Hong Kong J Psychiatry 2005;15:101-102


Advanced Family Work for Schizophrenia: An Evidence-Based Approach

Author: Julian Leff.
Gaskell (Royal College of Psychiatrists), London, 2005.
US$35.00; pp 100; ISBN: 190467 1276

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This book is a companion volume to Family Work for Schizophrenia, the second edition of which was published in 2002. In this slim volume, Professor Julian Leff has distilled 19 anonymised case histories from the comprehensive records of about 150 families discussed during his supervi- sion of family work for psychosis with mental health teams in North and South London. The 19 families chosen illus- trate the most difficult problems encountered by the teams

in the past 10 years. In most of the families discussed, the patients have a diagnosis of schizophrenia, but there have also been cases involving manic-depressive psychosis, and a few with other psychiatric conditions. The importance of family work in the treatment and prevention of relapse of schizophrenia is stressed.

This book is written in plain English and is thus easy to comprehend. The book consists of 9 chapters, followed by a list of references quoted in the text and an index. The professionals involved in the case histories (therapists under the supervision of the author) represent all of the dis- ciplines present in community health teams, such as nurses, psychologists, psychiatrists, social workers, occupational therapists and psychiatric assistants. This book is therefore not only relevant to the practice of doctors, but also to those of allied health care professionals working on the family of people with psychosis.

In Chapter 1, the introduction to the book, the author gives an important message that persistent effort is required in family work for psychosis. The follow-up period of the 19 families described ranges from 3 to 30 months, with an average of 12 months. The author mentions that in some instances, families and the therapists working with them reach a plateau; that is, they advance to a certain stage and then seem to lose their impetus. This can happen when symp- toms subside and there is a return to a more normal state. The author emphasises the need to move the work to a new phase by focusing on obtaining employment, promoting and sustaining outside relationships and enhancing the patient's self-esteem.

The problems represented by these illustrative families have been grouped under 7 headings (Chapters 2 to 8) for easy reference. Each family is described in detail, followed by a summary of the presenting problems, the formulation and the suggestions of the author. The follow-up progress and intervention at the subsequent session of the family work are illustrated with further recommendations by the author. The work for each family is analysed at the end by the author for its failure, successes and lessons learned. The methods of intervention are supported by evidence and some up-to-date references are included.

In Chapter 2, the author stresses that 'culture clash' can happen between the family and the wider society as well as within the family, hindering the family work for psychosis. When migrant groups come into contact with the host culture, there are a number of ways in which they can at- tempt to accommodate to the situation. One way is to strive to preserve their traditional cultural values. In working within these families, the author emphasises the need to be sensi- tive to cultural norms concerning communication. In Chap- ter 3, family work for people with a "psychotic illness and a physical condition" is discussed and this combination of phy- sical illness and psychosis is likely to engender over-involved and over-protective attitudes in carers. Over-involvement and over-protectiveness are common in Chinese families and this chapter is particularly relevant to our daily practice. It is essential to recognise that over-involved carers are doing what they believe to be the best for the patient and are de- voting a huge amount of time and energy to the task, which often becomes the centre of their lives. The author gives us an important message that therapists should be extremely careful to avoid the carer feeling that they are being criticised and displaced from their role.

Chapter 4 illustrates the work for families with "more than one member suffering from psychosis". Such families are relatively common in the clinical setting, and the author stresses the necessity to appreciate that the experiences and needs of the individual affected members are often very different, even when they have the same diagnosis. Their needs are shaped partly by their personalities and partly by the life stage during which the illness appears. Interestingly, a Hong Kong family that migrated to the UK is used as an illustrative example for family intervention in this chapter.

In Chapter 5, families with "parents in a conflictual re- lationship" are described and the term "emotional divorce" of parents affecting the well-being of the patient is explained. In "emotional divorce", the couple does not communicate with each other in family meetings and shows no physical closeness, greatly hindering the work on the family. Chap- ter 6 mentions the technique in dealing with "dysfunctional families" in which severe disruption of family roles and relationships is prominent. Chapter 7 describes how "unre- solved past traumas" such as childhood sexual abuse lead to a sense of shame or intense anxiety which are often concealed from others in the patient's family. Chapter 8 explains the way to deal with "exploitative carers" who may take advantage of the patient's vulnerability for their own benefit. In Chapter 9, the author shares some his experi- ences in doing family work, a particularly useful part of the book. He mentions that sometimes therapists feel like giving up when faced by a difficult family that seems to be stuck, and believes that a support group for therapists engaged in family work is essential. The most valuable contribution a therapist can make is to give the families and patients hope.

As I read this book, I noted that some of the patients illustrated are similar to those we encounter in daily practice, despite some families being quite different because of the cultural differences between the UK and Hong Kong. The detailed histories and follow-ups constitute a useful learn- ing experience for both skilled therapists and novices en- gaged in family work involving patients with psychosis. Moreover, with the increasing emphasis on physchotherapy and family work for patients in the training of psychiatrists, this book is useful and practical, especially for those pre- paring for the UK professional examinations.

Dr Siu Wei Man, Bonnie MB ChB, MRCPsych (UK),
FHKCPsych, FHKAM (Psychiatry)
Castle Peak Hospital
Tuen Mun
New Territories, Hong Kong, China


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