What is family therapy?

Professor Elizabeth Kuipers: What is family therapy? Well it’s an attempt to try and help everybody who might be in contact with a service user, probably living together, but that’s not absolutely necessary, who might be kind of immediately affected by the difficulties that might be ongoing; trying to get everyone who’s in that situation to come together, probably at home, that’s what we tend to do here, and all talk together about what the issues are. That’s the basis of it.

Well obviously one would like to feel that it was a collaborative effort, so I’m tempted to say nobody leads it, but we would recommend that 2 professionals, mental health workers, it would often be a psychologist and a nurse therapist, or another psychologist or a social worker, it doesn’t necessarily matter which profession, or a psychiatrist, that people go in pairs to a family because there’s usually more than 2 or 3 people in a room and it’s helpful to work together, and help facilitate the family to talk together about the problems. It’s trying to facilitate conversations about how to sort things out, particularly in families where those things can’t be done very easily, where it’s been very difficult to communicate easily, and even if you do talk to each other it can often lead to arguments and things. So it’s not very productive... so trying to have productive discussions about how to sort things out. We like to do this in the home because it’s just less stressful for a family to wait for us to arrive on the doorstep than for them all to come into some clinic. It just puts people at ease.

Why it helps, exactly why it helps, exactly what the mechanisms are, that’s a bit more complicated. We think at the moment that it’s probably because it helps calm things down, and that it helps people to feel, with psychosis, to feel less anxious and less upset and depressed about what they are having to deal with when they know that the family is sort there, kind of on their side and trying to help and I think it also, it can be helpful for carers to know a bit more about what they are dealing with, to really be able to talk together in a way that is helpful with the service user and sort of, sort things out, and that kind of combined process seems to be useful.

The most recent NICE guideline update, there were 38 randomised trials on family intervention, quite a lot of them from places like China these days, and it’s a very consistent result that it helps reduce the number of episodes people have, the number of relapses, the number of times people get unwell. It doesn’t totally prevent it all but it helps reduce it, and that’s a very strong effect across all the trials. So for a psychological treatment we have got really quite good evidence that it can be helpful.

The NICE guidelines currently recommend at least 10 sessions and that they should carry on between 3 months and 12 months. And not all families would need such a lot of that, but where families have got difficulties, where there has been lots of problems and crises, the evidence is best for relatively intensive work, perhaps fortnightly, it doesn’t have to be all the time, but over quite a long period of time and to let people sort of practise things a little bit differently in between. So it’s not for ever but the evidence is it’s helpful to do it perhaps for 6 months to a year, and certainly for 3 months.

Are all discussions in family therapy confidential? This is not as easy to answer as you might think. At one level of course they are confidential to the family members in the room. Usually people are offering family interventions as part of a team and so you would go back and write up the themes of what’s happening so that other people are aware of what’s happening and what the issues are, and of course if there’s something really worrying that’s being said that needs to be acted upon outside of a session, someone’s very suicidal, or something very worrying is happening, you might have to deal with that. However most things that are discussed within family intervention sessions are about how they are going to sort out a day to day problem of managing something, so it’s not a big, you are not dealing with big secrets ... it’s nothing very worrying about it. So it’s not really, the confidentiality issue is not really the point – you are not spilling terrible things that no one has ever heard before.

Does family therapy help people with bipolar disorder as well?

Professor Elizabeth Kuipers: Yes, there has been some evidence for that. Someone called Miklowitz has done some work particularly with adolescents with bipolar disorder and shown that it’s helpful. So when you are a carer for someone with bipolar disorder, in my experience, you tend to kind of go up and down in the same way that the person’s mood is going up and down, so things can be fine and then things can be difficult again, so it is helpful to talk to families about that. It does seem to be helpful as well.