A Casebook of Family Interventions for Psychosis

Overview

A practical guide to implementing family interventions for psychosis, which discusses different family needs and illustrates different approaches to offering the interventions.

  • Approximately 1 in 100 people experience psychosis, which can severely disrupt home and family life and place a heavy burden on carers
  • A practical guide to implementing family interventions for psychosis, which discusses different ...
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Overview

A practical guide to implementing family interventions for psychosis, which discusses different family needs and illustrates different approaches to offering the interventions.

  • Approximately 1 in 100 people experience psychosis, which can severely disrupt home and family life and place a heavy burden on carers
  • A practical guide to implementing family interventions for psychosis, which discusses different family needs and illustrates different approaches to offering the interventions
  • Shows how to tailor family interventions to meet different needs e.g. working via interpreter or with families in which multiple members suffer mental health problems
  • No direct competition on family interventions for psychosis.
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What People Are Saying

From the Publisher

"Clinicians working with family members of persons with psychosis need practical, hands-on information about different treatment models, strategies and case examples addressing common challenges and special populations, caregiver perspectives, and guidelines for developing family intervention services in routine practice settings. This outstanding book meets these vital needs, and deserves a place on the bookshelf of all clinicians working with this population."
Kim T. Mueser, Professor of Psychiatry and Community and Family Medicine, Dartmouth Medical School Hanover, New Hampshire

"This is a special book prepared by many of the most outstanding professionals in the field and will greatly enhance practical knowledge on working with families for clinicians and managers. Family work is not an "extra" and we all should be involved. Readers will find here a wealth of information and inspiration as well as excellent tools to apply the methods in their clinical settings."
Diane Froggatt, Secretary and Development Officer, World Fellowship for Schizophrenia and Allied Disorders

"This fine book, by taking a casebook approach, provides rich insights into how family interventions translate theory into practice. Few accounts, if any, give a clearer picture of what family interventions for psychosis look and feel like."
Professor George Szmukler, Psychiatry and Society, Institute of Psychiatry, UK

"This excellent book reflects a maturing of the field of family work for psychosis while also providing a powerful stimulus for future development. Its detailed focus on research-informed practice, combined with a critical reflective edge means that it contains a wealth of invaluable ideas and suggestions about developing and providing services for families, without being simply another ‘how to’ text. I would strongly recommend it to all who are concerned with improving services for people with psychosis, and it should be required reading on specialist family therapy and family interventions training programmes."
Dr Alex Reed, Family Therapist & Family Therapy Trainer

"Reading this book gave me an overwhelming sense of relief. For the last 25 years, I have been associated with families coping with psychosis. I have watched them struggle to understand, to accept, and to learn how to manage the bewildering array of difficult circumstances created by psychosis in a loved family member…This book shows us how to develop and utilize this resource for the benefit of all concerned, and is an invaluable resource for mental health clinicians, family carers and service users alike."
Dr. Margaret Leggatt, Founding Director SANE-Australia

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Product Details

  • ISBN-13: 9780470027080
  • Publisher: Wiley, John & Sons, Incorporated
  • Publication date: 6/2/2009
  • Edition number: 1
  • Pages: 396
  • Product dimensions: 5.90 (w) x 8.90 (h) x 0.90 (d)

Meet the Author

Dr Fiona Lobban is a Senior Lecturer in Clinical Psychology at the Spectrum Centre for Mental Health Research at Lancaster University in the North West of England. She also works as a Consultant Clinical Psychologist supporting family work in the Early Intervention Service for Psychosis in Lancashire care NHS Trust.

Professor Christine Barrowclough is Professor of Clinical Psychology at the University of Manchester, UK, and has been engaged in research and clinical work with families of people with psychosis for many years.

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Read an Excerpt


A Casebook of Family Interventions for Psychosis

John Wiley & Sons
Copyright © 2009

John Wiley & Sons, Ltd
All right reserved.



ISBN: 978-0-470-02708-0



Chapter One Why Are Family Interventions Important? A Family Member Perspective

Martin Gregory

Introduction

I have written this chapter as the father of a son who has suffered from schizophrenia. Our family unit benefited very considerably from participating in behavioural family therapy (BFT), and I will describe our experiences since our son first developed difficulties. After painting the picture of the family background, I will describe our family's story under the following headings:

The roller coaster that comes about from mental health problems.

Getting started on family therapy.

The process and its structure.

How the family benefited.

Family meetings.

How family therapy has helped with our son's social rehabilitation.

The longer term outcomes of the family intervention.

The chapter includes a section written by my wife, who talks about how she felt during the family therapy sessions and the pressures it put on her emotions.

There is a section on the perspectives of our son, and the thoughts of the two key therapists involved are also given.

The chapter concludes with some final messages and my reflections on the whole experience.

The Background to the Family

This story and its messages relate to a family from England and to the developments within the family during the 1990s. I worked in a managerial capacity within the corporate world of industry and my wife worked in a sales development and logistics capacity within a Swiss owned engineering business. In the early 1990s, our daughter was proceeding through secondary and further education whilst our son (who was 5 years younger) was at secondary school.

Simon was a nice boy. He was well presented and well balanced and seemed to be taking life and education in his stride. Although never strong academically, he coped well enough and, like many boys, seemed to have a fairly laid-back approach. It was in sport that he really excelled and represented his school at rugby, cricket and badminton (the county too in this sport). Outside of school he soon became a very competent squash player and played for both club and county. However, it was on the hockey field that he really shone and from an early age his blond hair and skilful play ensured that he stood out when playing for school and county. He played for the County U14 team when only 12 and went on to get to the final stage of an England trial. It was a significant disappointment to all in the family when he failed to gain selection for the County U16 squad, but by this time he was beginning to get established in senior club hockey.

In addition to all this he was in the choir of a prominent local church, and with other typical boy's activities such as cubs and scouts, he had a busy and active life. With his laid-back and cheerful approach, it was always difficult to gauge what his potential in life really was, or if he was capable of achieving more in any of these activities or in education.

His life seemed to be evolving quite straightforwardly, and with his 6 GCSEs he went off at 16 to a local college to do a BTEC course with a view to going on to further education like his sister. Typically, he did just enough to be accepted on a degree course in Transport and Logistics, this being a course of his own choice, although his grades were such that he had only two colleges to choose from.

So in September 1993, Simon went off to Wales to start his degree course with us as his parents having no hint of any problems or difficulties in his life. Being at college as opposed to a university, no student accommodation was available and so he found a bedsit in 'downtown' Swansea and seemed to settle in quite quickly. On the hockey front, he quickly established a regular first team place with the local HC, one of the top two sides in Wales, and was selected for the Welsh Universities squad.

It was only in his second term that there was any hint of a problem and it was during this period that we discovered that he was a regular user of cannabis (subsequently it was established that he had started taking cannabis several years earlier). It transpired that he was not attending college courses and spent much of his time shut in his own room. Then the phone calls home started late at night and during the night with the regular use of expletives (not previously a feature of his dialogue) and with him shouting and yelling accusations at both of us and indeed all and sundry who had any involvement in his life. Appointments were made for him to either go to a doctor or for a doctor to go to him, but neither came to fruition. The extent of the problem became clearer when eventually I was able get access to the bedsit and was told by Simon that he had just seen on TV that he was to become the next King of England.

It proved extremely difficult for us to ascertain what to do next because while it was possible to get very general information from libraries and the family GP (general practitioner), nobody actually offered advice on what to do. This was brought to ahead when the landlord of the bedsit wanted Simon evicted due to a potential threat of violence to others living in the house.

We did not know where to go for real help: people such as our GP showed sympathy but were unable to offer practical advice on what actions we should take. Eventually I spoke to my MD at work, who had some experience of mental health services and he arranged for us to meet the Manager of a local Day Centre who explained to us that we were entitled to request a mental health assessment. With this new information we were able to access a social worker who was the first person to offer practical help. In due course, he facilitated an assessment with police in attendance involving a really helpful psychiatrist and a GP, as well as the social worker himself. Thanks to the great skills of the psychiatrist, Simon was admitted to the psychiatric unit in Swansea as a voluntary patient.

The Roller Coaster

In April 1994 Simon started his first period of hospitalisation in Wales, but immediately ceased to recognise us as his parents and blamed us for his problems. Communication with him became virtually impossible and although we travelled down each weekend to see him, he would never talk to us. Whilst we were given an indication that he may be suffering from schizophrenia, at no stage was this confirmed and neither was he informed of this. After a few months he was transferred to supported accommodation locally, and at this stage he became slightly more communicative and was showing signs of recovery. This progress continued and after a few more months he transferred back to his home locality and returned to live in the family home.

Everything seemed to be moving forward for him; he resumed college, he got a job relevant to his career ambitions, and his hockey went well - indeed he represented the county at senior level. But then the roller coaster started, which was probably attributable to his own denial of the illness. He stopped taking his medication and returned to cannabis for comfort.

The next few years were a nightmare for all of us with difficult periods living at home, attempts to live in his own accommodation which highlighted his own fears, and several periods of hospitalisation. He blamed us for his problems, would not communicate with us rationally, and yet it was still us he turned to when in difficulty. He could not live with us but he could not live without us.

During this period, support from the community health team was spasmodic and ineffective and the fact that Simon kept disappearing and was non-compliant contributed significantly to this. Eventually, yet another major crisis arose whilst he was living at home, but this time his behaviour led to him being sectioned, which was the first time that his problems could be addressed on a compulsory basis. The behavioural circumstances leading to this included Simon locking himself in his room and seldom coming out. When he did come out, he was threatening and aggressive, particularly to his mother. In addition, a neighbour complained that Simon was trespassing on their property and spending time in a shed they had in an adjacent field. The social worker (supported by the psychiatrist) considered that sectioning was the only way forward. A change in personnel also facilitated a different type of approach to his care and treatment, and also to the way in which we were treated and involved as his carers.

Getting Started on Family Therapy

The new community psychiatric nurse (CPN) had recently completed a BFT training course, following the model originally developed by Falloon, Boyd and McGill (1984) and the social worker was also due to attend the same course. As a result, they suggested one day, when Simon was slightly improved, that perhaps BFT might be helpful to us as a family. They were keen to try their new intervention and considered that our family might benefit from BFT, particularly due to the communication problems we experienced. In their work with us, the approach they used was described in a detailed manual (Falloon et al., 2004).

As his carers, we had received very little support and were still ignorant about the illness and its treatments, and so when we were offered help as a family, we saw this as a potential lifeline - what could we lose? Could this programme really help us to understand things better and would we have an opportunity to talk through some of the problems that we as his carers faced? Although we were by no means certain of the answers to these questions, it did seem that the model of family work that was offered to us (BFT) could not make things worse so we accepted the offer.

We were given an outline of what BFT consisted of and what the potential outcomes and benefits might be, but we really needed very little persuasion. The therapists felt that it would be a good idea for our family and that it was possible that BFT would give us some of the information and support that we were looking for. In particular, we were told that the communications aspects of BFT might help the day-to-day relationship within the family. It was explained that we would need to meet every 2-3 weeks or so for maybe an hour at a time, and that there would be some practical work to help improve our skills.

Simon's sister did not take part in the sessions. It was impractical for her as by now she was living about an hour away from home and worked even further away. Apart from that, she had become a little nervous and reluctant to get too involved as Simon had seen her new home as a 'bolt hole', and when he had turned up there she became a little frightened. She was also building a new long-term relationship and was wary of this being disrupted. In any event, she came to the family home infrequently.

Getting Simon to buy in was a different matter. He was still in hospital at the time of the offer although he was allowed home on leave one evening a week. He was ambivalent about getting involved in the programme himself but, very fortunately, did not put any barriers in the way for his Mum and me to get started. Although this was not ideal within the BFT model, the support team now engaged with our family had the foresight to agree to proceed on the basis that Simon might join in later.

So after a preparatory meeting talking about goal setting, we started the programme with sessions being held in the family home on the evening of Simon's home leave. We left the lounge door open so that we were not talking behind closed doors, and for the first session or two Simon showed no interest in our discussions. However, it was not long before he started to pop in for a few minutes and gradually he became involved in discussions. This soon led to the agreement that home leave night was BFT night and this, linked to a Chinese take away (always a favourite of his!), made the whole package quite acceptable-indeed it became an evening that he looked forward to.

The Process and Its Structure

As with much of Simon's care in recent years, we have been very fortunate with the calibre of staff in his support team. This includes the psychiatrists, social workers, CPN, the members of assertive outreach and the support team for the supported house in which he now lives. This certainly applied with the therapists delivering BFT who were his social worker (who has been involved for many years) and his CPN. We will always be grateful for the way they handled our BFT programme, which was done sympathetically but in a very supportive way to each of us. The same two people remained with the programme for most of the modules so providing continuity, but importantly, this enabled them to gain a detailed understanding of the make-up of the family and the problems faced by each family member. It also was important to us that they were members of Simon's support team so that they did not walk away from the case at the end of each BFT session.

As previously explained, our BFT programme started without Simon, so immediately on commencement we were able to talk about ourselves, our attitudes, and address the objectives of the programme and the goals for mother and father individually. This was done by separate one-to-one meetings, and then sharing the goals of each of us and discussing these openly. For both of us, it was key that we found our own time and space both individually and together, and maybe have a holiday that we could enjoy without undue worry and stress. This in particular was something that we were able to revisit throughout the programme and see just how far we were moving on in achieving this.

It was very soon after this that Simon joined in the sessions, albeit initially for very short periods. At the beginning of each meeting, he would agree how long a period he thought he would be comfortable to stay, be it 10 or 15 minutes, and as soon as that period was up he would leave. Much later he felt able to stay for longer periods extending to 30 and then 45 minutes.

Over many months we addressed each of the modules within the model including positive and negative communication, making requests, expressing feelings, active listening and sharing information. While clinicians would probably find it helpful to know how long we spent on each topic and over what time frame, as a family member I did not experience or think of the therapy in that way. Neither can I remember at this stage how long we spent on each topic.

We also spent some time learning more about the illness, positive and negative symptoms and most importantly the types of medication. This was the first occasion in Simon's illness that we had been given the opportunity to talk freely about these things and without feeling the pressure of a time factor (as applies in clinical appointments). If we did not have time to deal with a particular query, we always addressed it next time round.

The really practical outcomes that we talked and learned about were family meetings (which I will come back to later in the chapter) and problem solving. We did not realise when we did the problem-solving work just how often we would use this simple technique (or at least our version of it) in the future.

The session on early warning signs proved the most problematical due to Simon's vulnerability to so many of these signs. This particular session was very upsetting to him (and consequently to us) and we had to keep 'parking' it until eventually, when he was so much better, it was completed partly outside of the meetings, and indeed it then resulted in the agreement of an advance directive to give guidance to each of us on our actions should there be signs of a relapse. An advance directive or advance statement is a document which mental health service users can complete when they are well. It allows them to say how they would like to be cared for during times of mental health crisis, loss of capacity and/or admission to acute psychiatric care. It can cover medical care and treatment and domestic arrangements.

Most of the sessions took place in the lounge at the family home, but we were always mindful of who sat where and we tried to rotate the seating positions. This was particularly important in the early stages when it was not possible for Simon and his mother to sit opposite each other. This was linked with one of Simon's ideas that his mother could control him through her eyes.

(Continues...)




Excerpted from A Casebook of Family Interventions for Psychosis Copyright © 2009 by John Wiley & Sons, Ltd. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

About the Editors.

Contributors.

Preface.

I INTRODUCTION.

1 Why Are Family Interventions Important? A Family Member Perspective (Martin Gregory).

II FIRST EPISODE PSYCHOSIS.

2 Family Work in Early Psychosis (Gráinne Fadden and Jo Smith).

3 A Model of Family Work in First-Episode Psychosis: Managing Self-Harm (Jean Addington, April Collins, Amanda McCleery and Sabrina Baker).

4 Working with Families to Prevent Relapse in First-Episode Psychosis (Kingsley Crisp and John Gleeson).

III INTERVENTIONS FOCUSING ON DRUG USE.

5 Family Intervention for Complex Cases: Substance Use and Psychosis (Ian Lowens, Samantha E. Bowe and Christine Barrowclough).

6 Family Motivational Intervention in Early Psychosis and Cannabis Misuse (Maarten Smeerdijk, Don Linszen, Tom Kuipers and René Keet).

IV VARIETY OF ISSUES ARISING IN WORKING WITH RELATIVES.

7 A Case of Family Intervention with a ‘High EE’ Family (Juliana Onwumere, Ben Smith and Elizabeth Kuipers).

8 Coming to Terms with Mental Illness in the Family –Working Constructively through Its Grief (Virginia Lafond).

9 Interventions with Siblings (Jo Smith, Gráinne Fadden and Michelle O’Shea).

10 Family Intervention with Ethnically and Culturally Diverse Groups (Juliana Onwumere, Ben Smith and Elizabeth Kuipers).

V WORKING IN DIFFERENT CONTEXTS.

11 Multiple Family Groups in Early Psychosis: A Brief Psychoeducational and Therapeutic Intervention (David Glentworth).

12 Meeting the Needs of Families on Inpatient Units (Chris Mansell and Gráinne Fadden).

VI SERVICE RELATED ISSUES.

13 Setting Up a Family Interventions (FI) Service – A UK Case Study (Frank Burbach and Roger Stanbridge).

14 Overcoming Barriers to Staff Offering Family Interventions in the NHS (Gráinne Fadden).

VII RELATIVES’ SUPPORTING EACH OTHER.

15 The COOL Approach (Claudia Benzies, Gwen Butcher and Tom Linton).

VIII CONCLUSION.

16 Summary and Conclusions –Where Are We up to and Where Are We Going? (Fiona Lobban and Christine Barrowclough).

Index.

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