‘I'm not a family therapist. OK?’ Working Constructively with Families in Aged Psychiatry

‘I’m not a family therapist. OK?’Working Constructively withFamilies in Aged Psychiatry

Catherine Hudgson,1 Pam Rycroft,2 and Shraeveni Giri3

1 Eastern Health Aged Persons Mental Health Service (Peter James Centre), Victoria2 The Bouverie Centre, Brunswick, Victoria3 Southern Health Aged Persons Mental Health Service (The Kingston Centre), Victoria

This paper reports on the first phase of a larger study aimed at investigating factorshindering family work and exploring ways to improve the amount and quality offamily contact within a community aged mental health service in Melbourne, Australia.During the first phase of the project, 28 mental health professionals were interviewedabout their views and experiences. Interviews were transcribed, coded, and analysedin terms of repeating themes. The range of attitudes, beliefs and feelings aboutfamily work is summarised in this paper. Polarities emerged around questions ofwhether or not to engage family members, and if so, what function family work fulfils.The interviews also provided useful information on clinicians’ beliefs about whatwould increase the possibility of family work. The paper concludes with a discussionabout how to recognize and value family work in this area and target sustainableinterventions during the second phase of the study.

Keywords: aged psychiatry, family therapy, qualitative research, mental health, Action Research

IntroductionA number of research studies over the past decades have established that includingfamily members in the treatment of people with mental health problems is beneficialfor all involved. For example, Pam Cuijpers’ (1999) meta-analysis of 16 studiesindicated that family interventions can have considerable effects on the psychologicalwell-being of relatives, family functioning and the relationship between the patientand relative. Many of these studies are in adult mental health and use outcomemeasures of relapse and readmission rates, as well as compliance with medication (eg.Falloon, Shanahan & LaPorta, 1992; Bustillo, Lauriello, Horan & Keith, 2001; Pilling,

Address for correspondence: Catherine Hudgson, Aged Persons’ Mental Health, PeterJames Centre, Cnr Mahoney’s Rd and Burwood Hwy, Burwood East, VIC, 3151 E-mail:[email protected]

THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF FAMILY THERAPYVolume 33 Number 4 2012 pp. 321–330 c© The Authors 2013 doi 10.1017/aft.2012.40

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Catherine Hudgson, Pam Rycroft and Shraeveni Giri

Bebbington et al., 2002; McFarlane, Dixon, Lukens & Lucksted, 2003; Pharoah,Rathbone & Streiner, 2003).

While research with aged patient populations is less common, it suggests involvingfamilies in the care of older adults is helpful and even vital in terms of short andlong term outcomes (Griffith, Brosnan, Lacey, Keeling & Wilkinson, 2004). In ourexperience, family members are the most likely providers of help to older people. Itis readily apparent that caring for an elderly family member with a mental illness isstressful and research shows that it can be potentially damaging to the psychologicaland physical health of the carer. Thus, ensuring the sustainability of this help byproviding support and care for carers is of the utmost importance.

A number of comprehensive programmes are available for working with familycaregivers (e.g. Brodaty & Gresham, 1989; Magai, Hartung & Cohen, 1995). Theseprovide a resource for clinicians working in this area to help them work with families.Key interventions which have been shown to be effective in reducing caregiver burdeninclude individual and family counselling, provision of information and meetings withextended family. Brodaty, Luscombe and Gresham (1998) implemented a structuredprogramme incorporating these areas and reported that the programme could notonly reduce psychological morbidity in the carer and delay institutional placement ofthe patient, but also reduce service costs associated with individual patients.

Caregivers of older people have themselves identified access to information andtraining as essential requirements in their struggle to continue the care-giving role(Blackwell, O’Shea, Moane & Murray, 1992). In a study that investigated theirperceived relationship with mental health professionals, caregivers ranked more com-munication with professionals as their greatest need (Biegel, Song & Sharon, 1995).Despite the benefits of such contact, reports are fairly common that relatives of mentalhealth clients find it difficult to access family interventions. In the current authors’clinical experience in aged psychiatry, it has become evident that mental health staffgenerally continue to shy away from contacting and working with families, preferringto direct the majority of their clinical time and effort to the patient. This concurswith the literature emanating from other psychiatric service settings. (e.g. Fadden,1997).

In order to address this issue and support staff in their interactions with fami-lies in one residential aged care facility, Tisher, Dean and Tisher (2009) conductedand evaluated a series of four in-service workshops. Staff members who participatedwere more satisfied with their interactions with families, and felt more appreciatedand less blamed by them. The objectives of the training included affirming staffmembers’ existing skills, helping them develop empathy for family members’ ex-periences, communication skills, reframing, reflection on their own behaviour andvalidation.

Thus, finding ways to increase family involvement in services appears beneficialfor patients, their families and staff. In order to encourage greater involvement offamily members in the treatment of their aged relative, a group of clinicians froman aged persons’ mental health service (APMHS) in Melbourne approached TheBouverie Centre (a Victorian statewide family therapy service) for help in supportingthis work. Over many years the APMHS clinicians have made concerted efforts todevelop involvement with carers and families of clients. There have been a number

322 THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF FAMILY THERAPY

‘I’m not a family therapist. OK?’ Working Constructively with Families in Aged Psychiatry

of carer projects, followed by the development of carer support groups, educationprogrammes and focus groups. Family work was written into departmental policy,and endorsed by local management as a necessary part of the role of all staff on boththe inpatient unit and in the community teams.

However, despite these initiatives, the findings from the projects and the lastfocus group for carers continued to suggest that carers were not satisfied with theirinvolvement in their elders’ treatment. This led to further discussions about whatmight be preventing clinicians from working more with family members, and howthey could be better supported in doing this work. In considering ways of supportingfamily work, the authors were conscious of the importance of research in relation tothe limited capacity of training by itself to bring about change in practice.

Proctor et al. (2009) point out the paucity of evidence in relation to implementa-tion of evidence-based interventions, and cite Boren and Balas (1999), who estimatethat new interventions ‘languish’ for 15–20 years before they are incorporated intomainstream care approaches. For example, Fadden (1997) found that in the 9 monthsto 3.5 years since completion of an intensive behavioural family therapy training,staff had worked with an average of 1.7 families only. This was consistent with TheBouverie Centre’s own recent experience, which has led to the development of theirimplementation principles, embedding training within a larger workforce develop-ment strategy.

Therefore the authors of this study were wary of simply assuming that furthertraining alone would increase staff involvement with families. It was decided as afirst step to engage staff members in conversations directly about their attitudes andcurrent practice in relation to working with families, as well as canvassing their beliefsabout what could encourage and support more family work. This comprised the firstphase of a larger study, which will develop, implement and evaluate interventionsaimed at encouraging greater family involvement, as based on the findings from thefirst phase reported here.

Project MethodologyParticipantsAll 35 clinical staff members from the APMHS community teams were invited to par-ticipate and complete consent forms. These staff members included multi-disciplinarymental health clinicians (nurses, psychologists, social workers, occupational therapistsand psychiatrists). All those who consented were included in the study (n = 28).

DesignThe larger project used a mixed method, quantitative and qualitative research designwithin an ‘Action Research’ framework, primarily utilising the strategies of ‘Partici-patory Action Research’ and ‘Cooperative Inquiry’ (Coghlan & Brannick, 2001). Assuch, the design unfolded during the cyclical process of ‘diagnosing’ the problem,planning, data collection, taking action and evaluating the action. The initial stepof ‘diagnosis’ involved exploring with staff members (through individual and groupinterviews), their feelings and attitudes towards working with families. This servedto inform the researchers about the barriers that hinder optimum family work and

THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF FAMILY THERAPY 323


interactions with a view to later developing and evaluating interventions to overcomethese barriers.

Demographic data was obtained and the ‘Opinions about Family Work’ scale(Farhall, 1996) was administered in order to provide baseline data for the larger study.This paper focuses on the individual semi-structured interviews, which were con-ducted to explore staff members’ attitudes, and experience in, working with patients’families. The interviewer was a Psychology Masters student with many years of ex-perience and an interest in aged psychiatry. She interviewed staff with the followingquestions as foci:1. How does contact with carers and families fit into the work you do?

2. Do you believe you need to work with families or not?

3. What value do you place on working with carers and families?

4. If you do work with families, what is it like for you?

5. What gets in the way of working effectively with families?

6. What do you think families and carers want from you?

7. What would need to happen for you to feel:1. More confident, and / or2. More willing and able to work with family members directly?

8. Any thoughts about how the service might better deal with the needs of carers andfamilies?

Twenty-five interviews of roughly 30–45 minutes each were sound-recorded andtranscribed. Three staff members declined to be recorded, but agreed for notes tobe taken. The resulting transcripts and notes were coded and analysed in termsof repeating themes, by two researchers independently. The latter cross checked alltranscripts and came to a consensus agreement where there was variance. The resultswere then provided to participants for feedback and member checking (Creswell &Miller, 2000).

Results of StudyWhat are staff members telling us?A number of themes (below) emerged from the individual staff interviews. They werefurther examined for possible trends based on the clinician’s discipline or current team.It is impossible here to represent in detail the range of responses, so only prevailingthemes are discussed.

Clinicians’ perceptions of family members’ need for support.Most clinicians believedfamily members were experiencing stress and needed a lot of support and understand-ing in their own right. This perception held across the various disciplines and teamsof professionals. However, as will be seen below, there was ambivalence about whetheror not it was the role of the clinicians interviewed to provide this support.

A small number highlighted that families were often concerned or even frightenedabout their relative being unwell. Mostly families were viewed as keen to be involvedin their elderly relative’s care and as grateful for the help.



Clinicians’ perceptions of how families and carers fit into their role

1. Resource. Two thirds of the participant clinicians considered families to be a‘resource’ to the work, and this included representatives from all teams and disci-plines. Families were seen as being able to provide important historical and contextualinformation about the client.

2. Crucial for treatment. Quite distinct from those who viewed families as ‘useful’as a resource, just over a half of the clinicians believed them to be necessary, evencrucial, for treatment to be effective and sustainable. For example: ‘they are the lynchpin of maintaining the client in the community’.

3. Unnecessary for treatment. However some clinicians viewed working with fam-ilies as largely unnecessary. For example: ‘there are circumstances where families don’twant to be involved. There are circumstances where there are no families’. One clinicianrepresented the view that family work fell well outside of the aged psychiatry role: ‘Idon’t regard myself as a family therapist, okay?’

4. Not helpful. A minority of staff members expressed the view that working withfamilies did not make enough of a difference: ‘I’d want to see some hard evidence thatsays that working with those carers and families makes a real difference. I know it certainlywould for some but I would say only about 3 or 4 percent’. And: ‘ . . . most people that arehighly active in involving families get a highly active response . . . ’.

There was also concern the clinician may be expected to intervene in long-standingissues within the family: ‘I’m not about re-inventing the family that has its own, youknow, thirty to fifty year history’.

5. Confusion about the role. There did appear to be some confusion amongstclinicians about what their role should be. One worker stated: ‘I hate family work,but I like working with families!’ This perhaps implied that formal family meetingsor therapy are viewed less positively than informal interactions. Despite the commonview that families need a lot of support and understanding in their own right, thisdidn’t translate to being seen as a valid part of the clinician’s role: only one personcommented that working with families was important in order to prevent familyburnout and mental illness in the family.

6. Engagement of family/carers. It was interesting that, despite the apparent dearthof family work, 41% of the clinicians in this study said that they were pro-activein engaging families. It may be significant that a large number of these were from aparticular team whose team leader had family therapy training. In contrast to this, aminority of clinicians indicated an active avoidance of engagement: ‘ . . . I don’t worrythem if they don’t worry me’.

What is it like for aged psychiatry clinicians working with families and carers?Clinicians reported diverse experiences of working with families. The most commonlyoccurring themes were that family work can be:



1. Anxiety provoking. Even those who clearly valued the work frequently reportedthis. Those who saw family work as integral to their role were more likely to experienceit as rewarding, but about half of those also found family work very challenging: ‘ . . . onthe whole I find it a bit intimidating . . . am I going to be skilled enough to deal with therange of ideas and emotions that come up? So it’s scary’.

2. Threatening. ‘ . . . if alcohol is mixed up in the family then you just are worried thatat any time the family might explode, and then you feel threatened’.

3. Challenging. Twenty per cent of clinicians reported that working with familiesevoked challenging feelings or frustration, particularly when families don’t want tofollow the clinician’s suggestions: sometimes you get the odd family that you know is veryresistant to anything you suggest – and you feel like hitting your head against a brick wall.

4. Rewarding. About half of the clinicians reported they found family work reward-ing, for example: ‘I get a lot of enjoyment out of it . . . great sense of satisfaction actuallyassisting and helping people work through problems’.

5. Mixed feelings. Some clinicians found the work to be rarely exclusively positiveor frustrating, but often both.

Obstacles to family work

1. Personnel and time. These were seen as major obstacles in a public mental healthsetting, by more than half of the participants. One stated that: ‘ . . . client numbers aregoing up . . . we’ve got to a point where we don’t talk about long-term support of clients . . .and: I have to say that when I am pressed for time it’s the families that slip out of the loop’.

2. Attitudes.(a) Carers’ attitudes

Some family members were viewed as unwilling to accept the changes that inevitablyaccompany illness: ‘Sometimes carers are quite fixed in their beliefs and they feel that theyknow the patient best’.

(b) Service attitudesOne clinician nominated the predominance of the medical model in the service as anobstacle.

(c) Staff attitudesAnother clinician spoke of family-of-origin issues for the professional being a possibleobstacle.

3. Confidentiality. This was seen as a concern for staff when some clients did notwant families contacted.

4. Conflict. Conflict within families (e.g. siblings not talking to other siblings) wasperceived as difficult, particularly when there was lack of clarity about the contactperson. Sometimes the conflict was within wider systems (e.g. between families andresidential care staff ).



5. Clinicians’ emotional issues. Some staff mentioned that working with familiescould raise emotions in themselves that were not necessarily productive.

6. Organisational barriers. Whilst the Department of Human Services has beenhighlighting the importance of the role of carers, a number of participants in thisstudy believed this was not translating into change at a clinical level. Although familywork was viewed as acceptable as long as it did not impinge on ‘real’ work, someclinicians believed it was not really valued in the service/organisation.

In relation to families, staff perceived time, access, caring responsibilities, stigma,grief and denial as obstacles for them participating in this kind of work. Families weresometimes viewed as being under significant stress and trauma and requiring time tosteady themselves before being able to move forward. Sometimes multiple problemswithin the family, such as mental illness or other physical or sensory problems in familymembers could become complicating factors. Cultural issues were also highlighted:within some cultures residential care was seen to reflect failure on the part of familymembers to carry out generational obligations.

What would increase workers confidence when working with families? Half of theclinicians believed that some professional development would be helpful, althoughthere was concern expressed about ‘preaching to the converted’, suggesting that thosewho want to work with families and are committed to it would have probably alreadysought it out. Training was most commonly suggested, with clinical supervisionmentioned by a few. A minority were ambivalent or actively against any professionaldevelopment. Other suggestions included employing a dedicated family therapist, acarer consultant position, and more carer groups.

DiscussionMaking sense of the findingsThe first phase of this project has brought up two main issues; firstly, the issue of whatactually ‘family work’ entails and how it is perceived by staff members. Secondly, howto effect change in practice so that clinicians involve carers routinely and this becomespart of their everyday work. With regard to the question of what constitutes familywork, a striking feature of the transcripts was that staff members’ views ranged quitebroadly, and reflected what appeared to be very different assumptions about:• Whether there was any point in engaging families in the work, and if so, whether

professionals should engage families pro-actively in the work, or simply respond tofamily members’ requests to be involved.

• What function family work fulfils.

• Whether family members have any worthwhile knowledge about the client.

• Whether or not it was the role of the service to meet the needs of families andcaregivers.

The wide range of clinicians’ views about family work highlighted the need for a sharedunderstanding of the centrality of families in treatment and the role of clinicians insupporting this. There was also acknowledgement that a ‘one-size-fits-all’ approachto working with families is neither possible nor useful. The challenge for this aged



persons’ mental health service was to define an intervention which addressed the aboveand supports clinicians in working with families, given the likelihood that:1. Few aged psychiatry clinicians and few families will engage in formal family therapy.

2. Incorporating family members and carers into the work with an older person canhappen in many different ways, and include many different levels of involvement.

3. Families themselves can negotiate with the clinician the level of involvement thatis appropriate for them, and the clinician can then decide whether s/he can offerthis, or needs to refer to someone who can.

Conclusion: Defining family work in aged psychiatryIt was apparent from the interview data that a number of the clinicians believed thatthey were expected to provide family therapy to their clients’ families, when very fewhad been trained as family therapists. This was met with protest by some who sawfamily work as well above and beyond their primary role. Others felt that workingwith families was absolutely necessary to ensure optimal treatment. This highlightedthe very different ideas about what was meant by ‘family work’, ranging from anycontact with family members at all, to formal family therapy sessions. These findingsechoed those of Kavanagh and colleagues (1993) and Fadden (1997): time and otherresponsibilities featured strongly in staff members’ responses, as did (in some cases) asense that they were being asked to work beyond what was seen as their role.

In their study of an adult psychiatric service, Mottaghipour and Bickerton (2005)stated that “no blueprint exists for incorporating family work into the everyday prac-tice of adult mental health clinicians. Thus families remain unseen by clinicians”(p. 2). Their ‘pyramid of family care’ framework presented a stimulus for thinkingabout the diversity of interventions that is possible as well as desirable for familieswithin the service. Such a framework outlines various hierarchical ‘levels’ of service,and includes tasks seen to provide a minimum level of care across a greater numberof families (connection and assessment, and general education) moving to more spe-cialised interventions (Psychoeducation, Consultation) and at the top of the pyramid –family therapy (for a few families), aimed at creating change in the family system.

The interventions at the ‘lower’ end of the pyramid of family care (e.g. connectionand assessment) are aimed more at engaging family members and setting up collabo-rative working relationships than assuming any need for change. At the ‘higher’ levelinterventions are not necessarily more highly valued: they are simply seen as applicableto only a small proportion of the total client family population. The authors assumethat significant gain can be made by broad application of simple interventions andtechniques with a large number of families, while more specialised interventions canbe reserved for those families who can be engaged in, who need and can utilise suchchange-oriented interventions.

The challenge that this model elegantly poses is for services to review the rangeof possible family interventions that can be offered, while delineating and acknowl-edging clearly what constitutes a minimal level of care, and on what basis familiesare assessed as needing further intervention. This should offer encouragement to staffwho generally incorporate the basic level skills into their everyday work as clinicians



(without necessarily acknowledging this), but who don’t necessarily see themselves asworking with families.

The following ‘working definition’ of family work was developed:

Family work focuses on collaborating with families and building on their strengths andresources. It comprises engaging and communicating with families and providing them withinformation about their family member’s illness and treatment. It is sensitive to families’needs and readiness to progress to more in-depth levels of involvement.

Phase 2 of the larger research project involves interventions aimed at operationalizingthe above definition and developing local versions of the pyramid of family care, forthe community teams involved. Details of the second phase of the project will bereported in the future, when follow up data will show whether or not it has beenpossible to re-define family work in such a way that clinicians have been able toincrease families’ involvement in this aged persons’ mental health service.

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‘I'm not a family therapist. OK?’ Working Constructively with Families in Aged Psychiatry