Getting families into the ACT

A report by LYNNE ROBERTS, Nurse Consultant at North Glamorgan NHS Trust in Merthyr Tydfil, South Wales.

Involving families in mental health services has been recognised as an important factor in the promotion of recovery for people with severe and enduring mental health needs. The ACT team (Addysg a Chymorth Teuluol – that is, Family Intervention Service) in North Glamorgan has introduced the behavioural family therapy model (BFT) as a structured form of family intervention specifically for families who have experienced psychosis.

The BFT model of family intervention

This model was originated in 1998 by the Meriden Programme in the West Midlands (see www.meridenfamilyprogramme.com) and has spread sporadically across the UK. The key principle of the approach is to work collaboratively with the family, recognising and developing their unique strengths and expertise to promote more effective outcomes for the family as a whole. The family intervention includes:

assessment of individual and family needs
information and sharing of knowledge about the illness
recovery and relapse management planning
communication skills training
problem solving and other techniques that promote positive results within the family unit.

Findings from evaluation

The ACT team has supported over 90 families in the past five years and recently undertook an evaluation of the service by exploring the families’ experiences of the intervention.

Overall, families and service users recognised the positive effects gained from the intervention and cited these key areas of development:

better understanding and knowledge about the illness and how best to manage behaviour and symptoms as they arose
feeling more empowered to regain control over their lives
communicating better within the family
increased involvement in care planning
increased optimism about the future
better relationships forged with mental health service providers.

Among the comments from families:

“It helped us feel more relaxed about L’s illness. In the beginning I worried about how it was affecting the children and felt stressed out all the time. I didn’t want them to notice that anything was wrong. But the family workers got it out in the open and even included the children. I didn’t want that at first, but they were right – it’s brought the family back together again.”

“It brought us together; we are a close family, but when L became ill we never talked or supported each other as we would have before. We tended to keep things to ourselves.”

Those who participated in the study felt the components of family intervention were essential to how they engaged as a family. They valued the combination of information sharing, communication skills and problem solving, and they reported that this had assisted in the family feeling more comfortable with each other and able to provide a better level of support.

Other family members supported this:

"I think the problem solving sessions were good for us – it was easier for Nick to tell us things in front of the family workers than it was to tell us on our own – having someone ‘independent’ appeared to allow him to tell us his real feelings about things. The practical steps we took to discuss and get over problems made us work together to solve things – often some very basic solutions.”

“If I had received the right help from my GP in the beginning, it never would have got so bad. But I can’t blame him – he didn’t seem to have a clue about mental illness. Do they cover it in their training?”

“I thought talking about the illness was a good thing because we hadn’t spoken much about my illness or what was wrong with me all together. I think for me to talk about my feelings and experiences openly in front of my parents helped them to understand what I was going through. I would often not show how I was feeling or try and cover things up when I felt bad. I didn’t want to show my parents that I was finding it difficult to cope. I felt confident to do this in the meetings.

Findings from the study also identified that what families had felt helped them engage more effectively with the family intervention team, suggesting how “staff qualities” were crucial in developing trust that promoted the family to connect more with services.

The timing of the family contact was also important and depended upon which stage of the illness or recovery the family were at. For example, families most in need of support appeared to be at “crisis points”; other families proved more reluctant to engage when things were gong well for fear of upsetting things again.

Families reported feeling “ignored or excluded” by services in the past, but felt that the focus of family work assisted in them having a more positive experience of inclusion and collaboration.

Families were also able to make recommendations about how services could be developed and improved in the future, indicating that more “family sensitive training” and “mental health awareness” could be provided to other services such as primary care, inpatient services, and employment and benefit agencies. This could help promote inclusion in earlier intervention with the right services and care planning. Families, who had been made to feel “more of a hindrance rather than a resource” by services felt that awareness raising and training might improve this.

Involving families in staff training was also felt to be key in “getting the message across to staff” to promote engagement between families and service providers.

In summary

The evaluation of the experiences of families in the BFT programme has indicated a very positive experience with clear gains attributed to the components of the model. This suggests that the BFT model is proving to be effective, thus supporting the continued service provision to ensure all families are offered formal family intervention, as recommended by NICE for anyone who lives with or is in close contact with a person who has schizophrenia.*

Family intervention should also be provided regularly over a minimum period of six months, allowing the family to connect with staff and engage effectively in meaningful activity promoting the recovery model.

It appears that there are some clear training needs in raising awareness for staff in key areas of the service such as primary care and inpatient units. This would include the “needs of the family” in relation to feeling supported, listened to and understood. Families also need to be more directly involved in care planning, particularly when relating to leave and discharge arrangements.

Families used in training have already proved to be an effective and powerful resource. Staff have fed back positively about such training by finding the “families’ voice and experiences” of benefit when reflecting upon current organisational practices.

The ACT team has also found the continued support of Grainne Fadden and the Meriden Team essential for the ongoing development and maintenance of the service. Networking has offered a chance to share new ideas and fully embed BFT as an effective evidenced practice.

* National Institute for Clinical Excellence (2002) Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care (NICE guideline), London: NICE.