Family therapy

• About family therapy
• Why do relatives need to be involved in treatment?
• What happens in family therapy?
• Is every member of the family involved?
• Learning about psychosis
• Dealing with problems
• Thinking about your own welfare
• Who can have family therapy?
• How long does family therapy last?
• What proves family therapy works?

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 people with schizophrenia who have family therapy with their relatives are less likely to relapse and be admitted to hospital.

Family therapy (also sometimes called family work or family intervention) is about helping family members and close friends support someone who has a mental illness like schizophrenia 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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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, becoming 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 them 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.

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What happens in family therapy?

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 cope better with the illness and its symptoms, leading to a more supportive and warm atmosphere. 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 psychosis and the particular diagnosis their relative has been given. Everyone is encouraged 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 unwell. Often the individual will be asked to answer questions about their own symptoms and to discuss them with the family, if they would like to, as they are the ‘expert’ in this situation;

• encourage discussion about particular problems and how best to solve them together, 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 views of the person who is unwell. By the end of each session, therapists will have helped the family decide a realistic solution for one small problem that can be tried out as 'homework', and then discussed again if necessary.

Sometimes, the therapists will invite family members join a relatives’ group where they can meet other people who are in a similar situation. Usually these supportive groups are for relatives on their own to share their experiences.

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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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Learning about psychosis

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

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

If family members are given information about what is known about the causes of psychosis, its symptoms and treatments, including medication and side effects, they can understand more about why the person who is unwell 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 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.

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 gain confidence, begin to look after themselves again and start 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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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 you and other relatives who offer support 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 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.

Sharing experiences at a relatives’ group can also help people understand that their feelings are not unusual, and a therapist can help find such a group. 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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Who can have family therapy?

The National Institute for Health and Care Excellence (NICE) 2009 guideline on schizophrenia recommends people are 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 other recommended treatment is cognitive behaviour therapy (CBT) for psychosis, and the NICE guidance says arts therapies should be considered – see the What you can expect from the NHS page). 

The NICE guidance says family therapy should be offered to all families who live with someone who has a diagnosis of schizophrenia, or who are in close contact with them.

The NICE guideline on bipolar disorder says family therapy should be considered for people when they are relatively stable, in addition to long-term medication. Cognitive behaviour therapy should also be considered.

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How long does family therapy last?

Family therapy is time-limited, and usually lasts between three and 12 months, with sessions every fortnight or every month. Sometimes it lasts longer, but with less frequent sessions. NICE recommends at least 10 sessions for people who have been given a diagnosis of schizophrenia.

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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 but 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 after an acute episode of psychosis. 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 with schizophrenia and then with families of people with 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.

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, King's College London – Elizabeth Kuipers, Julian Leff and Dominic Lam.