. If you are interested in the above and want to become active in research, we would advocate contacting your local research and development team. There are some rules for all research that we feel you should be aware of before you take this progressive step, including ethical consideration and research ethics. Such rules vary from institution to institution, but are summarized here from the many available. These are not definitive as research panels are constantly updating the information required.

Ethical considerations Ethical considerations include the following:

• • •

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Respect the autonomy of those who are either involved or going to be involved. Do no harm. Act in a just way to those who are either involved or going to be involved.

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Research ethics For any ethics panel you will need as a minimum:

• • • •

a clear methodology evidence of leadership ways of addressing potential/actual conflicts data management and security.

You will need to resolve the question of what will be done with the information and where will it go? Adherence to the Data Protection Act 1998 involves the following considerations:

• • •

consent security intellectual property.

Finally, remember that you have a duty of confidentiality to the people involved and the information involved.

Useful journal articles Table 23.2 includes a range of articles from various journals for you to search out and read. Then look at the various ways that they have addressed family interventions and the parties involved in the research.

Table 23.2 Useful journal articles

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Authors

Title

Journal

Levy-Frank, I., HassonOhayon, I., Kravetz, S. and Roe, D.

Family psychoeducation and therapeutic alliance focused interventions for parents of a daughter or son with a severe mental illness.

Psychiatry Research, 2011, 189(2): 173–179.

Aschbrenner, K.A., Mueser, K.T., Bartels, S.J. and Pratt, S.I.

Family contact and health status among older adults with serious mental illnesses.

Psychiatric Rehabilitation Journal, 2011, 34(4): 295–303

Absalom-Hornby, V., Gooding, P.A. and Tarrier, N.

Implementing family intervention within forensic services: The perspectives of clinical staff.

Journal of Mental Health, 2011, 20(4): 355–367.

Mihalopoulos, C., Magnus, A., Carter, R. and Vos, T.

Assessing cost-effectiveness in Australian and New Zealand mental health: Family interventions Journal of Psychiatry, 2004, for schizophrenia and related 38(7): 511–519. conditions.

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Table 23.3 Action plan Questions

List of questions that have been explored in relation to the identified theme of interest, maybe considering a flow chart of how you got to the questions you did

What is the central intent?

What do you want to do and what do you want to get out of it?

Are there any predictions or specific aims?

Include hypothesis and aims and objectives that can possibly be used as outcome measures.

Sample

Who will be involved and why them? Inclusion or exclusion of participants. How will they be recruited, opportunistic, purposeful, etc. What are the ethical constraints?

Structures

Methodology and your underlying philosophy which may influence the data collection and analysis. Where are you in the study – part of it or outside of it?

Outcomes

What can you now recommend from the study and how will this influence present and future practice? What predictions can you now make based on what you found?

Considering the styles and content of the studies listed in Table 23.2, think about what you may now like to study further and establish an action plan for yourself to achieve this. Table 23.3 may help you to formalize your thoughts and give some basic structure.

Summary

• • • •

Many people have been exposed to research and have been put off by the technical terms and the apparent demand for what seems like bureaucratic barriers. Generating questions and then reformulating them can be the start of the research process. It is important to understand that you can personalize the style of research and that you can have your own personal leaning that is reflected in what you accept as evidence. Understanding the process of research and some of its forms can reduce the fear and enable personal identification with your own practice. This could lead to taking this on further and practice-related research.

Questions 1 2 3 4 5

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What do you understand by the term pragmatism? What do you believe ontology, epistemology and axiology refer to? What are the basic characteristics of qualitative research? In mixed method research, name two structures. What is the central intent?

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Glossary

Aetiology: The cause of an illness or disease. Affective style: How an individual reacts emotionally. Antecedent: Something that precedes something else. Autonomy: A term central to informed choice in decision-making. It is linked to selfdetermination and the ability to make your own choices. Axiology: The value of something that can influence our perceptions, decisions and actions. Bond: One of the three elements of therapeutic alliance, implying here the things that tie the process together. CAGE-AID: A four item tool for measuring substance misuse (Brown and Rounds 1995). Care Quality Commission (referred to commonly as CQC): An organization that regulates, inspects and reviews adult social care services in the community. Cathartic: A process of releasing (sometimes trapped) emotions. Cognitive Therapy Scale: Scale for measuring application of cognitive skills in therapy. Devised by Beck and Young (1980). Collaborative: A partnership that in this instance involves some education related to ongoing involvement. Communication deviance: Referring to confusing and fragmented communication patterns that prevent family members from maintaining a shared focus. Constructivist: Generating knowledge and meaning between experiences and ideas. Coping strategy enhancement: Treatment package that utilizes present strategies and improves their applicability. Developed by Tarrier et al. (1990). Core skills: Fundamental skills for use in family interventions. Crisis intervention work: Relates to the Crisis Intervention Team, a time-limited intensive package of care that can reduce the risk of inpatient treatment. Focus is on keeping the person in their own home. Deinstitutionalization: Follows on from institutionalization. It focuses on relearning skills that long-term treatment (generally in a hospital in this case) has affected and replaced with modified practices of the institution. Didactic: Intended to teach or instruct.

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Dysfunctional: Refers to a conflicting or impaired functioning, especially in the family. The family derive their own way of functioning that is not necessarily positive for all parties. Early Intervention Team: A team of multidisciplinary members that tends to work with the age group of 14–35-year-old people experiencing psychotic-type illnesses. Early warning signs: Signs of progression from wellness to illness. These can be symptoms or sub-symptoms such as prodromes. Electroconvulsive therapy (ECT): A physical procedure whereby a person is anaesthetized and then an artificial seizure is induced by placing electrodes against the person’s head. It is used to treat people with severe depression and severe episodes of mania. Epistemology: What is known about a known and how we then come to know things. Ethnographic: A research strategy that studies people and ethnic groups. Family blaming: Can be unique blame aimed at the specific family, generally for some dysfunctional reaction. Generalization: Where the implementation of one course of action (for a specific problem) has a positive or negative influence on another potentially unassociated problem or problems. Genetic vulnerability: Links to the predisposition of the influence of genetic on the chance of developing an illness. Used in the stress–vulnerability model as one of the markers. Guided discovery: An approach to ‘guide’ an individual to ‘discover’ answers for themselves. A very effective form of therapy. Interpersonal skills: Skills used to deal with others. Intrinsic skill: Internally developed skills that are used, similar to tacit skills. Labels: The terms we attach to refer to actions as potentially deviant. Likert scale: A scale used in research, typically in questionnaires. Participants are asked to score a response on the scale (e.g. 1–5, with 1 being completely agree and 5 being completely disagree). Medicalized approach: Linking to the use of the medical model that has a more biological approach to treatment than psychological interventions. Mentally Disordered Offenders (MDO)/Court Diversion Team: These are a team of multidisciplinary people who aim to work with individuals who have either committed or have been accused of committing a crime and focus on advocating and working with them in the legal system. Their work often involves offering advice on hospitalization from court. Methodology: Guideline for the solution of a problem; should include things like tasks, phases, techniques, tools and analysis. Mixed methods: Mixing or combining methods of research from different research traditions. National Institute for Health and Clinical Excellence (NICE): It is responsible for developing evidence-based clinical guidelines for people using NHS services. Normalization: A principle that implies the acceptance of people with illness or a disability as being part of society and having the same involvement and opportunities that others in society have. Ontology: Metaphysical nature of being – ‘The known’. Operant conditioning: Use of consequences on a particular behaviour to modify future use of the behaviour. Commonly takes the form of reinforcers and reward, part of the work of B.F. Skinner.

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Paradigm: Philosophical and theoretical structure to describe distinct concepts commonly related to research. Paradox: Something that defies logic, containing conflicting ideas. Phenomenologist: Concerned with the study of consciousness as experienced from the firstperson point of view. Positivist: Concerned with positive facts and excluding speculation. Pragmatic: Refers to using what works, a practical approach. Praxis: The putting of theory into practice. Precipitating factors: Things that cause something or make behaviour more likely to occur. Prodromal signs: Can be non-specific symptoms of illness in the phase prior to an episode of the illness. Common symptoms include isolation and withdrawal. Psychiatrica democratica: Related to the Trieste or Italian experiment and Law 180, which involved the closing down of mental hospitals and a move to community care. Psychoeducation: Refers to education offered to people with a psychological problem, commonly in relation to the illness and treatment. Psychosocial interventions: An umbrella term for cognitive behavioural therapy, family interventions and relapse prevention. Qualitative: Qualitative methods explore the why and how of e.g. decision making, and not just the what, where, when. Commonly represented by themes. Quantitative: Information based in measurable quantities. Commonly expressed in numbers and statistics. Reductionism: An approach to understanding the nature of complex things by reducing them to the interactions of their parts, or to simpler or more fundamental things. Reflection: Art of looking back. We like to think of this as looking back on practice or looking back in practice. There are many models but all imply some development of practice from reviewing actions, behaviours or thoughts. This leads to the development of a plan based on this process. Reflexivity: Relates to the circular relationship of cause and effect and is often linked to the area of self-reference. Reframing: Changing the frame of reference that aids the unearthing of how role or self is perceived in thoughts actions and behaviours. It can focus on strengths as well as deficits. Role-play: The staged acting out of a series of behaviours in a safe environment that allows comment and skills development through feedback and support. Schemas: How we form impressions that affect the way we perceive or interpret information. Schizotypal: A diagnosis of a personality disorder where an individual has trouble with relationships and experiences disturbance in thought patterns. Skinner: The American psychologist B.F. Skinner developed the theory of operant conditioning. Social inclusion: The provision of rights to all groups or individuals in society regardless of their ability. Sociotropy: High levels of excessive need to please others, which causes the person to feel dependent on others. Stigmatization: The branding as different or other.

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Subclinical: Having a ‘problem’ that may be without any apparent signs. Systemic family therapy: Practically addresses current relationship problems and analyses some of the causes potentially related to impulses or childhood. Therapeutic: The positive effects of treatment or action on problems experienced. THORN initiative: Commencing in 1992 at sites in London and Manchester, the THORN initiative began training mental health practitioners in CBT for psychosis and families. White Paper: Documents produced by government that set out future policy on a particular subject.

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References

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Index

affective style 9, 91 agenda setting 44–45 alliance, therapeutic 54 anxiety 67, 119, 125, 128 formulations 74 hospital anxiety and depression scale 146 management 106 appraisal 18, 89, 100, 137 primary 100, 137 reappraisal 106 secondary 100, 137 assessment 11, 24, 28, 61–62, 84, 101–102, 120, 122 carers 11 case examples 124–125, 129–131, 135–137, 141–142, 146–148 of communication 93–96 engaging 55, 57–58 family 23, 28 impact of 93, 149 self 28, 49, 103 service user (see also rating scales and practice chapters) 28, 57 stress (see stress) 102 tools 27, 62–71 attitude 50, 90, 163 barriers 30, 55–57, 159–167 to engagement 55–57 to eliciting problems 55 potential 58–59, 11 Barrowclough, C 16, 23, 70 behavioural 74

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family therapy 22–23, 74 formulation 75–76 sessions 94 booster sessions 25, 153, 156 bounded rationality 53 BPRS, see Brief Psychiatric Rating Scale Brief Psychiatric Rating Scale (BPRS) 69 Brown, G 4–5, 9, 21 burden 4, 19–21, 120 burnout 156–157 Camberwell Family Interview (CFI) 17–18 carers 3, 5–6, 19, 48 assessment 11 CBT, see Cognitive behaviour therapy CFI, see Camberwell Family Interview cognitive behaviour therapy (CBT) 49, 167 collaboration 23, 117 communication 105 case example 129–133 deviance 91 skills 29–30, 42–43, 89–97 training 24 Community Care Act 5 co-working 24, 27–28, 49, 156–157 criticism 10, 17–18 cultural issues 87 dissonance 92–93 distraction 105 distress 19

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early warning signs 32, 86, 154–155 education 18, 23–24, 29, 105 of family 124–128 in family intervention 82–88, 101–102 educator 50 EE, see expressed emotion efficacy 83–84 emotional overinvolvement (EOI) 10, 17 engagement 24, 26–27, 52–60, 75, 122 aims of 55, 83 barriers to 55–57 not engaging 54 risks of 54 steps to 54–55 environment 15, 17, 39, 49, 127 EOI, see emotional overinvolvement evidence 7–13 positive 167 relapse 154–155 expressed emotion (EE) 10 burnout 156 difference to communication deviance 9, 91 definition 17 high EE 18 importance in family work 18–19 low EE 18 measurement 17–18 facilitator 50, 55, 114, 156 Falloon, I 22, 54, 71, 84–85, 94, 112 family blaming 3–4, 9 group 23 member 6 member interview (FMI) 66, 71, 141 questionnaire (FQ) 28, 66, 70, 125 Family Member Interview (FMI) 66, 71, 141 force field analysis 160 formulation 28, 72–81 example 103–104 General Health Questionnaire (GHQ) 28, 66, 70 genogram 61, 64, 71 GHQ, see General Health Questionnaire Government 160, 166–167 guided discovery 43, 96, 118, 132 homework 24, 44, 46–47, 50, 80, 96 hostility 10, 16–17

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involvement of family member 4, 11, 15, 38, 53 of service user 38, 85 KASI, see Knowledge About Schizophrenia Interview KGV, see Krawiecka, Goldberg and Vaughn Knowledge About Schizophrenia Interview (KASI) 27–28, 66, 70, 82, 88, 125–126 Krawiecka, Goldberg and Vaughn (KGV) 28, 57, 66–67, 124, 136, 141, 146 knowledge 10, 12, 42 Kuipers, E 24, 40, 56, 131 Manchester Short Assessment of Quality of Life Scale (MANSA) 12, 28, 66 media 82 influence 83 Meriden family programme 5, 11, 23, 175 mixed methods 172–175 model, of stress 100 modeller 50 negotiation 27, 123 National Institute of Health and Clinical Excellence (NICE) 5, 8, 11, 62 NICE, see National Institute of Health and Clinical Excellence National Service Frameworks 5 National Health Service Community Care Act 5 operant conditioning 74, 81 prevention, of relapse 32–33, 154 primary appraisal 100, 137 prioritizing family interventions 163 problem solving 23, 31–32, 106, 108–114, 140–150 protocol, relapse 155 Psychotic Symptom Rating Scale (PSYRATS) 69, 124, 141 psychoeducation 23–24, 83, 91, 120, 126–127, 162 PSYRATS, see Psychotic Symptom Rating Scale

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qualitative 172–175 quantitative 172–175 questioning, Socratic 41, 43 rationales (use of) 121 RAI, see relative assessment interview reappraisal 106 relapse effects of 4 expressed emotion 9, 10, 16, 19 family interventions 9, 22 fear of 153 medication 19 prevention 32–33, 154 protocol 155 readmission 8 stress 54 traffic light system 155 relationship, therapeutic 16, 42 Relative Assessment Interview (RAI) 27–28, 66, 70, 121, 125, 130 research mixed methods 172–175 qualitative 172–175 quantitative 172–175 rethink 11, 83 risk 9, 12, 48, 84, 157, 162 of engaging 52–55, 122 roles educator 50 facilitator 50, 55, 114, 156 modeller 50 problem solver 50 rules for family interventions 96–97, 112 Salford District Health Authority (study) 24 schema 74 second order intelligence 53 secondary appraisal 100, 137 service user assessment of 66 involvement 11, 38, 40, 85 session management skills 43, 49

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191

setting an agenda 44–45 SFS, see Social Functioning Scale shared capabilities 47–48 skills communication 89, 94 interpersonal 12–13, 42, 93 Social Functioning Scale (SFS) 66 social inclusion 5 sociogram 61, 65, 71 Socratic questioning 41, 43 solving, problem 23, 31–32, 106, 108–114, 140–150 starting family interventions 6, 37, 40, 62 stress 98 aim of stress management 101 assessment 101 formulation 103–104 identification 102 interventions 104 monitoring form 103 management 30–31, 96, 98–99 stress vulnerability model 31–32, 91, 100, 102 stigmatization 4, 39 solution 112–113, 143–144 systemic family therapy 4 Tarrier, N 5, 24 ten essential shared capabilities 47–48 therapeutic alliance 54 relationship 16, 42 timeline 61–64 transactional model of stress 100 trust 27–28, 41, 55, 157 use, of rationales 121 Vaughn, C 10, 17, 19 World Wide Web 86 Yerkes Dodson law 30

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Withnell & Murphy PB

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“Withnell and Murphy provide a structured and comprehensive resource for the mental health professional who seeks practical strategies that will empower families to engage with challenging issues, maintain the balance between stress management and recovery and build the foundations of lasting relationships.” Niall McLaughlin, Senior Lecturer, Mental Health Nursing, Canterbury Christ Church University, UK

t is rare that people live in the absence of family, friends or other social support networks, so working with families and staging effective family interventions is an important and logical aspect of promoting recovery in mental health nursing.

This book is a comprehensive and accessible guide that will help you to incorporate families more fully into the care of individuals with mental health needs. The authors carefully introduce the concept of family interventions before going on to demonstrate its practical application, offering examples from practice and also potential barriers to implementation. Key features of this book include: ● ● ● ●

Case studies of real family work Examples and practical tools to use in practice Aims and learning outcomes for each chapter Questions at the end of each chapter to enhance self assessment and reflection

Neil Withnell is a Mental Health Nurse and Senior Lecturer in Mental Health Nursing at the University of Salford, UK. Neil Murphy is a Mental Health Nurse and Lecturer in Mental Health Nursing at the University of Salford, UK. Cover design Hybert Design • www.hybertdesign.com

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WITHNELL & MURPHY

Family Interventions in Mental Health will be an invaluable tool for both mental health students and qualified practitioners. It will also be relevant to social workers and occupational therapists working in mental health settings or the community.

Family Interventions in Mental Health

Family Interventions in Mental Health

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Interventions in Mental Health

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I T H N E L L U R P H Y