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488 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS Schizophrenia is an Illness Some people are born with the vulnerability to this illness. This vulner- ability is genetically transmitted in some cases. In others, it results from pre-natal exposure to infections. Symptoms develop when a person vul- nerable to schizophrenia experiences a build-up of life stress. Details of where in the brain this vulnerability is located and how it works are not known and research is being done throughout the world to answer these questions. Incidence One in 100 people get schizophrenia over the course of the lifetime in all countries in the world. Studies that suggested that there were more people with schizophrenia in some places – like the west of Ireland – have been shown to be wrong. In these studies, each time a person entered hospital they were counted as a new case. So if a person was hospitalized three times, the same person was counted as three cases. We now know that the rate of schizophrenia in Ireland and around the world is 1 in 100. Family Members do not Cause Schizophrenia They can, however, help with recovery by being supportive, reducing stress and helping with medication. In particular you can help by: • understanding how distressing the symptoms are for the person with schizophrenia • making home-life and family relationship calm and predictable • helping the person with schizophrenia remember to take their medication. One of the Symptoms of Schizophrenia is Thought Disorder People with schizophrenia may talk a great deal but appear to lose the thread of what they are saying so that it is hard to understand what they mean. This is because they have lost the ability to control the amount of thoughts that they think and to put their thoughts in a logical order. Other times they simply stop talking abruptly. This is because they have the ex- perience of their mind going blank. The experience of thought disorder can be confusing and sometimes very frightening. People trying to cope with it may worry a good deal about it and try to make sense of it in strange ways. They may blame someone for putting thoughts into their head. They may blame someone for robbing their thoughts. You can help by: • acknowledging that thought disorder is confusing and distressing • avoiding arguing about the nonsensical and illogical things the per- son with schizophrenia says. SCHIZOPHRENIA 489 Another Symptom of Schizophrenia is Auditory Hallucinations People with schizophrenia may hear voices. This may sound like a run- ning commentary. It may sound like two people conversing about them. It may sound like someone talking to them. This is a very frightening experience when it fi rst happens. People may try to make sense of audi- tory hallucinations by attributing the voices to a transmitter, the TV, God, aliens or some other source. Sometimes people shout back at the voices to try to make them stop. Other times they feel compelled to follow instruc- tions given by the voices. You can help by • acknowledging that some hallucinations are distressing • understanding that hallucinations may be partially controlled by listen- ing to calming music, distraction or having a supportive conversation • avoiding arguing about the reality of the hallucinations. A Third Symptom of Schizophrenia is Delusions People with schizophrenia may hold strong beliefs which are implausible to members of their family or community. For example, they may believe that they are being persecuted by hidden forces or by family members. They may believe that they are on a mission from God, who speaks to them. Usually delusions – these strange beliefs – are an attempt to make sense of hallucinations or thought disorder. People who hold delusions usually refuse to change these even in the face of strong evidence that their position is implausible. You can help by • not engaging in conversations about delusional beliefs • not agreeing with delusional beliefs • not arguing about how ridiculous the delusional beliefs are. Problems with Emotions May also Occur in Schizophrenia People with schizophrenia may withdraw and show little affection or love. This withdrawal may refl ect a reoccupation with hallucinations or the in- tense experience of a high rate of uncontrollable thought that goes with thought disorder. They may also have outbursts of laughter or anger, which appear to be inexplicable. These outbursts are often a response to hallucina- tions. Occasionally, people with schizophrenia realise how the condition has damaged their relationships and their lifestyle. This may result in de- pression. On other occasions they may deny that any changes have occurred and become inappropriately excited and optimistic. You can help by • not trying to cheer the person up • not criticising them for feeling as they do 490 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS • taking a matter-of-fact accepting position with respect to their emo- tional state. Problems with Withdrawal, Daily Routines and Hygiene May also Occur People with schizophrenia may have little energy, sleep a great deal, avoid the company of others and pay little attention to washing or personal hygiene. This is partly because the experiences of thought disorder and hallucinations and attempts to make sense of these experiences through delusions have left them exhausted and with the realisation that they no longer know how to fi t in with other people. They may also have feelings that they cannot control and believe that they cannot direct their own behaviour. Because withdrawal, poor hygiene and a breakdown in daily routines are symptoms of an illness, it is almost impossible and probably harmful to try to persuade a person with schizophrenia to make major changes in these areas rapidly. You can help by • making requests for small, carefully planned changes where there is a good chance of success • praising and thanking the person for meeting these small requests • developing a points system where the person can win points for meet- ing small goals and these may be traded for things they want or would like to do. Some Symptoms are Treatable with Medication Thought disorder, hallucinations and delusions may all become greatly reduced or disappear with medication. Some patients get their medication in pills and others get it by injection. Some patients want to stop taking medication because it has side effects, such as shaking or feeling restless. It is important to take the pills or the injection according to the doctor’s or nurse’s directions. Patients who stop taking their medication may feel fi ne for weeks or months, but then relapse because they have not enough medication in their body to keep them from relapsing. Unfortunately, medication may have long-lasting side effects, including a peculiar move- ment disorder called tardive dyskinesia involving strange facial move- ments and hand movements. These long-term side effects can be reduced if a lower dose of medication is taken. If patients live in a calm household with predictable routines, then they can usually manage on a lower dos- age of medication. You can help with medication by • fi nding out the person’s medication regime • reminding them to take their medication • praising them or thanking them for managing the illness by taking medication. SCHIZOPHRENIA 491 Family meetings may help with Support and the Reduction of Stress Family meetings help you to help the family member with schizophrenia to feel supported and understood. It also helps you to learn how to reduce stress in his or her life. With high support and low stress, fewer relapses will occur and less medication will be needed. The key to high support is to show you understand, communicate clearly and calmly; and follow the guidelines given above. The key to stress reduction is to make home life calm and predictable. You can help by • making simple daily routines and following these • making small changes in daily routines one at a time • deciding on all changes in a calm way • communicating clearly and simply about any changes • avoiding criticism • avoid letting the person with schizophrenia know that you are worry- ing about him or her. Most People with Schizophrenia can Live an Independent Life Schizophrenia is a chronic condition like diabetes. Most insulin-depen- dent diabetics, if they take their insulin, live relatively independent lives. The same is true for most people with a diagnosis of schizophrenia. One in four people with schizophrenia make a complete recovery from their fi rst episode and do not relapse. The remaining three out of four live rel- atively independent lives but relapses occur at times of stress or when medication is stopped against medical advice. Long-term Recovery can be Helped by Spotting Relapses before They Happen The fewer relapses a person with schizophrenia has, the better. One important job for the whole family is to learn the signs that a relapse may be about to happen. These signs may include major stresses, like a change in family routine or forgetting to take medication. They may also include changes in the person with schizophrenia’s behaviour or experiences, for example, a change in their sleep pattern, energy level, memory, capacity to concentrate, hallucinations or delusions. When you have learned relapse signs, you need to follow a relapse prevention plan as soon as these signs occur. This plan should have three parts: 1. Contact our service and request an immediate relapse prevention ap- pointment. 2. Make sure the person with schizophrenia has taken their medication. 3. Avoid showing excessive worry or criticism. 492 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS Changing Behaviour Patterns: Communication and Problem- Solving Skills Sessions After the psychoeducational sessions the family are invited to use further sessions to refi ne their ways of communicating and solving problems so that routines may be developed that make family life predictable and calm. In communication skills training, family members are coached to fol- low the guidelines set out in Chapters 9 and 14. Family members may be invited to discuss a particular issue, such as how the next weekend should be spent, with view to clarifying everyone’s opinion about this. As they proceed, the therapist may periodically stop the conversation and point out the degree to which the family’s typical communication style conforms to or contravenes the guidelines for good communication. All approximations to good communication should be acknowledged and praised. Alternatives to poor communication should be modelled by the therapist. Typically, there are problems with everyone getting an equal share of talking time with the symptomatic family member usually get- ting the least. Often messages are sent in a very unclear way and listeners rarely check out that what they have understood is what the speaker in- tended. It is important not to criticise family members for such errors but to praise them for successive approximations to clear communication. With problem-solving training, family members’ specifi c goals may be listed and an order for addressing them agreed starting with the least challenging. Big problems should be broken down into smaller problems, and vague problems should be clarifi ed before this prioritising occurs. Families have a better chance of achieving goals if they are specifi c, visu- alisable and moderately challenging. In prioritising goals it is important to explore the costs and benefi ts of goals for each family member so that ultimately the list of high priority goals are those that meet the needs of as many family members as possible. Common goals for families in which young adults have schizophre- nia include: arranging exclusive time that the parents can spend together without their symptomatic young adult; arranging ways in which young adults can take on some age-appropriate responsibilities, such as meeting friends, cleaning their own clothes; managing money; ensuring that they have private living space free from parental intrusion; and taking medi- cation regularly. For couples, goals may include spending enjoyable time together with a minimum of interference from the symptoms; or reducing the degree to which the non-symptomatic partner shows their worry and concern to the partner with schizophrenia. Family members are asked to select the least challenging goal or prob- lem and use the guidelines for problem-solving given in Chapter 9 to solve it. This attempt is observed by the treatment team or therapist. Feedback on problem-solving skills that were well used is given and alternatives to poor problem-solving skills are modelled by the therapist. SCHIZOPHRENIA 493 Common pitfalls for family members include: vague problem defi ni- tion; trying to solve more than one problem at a time; and evaluating the pros and cons of solutions before all solutions have been listed. The latter is an important error to correct, since premature evaluating can stifl e the production of creative solutions. Often families need to be coached out of bad communication habits in problem-solving training such as negative mind reading where they attribute negative thoughts or feelings to others, blaming, sulking and abusing others. At the end of an episode of prob- lem-solving coaching, family members typically identify a solution to the problem, they are invited to try out this solution before the next session and a plan is made to review the impact of the solution on the problem in the next session. It is always important to review such tasks that clients have agreed to do between sessions. Once problem-solving skills have been refi ned they may be used to solve major structural problems. Where one parent has been shouldering the burden of care in managing a young adult with schizophrenia, problem solving may focus on helping both parents share the load more equally and strengthen the boundary between themselves and the symptomatic young adult, so that the youngster can move towards independence and the parents can spend more time with each other in a mutually support- ive relationship. In single parent families, problem-solving sessions may be used to help the parent develop supportive links with members of the extended family and broader social network and strengthen the bound- ary between the single parent and the young adult with schizophrenia. In couples where one member has schizophrenia, problem-solving may be used to explore ways in which the couple can gradually develop strategies for creating episodes in which they minimise the intrusion of psychotic symptoms into their relationship. Transforming Belief Systems: Reframing and Externalising Problems Parents and partners of people with schizophrenia may believe that they are responsible for the illness and feel intense guilt. This guilt may lead them to become intrusively over-involved or highly critical of their family symptomatic member’s unusual behaviour. All family members experi- ence grief at the loss of the way the ill family member used to be before the onset of the symptoms and also a sense of loss concerning the hopes and expectations they had for the future, which must be modifi ed. Part of the role of therapist is to help family members express these emotions, but in such a way that the critical, over-involved or despairing presentation of the emotions is minimised. The psychoeducational ses- sions, by helping family members understand that much of the patient’s unusual behaviour is not motivated by malicious intentions, goes some 494 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS way to help parents reduce criticism. Reframing statements about emo- tional states made by family members is a technique that can be used to minimise the negative impact of intense emotional expression. For ex- ample, if a family member expresses criticism by saying: I can’t stand you. Your driving me crazy. this may be reframed as: It sounds like you really miss the way ABC used to be and sometimes these feelings of loss are very strong. If a family member expresses over-involvement by saying: I have to do every thing for you because you can’t manage alone. this may be reframed by saying: It sounds like you fi nd yourself worrying a lot about ABC’s future and wondering if he will be able to fend for himself. In response to statements like: You make me so miserable with your silly carry-on. Sometimes I think what’s the point. a reframing may be offered as follows: When you see ABC’s symptoms, it reminds you of how he was before all this. Then you fi nd your mood drops and this sadness and grief is hard to live with. All of these reframings involve labelling the emotional experience as aris- ing out of underlying positive feelings that the non-symptomatic family member has for the symptomatic family member. The reframings also describe the emotions as arising from the way the non-symptomatic fam- ily member is coping, rather than being caused exclusively by the symp- tomatic person. That is, they give the message that the non-symptomatic family member owns the feeling, they are not imposed on the non-symp- tomatic family member by the symptomatic family member. Reframing is a process that occurs throughout therapy rather than being covered in a couple of sessions. Where family members lose sight of the fact much of the unusual and distressing behaviour arises from the illness – schizophrenia – not the family member, they may be invited to externalise the illness and join forces in preventing it from destroying their relationships. This is a SCHIZOPHRENIA 495 particularly useful intervention when working with couples. Here are some questions that may be used when making this intervention. Can you give an account of those times when you have both been stronger than the schizophrenia and prevented its symptoms from intruding into your relationship? What ways have you found for pushing the symptoms of schizophrenia out of your relationship so you may enjoy each other’s company? Relapse Management Signals that may herald relapse, such as the build-up of life stress or the occurrence of prodromal symptoms, may be discussed during the disen- gagement phase of therapy. Plans for reducing stress, increasing medica- tion and avoiding catastrophic interpretation of symptoms may be made. Plans for booster sessions may also be discussed. A critical issue is the de- velopment of a simple and clear relapse management plan, which should involve immediate contact with the therapy service and an immediate family meeting. SUMMARY Schizophrenia is conceptualised in major classifi cation systems as a debilitating psychological disorder with a prevalence of about 1%. It is characterised by positive symptoms, such as delusions, hallucinations and thought disorder, and negative symptoms, such as impaired social functioning and lack of goal-directed behaviour. Family-based stress has a marked impact on individuals genetically vulnerable to schizophrenia when it occurs in the absence of protective factors, such as coping skills, social support and appropriate levels of antipsychotic medication. In view of this, it is not surprising that the treatment of choice for schizophrenia and related psychotic conditions is multimodal and includes antipsychotic medication coupled with psychosocial interventions, such as marital or family therapy, which aim to reduce family stress, enhance coping and mobilise social support. Integrative models of schizophrenia, which take account of interactional behaviour patterns, cognitive processes and belief systems, and both genetic and developmental vulnerabilities, offer a com- prehensive systemic framework from which to conduct such multimodal therapy. Good premorbid functioning, an acute onset and a clear precipi- tant are all associated with a better outcome. A better outcome occurs for females rather than males and in individuals from families in which there is little psychopathology. If there are additional affective features or a family history of affective disorders rather than schizophrenia there is a better prognosis. In effective marital and family therapy programmes for 496 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS schizophrenia emphasis is placed on blame-reduction, the positive role family members can play in the rehabilitation of the family member with schizophrenia and the degree to which the family intervention will alle- viate some of the family’s burden of care. These programmes include psy- choeducation, communication and problem-solving skills training and a variety of techniques, such as reframing, externalising the problem, and so forth, to address problem-maintaining belief systems. Effective pro- grammes also include sessions on recognition of prodromal symptoms and the development of a clear relapse management plan. FURTHER READING Falloon, I., Laporta, M., Fadden, G. & Graham-Hole, V. (1993). Managing Stress in Families. London: Routledge. Kuipers, L., Leff, J. & Lam, D. (2002). Family Work for Schizophrenia – A Practical Guide, 2nd edn. London: Gaskell. Kuipers, E. & Bebbington, P. (2005). Living with Mental Illness, 3rd edn. London: Souvenir Press. Part V RESEARCH AND RESOURCES [...]... (Brent et al., 199 7; Cottrell, 2003; Harrington et al., 199 8a; Harrington, Whittaker & Shoebridge, 199 8b; Lewinsohn, Clarke, Hops & Andrews, 199 0; Lewinsohn et al., 199 6, Moore & Carr, 2000b) Effective family therapy and family- based interventions aim to decrease the family stress to which the youngster is exposed and enhance the availability of social support to the youngster within the family context... show that family therapy is more effective than other treatments in engaging and retaining adolescents in therapy and also in reducing of drug abuse (Cormack & Carr, 2000; Rowe & Liddle, 2003; Stanton, 2004; Stanton & Shadish, 199 7) Family- based therapy is more effective in reducing drug abuse than individual therapy, peer group therapy and family psychoeducation Furthermore, family- based therapy leads... 2002; Sandler et al., 199 2) Such programmes focus on: engaging families in treatment; assessing and understanding the context of the loss; acknowledging the reality of the death; modifying the family s worldview so that it incorporates the loss; facilitating problem solving and reorganising the family system, and moving on With respect EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 515 to practice, ... during family therapy sessions Silver, Williams, Worthington 516 RESEARCH AND RESOURCES and Phillips ( 199 8) found that a treatment programme based on Michael White’s narrative therapy externalising procedure was more effective than traditional behavioural programmes for soiling (White & Epston, 198 9) In this type of family therapy, the soiling problem was externalised and defined as distinct and separate... approaches Family therapy can also be effectively combined with other individuallybased approaches and lead to positive synergistic outcomes Thus, family therapy can empower family members to help adolescents: engage in treatment; remain committed to the treatment process; and develop family rules, roles, routines, relationships, and belief systems that support a drug-free lifestyle In addition, family therapy. .. drug problems and the family therapy associated with this, and then framing invitations for resistant family members to engage in therapy so as to indicate that their goals will be addressed and feared outcomes will be avoided (Santiseban et al., 199 6; Szapocznik et al., 198 8) Once families engage in therapy, effective treatment programmes for adolescent drug abuse involve the following processes which,... families has evolved from the structural and strategic family therapy traditions (Haley, 199 7; Minuchin, 197 4) Effective family therapy in cases of adolescent drug abuse helps family members clarify communication, rules, roles, routines, hierarchies and boundaries; resolve conflicts; optimise emotional cohesion; develop parenting and problem-solving skills; and manage lifecycle transitions Multisystemic... with attentional and overactivity problems (Nolan & Carr, 2000) Multimodal programmes typically include stimulant treatment of children with drugs such as methylphenidate combined with family therapy or parent training; school-based behavioural programmes; and coping skills EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 505 training for children (MTA Cooperative Group, 199 9) Family- based multimodal... into adolescence and adulthood are parental conflict and violence; a high level of intrafamilial and extrafamilial EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 507 stress; a low level of social support; and parental psychological adjustment problems such as depression or substance abuse Reviews of current outcome studies indicates that functional family therapy and multisystemic therapy are currently... the effectiveness of family therapy and family- based interventions for the following problems, which occur during childhood and adolescence, will be considered in this section: • physical child abuse and neglect • conduct problems • emotional problems • psychosomatic problems EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 501 Physical Child Abuse and Neglect Child abuse and neglect have devastating . V RESEARCH AND RESOURCES Chapter 18 EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY An important question for clinicians and service funders is, ‘What type of family therapy approaches and practices. school-based behavioural programmes; and coping skills EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 505 training for children (MTA Cooperative Group, 199 9). Family- based multi- modal programmes. features or a family history of affective disorders rather than schizophrenia there is a better prognosis. In effective marital and family therapy programmes for 496 FAMILY THERAPY PRACTICE WITH