The Family and Schizophrenia: Recovery and Adaptation

International Journal of Mental Health ISSN: 0020-7411 (Print) 1557-9328 (Online) Journal homepage: https://www.tandfonline.com/loi/mimh20 The Family and Schizophrenia: Recovery and Adaptation Nick Kates & Jan Hastie To cite this article: Nick Kates & Jan Hastie (1986) The Family and Schizophrenia: Recovery and Adaptation, International Journal of Mental Health, 15:4, 70-78, DOI: 10.1080/00207411.1986.11449044 To link to this article: https://doi.org/10.1080/00207411.1986.11449044 Published online: 04 Sep 2015. Submit your article to this journal View related articles Citing articles: 1 View citing articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=mimh20 Int. 1. Ment. Health, Vol. 15, No.4, pp. 70-79 M. E. Sharpe, Inc .. 1987 THE FAMILY AND SCHIZOPHRENIA: RECOVERY AND ADAPTATION NICK KATES AND JAN HASTIE When a person develops schizophrenia, the effect on his or her relatives can be devastating; the family may be faced with many new challenges and difficulties. Family members have to understand the illness and its possible outcomes, adjust to the accompanying deficits or problem behaviors, cope with with feelings of anger and guilt, come to terms with a number of losses, rework long-term family plans and aspirations, deal with changes in family relationships, and find support from key people in their environment. Preexisting problems in family transactions or functioning may be exposed or exacerbated by acute or continui!1g crises; and family members' developmental tasks, such as separation or independent living, may become more difficult. The distress and personal anxiety felt by other family members can contribute to such problems, and the family may be unaware of the helping resources that are available within its own community. Families need support, information, and understanding to help them handle the problems associated with schizophrenia in one of their members [1], but they often fail to receive the necessary response at the right time. When working with families in such situations, the therapist needs a coherent conceptual model to enable him or her to understand not just what a family is going through but also how family members' reactions may change as they move through the various stages of adapting to the The authors are, respectively, Assistant Professor and Clinical Lecturer in the Department of Psychiatry, McMaster University, Hamilton, Ontario, Canada. Requests for reprints may be addressed to Dr. Nick Kates, c/o E.R.M.H.S., 615 Britannia Ave" Hamilton, Ontario, Canada L8H 2A5, This paper was presented at an international symposium on "The Future of the Mentally III in Society," held under the auspices of Enosh, the Israel Mental Health Association, in Jerusalem in 1983. 70 THE FAMILY AND SCHIZOPHRENIA presence of schizophrenia in a relative. This, in turn, will affect the timing of specific interventions or programs. We have identified five separate, although overlapping, stages a family passes through from the initial onset of the problem and symptoms to eventual adjustment and growth, and we shall here consider the tasks the family and the therapist face at each stage. Underlying principles in work with families Work with families can have three different components: therapy (dealing predominantly with dynamic or systems issues), education, and support. Although the three often overlap, it is important to be able to separate them in order to identify the families' specific needs. There are, however, some important therapeutic principles that should underlie all work with families. 1. The starting point in therapy should be based on a comprehensive assessment of the family's needs rather than on what the therapist assumes would be useful. It is necessary to take a longitudinal view of the phases of recovery and adaptation and of the therapeutic process, to perceive individual events in a long-term context. 2. Any social or cultural factors that may affect a family's views of, or response to, the illness or therapy-views or responses that often are misinterpreted as indifference or resistance-need to be taken into consideration during the assessment. 3. The family needs to be fully and honestly informed of all procedures and treatments and their implications. 4. The therapist must be able to recognize which facets of the family system are most amenable to change. He or she also needs to know when not to intervene or expose the family to a treatment or program it is unprepared for or may not want. 5. The family should be provided with an acceptable and serviceable concept of what schizophrenia is, but oversimplified explanations should be avoided. If a family has been informed at some stage that schizophrenia is solely the result of a biochemical disturbance and that the only treatment is medication, this can be a major stumbling block to attempts to work on wider issues with the family. 71 NICK KATES & JAN HASTIE 6. The family should be encouraged to take responsibility for setting its own realistic, short-term and long-term goals. 7. The therapist must realize that he or she may serve multiple functions with the family, including explaining, teaching, assessing, supporting, interpreting processes, comforting, and possibly celebrating, and must decide which functions he or she wants to take on and which he or she may wish to hand over to someone else. It is important that the respective functions be clear and that the therapeutic approach be consistent. 8. The focus with families should be on coping with practical problems and issues as they learn new behaviors and solutions to problems, which they try out between therapy sessions. 9. Over time, the aim should be to shift a family's main support systems from medical to nonmedical services. To achieve this, the therapist needs to be aware of the alternative resources that are available within the community. 10. The family should be taught how to anticipate potential crises and what to do if they occur. 11. The therapist needs to be clear and realistic about his or her availability. Family members can feel let down when a therapist tells them to call any time and then is unavailable when they do, especially since crises often occur outside office hours. The therapeutic process There are four steps in the therapeutic process: engaging the family, building an alliance, active treatment, and termination. Although most attention is paid to the active treatment component [2], the other three steps can be vital to the success of a therapeutic strategy. Engagement The process of engaging a family is often overlooked, but it is the key to building a therapeutic alliance and to successful treatment. Engagement refers to the process by which the family and the therapist come to a common or shared view of what the problems are and what they should be doing. This is the starting point of all work with families. 72 THE FAMILY AND SCHIZOPHRENIA The alliance The alliance involves the family and the therapist's working together to achieve common goals. Sensitive issues need to be addressed, but family members are more responsive if they think the therapist is on their side, especially if they have had previous unfortunate experiences with psychiatric services. If this has been the case, the therapist does not need to feel defensive or to justify what has taken place, but should allow family members to express their frustration or hostility and demonstrate a respect for their feelings by listening. If a family is already feeling helpless or guilty, the therapist must avoid giving the impression that anyone is being blamed or castigated for what has happened. Termination Termination is always a key part of the therapeutic process, particularly with a family that is hard to engage. Sometimes, if family members appear uninterested or fail to follow through with the therapy, for whatever reasons, there is a tendency to dismiss them. It is useful, h0wever, to see termination with one service or therapist as being part of a continuing therapeutic process, which can pave the way for future interventions when the family may be more receptive. Rather than reject the family that is unwilling to participate in therapy, it may be worthwhile to meet with family members to let them know their decision is being respected, but also to convey the idea that the next time they have problems, they may want to reconsider getting help as a family. Instead of increasing a family's alienation or sense of injustice, one thus leaves the door open for a return without loss of face. Phases of therapy A family's needs, understanding, and reactions change as the illness or episode progresses, and the therapeutic tasks of the early crisis are very different from those of later stages of recovery, even though the underlying principles are the same. To be able to help families, one must therefore differentiate their needs and responses, and therefore the work that needs to be done and the most suitable intervention, according to the phase of recovery and adaptation the family has reached. 73 NICK KATES & JAN HASTIE Families usually pass through five separate phases, each of which presents different tasks and problems that the family has to cope with. In general, these correspond to the stages of individual recovery outlined by Dawson and co-workers [3], and it is important to utilize a family model that is congruent and consistent with individual therapy or case management. These five phases are crisis, acceptance, adjustment, growth, and anticipation. Crisis A crisis arises when attempts to contain or manage the patient's behavior or symptoms no longer work. The family's needs and responses will vary depending on whether this is the first or a subsequent episode and on its familiarity with, and acceptance of, the presence of schizophrenia. The therapist has to complete a comprehensive assessment and begin to build an alliance with the family members, who need to understand why they are being seen without feeling they are being interrogated or blamed at a time when they are feeling vulnerable or possibly guilty. The therapist needs to have a clear understanding of the purpose of the family session, and should avoid making premature interpretations that might ahenate the family or reinforce maladaptive behavioral patterns. The therapist must be sensitive to what family members may be going through, encourage them to ask questions or to bring thoughts or feelings into the open in a nonrecriminative atmosphere, and fully explain any hospital or clinic procedure that is being used. A time of crisis is not usually the best time for the family to worry about making major long-term decisions; decisions that can wait should be postponed until the crisis has subsided and everyone involved has a better understanding of the problems. The family's social support system should be assessed to see what resources are available to help it through the crisis should the need arise. Even if hospitalization is necessary, the organization of community resources and building the alliance should begin as soon as possible. Acceptance Acceptance is the phase in which family members come to terms with what has happened to their relative and themselves and understand its 74 THE FAMILY AND SCHIZOPHRENIA implications. This can include accepting the presence of a long-term and possibly debilitating illness, learning about schizophrenia and the problems it can pose, and beginning to perceive the impact the illness is having on the family system and its individual members. It may take two or more episodes or hospital admissions for some families to reach this stage of acceptance. Denial and a "clutching-at-straws" as the family searches for any hope may be a natural, not a pathological, reaction. The family needs help in examining and dealing with some of its losses, especially lost hopes or aspirations and other affective responses. As family members become less preoccupied with the immediate crisis, one can explain the illness in more detail, describing the deficits and behaviors that may be expected and thus helping the family develop an acceptable concept of schizophrenia. This is often a good time to discuss the possible social stigma of schizophrenia and the reactions of others, and to help the family redefine its goals. Reading material may be very useful, and contact with other families that have been through the same experience may be helpful. Adjustment During the adjustment phase, the family begins to examine changes it may have to make and develops new ways of coping. This may be a suitable time to address any family-systems issues that may have been exposed or created by the illness. If indicated, more active, interpretive family psychotherapy may be attempted. This is also a time to teach new coping responses, behaviors, and ways of dealing with deficits. These new skills should be practiced, individually and/or collectively, as they are being learned. Role-playing is a very helpful technique for teaching families and individuals new ways of handling day-to-day situations. The family should learn how to recognize any signs of a possible recurrence of schizophrenia, and the therapist should clearly define his or her availability in these situations and inform the family about alternative resources at hand. In general, support should be practical, helping the family with goal-setting. And there should be a shift in it from medical services to other community resources and supports whenever possible. The latter may include 75 NICK KATES & JAN HASTIE the family physician, social agencies, and other families. Growth Having negotiated the earlier phases, the family can now build on its previous experiences and continue with some of the ongoing developmental tasks it faces. Some families will be able to reduce or discontinue their contact with psychiatric aid; others will find it comforting to know someone is available if needed. It is useful to see discharged families again in a prearranged, follow-up, "booster" session six months after discharge to reinforce the progress they have made. By this time the family will probably have established its primary support networks within the community, although many families will continue to remain involved with self-help groups, and some families will want, or need, to be active in providing help and support to other families. Antir;ipation It is usually difficult to anticipate the first psychotic episode, although the family may be aware at an early stage that something unusual may be happening. Once the initial episode has passed, however, and the family has begun to readjust, family members should be helped to utilize what they have learned in recognizing or preventing impending crises. Although they may be frightened or frustrated at the prospect of having to readmit their ill member, they will know what they can do when things start to go wrong. During the prodromal period, the therapist must assess any changes in family processes or interactions and look for signs of stress in family relationships that may be contributing to the developing problem and that may respond to early intervention. Similarly, stressors or potentially correctable changes in the external environment need to be recognized. The family should become familiar with the emergency or backup resources that are available if a crisis should arise, and should be encouraged to continue to utilize its support systems in the community. Timing of interventions In considering the phases described above, one must bear in mind that the experience of each individual family and the time it takes to pass 76 THE FAMILY AND SCHIZOPHRENIA through each phase will be different. Indeed, some families never progress beyond the phase of continuing crises or initial acceptance, and others resolve these issues by eventually "extruding" the family member with schizophrenia. Many families, however, adjust rapidly, particularly if their premorbid functioning was healthy and supportive. It is clear that the five phases are not completely separate or discrete, but generally overlap. Nevertheless, the major tasks of each need to be addressed before the family can deal with the next phase. This highlights the importance of the timing of a clinical intervention and the need to ensure that the family has been adequately prepared for specific treatments. For example, a group program that concentrates on reducing expressed emotion within a family, such as that described by Hastie, 1 works most successfully with families that have begun to come to terms with the presence of the illness and deficits and are ready to look at ways of adjusting to them. The primary therapist or case manager thus has an opportunity to prepare the family fully for the work of the group. Other issues that may interfere with their work in the group, such as a parent's style of communication, can be addressed concurrently without interfering with the group work. Similarly, self-help groups may be especially useful to certain families at a time of crisis and during the period of acceptance, and some families find the support group less necessary as the acute crisis recedes and they come to terms with the illness. Interventions can be designed to help engage, support, educate, or treat the family during the different phases of its recovery. For example, coping with the crisis and early acceptance can be furthered by participating in a semiformal meeting of families with an acutely ill relative at that particular time. In Hamilton, Ontario, such sessions have included a short presentation on the illness, followed by a period for questions and an opportunity for families to discuss their problems with other families in a similar predicament. The nonobtrusive presence of a therapist conveys the message that he or she is available, heightens the feeling of confidence on the part of the family, and hastens the process of engagement. Later, when families have achieved more acceptance or understandmg, the contact can be more formal and include a greater educa77 NICK KATES & JAN HASTIE tional component [4], focusing on deficits and behaviors and identifying families that may be ready or interested in other treatment programs. Conclusions In brief, we recognize that a family has multiple adjustments and changes to make when a relative develops schizophrenia. There is a certain sequence to the process of adjustment and recovery, with five separate, though overlapping, stages, each of which presents specific tasks for the family and challenges for the therapist. The model outlined here can help a therapist understand what families may be going through at a particular moment in time. This is a starting point in working with families and devising a treatment plan that meets their needs. An understanding therapist can help families to recover from what can be a devastating setback, to make the necessary adjustments and changes, to continue to fulfill their potential as a unit within their community, and, most important, to aid their ailing member in coping with his or her disorder and reentering that community. Note 1. 1. Hastie (1983) An educational support program for families in schizophrenia. Paper presented at the American Association of Partial Hospitalization's Annual Meeting, Washington, DC, August. References 1. Seeman, M., et al. (1982) Living and working with schizophrenia. Toronto: University of Toronto Press. 2. Bee1s, C., & McFarlane, W. (1983) Family treatment of schizophrenia: Background and state of the art. Hospital & Community Psychiatry, 33, 541. 3. Dawson, D., Blum, H., & Bartolucci, G. (1983) Schizophrenia infoeus. New York: Human Sciences Press. 4. Anderson, C., Hogarty, G., & Reiss, D. (1981) The psychoeducational family treatment of schizophrenia. In New developments in interventions with families of schizophrenics. San Francisco: lossey-Bass. 78