There have been substantial developments in how family work is delivered in current clinical practice, and a clear rapprochement between different family work models. Although family work is recommended in the National Institute for Health and Care Excellence guidelines for psychosis and family members in the UK have a legal entitlement to have their needs assessed, implementation of family work remains problematic. Burbach (Reference Burbach2018, this issue) provide a useful summary of contemporary family work for people with psychosis. It is helpful in conveying how family approaches have evolved and developed over time, with the old divisions between systemic family therapy and the more psychoeducational approaches becoming blurred. The flexibility of current practice is conveyed well, as is the current pragmatic and positive style of delivering these approaches. There is a good section on cultural issues, emphasising the fact that the respectful, psychologically curious and non-dogmatic nature of these approaches means that they are acceptable across cultures. The variation in what different families require is well conveyed, and the value of even brief interventions is highlighted. The extensive clinical experience and expertise of the author is evident throughout.
The article well describes the different phases of a brief family intervention and what the intervention looks like. In a way, this feels like the first step – the ‘what’ of family work. Here, I address relevant areas that are linked with clinical and organisational factors, more related to the next step – the ‘how to’.
Clinical considerations
There are many challenges that clinicians may struggle with in relation to delivering family interventions (Bucci Reference Bucci, Berry and Barrowclough2015), and guidance on the most common of these would be helpful. These include the following questions: Who should decide if family work is appropriate for this family? What if the patient does not want to engage in the sessions but other family members do? Can cognitive therapy for the patient and family work be delivered at the same time? Who should deliver family work, the care coordinator or someone else? At what point should family work start? Where should sessions be delivered?
The issue of confidentiality is one of the most challenging for clinicians delivering family work, and one on which guidance is frequently sought (Gold Reference Gold, Philip and McIver2009). The following is an example of the kind of practical guidance clinicians value to help them to deal with confidentiality conflicts.
It is generally helpful to start to have conversations with the patient about their concerns, for example, what are they worried about? Is there certain information they wish to remain private? What might be the benefits for them if their family understood more about what they are experiencing? There are many helpful articles on the topic of confidentiality that family workers can be guided to, such as Rapaport (Reference Rapaport, Bellringer and Pinfold2006) and Wilson (Reference Wilson, Pillay and Kelly2015).
Organisational considerations
Supervision
Supervision is an area that I would have liked to see emphasised more in the article, as it is essential for anyone practising family work in order to address the challenges faced and to ensure safe practice (Eassom Reference Eassom, Giacco and Dirik2014). It is essential not only at a clinical level, but is also one of the factors that facilitates implementation of family work at an organisational level.
Service issues
Although there is a very brief section on service considerations, we have known for 25 years, since Kavanagh (Reference Kavanagh, Piatkowska and Clarke1993) first highlighted the issue, that the biggest challenge in relation to family interventions is their widespread dissemination in practice. There have been publications outlining barriers to implementation (Berry Reference Berry and Haddock2008; Bucci Reference Bucci, Berry and Barrowclough2015), articles looking at factors facilitating implementation (Bailey Reference Bailey, Burbach and Lea2003; Fadden Reference Fadden and Heelis2011) and an excellent systematic review of both facilitating and hindering factors (Eassom Reference Eassom, Giacco and Dirik2014).
Anyone attempting to deliver family interventions is likely to experience setbacks, so an awareness of the challenges and what helps to overcome them will make it less likely that they will become despondent and give up. Barriers to implementation include lack of training and supervision, failure of the organisation to prioritise family work, lack of ring-fenced time and attitudinal barriers (Bucci Reference Bucci, Berry and Barrowclough2015). Facilitating factors include strong leadership and management support, developing a culture that is positive towards family work delivery, creating roles specifically for delivering family work or having family work champions, training and supervision, making family work part of routine clinical work and engaging with family members as equal partners (Eassom Reference Eassom, Giacco and Dirik2014). There is some evidence that there is less resistance to the delivery of family work than in the past, and that there has been some attitudinal shift even if the delivery of family work is still problematic (Selick Reference Selick, Durbin and Vu2017).
Future directions
Technological options to delivering family work are a possible direction for the future, and are mentioned in the article. Self-help options can also be relevant for family members who find it difficult to have time away from the home because of their caring responsibilities; for example, a ‘Caring for Yourself’ manual (Fadden Reference Fadden, James and Pinfold2012).
The article clearly has a recovery focus, and the concept of recovery for family members is developing, giving rise to interesting question such as those related to co-recovery (Fox Reference Fox, Ramon and Morant2015). For example, can family members attend to their own recovery if the patient remains unwell?
There are helpful developments around co-production (Bradley Reference Bradley2015) and carer peer support (Craddock Reference Craddock2013; Bourke Reference Bourke, Sanders and Allchin2015). It would be interesting to consider how increased involvement with family members as partners in delivering care would affect implementation challenges. This could potentially be a valuable addition to the workforce in areas where there are capacity issues.
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