Family therapy

• About family therapy
• What happens in family therapy?
• Learning about psychosis
• Dealing with problems
• Is every member of the family involved?
• Thinking about your own welfare
• How long does family therapy last?
• What proves family therapy works?

About family therapy

Family therapy is not about ‘treating’ or blaming the family – there is no evidence whatsoever that a family’s influence can cause psychosis. Families can, however, play an important role in helping someone to stay well. Family therapy is about helping family members and close friends best support someone who has psychosis, 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 with psychosis, and it can give relatives the skills to work more collaboratively with health professionals.

Research has consistently shown that people with schizophrenia who have family therapy with their relatives have fewer relapses and are less likely to return to hospital.

The National Institute for Health and Clinical Evidence (NICE) 2009 Updated Guidance on Schizophrenia recommends people be offered psychological treatment as well as medication. Family therapy is one of the psychological treatments that are recommended because they are proven to make a difference: the others are cognitive behavioural therapy and arts therapies. Research has shown that people who have family therapy are less likely to relapse and be admitted to hospital.

The Guidance says family therapy should be offered to all families who live with a person with schizophrenia or who are in close contact with them.

The NICE Guidance on Bipolar Disorder says family therapy should be considered for people when they are relatively stable, in addition to long-term medication. Cognitive behavioural therapy should also be considered.

Family therapy is also sometimes called family work or family intervention.

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What happens in family therapy?

The confusing and disturbed behaviour that can be a symptom of psychosis affects everyone in the family. Looking after someone with psychosis is emotionally demanding: relatives may feel shame, anger, anxiety, intense worry, frustration, 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 ill, 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, becoming over protective and over involved in his or her daily life.

Both of these reactions are completely understandable but can be difficult for someone with psychosis to deal with – they can make them feel more anxious and depressed, and hinder recovery. They can also make the family members who are offering support feel more depressed, more stressed and more burdened.

Family therapy normally takes place in people’s homes. Typically, two family therapists will work with relatives and the person who is ill to develop strategies to cope better with the illness and its symptoms, leading to a more supportive and warm atmosphere. This in turn can help people with psychosis to make better progress. It can also help relatives to feel more positive about, and more effective in, their supporting roles.

The therapy:

• makes sure family members have all the information they need about psychosis and the particular diagnosis that has been given. These sessions allow everyone to ask questions and learn more about the illness so they can properly understand the difficulties posed by its symptoms and the behaviour of the person who is ill. Often the individual who has psychosis will be asked to answer questions about their own symptoms, if they would like to, as they are the ‘expert’ in this situation;

• encourages discussion about particular problems and how best to solve them, and discussion about recovery plans. The therapists will encourage everyone to listen to each other and to take account of everyone’s views when talking about a particular issue, including the view of the person who is ill.

Sometimes family members may also be invited to join a relatives’ group where they can meet other people affected by psychosis. Usually these supportive groups are for relatives only to share experiences.

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Learning about psychosis

Relatives often find it hard to get information from mental health professionals about the person who is ill. Sometimes this is because of confidentiality issues (see Confidentiality page).

An important part of working with families is about giving information and answering any questions they may have.

If families are given information about what is known about the causes of psychosis, its symptoms, medication and side effects, they can understand more about why the person who is ill behaves the way they do.

Information can help families 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 will do over a couple of years; that delusions and hallucinations are real (and often frightening) to the person who is experiencing them.

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Dealing with problems

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

The behaviour caused by psychosis, 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 or feel irritated and annoyed.

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

So, for example, the person with psychosis 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. 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.

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 ill might take their own life.

Therapists aim to help family members help the person who is ill gain confidence, begin to look after themselves again and start to lead as independent a life as possible. Some families 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 someone in these circumstances, after listening to everyone’s views.

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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 ill and/or all those who are involved in supporting them. This can include extended family members, and people who aren’t blood relatives. It is best that everyone involved in supporting an individual attend the sessions regularly.

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

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Thinking about your own welfare

Supporting someone with psychosis is a demanding job and can affect your own health in different ways. Sometimes it is difficult to think about your own needs, especially when someone is very ill and you feel you have to do lots of things for them. Family therapy can help relatives who are in a supporting role feel less anxious and worried as problems, and potential solutions, are openly discussed. Family therapy may help people realise that it is a good idea to sometimes take time away and have breaks from the family home.

Families often feel very isolated when a relative has psychosis. They may feel rejected by their friends and neighbours because of the stigma still associated with mental illness. 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 the emotional responses they have ­– particularly the negative ones – are normal.

Sharing experiences at a relatives’ group can also help people realise that their feelings are not unsual, and a therapist can help find such a group. Discussing day-to-day problems with other families affected by psychosis can supplement ideas for dealing with difficult issues in a calm and tolerant way.

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How long does family therapy last?

Family therapy is time-limited, and usually lasts between three to 12 months, with sessions every fortnight or every month. Sometimes it lasts longer, but with less frequent sessions. NICE recommends at least 10 sessions.

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What proves family therapy works?

Researchers and psychologists talk about ‘high expressed emotion’ in families. The term was first used in the late 1960s and early 1970s but is 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 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 with schizophrenia who live with ‘high expressed emotion’ families are more likely to relapse after an acute episode of psychosis. Studies have also shown that people with 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 staff began to work with families in the 1970s, initially concentrating on families of people with schizophrenia and then with families of people with other mental health problems.

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

Other studies have shown that family therapy works not just for psychosis, but also for other long-term mental and physical health problems.

There are several versions of family therapy for psychosis that have been proven to be successful. These include one developed by researchers at the Institute of Psychiatry – Elizabeth Kuipers, Julian Leff and Dominic Lam.

This kind of family therapy was first recommended for people with schizophrenia by the National Institute for Health and Clinical Excellence (NICE) in its guidelines published in 2003.