Working with families Steve Wood Lecturer/Practitioner

Working with families


Steve Wood

Lecturer/Practitioner


Family interventions

• Let’s start with a question -

–What do you understand by the term “family interventions”?


Family work & Family therapy • Family work (Family

management)• Family therapy

Burbach, F. (1996) Family based interventions in psychosis: an overview of, and comparison between, family therapy and family management approaches Journal of Mental Health 5, 2, 111-134

• Family work (Family management)– accepts biological

element in disorder but believes work with families to reduce stress can improve its course

• attempted to develop non-blaming formulation

• argue retain concept of “schizophrenia” for practical, heuristic reasons

• emphasis on empiricism• criticised that has “lineal

conceptualisation”

• Family therapy– systemic theory; symptoms

developed & maintained in context of family’s interactional processes & organisation

• implied, or appeared to, that families “caused” schizophrenia – families felt blamed

• believe potentially harmful effects of using diagnosis “schizophrenia”

• emphasis on theory• understands in terms of

“reciprocal” or “circular” causality


General aims of working with families

• to work in a pragmatic way, and on the basis that the family is doing their best in the circumstances in which they find themselves, thereby without making the family feel blamed, toA. help the family learn to manage their problems

more effectively andB. enable family members to pursue individual goals


Underpinning concepts

•Family “burden” or “strain”

•Stress vulnerability•Expressed emotion


Tom’s story

When my son was 17, my family and I spent a year under siege. It took a year for us to get him the help he desperately needed. We spent a year with our bedroom door locked, the kitchen knives hidden away. Louis’s elder siblings kept out of the way.

When he was finally admitted to hospital, he was diagnosed with schizophrenia and we thought things would get better. When he left hospital, he received a depot injection of medication, and eventually starting doing odd jobs. But when the arrangements for receiving his injection changed, he dropped out of this routine.

In December 1998 my wife and I were told that Louis had jumped 80 feet from the railway bridge on our road onto the tracks below. He spent a year in rehabilitation and began to make progress – taking low doses of medication and beginning to stand with the aid of leg irons and a stick.

But in June 2002, my wife noticed that Louis was becoming mentally ill again. I had, naively, assumed that getting help would be easier second time round. I was wrong. It took until December 12th 2002 before Louis was admitted to hospital.

It took months for Louis’s records to arrive, and when we supplied his history, it made little difference. Louis began to talk to trees, foul his bed, scatter food around, leaving the front door left open when out, turn off the freezer, turn his pictures to face the wall, pick up oddments of rubbish to put in his pocket, sit in the middle of the road in his wheelchair in the dark and rush out in his wheelchair into the middle of a busy intersection.

We were promised an informal assessment but Louis was out when the team arrived. But when he was finally assessed, the medical team described him as an angry young man and concluded that the fact that his uneaten meals were scattered around the floor “no worse than an untidy student’s bedsit”.

I believe Louis could – and should – have received help under the Mental Health Act long before he was sectioned. Most of the professionals we have met have been very sympathetic. I have tried to be reasonable in my fight to get the right help for my son, but it was not until my wife wrote an impassioned letter that we seemed to achieve a real breakthrough”.

We are appalled at how badly the system has let Louis down. On every occasion when an assessment was imminent and we thought Louis knew he would be admitted, our unspoken fear was that he would not stay alive until then. Although our frustrations pale in comparison with what Louis has experienced, I would not wish them on anyone.


Family “burden” or “strain”• definition – “All the difficulties and challenges experienced

by families as a result of someone’s illness.”• most research focused on families of people with

– serious mental illness, in particular schizophrenia– Alzheimer’s disease

• commonalities between these disorders– long-term caregiving with strong possibility of deterioration– high physical & emotional care demands– often major cognitive, emotional & behavioural disruptions

• subjective & objective dimensions– objective

• everything caregiver/s has to do, experiences or cannot do as consequence of caregiving task

– subjective• the distress experienced by the caregiver in dealing with the

objective stressors

from Sales, E. (2003) Family burden and quality of life Quality of Life Research 12(Suppl. 1): 33-41


Main areas of burden• patient behaviours• disruptions in family life

– physical health– children in the home– social & leisure activities– domestic routine– income– employment– relations with neighbours

• relatives’ own symptoms• overall feeling of burden

from Loukissa D (1995) Family burden in chronic mental illness: a review of research studies Journal of Advanced Nursing 21, 248-255


Str

ess

VulnerabilityLow High

High

Well

Ill

Stress vulnerability

Vulnerability threshold

Adapted from Zubin & Spring, 1977


Natural

Day to day stress

Life events

Medication

P.s.i.

Stress vulnerability

Time

Vulnerability threshold

Adapted from Andrews & Jenkins, 1999


“I’d like to see her up and about, sort of with an eye on the place. As I said to her ‘I’m not asking you to get to the moon -

everyone has setbacks - but promise me you’ll at least try! Show me that you’re

trying, not just say you are and do nothing!”

“I’d like to see her up and about, sort of with an eye on the place. As I said to her ‘I’m not asking you to get to the moon -

everyone has setbacks - but promise me you’ll at least try! Show me that you’re

trying, not just say you are and do nothing!” (High - few allowances for the illness or

patient’s known deficits)

“I’m trying to knock it out of his mind - that he’s not Jesus Christ. I always tell him,

‘That’s a bunch of horse shit - don’t give it to me!’ And that’s putting it mildly!”

“I’m trying to knock it out of his mind - that he’s not Jesus Christ. I always tell him, ‘That’s a

bunch of horse shit - don’t give it to me!’ And that’s putting it mildly!” (High - attitude towards legitimacy of illness - intolerant of sick talk)

“He had some strange experiences. He told me, ‘I saw Christ walking up the hill,’ while we were sitting on the porch. He said Christ had on a

purple robe and sandals. I just listened to him and said nothing. At the very beginning of the illness I might have thought, ‘Well, I’ve heard of miracles,’

but later of course I knew he was ill”

“He had some strange experiences. He told me, ‘I saw Christ walking up the hill,’ while we were sitting on the porch. He said Christ had on a

purple robe and sandals. I just listened to him and said nothing. At the very beginning of the illness I might have thought, ‘Well, I’ve heard of miracles,’

but later of course I knew he was ill” (Low - attitude towards legitimacy of illness - accept

patient’s experiences real for them)

“I realized that if I got upset, exploded, it was bad for Martin. It had a more calming effect on him if I

kept very calm. So I let many things pass. I wouldn’t make an issue. I became more

permissive in order to survive”

“I realized that if I got upset, exploded, it was bad for Martin. It had a more calming effect on him if I

kept very calm. So I let many things pass. I wouldn’t make an issue. I became more

permissive in order to survive” (Low - having learned to control emotions and be flexible)

How do you think these different approaches might impact on the

atmosphere within the family and the client’s mental health? ?

Expressed Emotion


Dimensions & components of EE• originally conceptualised on 3 dimensions, each with

positive as well as negative aspects1. critical comments/positive remarks2. hostility/warmth3. emotional involvement, from under- to over-involved

• therefore, in itself, the term “Expressed Emotion” is neutral• early studies measured positive as well as negative

aspects, as it was believed that there might be a “cancelling out” effect

• due to observation that, where both present, positive aspects did not offset negative aspects, attention focused on the negative aspects

• the terms “high EE”, “low EE”, “critical comments”, “emotional over-involvement” often used rather loosely

• however, in the research, and in the training of raters, very precisely defined


Butzlaff & Hooley meta-analysis

• all but 3 studies (89%) showed significant association between EE & patient relapse, if no relationship would expect 50-50

• would need 1246 new studies averaging null results to lower significance level to “barely significant”

• EE stronger predictor of relapse in more longstanding illnesses• strong support for role of EE as relapse predictor in mood disorders• positive association between high EE & poor outcome in eating

disorders• relationship with relapse undoubted, non-replications do not call

into question predictive validity• may be more reliable predictor when patients ill longer, or patients

may become more susceptible to EE as illness continues• effects undoubted, studies needed to answer “How?” & “Why?”

Butzlaff, R.L., & Hooley, J.M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry, 55, 547-552.


Process of working with families

• Engagement• Assessment• Formulation• Intervention• Review• Ending


Factors affecting engagement

• characteristics of the family members – e.g. physical health & age, competing demands, lack of

understanding, inappropriate beliefs, apathy, pessimism, dissatisfaction with practitioner or treatment, expectations & attitudes towards treatment

• features of the illness – e.g. acute crisis, chronic course, aggressive behaviour

• relationship with services – e.g. dissatisfaction & stigma, differing priorities

• clinic & service variables


Process of engagement• Initial meeting or meetings• Introductions• Offer explanations, possibly supported by written information, of

– what family work might have to offer– what it might involve for the family

• Offer opportunity for family to ask questions• Discuss and agree ground rules

– e.g. punctuality, duration of sessions, smoking, breaks, interruptions etc.

• As appropriate,– leave family to discuss and decide whether to proceed,

making arrangement to contact– explain next steps and make arrangements– leave written information and contact details


Assessment in family work

• Meeting or meetings with each individual to -– build picture of their

• background and relationship to index patient• knowledge and beliefs about index patient’s disorder• perception of current difficulties relating to the disorder

& their coping strategies for each• current and desired activities • other problems

– discuss and agree individual goals

• Possibly a meeting or meeting with family as a whole to assess problem solving & communication skill


Formulation in family work

• Synthesize information gleaned from assessment• Arrive at a view of

– main issues– contributing factors– maintaining factors– protective factors

• Formulate plan of intervention • Meeting with family to

– provide feedback– discuss and adjust formulation – discuss and agree plan of intervention– agree number of sessions after which to review


Intervention - educationrationale - basic right to information; focus on increasing understanding of client’s

experience of illness; focus on beliefs about causes, symptoms,

treatment & management of illness; encourage positive, desirable behaviours; all of which should reduce conflict, stress and

burden.


Intervention – Teaching communication skills

helps people learn new and more effective ways of communicating with others;

focuses on the structure rather than the content of communication;

main skills taught – Expressing a positive feeling, Making a positive request, Expressing an unpleasant feeling, Active listening


Intervention - Teaching structured family problem solving

rationale – tackling the ‘right’ problem; making better use of the family’s

resources;increasing probability of success; all of which should enhance confidence,

and reduce conflict, stress and burden.


Intervention -Teaching family stress management

aims to enhance coping in areas where problems insoluble or only partially soluble;

work on concrete examples rather than more general worries;

invest time in detailed analysis of problem situations;

use role plays to help assessment & in planning behaviour changes, where targeted situations involve interactions between family members;

ensure all details of strategies have been covered before implementing plan.


Review in family work

• Compare current difficulties with those at baseline

• Review overall progress towards goals• Discuss need for further sessions • Discuss and agree plan for future sessions if

needed


Issues relating to ending

• Begin handing over from the earliest sessions• Avoid acting as a friend• Ensure family know how to contact services• Leave time in final session for any unfinished

business

Documents

Working with families Steve Wood Lecturer/Practitioner