Family work seems destined to be never the bride in general psychiatry, and this is despite powerful friends in the form of NICE guidelines, the National Service Framework for Schizophrenia and carer lobby groups. So a new book by the psychiatric doyen of family work for those affected by schizophrenia can only be welcome.
In 1992 in order to raise the profile of family work in general psychiatric settings, Julian Leff together with Elizabeth Kuipers and Dominic Lam published an influential and highly accessible 150-page practical guide entitled Family Work for Schizophrenia. This manual, updated in 2002, targets community mental health workers and is a rich source of advice on techniques and strategies. It also summarises the evidence that family work can significantly improve the course of schizophrenia. To date nearly 5000 copies have been sold over 14 years, an average of about three for each adult community health team in the UK. But despite this, child and adolescent services continue to hold the monopoly on family work. So the publication of a companion volume, Advanced Family Work for Schizophrenia, is a welcome reinforcement for promoting family work in adult services. But don't be put off by the title, which is misleading. This slim volume is for all mental health staff, irrespective of experience or expertise, and is only ‘advanced’ in the sense that it focuses on families with special characteristics. The complete absence of jargon and clarity of expression also make it accessible to interested relatives and lay people.
The format is simple. Of the 95 pages of this 4-hour read, 85 are devoted to case examples. These consist of 19 families seen by community mental health workers supervised by Professor Leff. For the purposes of presentation, the families are grouped into chapters according to characteristics that challenged the teams involved. These include families from minority ethnic groups (who in fact comprised 12 of the 19 families); families where someone has both a psychotic illness and a physical condition such as learning disability; families where more than one person has a psychosis; and families where the parents of the identified patient are in conflict or are separated. Other examples include families with long-standing communication difficulties and situations characterised by unresolved past trauma or an exploitative carer.
This is a thoughtful workbook of well-honed examples, full of user-friendly formulations and pragmatic suggestions informed by a lifetime of working and researching in the field. It is not about family therapy per se, but about incorporating a family perspective and selected family therapy techniques into an eclectic approach which embraces medication, education, social interventions, the exploration of loss, guilt and envy, dealing with family over involvement and criticism, and much more. Family therapy techniques such as positive reframing, recruiting the perspective of every family member, a focus on communication difficulties, exploring the meaning of key events or behaviours, and even the use of paradoxical interventions are woven into the eclectic mix. This magpie approach is beautifully illustrated in the detailed case examples. Leff's particular talent is for distilling complex situations into readily understandable themes, which then lead to often deceptively simple interventions that always manage to be respectful to those involved. Examples of this include an elderly father heavily reliant on providing care for two sons with schizophrenia, being asked to teach each son one simple thing; and the empathic observation that the most stressful vacation for a person with schizophrenia is a caravan holiday with the family, which allows no means of escape from stressful social interaction.
Although Advanced Family Work for Schizophrenia can stand alone as an illuminating source of case examples covering a range of situations, it is best read in the context of the earlier volume, Family Work for Schizophrenia, which explains the method and the evidence-based rationale.
One final point of interest to trained family therapists in particular: Professor Leff goes out of his way to distinguish between family work and family therapy. He avoids using the term therapy since he does not consider family members to be in need of treatment, preferring to see them as allies in the struggle to help the ill person. Although making it more accessible for novices, this approach dodges some of the most influential and useful ideas in contemporary family therapy, such as social constructionism, narrative and a focus on meaning systems. A challenge for volume three perhaps?
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