Family therapy

About family therapy

Families can play an important role in helping someone who has experienced the symptoms of psychosis to recover and stay well.

Research has consistently shown that when people who have been given a diagnosis of schizophrenia have family therapy with their relatives, they are less likely to relapse and less likely to be admitted to hospital.

Family therapy (also called family work or family intervention) is about helping family members and close friends support someone who has a mental illness in the best way, and helping relatives and members of the extended family look after themselves emotionally. It can help family members deal with some of the problems that can result from living with or supporting someone who has experienced psychosis, and it can give relatives the skills to work more collaboratively with health professionals.

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What happens in family therapy?

Individual family therapy normally takes place in people’s homes.

Typically, two family therapists will work with relatives and the person who is unwell to develop strategies to help everyone cope better with the illness and its symptoms. This in turn can help people who have been unwell to make better progress. It can also help relatives to feel more positive about, and more effective in, their supporting roles.

Family therapists make sure family members have all the information they need about the particular diagnosis their relative has been given. Everyone is encouraged to ask questions and learn more about the symptoms and causes of the illness, and about medication that has been prescribed, and its side effects, to help them properly understand the behaviour of the person who is unwell. Often the individual who is unwell will be asked to talk about their own symptoms and to discuss them with the family, if they would like to, as they are the ‘expert’ in this situation.

Information can help family members understand, for example, that they are not to blame for the illness; that the behaviour caused by the symptoms of psychosis cannot be helped; that some of the symptoms do not generally respond to drugs immediately but may do over a couple of years; that delusions and hallucinations are real (and often frightening) to the person who is experiencing them.

Family therapists also encourage discussion about day-to-day problems and how best to solve them together.

The atmosphere at home and the way daily problems are tackled are as important as medication for someone who has a mental illness that involves the symptoms of psychosis. The illness can make people very sensitive to stress and easily upset or unsettled.

The behaviour caused by the illness, however, can make life for other members of the family extremely difficult. If someone is talking to themselves, spending all day in bed, not taking care of their personal hygiene and taking hours to get anything done, it’s not surprising that sometimes relatives react in an angry way, feel irritated and annoyed and that things need to change.

Discussing problems in sessions with therapists means the views of every member of the family can be listened to and considered, including those of the person who is unwell.

So, for example, someone who has been given a diagnosis of schizophrenia may be sleeping for long periods of time because of the medication they are taking, or because there is nothing for them to do if they get up, or to avoid seeing people who may seem threatening. By talking about the problem, family members can understand more about each others’ perspective, start suggesting solutions and discussing together the pros and cons of each way forward. They can also discuss what each person needs to do to begin to change things.

All family members can raise any issue during the sessions with the therapists – from resentment about nothing getting done around the house to fears that the person who is unwell might take their own life.

Therapists aim to help family members help the person who is unwell move forward on the road to recovery by gaining confidence, by beginning to look after themselves again and by starting to lead as independent a life as possible. Some family members may be keen for someone to return to work or full-time education, while others may be worried and hesitant about that happening, for example. Discussing this in a session with therapists can help the family consider the best way to support each other in these circumstances, after listening to everyone’s views.

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Why do relatives need to be involved in treatment?

The confusing and disturbed behaviour that can be a symptom of psychosis affects everyone in the family. Looking after someone who has a serious mental illness is emotionally demanding: relatives may feel shame, anger, anxiety, intense worry, frustration, sadness or guilt – feeling somehow responsible for the illness, or for feeling resentful about their caring role.

Some of these feelings and emotions can sometimes make a relative feel irritated by the person who is unwell, thinking the individual is to blame for the problems, and becoming critical of them. Alternatively, some family members attempt to make things better by trying to do everything for their relative, and then become over-involved in his or her daily life.

Both of these reactions are completely understandable, particularly in the short term, when there is a crisis. However, in the longer term, they can be difficult for the person who is unwell to deal with – they can make him or her feel more anxious and depressed, and hinder recovery. These reactions can also make the family members who are offering support feel more depressed, more stressed and more burdened.

Family therapy can help family members feel less anxious and worried as problems, and potential solutions, are openly discussed. Family therapy may help people realise, for example, that it is a good idea to sometimes take time away and have breaks from the family home and think about their own needs.

Families often feel very isolated when a relative develops a mental illness. They may feel rejected by their friends and neighbours because of the stigma still associated with mental health problems, particularly one that involves the symptoms of psychosis, and because of feelings of shame that this has happened to their family. Therapists can help families discuss these issues and come up with strategies to break the isolation they feel.

Family therapists can also help relatives realise that the emotional responses they have ­– particularly the negative ones – are normal and understandable. Therapists can help family members feel more positive about the future and more positive about each other again, despite the difficulties.

A family therapist may suggest family members join a relatives' support group. Sharing experiences at a relatives’ group can also help people understand that their feelings are not unusual. Discussing day-to-day problems with other families who have been affected by psychosis can supplement ideas for dealing with difficult issues in a calm and tolerant way. 

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Is every member of the family involved?

The definition of family includes all those who are living with someone who is unwell and/or all those who are involved in supporting them. This can include extended family members, and people who aren’t blood relatives. Everyone involved in supporting an individual will be asked to attend the sessions regularly.

Sometimes family therapists may work with an individual member of a family. A therapist may see them separately for a while, to let them talk openly and honestly about how they are feeling without them having to worry about upsetting the person who is unwell or other family members.

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What proves family therapy works?

Researchers talk about ‘high expressed emotion’ in families. The term was first used in the late 1960s and early 1970s and it can be confusing to people who don’t work in medicine or science. ‘High expressed emotion’ doesn’t mean that emotions are discussed openly. It is how doctors and researchers describe behaviour towards someone with mental health problems that is either critical (angry or resentful) or over-involved (when family members find it hard to let someone do things for themselves because they are worried about them).

Over the years, research studies have found that people who have schizophrenia who live with ‘high expressed emotion’ families are more likely to relapse. Studies have also shown that people who have other mental health problems – like eating disorders – are also less likely to get better if they are living with relatives who have high expressed emotion.

Family therapy was developed as a way of helping families cope with the problems caused by mental illness in a calm and less anxious way. Mental health professionals began to work with families in the late 1970s, initially concentrating on families of people who have schizophrenia and then with families of people who have other mental health problems.

Research has tested how successful this kind of family therapy is. The studies show that family therapy for psychosis does make it less likely that a person who is unwell will relapse, and does make life easier for family members. Studies show it also helps people who have experienced the symptoms of psychosis to recover socially, and that they are more likely to take medication regularly.

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Who can have family therapy?

National Institute for Health and Care Excellence (NICE) guidance* recommends that everyone who has been given a diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder or delusional disorder who lives with, or who is in close contact with, families and relatives, should be offered family therapy as part of their treatment, which also usually includes medication. NICE says family therapy may be particularly useful for people who have recently relapsed, or who are at risk of becoming unwell again.

Family therapy is one of two talking therapies recommended in the NICE guideline about psychosis and schizophrenia*. The other is cognitive behaviour therapy (CBT).

In the same guideline*, NICE says mental health professionals should offer family intervention and CBT to people who are experiencing psychosis for the first time.

When people first become unwell, some may want to try treating their symptoms using only talking therapies, without medication. NICE stresses that CBT for psychosis and family therapy are proven to be more effective when given with medication. However, if someone who is experiencing a first episode of psychosis wants to try family therapy and CBT without medication, NICE recommends a short trial (up to a month) of talking therapies only. During that time, mental health professionals should monitor their symptoms and when treatment is reviewed, antipsychotics should once again be considered.

In the guideline about psychosis and schizophrenia*, NICE says family therapy or CBT should be offered to someone who is thought to be at increased risk of developing psychosis because of the experiences they are having (see Early intervention services page and Psychotic-like experiences page). (Mental health professionals should not prescribe antipsychotic medication to people who they think may be at risk of developing psychosis, or as a preventative measure).

The 2014 NICE guideline about bipolar disorder recommends that in the longer term, adults who are given a diagnosis of bipolar disorder should be offered family therapy to help them stay well, if they are living or in close contact with, their relatives. People who have bipolar disorder are also usually prescribed long-term medication (see Bipolar disorder page and Medication for bipolar disorder page).

The NICE guidance about bipolar disorder emphasises the value of family therapy for relatives and other carers.

NICE recommends carers of people with bipolar disorder should be given information about diagnosis, treatment, different services available and the sort of support available to them. An education and support programme may be part of family therapy for bipolar disorder.

The group of experts who developed the 2014 NICE guidance about bipolar disorder decided the type of family intervention recommended for people who have experienced psychosis or who have a diagnosis of schizophrenia* is also suitable for people who have a diagnosis of bipolar disorder.

NICE recommends family therapy last for between three months and one year, and includes at least 10 planned sessions, and should be delivered by therapists who have had specialist training. Family therapy may sometimes be given with other families, if everyone involved agrees to that happening.

However, family therapy is still not widely available on the NHS. A study published in August 2014, found that only two of 187 people who used mental health services provided by a large NHS trust in north west England received family therapy within a 12 month period.

*Psychosis and Schizophrenia in adults, NICE Guideline on Treatment and Management, updated edition 2014, uses the term 'psychosis' to describe the symptoms of psychosis experienced by people who have a diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder or delusional disorder. Recommendations for supporting people who are having psychotic-like experiences that are distressing are also included. The guideline does not include recommendations about treatment of psychosis experienced by people who have bipolar disorder or psychotic depression – or people who have Parkinson's disease or dementia, or another condition that causes the symptoms of psychosis. Recommendations for treatment in these circumstances are included in other NICE guidance.



This page was last updated 29 September 2014
Links checked 11 July 2016