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PART 1 : THE CONTEXT OF FAMILY INTERVENTIONS

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IntroductionrnrnIt would not be unreasonable to expect that any person experiencing serious mental health difficulties would receive care and support from family members, and that being at home in a familiar environment would be the ideal place to receive this care and support. Unfortunately this is not always the case, and in reality many people experiencing mental illness are treated in hospitals.rnIt is generally accepted that family members, and carers, often feel unable to help. They can feel stressed through being with their relative 24 hours a day, often witnessing behaviours and symptoms which are difficult to understand. They experience a variety of emotions and distress because they are with their relative, largely without a break. This includes general stress, anxiety and a fear of what may happen, and frequently guilt. Alongside these emotions the family member may experience financial difficulties, as going out to work may not be possible with the constraints of providing supervision and care. There are often restrictions onrnrn4 THE CONTEXT OF FAMILY INTER VENTIONSrnrnrnsocial activities and disruption for siblings and other family members. This also has an effect on an individual’s physical and mental well-being. It is thought that carers are twice as likely to have mental health problems if they provide a substantial level of care to someone with a mental illness (Department of Healthrn1999).rnrnrnA brief look back through the historyrnrnThe involvement of family in the care of mental illness has been somewhat curtailed. Although the family has traditionally cared for mentally unwell members of society for many years, the transition from family-based care to institutional care became the norm. As it became evident that people experiencing mental health symptoms needed treatment, the early treatment of mental illness subjected the sufferer to an ‘asylum’ with little thought to the family members. In the early years, there was the view that mental illness was caused by the family, and the notion of family blaming (Johnstonern1999).rnFor many years people suffering from mental illness were isolated from societyrnand placed in large institutions. Alongside this isolation was the combined prejudicedrnview of society. It is well documented that people with a diagnosis of schizophreniarn(in particular) experience discrimination and stigmatization (Sayce 2000). Whilernattempts to reduce this are ongoing, it is an added burden for both the sufferer andrnfamily members.rnAt the beginning of the twentieth century a small French town of Ainay-le-rnChâteau became a setting that did not isolate individuals with mental illness but ratherrnwelcomed them with open arms. In this rural town ‘mentally ill men’ were welcomedrnas part of the family (family colony). These men (lodgers) lived everyday lives withrnordinary families (foster parents), and even held down jobs. This setting providedrninvaluable social insights into the effects of family involvement and has beenrndocumented as part of a four-year ethnographic study by Denise Jodelet (1991).rnThis particular study highlights the importance of ‘family’ involvement, and the bene-rnfits that support and care can provide.rnIn 1948 Henry Richardson explored the importance of family care in thernrecovery from both physical and mental health difficulties. His book Patients havernFamilies is well regarded as a significant step forward and is seen as a contributingrnfactor to the development of systemic family therapy. Systemic family therapy isrnvery effective and is supported by evidence. This approach is based on the idearnthat the problem lies within the whole family and not one single individual. Wernhighlight this but acknowledge that this is a very different approach to familyrninterventions.rnThe most significant piece of work that can be regarded as paving the wayrnforward for family interventions was carried out in the 1950s. George Brown (arnmedical sociologist) and colleagues began to study the outcomes of relocating long-rnterm mentally ill people into community settings (Brown et al. 1958). The resultsrnfocused on the environment that patients were discharged to. Interestingly patientsrnwho were discharged to family homes fared far worse (in terms of relapse andrnreadmission to hospital) compared to those who lived on their own or in a supportivernrnINTRODUCTION TO FAMILY INTER VENTIONS 5rnrnrnresidential setting. Those who were discharged to hostels, where there was little warmth and support, experienced the worst outcomes. Further work carried out in the 1960s and 1970s (Brown et al. 1962; Brown et al. 1972) led to the development of the now very familiar term expressed emotion, which we discuss further in Chaptersrn2 and 3.rnThe significance of social inclusion gathered pace in the 1980s with increasingrnrecognition by the government. The advent of ‘community care’ was outlined in whatrnwas referred to as the Griffiths Report (Griffiths 1988), which emphasized the bene-rnfits of maintaining individuals in their own homes. In 1989 came the publication ofrnthe White Paper Caring for People: Community Care in the Next Decade and Beyondrn(Department of Health and Department of Social Security 1989). This was added tornin 1990 by the National Health Service and Community Care Act (Great Britainrn1990).rnThe introduction of the National Service Frameworks in the 1990s included arnframework for mental health. Within this framework is recognition that carers’ needsrnshould be met (Department of Health 1999). This was further enforced in 2004 withrnthe publication of the Carers (Equal Opportunities) Act (Department of Healthrn2004a). Further to this came the National Institute of Clinical Excellencern(NICE) guideline recommending that family interventions be offered to all familiesrnwhere a family member has experienced schizophrenia (NICE 2002).rnrnrnFamily interventionsrnrnFrom the development of expressed emotion came the recognition that work needed to be carried out with family members that would ultimately reduce their stress, increase understanding and, importantly, benefit the individual experiencing the symptoms of mental illness. Work by Leff et al. (1982) was significant and seen as a vital piece of research in kick-starting a whole wave of studies which attempted to determine how effective interventions with families could be. The studies have strengthened the evidence base for family interventions and outlined the effectiveness of this approach. When you also add the potential financial savings to services (as high as 27 per cent: Tarrier et al. 1991) it only strengthens the need for family interventions to be offered as part of everyday practice.rnHowever, despite the need for family interventions, they are certainly not offered in many mental health services. There are a few notable exceptions: in Bath (Smith and Velleman 2002), Somerset (Stanbridge et al. 2003) and the work of the Meriden family programme in the West Midlands (www.meridenfamilyprogramme.com).rnThere has been a considerable push to develop training courses across Britain and this is leading to a significant number of trained therapists, yet despite this training professionals are not carrying out family interventions. Why is this? It may be that services do not recognize the benefits or do not have the available resources. It may be that family members do not want this intervention. It may be that therapists feel they do not have the support to carry out the work.rnWhatever the reasons, the benefits cannot be ignored and mental health services need to look at the barriers to the implementation of family interventions. This is addressed further in Chapter 22.

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