A family intervention in psychosis service integrating the systemic and family management approaches

Frank R. Burbach and Roger I. Stanbridge

Journal of Family Therapy, 1998, vol. 20, ps 311-325.

A project to establish new family intervention services to support people with psychotic symptoms and their families is described. The new services are developed by training a whole team in each main population centre. The multidisciplinary training course and the family intervention service are described, and the way in which we integrate the 'family management' and 'family therapy' approaches is discussed.

Introduction

It is widely recognised that care in the community is based on a partnership existing between statutory services and carers/families/relatives. There is currently a great deal of concern being expressed by user groups and mental health organisations (Mind/Sane/NSF) about the fact that families feel unsupported, carry too great a burden of care, and ' that communication between services and families is often poor. Research has also shown that the home environment can have a significant positive or negative impact on relapse rates for severe mental health problems (Brown et al., 1962, 1972). Despite a large number of impressive controlled studies demonstrating the efficacy of family interventions in severe mental health problems (cf. reviews by Burbach, 1996; Dixon and Lehman, 1995; Goldstein and Miklowitz, 1995; Lam, 1991; Mari and Streiner, 1996), there have been relatively few initiatives with families in routine clinical settings (Kuipers et al., 1992).

In Somerset, as in other areas of the UK, large Victorian hospitals have been closed and replaced by smaller, more locally accessible units. Services continue to evolve, but supporting the needs of families in cases where a member has severe mental health problems is acknowledged as a priority. Fortunately, we have a tradition in Somerset of working with families with a wide range of mental health problems, including psychosis (cf. Brennan and Challenger, 1996; Procter, 1985, 1986; Procter and Pieczora, 1992; Procter and Stephens, 1984). It is in this context that a new accessible, flexible family support service is being developed.

The Family Support Service

Over the next five years we plan to establish a specialist service, supporting families where a member experiences psychotic symptoms,' in each of the four major population centres in Somerset (Yeovil, Taunton, Bridgwater and Wells). The Family Support Service will complement the existing local services (acute inpatient ward; community mental health team(s); rehabilitation day centre; residential units) in each area. The aim of the service is to support families in specific ways, according to the individual needs of each family. This is done in a collaborative manner with the sufferer and his or her family, following an assessment process where needs and goals are agreed. One of the main aims of the service is to help families identify helpful ways of dealing with the specific problems they encounter, including strategies for coping with psychosis. The other main aim is to help family members look after their own, as well as each others' needs. All families are given an information leaflet about the service, which offers a range of ways in which the service might be of assistance (see Table 1).

The objective of the service is to intervene as early as possible but it also works with well-established cases. This means that we often see the sufferer with his or her parents and siblings, but we also see sufferers and their partners. We include children as appropriate. Attendance at sessions is negotiated with each family and varies according to their specific needs/wishes. Early intervention is likely to lead to a better long-term outcome for psychotic disorders (Birchwood et al., 1997) and many who work with families would agree that early intervention is preferable (Burbach, 1995). Entry into the Family Support Service is therefore determined by the presence of psychotic symptoms rather than the confirmation of a particular diagnosis.

TABLE I Extract from the Family Support Service leaflet

What sort of help can the service provide?

* To build on family strengths and resources.

* To identify helpful strategies for dealing with specific problems.

* To help the sufferer and family members to understand the symptoms.

* To provide information about psychosis and stress.

* To help families reduce levels of stress while also providing appropriate stimulation.

* To identify particular strategies for coping with psychotic symptoms.

* To help in maintaining and improving relationships and communication within the

family.

* To help family members balance the burden of caring with attention to their own needs.

* To support family members and to encourage them to maintain hope.

* To help families plan for the future.

* To help families to access appropriate services.

* To help maintain clear communication between the family and the mental health services.

Two members of the Family Support Service are allocated to each family. Families are seen in a variety of settings including inpatient units, community units and people's homes. Meetings are by arrangement, according to need. A co-therapy model is used and all members of the service meet monthly for supervision and to deal with administrative matters.

The service is provided by existing staff drawn from the range of units. This multidisciplinary group will, in addition to their particular professional training, also receive specific training in this area of work. It is to this end that we have established the Family Interventions (Research, Skills, Theory) in Psychosis Course.

Family Interventions: Research, Skills, Theory (FIRST) in Psychosis Course

The course has two main aims. First, to teach basic family intervention theories, skills/techniques and research findings to multidisciplinary groups of staff. Second, to train a team that will deliver the local Family Support Service. The course philosophy is based on an integration of the family therapy and family management approaches to severe mental health problems (cf. Burbach, 1996).

The course consists of three twelve-week modules spaced over one year. Students attend nine half-days and three whole days per module, and further home study is required. Each module is assessed by means of a written assignment and key learning/skills ratings. The course is accredited by the Institute of Health Studies, Plymouth University, at degree and diploma level, the English National Board for Nursing (ENB A28), and the Association for Family Therapy (foundation level).

The first module covers basic theories of family functioning (for example, systems theory; family life cycle; family structure and beliefs) and basic skills training (for example, engaging families; interviewing skills; goal setting). The second module presents research findings in relation to family interventions in psychosis, evaluates the contributions of the family therapy and family management approaches, and introduces their core techniques. It also includes consideration of issues such as user empowerment, self-help groups, hospitalisation, medication, education and a review of government reports into mental health services. The third module focuses on the application of family intervention theories and techniques in mental health settings. Basic cognitive behavioural techniques for working with hallucinations and delusions are introduced, together with further consideration of therapeutic techniques such as task setting, genograms, reframing and active techniques. Issues that are common to all three modules include gender, cultural and socio-political perspectives.

Students begin supervised work with families midway through the second module. Where possible, this is done using a team approach involving one-way screen, ear piece and video. Although the Family Support Service itself does not revolve around the traditional family therapy clinic format, we have found it particularly useful for training purposes. The team's identity begins to form as the new clinical service is launched within the context of the training course. This aspect is significantly different to most other courses, which tend to provide education and training to individuals in a manner that is difficult to generalise to their work setting. The advantage of our training approach is that trainees are able to practise and develop their new-found skills, because they receive ongoing supervision and have the support of a team of colleagues who have had the same basic training. (For further consideration of these issues see Quarry and Burbach, 1997.)

The other significant feature of the FIRST course is in the integration of the family therapy and family management approaches. To the best of our knowledge, other courses teaching family intervention with this client group have used family management approaches exclusively. Whereas it is acknowledged that the manualized treatment approaches are more easily taught, it appears that they are not sufficiently flexible to respond to the range of needs presented by families. This has led us to develop our own integrated approach to family interventions in psychosis.

The Family Support Service approach

Individualised

Research (Fadden, 1997; Kavanagh et al, 1993) has shown that therapists trained in family interventions have difficulties in putting the new skills into practice. This seems to be related to service issues such as the lack of like-minded trained colleagues and the absence of a supportive structure in the workplace but, in addition, appears to reflect deficits in the training process itself Fadden's survey of eighty-six therapists who had undergone behavioural family therapy (Falloon et al, 1984) training in Buckingham found that the main difficulty encountered by therapists in putting family interventions into practice was a 'lack of availability of "suitable" or appropriate families'. She urges that the issues surrounding therapists' criteria for 'suitable families' and the process of engaging families be addressed in training.

Informal discussion with colleagues who have been on family management courses has revealed that many therapists believe their new skills/knowledge do not equip them to work with the range of families they encounter. This is not surprising, given that families where a member experiences psychotic symptoms are often severely traumatised and, by the time they are in contact with mental health services, are often functioning poorly (Terkelsen, 1987). Indeed, Hatfield (1990) and Marsh (1992) have described the development of severe mental illness as a 'catastrophic event' for families. In considering a respectful approach to families, treatment protocols that were originally developed for research purposes and which are taught on many family intervention courses appear insufficiently responsive to the needs of individuals within the range of families.

On the FIRST course in psychosis, trainees are taught basic family therapy theories and skills in order to enable them to form therapeutic relationships with a wide range of families, and to agree an intervention plan with the family which will meet their particular needs. In some cases this has included exploration of the nature and origin of the psychotic experience, developing strategies for coping with these symptoms, clarifying communication to avoid misinterpretation, helping family members express their feelings of loss following psychotic symptoms, helping parents implement solutions to problems which they have identified, and enabling families to negotiate family life-cycle stages such as 'children leaving home'. This individualised approach with families both enables and requires a close collaborative relationship between therapist and family.

Collaborative

Most of the recent family intervention approaches have been tailored to those clearly diagnosed as having schizophrenia and have included sessions aimed at helping family members to better understand, and adjust to, this disorder. In addition to such educational sessions, some approaches (e.g. Falloon et al., 1984) teach family members how to communicate clearly and solve problems. Barrowclough and Tarrier (1992) advise that education sessions need to be conducted in a sensitive manner, taking into account the family members' views and not overloading them with information. We are concerned, however, that the inexpert or rigid use of educational materials, or an insensitive coaching style with regard to communication or problem-solving skills, could place the family in the dependent position of asking questions of a therapist who is deemed to have the answers. This may create a hierarchical, 'teacher-pupil' relationship with the family. While acknowledging that we have specialist knowledge regarding symptoms and family processes which we would want to share with the family, we assume that family members are the most knowledgeable about their own situation. We see the therapist's role as that of an enabler, who has joined the family in order to facilitate fresh perspectives and to aid in evolving solutions. In contrast to a fixed hierarchical therapeutic relationship, a collaborative approach involves ongoing negotiation between therapist and family to agree goals and methods of therapy.

Similarly, Marsh (1994) advocates a therapeutic relationship which is based on collaboration, as this enables and empowers families and thereby enhances their competencies in coping. She identifies these and other benefits with a shift in professional practice from a 'pathology paradigm' to a 'competence paradigm'. Reviews of I consumer studies' of family therapy (cf. Reimers and Treacher, 1995) appear to provide support for the adoption of a collaborative approach in that the therapeutic alliance is identified as the crucial factor relating to users' satisfaction and positive outcome.

informative

Some form of family education regarding the prevalence, nature and treatment of schizophrenia is common to most recent family intervention approaches (Haddock and Lewis, 1996). This has had the aim of improving psychiatric care, by consolidating the treatment alliance with the sufferer and his or her family, monitoring mental state over the course of the disorder and improving medication compliance.

Education is designed to correct misconceptions regarding the nature, severity and chronicity of the disorder which are prevalent in society. However, others (e.g. White, 1987) have argued that the use of the term 'schizophrenia' is synonymous with chronicity, incurability and deterioration, which results in a reinforcement of the sick role and objectives the person so classified (i.e. schizophrenia constitutes their total identity; for example, 'he or she is a schizophrenic' as opposed to being a person suffering from schizophrenia). Due to diminished expectations, sufferers may not achieve their full potential.

Research has indicated that while education does not have significant long-term effects on relatives' perceptions of the patients' difficulties, or on their knowledge about schizophrenia (Lam, 1991), it leads to increased optimism concerning the family's role in treatment and reductions in relatives' stress (Birchwood et al., 1992). It is for these reasons that many clinicians continue to use educational approaches, arguing that education sessions are a useful way of developing a therapeutic alliance (e.g. Hughes et al., 1996).

In our service we do not routinely schedule formal education sessions as, in addition to being ineffective at changing attitudes and beliefs, education about schizophrenia is often not relevant, in that the diagnosis of schizophrenia is usually premature during a first episode of psychosis, and may remain contentious in many cases. McFarlane and Beels (1983) argue that the risks and indications of different family interventions should be considered according to individual cases, and that 'giving the patient and family full information about schizophrenia only seems justifiable if that is, in fact, what the patient has' (p. 331). This would suggest that in a routine clinical setting, for a service such as ours which seeks to engage families as early as possible, formal education about schizophrenia would not be appropriate. Our concern would be that routine use of educational material regarding schizophrenia may precipitate premature diagnosis, with the concomitant risks associated with labelling.

Although the Family Support Service approach does not rely on educational material about schizophrenia, an important part of our role includes the provision of information. The information provided varies in each case as it is tailored to fit the family members' construal of their situation. We try to provide information which, while acknowledging the severity of the sufferer's distress, helps to de-catastrophize the situation and engenders cautious optimism. In common with most family management approaches, we find that the widely applicable stress-vulnerability model (Zubin and Spring, 1977) is often useful in this regard. This often leads to discussion regarding appropriate levels of stress and stimulation, and we often emphasize a gradual, incremental process of recovery. We do not avoid discussing issues regarding diagnosis and often provide information about the current scientific status of diagnostic labels and discuss issues of course and prognosis, and various treatment options. We provide information about coping strategies in addition to encouraging the sufferer to discuss careful titration of neuroleptic medication with their psychiatrist in order to maximise its effectiveness. One of our aims is to promote supportive family involvement regarding medication and other treatment issues. We also provide information about the availability of useful services and users' rights.

As we do not rely on educational sessions to engage families, the FIRST course trains staff to use established family therapy techniques (for example, brief therapy first interview) to engage with families in a therapeutic alliance. Our initial assessment not only establishes therapeutic goals but also explores the psychotic symptoms in detail (cf. Chadwick et al., 1996) and considers these in the context of family beliefs.

Systemic

Underpinning our work is the systemic perspective which locates the individual's difficulties in their family, cultural and socio-political context. Seemingly meaningless behaviour often becomes more understandable when considered in context. Although we would consider multiple levels of meaning (Cronen and Pearce, 1985), of particular relevance are the interpersonal interactions which maintain problems. For example, where parents identify their symptomatic offspring's withdrawal as a problem, their attempts at involvement are often perceived as intrusive and critical, and prompt further withdrawal. In this situation others might attempt a linear, behavioural approach (for example, teaching problem solving techniques), with the inherent danger that this might intensify the polarisation between them. Although our approach would sometimes be to connote the behaviours positively and to paradoxically prescribe the status quo (Selvini-Palazzoli et al., 1978), more commonly we would seek to positively connote behaviour and explore the nature of the interactions (in this example a cycle of pursuit and withdrawal) in a collaborative manner with the family. In this way we would be able to acknowledge in a non-blaming manner the distressing interactions in which they had all become stuck. We find that families welcome the systemic perspective in situations which are inherently laden with feelings of guilt and blame.

Although some family management practitioners have acknowledged the importance of an interactional perspective (cf Burbach, 1996) there are other aspects of a family therapy approach which we find valuable. In particular, we find it useful to locate a family's difficulties in the context of transitions in the family life cycle (Carter and McGoldrick, 1989) and to consider the family structure in terms of boundaries, roles and power distribution (Minuchin, 1974). For example, symptoms often occur at a time when a young person is emerging into adulthood and establishing a separate identity. It is important to consider the family life cycle, as, for example, symptoms may occur in the last offspring to leave home in the context of fears regarding the parents' well-being. Similarly, it is important to consider family structure, as the symptoms may be connected with issues such as disempowerment, closeness or distance between family members, and the family's relationship with the outside world.

We find it useful to be aware of theories developed by family therapists regarding the interactional processes associated with psychosis (cf. Burbach, 1996). Symptoms may be related to processes such as scapegoating (for example, anger related to marital conflict directed towards another family member) or disqualification (for example, family members negating a young person's view of themself/beliefs/actions/speech), and knowledge of the various family dynamics provides a therapist with a wider range of therapeutic options. Obviously this does not imply a belief that there is a single and all-embracing family dynamic associated with psychotic symptoms, and our use of these theories is consistent with the stress-vulnerability model.

We consider the systemic perspective to be essential in our work with families, as although we might first adopt a more direct, problem-oriented approach, we often find that with this complex client group the ability to formulate systemically is required as problems are often maintained through interactional processes. In addition, we adopt a cognitive behavioural, constructivist position which sees the interrelatedness of cognitions, affect and behaviour: i.e. beliefs shape behaviour and behaviour reflects beliefs.

Incorporating solution-focused and cognitive behavioural approaches

The content of most Family Support Service sessions is informed by the therapeutic goals which are agreed with the family during the assessment phase or subsequently. Family members' goals are often specific (for example, carrying out household chores, developing a social network) and lend themselves to a problem-solving approach; however, on other occasions a more explorative approach is required (for example, family grief). In the latter situations we would aim to have 'therapeutic conversations', assessing efficacy not in terms of goal achievement but in terms of 'usefulness' to the family.

With a solution-focused, cognitive behavioural perspective we feel able to work with families at various levels.

(1) Some families present with readily accessible problems which are amenable to a relatively straightforward behavioural problem-solving approach. In these situations we would use the six stage approach but in a less formal and more collaborative manner than that proposed by Falloon and colleagues (Falloon et al., 1984). Families in therapy often present a wish to eradicate problem behaviour. We seek to translate this into a constructive goal (for example, a wish that somebody would spend less time in bed could be restated in terms of what the family would like that person to be doing more of). As Barrowclough and Tarrier (1992) point out, this technique allows family members to begin to generate constructive solutions to problems.

(2) While acknowledging the often extremely distressing nature of the symptoms, in general we would take a normalising stance, encouraging open discussion and locating the psychotic experience at one end of a continuum of psychological processes. This is explicit from our first contacts with the family as it is outlined in our information leaflet (see Table 2). We are aware that in many cases medication is only partially successful in eliminating psychotic symptoms (c£ Johnstone et al., 1984; Shepherd et al., 1989), and the goal of the intervention is often to help people to manage their symptoms in a way which minimises their effect on quality of life. We find Hearing Voices Network (Romme and Escher, 1993) and Coping Strategy Enhancement (Tarrier et al., 1990) ideas useful in this regard. We believe it is an advantage to work 'individually' in the presence of family members, as they can be both a useful resource within the session and also reinforce coping strategies between sessions.

(3) In many cases we find it necessary to adopt a more cognitive approach as the goals are predominately concerned with attitudinal change. In addition, behavioural change often requires a shift in ways of construing. Like Tarrier and his colleagues (Barrowclough and Tarrier, 1992), we often invite families to keep written records of problem situations to elicit unhelpful 'automatic thoughts'. These techniques can be used for either self-monitoring and/or monitoring by other family members.

(4) In other cases people find it more difficult to adopt alternative perspectives because they conflict with core beliefs/constructs. These may be individual, family or cultural beliefs and it is often useful to explore transmission of beliefs or 'myths' through the generations. It is also important to be aware of the way in which families construct shared systems of beliefs which shape each individual's thoughts and actions (the 'Family Construct System': see Procter, 1996). The therapy can enable the family's exploration of family beliefs through verbal means

TABLE 2 Extract from the Family Support Service Leaflet

What do we mean by 'psychosis'?

People are predisposed to react to stress in different ways. These have been viewed as being arranged along a line with the two ends called 'neurosis' and 'psychosis'.

'Neurosis' 'Psychosis'

At the neurotic end people experience a disturbance of emotions and thinking (e.g. clinical depression), while psychosis involves a disturbed sense of reality. Common symptoms of psychosis may include hearing imaginary voices (hallucinations), jumbled thoughts, feeling watched or controlled, believing that thoughts are being put into your mind, believing that people are against you or that you have special powers (delusions), and losing emotional feeling.

When the sufferer loses touch with reality his or her behaviour will be affected; for example, he or she may stay in bed or talk back to the voices. Often the sufferer will feel afraid or angry. Of course this is also very hard for the family to cope with. As everyone gets more and more stressed the original problems tend to get worse. People often value some help to break such cycles and the Family Support Service can also assist with this.

such as interventive circular interviewing (Selvini-Palazzoli et al., 1980; Tomm, 1987) as well as through more active techniques such as constructing a genogram with the family (McGoldrick and Gerson, 1985) and art techniques (Stanbridge, 1995).

Conclusion

In this paper we have described a project to establish Family Support Services in Somerset, and the philosophy of our approach. We intend to formally evaluate the project once we have established Family Support Services in each of the four planned sites and are routinely gathering data to this end. We are currently in the process of establishing our second service. Feedback from families, clinicians and managers has been positive. Families have welcomed the service, which is reflected in high attendance rates. Clinicians and managers have noted the benefits for individual families, an increase in consideration of the person and their network on the inpatient unit, and have commented on the way in which the service has fostered closer working relationships between units within the service and between mental health and social services. We have received active support from managers and senior clinicians in establishing the new service and interest from other parts of the South-west region in using this model.

We believe that our approach offers distinct advantages. In particular, we have sought to integrate the systemic and family management approaches, and have set about establishing the new service by creating a programme which trains whole teams. Training staff to take a flexible and integrated approach, and providing ongoing supervision, should enable the establishment and maintenance of high quality services throughout Somerset.

Acknowledgements

We would like to thank Dawn Wood for preparing the manuscript. We would also like to thank Andy Carberry and other colleagues from the Avalon, Somerset, NHS Trust and the Institute of Health Studies, Plymouth University for their support in enabling this project.

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