The family & cultural aspects of psychosis- Theoretical perspectives & interventions Kevin Hawkes, Family Therapist March 2012

Exercise Why work with families? What might be the barriers or difficulties in working with families? Three Levels of Context Individual families Clinicians Organizational

Why work with families? GOOD PRACTICE POLICY EVIDENCE National Plan Policy Implementation Guide Common Sense Needs of Service Users & Families NICE Guidelines Moral Imperative Meta-analyses Reviews

Barriers to family work: Lack of confidence Lack of training High case loads Disempowered Previous difficult experiences Concerns about complaining models of care Overwhelmed by change Delivery of therapeutic intervention is not measured Service User/ Carers CLINICIANS ORGANISATION Fadden 2006

Effects of psychiatric disorder on families- concrete Financial difficulties Constraints on social activities Effects on work/employment Effects on children Effects on health Disruption of household activities

Effects of psychiatric disorder of families- emotional Stress Sense of loss Effects on own mental health Family relationships strained Emotional reactions: anxiety about the future, fear of assault etc.

Development of family-based approaches Bateson et al. (1956): Double bind theory Laing (1960): Popularized theories Minuchin (1974) Structural family therapy Haley (1980): Strategic family therapy Milan Team (1978) Psycho-educational Approaches (McFarland 1983, Faloon 1983) 2000’s Integrative approaches

Key Systemic Ideas: Communication Relationships Meaning / Context Multiple perspectives Circularity Story, voice & power

Working with families living with psychosis- an integrative stance Exercise: Groups of 3 or 4 Imagine a time when someone you are close to had a health problem or difficulty What were the things that you / others did to be helpful Did any of these actions maintain or worsen the difficulties?

Key practice principles: Emphasizes strengths, resources, competencies People usually act in a way that they believe is for the best or logical in the circumstances Distinguishes between actions and intention of family members The attempted solution to a difficulty may unintentionally be problem-maintaining

Exercise Think of a time in your family life, where everyone was feeling stressed. What were the effects on communication within the family?

The Influence of Stress on Communication Strained interactions between family members Reduced levels of communication Emergence of patterns of communication that have proved ineffective or unhelpful Increased chance of hostility or critical comments Family members often feel stuck & would like to know what they can do differently

Expressed emotion Research construct defined by interview with the relative. High expressed emotion: hostility, critical comments and emotional over involvement. Clients living in high EE environments are more likely to relapse than those living with low EE environments, (risk factors are high EE; contact time & medication). Psychoeducation; enhancing coping & communication skills

Expressed Emotion “EE is it an adaptive response to the situation families find themselves dealing with an ill relative” Grainne Fadden 1998

Elements of family meetings Appreciating and supporting family strengths and resources Providing opportunities to identify and address fears and concerns Countering blame and guilt Addressing relational patterns which are unintentionally problem maintaining Supporting and amplifying hope and ‘realistic’ optimism Psychoeducational discussions regarding psychosis and a recovery model

Elements of Family Meetings (cont) Negotiation of significant transitions in family life Gender relationships & expectations Family roles & identity Impact of cultural beliefs (about family/psychosis) Assisting family in developing skills around communication and problem solving

Effectiveness Family management approaches: EE is a robust predictor of relapse Studies consistently demonstrate family interventions reduce relapse rates (from 60% down to 25% / 30% over 12 months) Training staff to deliver FI resulted in a a reduction of High EE in most families worked with

Finnish network-based approaches (Open Dialogue) Rapid response Engaging the social network from the outset Integration Continuity Network meetings as primary vehicle for treatment Language & dialogue psychosis is a crisis in language (Yuri Alanen; Jaakko Seikkula)

Effectiveness Systemic approaches, (generally less well researched): Finnish Open Dialogue approach, 2 year follow up: 81% working, studying or job seeking 80% free from symptoms 35% had required neuroleptic medication 19% relapsed

References Dallos, R. & Draper, R. (2000) Introduction to family therapy. Milton Keynes: Open University Press. Froggatt, D., Fadden, G., Johnson, D.L., Leggatt, M. & Shankar, R. (2007) Families as partners in mental health care. Toronto: World Fellowship for Schizophrenia Pitschel-Walz G., Leucht S., Bauml J., Kissling W. & Engel R.R. (2001) The Effect of Family Interventions on Relapse & Hospitalization in Schizophrenia – a meta analysis, Schizophrenia Bulletin, 27, Rivett M. & Street E. (2009) Family Therapy: 100 Key Points & Techniques, London, Routledge Seikkula, J., Alakare, B. & Aaltonen, J. (2001) Open dialogue in psychosis 1: An introduction and case example. Journal of Constructivist Psychology. 14: Seikkula, J. & Arnkil, T.E. (2006) Dialogical Meetings in Social Networks. London: Karnac