Introduction 1

I. Introduction __________________________________________________________________________

1 Introduction to our approach

From the late 1960s to early 1970s, researchers at the Medical Research Councils Social Psychiatry Unit in ondon !ere in"esti#atin# !hether $amily atmos%here can in$luence the course o$ illness in schi&o%hrenia' (hey $ound that %atients li"in# !ith a critical or o"erin"ol"ed relati"e !ere more %rone to rela%se' (hey coined the term )hi#h e*%ressed emotion to descri+e such $amilies ,-ro!n . Rutter, 1966/ -ro!n et al, 19701' (hese $indin#s !ere re%licated $irst in the Medical Research Councils Unit usin# a shorter inter"ie! schedule +y 2au#hn . e$$ ,19761' Since then $urther re%lications ha"e +een re%orted throu#hout the !orld and in di$$erent cultures ,e'#' 2au#hn et al, 1934/ 5en6ins et al, 1936/ e$$ et al, 19371' More recently, ho!e"er, there ha"e +een a $e! re%orts that did not re%licate the earlier $indin#s' Par6er . 7ad&iPa"lo"ic ,19901 summarised the recent contro"ersial studies' )8*%ressed emotion ,881 is essentially a clinical conce%t' 9t contri+utes little to our understandin# o$ the aetiolo#y o$ the illness, +ut is a ro+ust %redictor o$ the course o$ the illness !hen someone !ith schi&o%hrenia li"es !ith relati"es' (he model o$ treatment descri+ed in this manual $rom this %redicti"e %o!er o$ 88' 9n our research and in our clinical !or6 !e ha"e selected $amilies in !hich at least one mem+er is rated as )hi#h F8' (his does not im%ly that lo!:88 $amilies are not in need o$ hel%, only that hi#h:88 $amilies ha"e a hi#her %riority, and !e ha"e to +e selecti"e !hen trained thera%ists are in short su%%ly' ;e are in the %rocess o$ settin# u% a national trainin# net!or6 $or $amily !or6 !ith schi&o%hrenia, !hich is aimed %rimarily at %sychiatric nurses' 7o!e"er, any %sychiatric %ro$essional could +ene$it $rom the trainin#' (his Practical Guide $orms %art o$ the trainin# materials, !hich also include "ideo:ta%es and a trainin# manual' (rainin# in the use o$ the Cam+er!ell Family 9nter"ie! ,CF5/ -ro!n . Rutter, 19661 and the F8 ratin# scales is not %art o$ the course, since !e "ie! these techni<ues as mainly $or use in research studies'
0 Family Work for Schizophrenia

Most ser"ices !ill +e in the %osition o$ ha"in# to concentrate resources on the $amilies in #reatest need' 9n the a+sence o$ ratin#s o$ relati"es 88, such $amilies can +e identi$ied +y the $ollo!in# rules o$ thum+= ,a1 relati"es li"in# !ith %atients !ho rela%se more o$ten than once a year des%ite +ein# com%liant !ith maintenance neurole%tics ,+1 relati"es !ho $re<uently contact sta$$ $or reassurance or hel% ,c1 $amilies in !hich there are re%eated ar#uments leadin# to "er+al or %hysical "iolence/ and any $amily that calls in the %olice ,d1 a sin#le relati"e, usually the mother, loo6in# a$ter a schi&o%hrenic %atient on her o!n' >ur model o$ treatment is hi#hly s%eci$ic and consists o$ a %sycho:educational com%onent and a structured $amily a%%roach, !ith an em%hasis on co#niti"e?+eha"ioural techni<ues' 9t is 6no!n that educatin# relati"es a+out the illness and !or6in# !ith them to tac6le some o$ their %ro+lems attenuates their critical or o"erin"ol"ed +eha"iour, hence %re"entin# rela%ses ,see, $or e*am%le, e$$ et al, 1930, 193@, 1939, 1990/ (arrier et al, 19331' (he $ollo!in# are the +asic assum%tions and %hiloso%hy o$ the treatment model= ,a1 Schi&o%hrenia is conce%tualised as an illness !ith a +iolo#ical ori#in' A diathesis?stress model is used to e*%lain ho!, in a "ulnera+le %erson, stresses such as une*%ected li$e chan#es mi#ht +rin# on the illness or a rela%se' ,+1 9nstead o$ the relati"es +ein# +lamed, they are enlisted as thera%eutic a#ents, in order to hel% the %atients' Furthermore, the +urden and stress o$ li"in# !ith a schi&o%hrenic %atient are ta6en seriously' ,c1 (here is an em%hasis on o%enness and !or6in# in %artnershi% !ith the $amily' 9n$ormation a+out the illness is shared' 9n doin# so the thera%ists also admit that there is a lot a+out the illness that is not 6no!n' Colla+oration is elicited +y mutual !or6 on #oal settin#, %rioritisin#, and tas6 settin#' ,d1 Families are seen to ha"e needs and stren#ths' A %ositi"e a%%roach is used to +uild on the $amilies stren#ths in order to tac6le their %ro+lems'

,e1 (he %sychosocial $amily inter"ention descri+ed here is o$$ered as %art o$ a %ac6a#e, in conBunction !ith dru#s and out:%atient mana#ement' (here is no attem%t to su+stitute traditional mana#ement !ith $amily treatment'
Introduction C

Differences between our approach to work with families and that of others
Peo%le +e#an to !or6 !ith $amilies in the early 19@0s' At $irst, the $ocus !as on $amilies !ith a schi&o%hrenic mem+er, +ut it soon +roadened to include $amilies !ith the !hole ran#e o$ %sychiatric conditions' (he earliest !or6 !as +ased on %sychoanalytic theory/ ho!e"er, in recent years this a%%roach has +een ecli%sed +y the rise o$ systemic $amily thera%y' (he !or6 !e descri+e in this manual +elon#s to neither o$ these schools, althou#h it has +orro!ed ideas and techni<ues $rom the systemic a%%roach' (he di$$erences +et!een our mode o$ !or6in# and the others are !orth s%ellin# out' ,a1 (he disease conce%t o$ schi&o%hrenia (here are a num+er o$ %sychoanalytic theories !hich trace the ori#in o$ schi&o%hrenia to distur+ed %arent? child relationshi%s' ;ithin this tradition, schi&o%hrenia is "ie!ed as a %urely %sycholo#ical distur+ance !hich is e*%lica+le in terms o$ the distur+ance induced in the child +y the %arents' (he systemic "ie! is rather di$$erent, since schi&o%hrenia is seen as the %resentation +y one mem+er o$ a )mad $amily situation' (he madness characterises the !hole $amily system, in !hich one mem+er is )chosen to %resent it to the %ro$essional' (his %erson is o$ten re$erred to as )the desi#nated %atient, !ith the im%lication that the %atholo#y lies in the !hole $amily' 9n contrast to the a+o"e a%%roaches, !e consider that schi&o%hrenia is a +iolo#ical illness o$ the +rain that can occur in $amilies !hich are $unctionin# %er$ectly !ell' ,+1 (he role o$ the $amily 9t is e"ident $rom the a+o"e that +oth %sychoanalytic and systemic theories im%licate the $amily in the causation o$ schi&o%hrenia' ;e consider that $amilies do not e*ert a causal in$luence, althou#h they can modi$y the course o$ the illness' (c) The aim of therapy 9n +oth %sychoanalytic and systemic $amily thera%y, the aim is to correct %resumed $amily dys$unction' (he $amily is conse<uently the client o$ the thera%ists' ;e do not "ie! the $amily as in need o$ treatment' 7ence !e
4 Family Work for Schizophrenia

a"oid callin# our inter"entions )$amily thera%y' >ur aim is to hel% the $amily to co%e +etter !ith the sic6 mem+er !ho is su$$erin# $rom a de$ined disease' ;e see the $amily as an ally in treatin# the schi&o%hrenic %atient' ,d1 The role of insight 9n %sychoanalytic, +ut not systemic, $amily thera%y, the insi#ht o$ the thera%ist is $ed +ac6 to the $amily in the $orm o$ inter%retations to e$$ect chan#e' Althou#h !e "alue a %sychodynamic understandin# o$ $amily relationshi%s, !e do not ma6e inter%retations to the $amily' ;e ha"e $ound that in $amilies !ith a schi&o%hrenic mem+er they $ail to %roduce chan#e' (e) The role of the therapists 9n traditional %sychoanalytic thera%y, the thera%ist a"oids ans!erin# direct <uestions and does not o$$er ad"ice' ;e set out to #i"e the $amily in$ormation, ad"ice and #uidance' 7o!e"er, !e do not e*%ect the $amily to +e a %assi"e reci%ient o$ these' 9nstead, !e encoura#e the $amily to ta6e an acti"e %art in discussin#

the in$ormation %ro"ided and to !or6 !ith us to $ind solutions to their %ro+lems' 9n addition, !e are acti"e on +ehal$ o$ the $amily in ne#otiatin# !ith "arious ser"ices to hel% to en#a#e them !ith the $amily' (his !ould not +e underta6en +y a traditional %sychoanalyst, althou#h a systemic thera%ist mi#ht !or6 !ith e*ternal a#encies as %art o$ the lar#er system !ithin !hich the $amily o%erates'

General interpersonal effecti eness

(he model o$ thera%y +ein# used here em%hasises the im%ortance o$ ra%%ort ,a #ood and harmonious !or6in# relationshi%1 !ith $amilies' (o +e consistent !ith our $amily !or6 model, the thera%ists should ne"er criticise or +lame the $amily' A%art $rom +ein# an undesira+le role model $or the relati"es, any criticism is li6ely to +e %assed on to the %atient' (he Ro#erian %rinci%les o$ thera%ists +ein# !arm, em%athic and #enuine are seen as crucial $or e$$ecti"e !or6in# !ith $amilies' (hera%ists should sho! ade<uate !armth to!ards indi"iduals in $amilies as human +ein#s in need o$ hel%' 8m%athy is de$ined as the a+ility to understand accurately the %ers%ecti"es o$ other %eo%le' 9t is di$$erent $rom sym%athy, !hich is the sharin# o$ or ha"in# com%assion $or another indi"iduals %ain' 9t could +e ar#ued that too much sym%athy could ma6e thera%ists lose their o+Becti"eness and hence a+ility to hel%' Furthermore, thera%ists should +e and sincere !ith $amilies' Any unrealistic or unmet %romise !ould +e Bud#ed +y $amilies as insincere'
Introduction @

(hera%ists should not ado%t an authoritarian attitude nor im%ose the o$$icial "ie! o$ schi&o%hrenia on $amilies' (here is an im%ortant distinction +et!een ma6in# $actual statements a+out !hat !e 6no! re#ardin# the illness and +ein# insensiti"e and authoritarian' Moreo"er, it is im%ortant to elicit $amilies "ie!s re#ularly to #ain their colla+oration' Family mem+ers $eelin#s, e*%eriences, stren#ths and needs should +e res%ected' Families %ast or %resent attem%ts to co%e, no matter ho! undesira+le they may +e to the thera%ists, should +e res%ected as their +est e$$ort to co%e #i"en their resources' (he %remise o$ our model is that these inter%ersonal <ualities are necessary +ut not su$$icient $or a #ood thera%eutic outcome' (he techni<ues descri+ed in this treatment model are enhanced !hen carried out in aD#ood thera%eutic relationshi%' 9$ not, thera%y can +e seen as ro+otic, and $amilies !ould thin6 that the thera%ists do not care a+out or understand them' Considera+le s6ill is re<uired to con"ey a #ood and carin# %ro$essional attitude' (he de#ree o$ !armth and #enuineness +ein# e*%ressed +y the thera%ists is im%ortant' -ut one could ar#ue that the amount o$ !armth and #enuineness %ercei"ed +y indi"idual $amily mem+ers is more im%ortant' (he !ay to $ind out is +y as6in# $or re#ular $eed+ac6' Perha%s one o$ the +est !ays to learn ho! to con"ey these <ualities initially is to o+ser"e ho! your more e*%erienced collea#ues do

Support !roup for therapists

;or6 !ith $amilies !ith a schi&o%hrenic mem+er is emotionally demandin#' ;e ha"e $ound that thera%ists +ene$it $rom ha"in# a su%%ort #rou% o$ their %eers !hich meets a+out once a month' this may not al!ays +e $easi+le, +ut should +e #i"en hi#h %riority' Euidelines on ho! to run such a #rou% !ill +e $ound in our "rainin! #anual for "herapists ,a"aila+le $rom the authors1'

Summary
;e conce%tualise schi&o%hrenia as a +iolo#ical illness !hich ma6es the %atient sensiti"e to stress' Conse<uently our thera%eutic a%%roach in"ol"es dru# treatment in conBunction !ith $amily !or6' Families are seen as %artners o$ the thera%ists in an alliance to hel% the %atients' ;e do not +lame the relati"es $or the illness, nor do !e "ie! the $amily as in need o$ treatment' (hera%ists should +e !arm and em%athic, +ut also need to !or6 acti"ely !ith the $amily on their %ro+lems' (hera%ists +ene$it $rom ha"in# their o!n su%%ort #rou%'