Family work in early intervention

Timing

Key tasks

Process

Example

Family work in early intervention

The aims of family work in psychosis are two fold:

• To provide on effective treatment for the client,
  
  
• To address the needs of all family members who ore affected by their relative’s psychosis.
  
  

There are a number of principles that guide this work and a value base that is positive towards family members and the situation in which they find themselves:

• A collaborative working relationship is established between the client, family members and the professionals who are working with them.
  
  
• The difficulties faced are seen in an objective way and the combined efforts of all three — client, family and professionals are seen as the best way of addressing issues.
  
  
• The value base underlying the approach is non-judgmental towards family members. Their past or current attempts to deal with the psychosis are valued and are seen as their best efforts to cope with a complex and unfamiliar situation within the limits of their current resources.
  
  
• The focus of the work is here-and-now and towards the future. There is an emphasis on positive achievements, and difficulties are addressed in a constructive way, arriving at a range of potential solutions that can be tried out.
  
  
• There is an emphasis on the honest and open sharing of information with all family members including the client.

TIMING

The engagement process with the family should begin at the earliest contact with services. Taking this approach from the beginning avoids the conflicts regarding issues relating to confidentiality which people after describe when they start to see the client, and then they try to involve the family at a later stage. Family work can be introduced naturally at the first contact with the services using a simple rationale: e.g. ‘If someone is not well in a family, those who are close to them and who care about them are affected too. They try to do the best they can to help but do not always know what to do for the best. If all family members are involved, it is possible to work out the best ways of helping the client, and also to alleviate stress that other family members are experiencing because of the situation in which they find themselves.’

• To engage the family in a therapeutic working relationship with professionals.
  
  
• To provide family members with the time to talk about what has been happening, to normalise their reactions and provide them with empathic support.
  
  
• To interview family members individually in order to get a picture of how each understands their situation is affected by what is happening, and can contribute to getting family life back on to an even keel again.
  
  
• To assess how family members relate to each other and how they as a unit address the issues with which they are faced.
  
  
• To provide the family with knowledge and to help them to deal with the situations they face as a result of psychosis.
  
  
• To help them to make contact with other people in similar situations to reduce feelings of isolation and stigma.
  
  

The initial engagement with the family can take time. Professionals have to be prepared to cope with the expression of a wide range of emotions which can include anger directed towards them, disbelief of what they are saying, and raw feelings of sorrow and grief. These intense feelings tend to dissolve over time. However those working with families should ensure they have sufficient support and supervision for themselves to help them cope with these early stages of therapy, and indeed throughout the therapeutic process.

The content of the family work is determined by the needs and desires of the individual family. For most, it involves the provision of information and helping the family to reach as complete an understanding as is possible of the development and nature of psychosis. There is an emphasis on identifying early working signs of relapse, and what the service will do in response.

Helping families to find new ways of addressing day-to-day difficulties is a core part of family work. Managing these ordinary and common issues is a top priority for family members, as these cause the greatest disruption in their lives. There is also a focus on how family members communicate with each other and on helping them to develop clear and less heated ways of talking with each other.

Example

Tom had been experiencing difficulties since his early teens, and was referred by his GP to the mental health services when he stopped attending school at 16, complaining that he was being picked on by his peers. Initial meetings with him and his parents revealed that the difficulties were more widespread, with Tom keeping the family awake at night, talking about voices and becoming extremely angry and shouting when his parents and brother refused to say that they could hear them as well. The atmosphere was tense in the house, with the father being very critical of Tom’s laziness, reflected as he saw it in his staying in bed until the afternoon. His mother’s main concern was that he never wanted to wash, and was not eating properly. His brother resented the fact that Tom was getting all the attention in the family, and was spending more and more time outside the house.

Tom started to take medication which resulted in him feeling calmer and sleeping better at night. He also reported that the voices were not as loud as they previously had been. All family members were involved right from the start. Each was given time on their own to talk about their views of what was happening. Family sessions were held to provide information on psychosis to the family, and to help all of them to understand what had been happening. Quite a bit of time was spent on helping them to look at the way they communicated with each other. Particular emphasis was placed on them noticing the good things that were going on, and in developing ways of asking each other for what they wanted without being critical and angry.

Good progress was made, but the father continued to be very negative towards Tom and the things he did. He was offered an individual session where he became extremely upset and talked about his sadness about what was happening with Tom. He always had very high hopes for him, as this was his ‘true’ son, (the other boy was adopted). Mostly he felt sad that he saw a very bleak future for Tom.

After the session, the family sessions became more productive, and they were all able to focus on more realistic things to work towards. All were very pleased when Tom got a part-time job in a local shop, as they saw this as the first step towards him leading a better quality of life.