Utilizing Family Strengths and Family Resources at MultiLevels: A Journey of Developing Contextually

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Utilizing Family Strengths and Family Resources
at Multi-Levels A Journey of Developing
Contextually Relevant Knowledge for Family
Centered Social Work in Hong Kong

• Joyce L. C. Ma
• Professor Chairperson
• Department of Social Work
• The Chinese University of Hong Kong

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Content of todays Presentation

• Reasons of working with families of the mentally
  ill
• My journey of developing socially relevant and
  culturally specific knowledge
• Discussion and recommendations

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Reasons of working with families of people with
mental illnesses

• Shift of views toward families of people with
  mental illnesses
• Families as a pathology in 1960s and parent
  blaming to
• Families as resources and full partners in
  psychosocial management from 1980s onwards

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Relationship between family atmosphere and
relapse of schizophrenia

• Relationship between family expressed emotion and
  relapse confirmed at two year follow-up in an
  English study (Brown, Birley Wing, 1972)
• High emotional expressed families (HEE)
• Low emotional expressed families (LEE)

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Relationship between family atmosphere and
relapse of schizophrenia

• HEE families 58 relapse rate
• LEE families 16 relapse rate
• Emotional climate of the family
• Criticism
• Hostility
• Emotional involvement
• Warmth
• Positive remarks
• Contact hours less than 35 hours per week (Vaugh
  Leff, 1976)

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Cross-cultural applicability

• Mexican-American families
• Chandigarh, Northern India
• 90 LEE
• Respond to the breakdown of family members
• Tolerance
• Sadness
• Not anger
• Not hostility as in the West

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Insights of the study

• Importance of socio-cultural context
• Socially relevant and culturally-specific
  knowledge for Chinese families in Hong Kong

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Problems and difficulties experienced by families
of the mentally ill

• Spillover effects of childhood disorders (e.g.,
  autism, ADHD) on parents and families
• Divorce rate is in the 80 range in families with
  children with autism spectrum disorder
• Maternal depression common for mothers with ADHD
• Mother with a child suffering from ADHD in a
  problem-solving context more controlling and
  hostile than mother with a normal child
• Burden of Chinese families in caring people
  diagnosed with schizophrenia (Chan, 1993 Sun,
  1994 Wong, 1991 2000)
• Objective burden and subjective burden equally
  heavy
• High psychosocial distress of caregivers
• Family functioning less healthier (Sun, 1994)

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Problems and difficulties experienced by families
of the mentally ill

• Burden of caregiving equally heavy for parents
  with young people suffering from eating disorders
• United Kingdom (Treasure, Murphy, Szmukler, Todd,
  Gavan Joyce, 2001)
• Germany (Graap et al., 2008)
• Hong Kong (Ma, 2008)
• Family work done in the past
• Mutual help groups for psychotic patients and
  their families (Ma, 1986)
• Self-help groups across several social service
  agencies providing psychiatric rehabilitation
  (Ma, 1992)

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Knowledge gap

• Insufficient studies on practice knowledge in
  utilizing family strengths and family resources
• Heightened awareness on importance of involving
  father in mental health services but professional
  engagement of the father was limited

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Definition of Family Centered Service Delivery

• Family-centered service delivery, across
  disciplines and settings, recognizes the
  centrality of he family in the lives of
  individuals. It is guided by fully informed
  choices made by the family and focuses upon the
  strengths and capabilities of these families
  (Allen Petr, 1996 p. 68)

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Concept of Family in Traditional Chinese culture

• ?
• A pig under the roof

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Meaning of Marriage in Ancient China

• ??
• Looting of women in the evening

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Meaning of Woman in Ancient China

• ?
• A person kneeling down
• Woman be submissive, subordinate and subjugate to
  men
• Imbalance of power between men and women in
  Chinese families

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My journey began when I was a social worker in
mental health services in a general hospital

• Continue developing the knowledge as a social
  work academics in the university

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Applicability of structural family therapy for
Chinese young people suffering from anorexia
nervosa in Hong Kong and Shenzhen

• Adaptation of the Micuccis Model (1998) to the
  Chinese Context
• Integrated four theoretical perspectives
• Psychodynamic
• Feminist psychodynamic
• Socio-cultural
• Family systems

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Essential Family Processes in Families with ED

• Isolation and conditional acceptance
• Control versus genuine connection
• Symptomatic cycle
• Three processes interwoven with each other
  (Micucci, 1998)

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Treatment Principles

• Focus on identifying constricting family process
  that has maintained the symptoms of ED
• Ultimate goal
• Assist the emaciated young person and the parents
  to interrupt the symptomatic cycle of
  interactions
• Cultivate a holding environment for recovery

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Treatment Steps

• Redefining the problem and negotiating the
  contract
• Encouraging parental collaboration
• Addressing unresolved conflicts
• Handling relapses
• Supporting individual development and
• Supporting the transformation (Micucci, 1998)

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Modification of the Model in a Chinese Context

• Enrichment of the cultural perspective
• Definition of family, jia (?) for family
  assessment
• Mainzi (??), face to identify hidden messages of
  the emaciated young person and to allow gracious
  exit of individual family member/s in refusing to
  deal with the family conflicts
• Motivating and engaging the ambivalent young
  person in treatment
• Working on other family problems (Ma, 2008)

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Results of our study

• Chinese emaciated children and adolescents
  benefited from family treatment and routine
  psychiatric treatment
• Treatment effect changes on patients
• Excessive concern over body shape
• Personality characteristic of perfectionism
• Change in the six dimensions of the level of
  psychological distress is statistically
  insignificant but clinically significant
• Symptomatic to functional range (Ma Lai, 2009)

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Change in parents marital quality

• Mean scores of our sample lower than the norms
  gathered by Shek (1995)
• Marital quality poorer in terms of marital
  satisfaction than adjusted Chinese couple (Ma
  Lai, 2009)

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Subjective experiences of the parents

• Family therapy beneficial
• Create a social context for them to iron out
  their difficulties in coping with AN
• Resolve disparity in refeeding the emaciated
  daughter
• Provide strong emotional support
• Instill hope (Ma Lai, 2006)

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Patients perspective

• Learn the pains and suffering of their parents as
  great as her own suffering
• Emotional support
• Parents
• Siblings
• Therapist (Ma Lai, 2006)

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Path of changes in the eyes of a young person
with AN and parents in Shenzhen

• Mother-daughter conflicts
• Coming back of the disengaged father and active
  involvement in the care of the emaciated young
  person
• Triangulation of the young person into the
  couples conflict
• Therapists intervention to assist the family to
  interrupt the symptomatic cycle
• Change in parenting methods
• Parents assisted patient to expand the scope of
  life
• Patients recovery (Ma, in press)

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Contributions of our studies

• Family therapy applicable for young people with
  an ED
• Outcome research
• Hearing the voices of the young person and her
  families
• Succeeded to develop ways to engage the
  previously uninvolved father in parenting and
  care of the young person with an eating disorder

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Contributions of our studies

• Identify the symptomatic cycles and shift the
  family attention from the symptom to the
  symptomatic cycles that have impeded the parents
  collaboration and the patients recovery
• Foster the positive forces for change (e.g.,
  active involvement of the father in parenting and
  care of the patient)
• Help family to interrupt the symptomatic cycles
• Support
• Advice
• Creation of the holding context to resolve the
  conflicts
• Help parents to assist the patient to expand her
  scope of life

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Contributions of our studies

• Track the process of change to fill the knowledge
  gap
• Shed light on the critical roles played by the
  therapist in treatment

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All in the same boat A preliminary study of the
program outcome of social network project in a
deprived community in Hong Kong

• Tin Shui Wai, A City of Sorrow and Sadness

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Tin Shui Wai

• geographically isolated area
• majority residents are new arrivals, low income,
  low educational level, underemployment and
  unemployment
• weak social network
• residents are not familiar with community
  resources

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FAMILY AMBASSADOR PROJECT

• Collaboration between our centre
• ELCHK, Tin Shui Wai Integrated Youth Service
  Center
• Financially supported by a private fund

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FAMILY AMBASSADOR PROJECTObjective

• To mobilize residents in the community, develop
  their potentials and capability as peer helpers
  and foster mutual help and support in the
  community to minimize social isolation and social
  exclusion

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Training of the Family Ambassador
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Roles of the family ambassador

• Promote the concept of family mental health and
  develop strength perspective of family
• Share own family story and ways to face life
  adversities
• Introduce the community resources to the
  residents
• Mobilize the residents to utilize the community
  resources

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Closing Ceremony
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Project efficacy

• 64 FAs registered and 61 (95) FAs complete the
  project
• FAs outreach 381 (average 6.24) friends,
  relatives and neighbors to promote the message of
  family mental health,
• FAs outreach 270 (average 4.4) friends, relatives
  and neighbors to introduce and mobilize them to
  use community resources

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Service efficacy

• 58 FAs give written feedback after the completion
  of the project
• 49 FAs(85) like to be family ambassador
• 51 FAs(88) more involve in community and
  concern the needs of others
• 54 FAs (93) are willing to continue the service
  

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Service efficacy

• Focus group was held in January 2008.
• 9 FAs participated the meeting
• The results showed that the project has positive
  impacts to individual, family and community.

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Participants feedback

• Individual Level
• Positive thinking
• Optimistic
• Feel blessed
• Positive self-image
• Improve self-confidence (Ma, Wong Cheng, 2009)

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Applicability of Multi-Family Groups in Hong Kong

• The practice team of our center

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Model development

• Implemented since March 2008 to presence
• Qualitative Research
• Pre and post in-depth interview to gather the
  experiences of the participant families
• Review of the group process
• Documentation of family responses toward
  different types of activities and skills
• Total 23 families attended the multiple family
  group, 5 groups were conducted (1 for adolescents
  with school problem, 2 for children with learning
  problems, 2 for children with ADHD)

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Issues addressed in model development

• Content of the group ?
• Frequency ?
• Composition
• Clientele specific
• Problem specific
• Types of group activities
• Process versus content
• Intervention efficacy

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Discussion

• Commonality across the three projects
• Family-centered practice
• recognizes the centrality of he family in the
  lives of individuals
• Guided by the fully informed choices made by the
  family and
• Focuses upon the strengths and capabilities of
  these families (Allen Petr, 1996 p. 68)
• Positive feedback and appreciation from the
  families

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Discussion

• Flexible use of research methods
• Hearing voices of the service users
• Pre- and post-treatment individual and conjoint
  interviews
• Review of the treatment videotapes with consent
• Focus group interviews
• Reflective thinking and synthesis of practice
  knowledge
• Peer discussion
• Conference presentation
• Academic writing

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Discussion

• Navigating upstream to face the barriers of
  family work
• A lack of physical space in which to meet the
  families
• No mandate to provide family care (i.e., lack of
  reward or recognition for family work)
• Long working hours of Hong Kong low-income
  families
• Dominant discourse of parent-blaming in general
  and mother-blaming in particular
• Lack of professional competence and confidence

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Recommendations

• Venues for continued professional sharing and
  discussion on family work
• Supportive agency policy
• Family centered service model
• Physical space
• Incentives and reward for good family practice
• Staff training, professional development and
  supervision
• Flexible office hours

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END OF PRESENTATION

• THANK YOU VERY MUCH