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Intervention and Dialogue with Families

Written by Jon Crossley on . Posted in Clinical Psychology Bite-Size

Intervention and Dialogue with Families

Issue 39 – June 2014

Authors: Jon Crossley (Clinical Psychologist, Leicester University) – contact via steven.coles@nottshc.nhs.uk

Key points

  • A robust evidence base has been established for Family Intervention with psychosis in research settings, however, questions have been raised about how this can be transferred into day to day practice
  • The Open Dialogue Approach illustrates the potential for routine mental health care to be based on family-centred models for people with a label of psychosis

 Implications for practice

  • View families as a potential asset and resource
  • Recognise that family interventions for psychosis vary in content and approach
  • Draw on an approach that fits with the family’s needs and preferences
  • Seek to engage in dialogue rather than impose ideas
Research has recently identified that a range of negative life events significantly increase the risk of having unusual experiences, commonly known as psychosis1. These life events primarily fall within the realm of relational stress, for example abuse, neglect, bullying and discrimination2. There is also robust evidence that particular types of relational stress within the family can influence unusual experiences over time. Individuals living in families where the atmosphere is characterised by high levels of criticism, hostility or emotional over-involvement, otherwise known as high expressed emotion (EE), have much higher rates of relapse and hospitalisation than where there is low EE 3.

Structured Interventions

Interventions have been developed to address high EE within families. These approaches have been well researched within formal research trials, culminating in a robust evidence base that Family Intervention is effective in reducing relapse rates and hospitalisations, with results sustained over time4. The latest NICE Guidelines recommend Family Intervention for people who receive or are at risk of receiving the label of psychosis5. Several guides have been written, that clearly describe the structures and techniques of Family Intervention6;7. While the emphasis varies between approaches, the underlying principles are consistent3. Psycho-education is used to help the family make sense of the unusual experiences. Problem-solving approaches are employed, so as to find more adaptive ways to manage communication problems and other difficulties. Finally, or alongside, attention is given to containing and processing accompanying emotions such as grief and loss. The underlying assumption held throughout is that the family is a potential asset and resource, with their strengths identified and built upon. Within structured approaches, although the family are not regarded as responsible for the difficulties, their capacity for shaping the individual’s unusual experiences and distress is recognised and discussed. The information that Family Intervention has repeatedly been found to prevent relapse is shared to motivate families to engage with the approach. Hope is nevertheless balanced with realism, with the acknowledgement that change is likely to be gradual. ‘Solutions’ and coping strategies are drawn from the family where possible, rather than being imposed by the staff member. 

Critique and Developments

Despite the positive findings from research trials, the degree to which the outcomes generalise to routine care has been questioned. There is also uncertainty about which specific components are effective; it has been questioned if improvements in communication and coping play the supposed pivotal role, or if psycho-education merely leads to greater compliance with psychiatric care8. The Open-Dialogue Approach (ODA) of Western Lapland however illustrates the potential of family-centred models of routine care for psychosis. It has achieved overwhelmingly positive outcomes for over two decades9, through the systematic application of seven principles. These principles concern an immediate response to psychotic crises, where the family and social network are invited to engage in regular meetings adapted to the needs of the individual and family, until the disturbance has calmed down. Repeated trials have found that two years after the initial crisis, at least 70% of individuals have not had a single relapse and are either studying, employed or actively seeking work10.   Within ODA, psychotic reactions are understood as attempts to make sense of and cope with experiences that are so difficult that it has not been possible to construct a rational spoken narrative11. Psychosis is therefore seen as a ‘crisis in language’ 12. The aim of meeting is to promote a sense of security in order to generate dialogue. Through dialogue a language is created for experiences that were not previously discussed, and a positive sense of identity is negotiated and constructed10. There are significant differences to the more structured and expert approach that Family Intervention adopts. Instead of psycho-education with its potential to underestimate human experience, the aim is to have a conversation ‘without rank’, away from the usual social hierarchy of psychiatric treatment 11. This takes the conversation away from the constricting space that medical frameworks can occupy, which often ‘make it difficult to see things in their proper light and to talk about what these things mean’13. Instead a common language is created which pushes against the isolation that often follows psychotic crises14. Although different in philosophy and approach, the consistent positive outcomes for Family Intervention and ODA highlight the potential benefits of including families in order to find helpful ways forward.   REFERENCES
  1. Read, J. & Bentall, R.P. (2012). Negative childhood experiences and mental health: theoretical, clinical and primary prevention implications. The British Journal of Psychiatry, 201, 83-84.
  2. Read, J. Bentall, R.P. & Fosse, R. (2009). Time to abandon the bio-bio-bio model of psychosis: exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms. Epidemiologia e Psichiatria Sociale, 18, 299-310.
  3. Kuipers, E. (2006). Family interventions in schizophrenia: evidence for efficacy and proposed mechanisms of change. Journal of Family Therapy, 28, 73-80.
  4. Fadden, G. (2006). Training and disseminating family interventions for schizophrenia: developing family intervention skills with multi-disciplinary groups. Journal of Family Therapy, 28, 23-38.
  5. NICE (2014). Psychosis and schizophrenia in adults: treatment and management. NICE Clinical Guideline 178
  6. Falloon, I.R.H., Boyd, J.L. & McGill, C.W. (1984). Family care of schizophrenia. New York: Guildford Press.
  7. Kuipers, E., Leff, J. & Lam, D. (2002). Family work for schizophrenia: a practical guide. London: Gaskell Press.
  8. Pfammatter, M., Junghan, U. & Brenner, H. (2006). Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses. Schizophrenia Bulletin, 32, 64-80.
  9. Aaltonen, J., Seikula, J. & Lehtinen, K. (2011). The comprehensive open-dialogue approach in Western Lapland: I. The incidence of non-affective psychosis and prodromal states. Psychosis, 3:3, 179-191.
  10. Seikula, J., Alakare, B. & Aaltonen, J. (2011). The comprehensive open-dialogue approach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis, 3:3, 192-204.
  11. Borchers, P., Seikkula, J., & Lehtinen, K. (2013). Psychiatrists’ inner dialogues concerning workmates during need adapted treatment of psychosis. Psychosis, 5:1, 60-70.
  12. Penn, P. (1999). Metaphors in regions of unlikeness. Human Systems, 10, 3-10.
  13. Frank, A.W. (1995). The Wounded Storyteller: Body, Illness, and Ethics. Chicago: University of Chicago Press.
  14. Hoffman, L. (2006). A bright new edge: the art of withness. In H. Anderson & D. Gehart (eds.), Collaborative Therapy: relationships and conversations that make a difference. New York: Routledge.

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