The family & cultural aspects of
psychosisTheoretical 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
Meta-analyses
NICE
Guidelines
EVIDENCE
Reviews
Moral
Imperative
Needs of
Service
Users &
Families
National Plan
Policy
Implementation
Guide
Common
Sense
Barriers to family work:
Service User/
Carers
Disempowered
Concerns
about
complaining
CLINICIANS
Lack of
confidence
High case
loads
Lack of
training
Previous
difficult
experiences
ORGANISATION
models
of care
Overwhelmed
by change
Delivery of
therapeutic
intervention
is not
measured
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 psychosisan 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)
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•
•
•
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)
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•
•
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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, 73-92
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: 247-265.
Seikkula, J. & Arnkil, T.E. (2006) Dialogical Meetings in Social Networks. London: Karnac
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The family and cultural aspects of psychosis