The Place of Systemic Interventions in Psychiatry

1
The Place of Systemic Interventions
in Psychiatry

• Eia Asen, M.D., FRCPsych
• Consultant Child Adolescent
  Psychiatrist
• Consultant Psychiatrist in
  Psychotherapy
• Marlborough Family Service
• London NW8 OPJ
• Swansea 10th June 2005

2
Types of Interventions in
Psychological Medicine

• Intra-personal
• Biological
• Psychodynamic
• Cognitive-Behavioural
• Inter-personal
• Systemic

3
The Individual in ContextLevels of Intervention
4
From Family Therapy to Systemic
Intervention

• The family as site of intervention?
• Who is the patient?
• What is the family?
• Therapy for the family?
• Systemic Interventions are aimed at
• - blocking dysfunctional interactions /
  communications
• - activating and encouraging new interactions /
  communications

5
Systemic approaches

• Structural
• Strategic
• Milan systemic
• Social constructionist
• Narrative
• Brief solution-focused
• Psycho-educational
• Behavioural

6
Evidence Base for Systemic Interventions in
Psychiatry

• Type I evidence (at least one good systematic
  review, including at least one RCT)
• schizophrenia, depression, alcohol
  dependency,
• children conduct disorder, anorexia nervosa
• Type II evidence (at least one good randomised
  controlled trial)
• adult anorexia nervosa, marital and family
  distress,
• children asthma, enuresis and encopresis
• Type III evidence (at least one well designed
  intervention study without randomisation)
• bi-polar disorders, anxiety disorders
• Type IV evidence (at least one well designed
  intervention study)
• various disorders
• Type V evidence (expert opinion, including the
  opinion of service users and carers) various
  disorders

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Examples of Systemic Interventions

• Couple
• Family
• Multi-Family
• Social Context
• Professional System

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Systemic Couple Interventions evidence base

• London Depression Intervention Study
• (Leff et al 2000)
• RCT CBT vs PAT vs Antidepressants
• Partner Assisted Therapy
• Significant reduction in depression both at end
  of treatment and on 2 year F.U. (BDI)
• more acceptable than CBT and medication (low
  drop-out rates)
• No more expensive than medication

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Systemic Couple Therapy for Depression

• - Depression conceptualized as an interactional
  event contextual processes maintain or
  reinforce symptoms
• - Depression of patient affects the partner
  and partners responses affect patient and
  depression
• - Depression is 3rd person in relationship
• - Partner graduates from informant to being
  part of it
• - Reducing EE
• - Enacting and re-solving familiar couple issues
• - Experimenting with new interactions (homework)

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Phases of Systemic Couple Therapy in Depression

• First Phase Problem and Solution-focused
• Second Phase Examining long-term relationship
  patterns
• Third Phase Relapse Prevention

11
Family Work with Persons with schizophrenia
and other psychosis

• Ingredients
• Educational Sessions for Family
• Relatives / Carers Groups
• Single Family Sessions

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FAMILY PSYCHO-EDUCATION

• Single Families Format
• 1) Formal Problem Solving
• 2) Communications Skills Training
• 3) Relatives groups
• Reduce stigma
• Relieve the carer burden
• Reduce EE in key relatives
• Develop empathy
• Expand social network
• Anderson Leff Falloon Goldstein
  Miklowitz

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MULTIPLE FAMILY THERAPY

• Laqueur et al.1960s
• Group Therapy Family Therapy
• sheltered workshops of communication
• meeting other families
• learning by analogy
• improved communication
• less constraint on therapist

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Marlborough Multi-Family Model

• Family Day Unit for Multi-Problem Families
• whole days for weeks to months, since 1977
  psychotic parents
• Family School for excluded and marginalised
  pupils and their families half days for months,
  since 1981 psychotic parents teenagers
• In vivo real life situations
• Clinicians as convener, catalyst and stage
  manager, connecting families with families
• Provides context in which resources and strengths
  are emphasised

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Families as consultants to other families

• Experienced families engage new and sceptical
  families, offering hope
• Families support each other and reflect on their
  own process
• Families observe and comment on unhelpful
  patterns they see in each other
• Families provide a network of support for
  isolated families outside of the programme
• Families provide a resource for each other to
  help prevent relapse

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Multi-Family Group Psychodeducation (McFarlane)

• Joining
• Minimum of 3 single family sessions
• Educational Workshop
• whole day
• Ongoing MFG
• - Fortnightly 90 min
• 5 8 patients and families
• 2 clinicians

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Mental Health Matters Workshops (Cooklin)

• Survival skills workshop (educational not
  therapeutic)
• one off events, repeated 6 weekly, open
  group
• Each workshop theme-oriented diagnosis,
  treatment, voices groups, young carers
• formal presentation
• small groups discussions
• reflections plenary
• mid-workshop evaluation
• joint lunch
• small group discussions / events
• closing plenary
• Various groups constellations, incl. single role
  groups
• patients only, carers only, professionals only
• Aim cross-family, cross-generational

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Marlborough Psychotic Adults Multi-Family
Workshops / Discussion Groups

• 7 families containing psychotic member
• Single Family Preparation
• Initial Whole Day Workshop
• Fortnightly Meetings (2 hours)
• 1 year
• 4 staff (psychiatrist, CPN, family therapist)
• all systemically trained - to guarantee
• presence of at least 2 at each MFG
• meeting

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MFG activities

• Whole group discussions
• Sub-group discussions (carers only, patients
  only)
• Specific problem solving
• Playful exercises (sculpts, collages, genograms)
• Reflecting teams
• Lunch and tea

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Themes

• Illness and its course, specific crises
• Early relapse signs and prevention
• Medication adherence, alcohol and substance
  misuse
• Illness and management and coping strategies
• Partner issues
• Parental concerns vs intrusiveness and
  over-protection
• Emotional reactions
• Social networks
• Space giving and limit setting
• Work Issues
• Young carers
• Living and leaving home issues

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Work with Social Context / Professional Network

• Working with neighbourhood and friendship
  network aim to identify and foster a close
  confiding relationship
• work within culture-specific / religious
  framework
• coordinate professionals inputs via network
  meetings which include all significant adults

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Framing Multiple Family Group Work

• Ingredients of introductory speech
• Welcome
• if you look around you can see that you are not
  alone
• there are plenty of other sufferers and their
  families, many of whom have experienced social
  isolation, stigmatization, increased financial
  and psychological burden
• today we are meeting to compare notes, what
  works and what doesnt work when living with the
  illness

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Framing Multiple Family Group Work (2)

• we will also want to talk about whats known and
  whats not known about the illness
• the illness has many causes, its multi-factorial
• what we do know is that without the intensive
  involvement of families, there is a much greater
  chance of relapse
• we need you families to help the ill person
• we have found that the more information people
  have, the better equipped they are to deal with
  problems as they occur
• we hope that families and sufferers can talk to
  each other, get advice. Feel free not to talk
  about anything that you dont wish to

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Framing Multiple Family Group Work (3)

• if there is someone here who has participated in
  a workshop programme, well ask you to talk about
  it
• we will want to know about familiar dilemmas,
  issues and problems and find ways of discussing
  these and re-solve some
• we would like people to introduce themselves. And
  to say one or two things about who they are and
  what makes them tick. Many people probably want
  to talk about the illness and the problems it
  presents. We will get to that later, but for now
  we want you to say something about the rest of
  your life and the kind of things you and your
  family are proud of. I could start by telling you
  a bit about myself (then turns to the next
  person)
• later we shall talk about how mental illness has
  changed our lives

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The Problem Solving Process

• Aim to define, address and solve illness related
  issues
• Step 1 Defining the problem
• (the problem is the problem the person is
  never the problem)
• How has the illness affected each family member
  since we last met?
• Typical issues conflicts and disagreements
  compliance with medication substance abuse life
  events safety issues outside agency events
  daily living skills finding and keeping
  employment.
• Circular and reflexive questioning of the
  problem, to narrow it down, make it more
  concrete and place in an interactional frame.

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• Step 2 Generate and list all possible solutions
• All group members are encouraged to contribute,
  without evaluating or discussing these in this
  round
• Step 3 Discuss advantages and disadvantages
  (pros and cons) of each in turn
• Eliminate specific suggestions

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• Step 4 Choose the solution that best fits the
  problem
• Family is asked which of the solutions they would
  like to test over next 2 weeks
• Step 5 Plan how to carry out this solution
• A very detailed plan is developed, involving real
  and hypothetical scenarios
• Step 6 Review implementation
• This is done at a follow-up meeting

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The Individual in ContextLevels of Intervention
29
Work with Social Context / Professional Network

• Working with neighbourhood and friendship
  network aim to identify and foster a close
  confiding relationship
• work within culture-specific / religious
  framework
• coordinate professionals inputs via network
  meetings which include all significant adults

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Systemic Interventions in Psychiatry

• Multi-level
• Multi-contextual
• Multi-family
• Multi-perspective
• Multi-modal
• --------------------------------------------------
  -
• Systemic skills
• Context Reading
• Context Making
• Context Managing