Keywords

Introduction

“Both clinical experience and research tell us that the therapeutic alliance between staff, children and their parents needs to be positive if the child is to have a good chance of making progress during the course of their admission”(Gross & Goldin, 2008). Family therapy plays an integral part in the recovery process and has a beneficial impact on the lives of adolescents and their families by improving functioning and quality of life (Merritts, 2017). For these reasons, family therapy is an essential part of the Walker Unit treatment programme delivered in conjunction with other treatment modalities. Our aim is to support the young person and their entire family system to change, so that a therapeutic discharge into a modified (improved) home environment can occur. Groundwork for family therapy is laid during the admission process described in Chap. 4. It begins with the assessment meeting at the mental health facility (if they are an inpatient) or at the local community mental health centre. To emphasise the importance of engagement by all family members, we require, from the outset, the participation of all family members living in the same household.

Family Therapy

The Walker Unit family therapy frame consists of weekly sessions. Sometimes the treating team will meet with a subset of the family (for example only the siblings) for specific therapeutic goals. For families who live a great distance from the unit we offer a hybrid of face-to-face and virtual meetings. Virtual meetings have also been used extensively during the COVID pandemic (see Chap. 20). We offer divorced or separated parents the option of being seen separately. For therapeutic reasons they may, however, be required to attend sessions together on some occasions.

A co-therapy approach is taken with sessions led by the consultant psychiatrist and a psychologist or social worker. The psychiatrist in training assigned to the patient is also a member of the family therapy team. Sessions may also be attended by the patient’s primary nurse, and by students on clinical placement. Therapy can follow several different approaches, such as structural, systemic and multigenerational with consideration given to the underlying capacity demonstrated by the family to engage in the therapeutic process.

The main task of the first session is to construct a genogram which includes information about the quality of the relationship between members, personality traits/ characteristics, hobbies and interests, employment status, legal issues and education. Special attention is given to parental upbringing, past domestic violence, serious family illness, migration, traumatic events such as deaths, suicide and abuse as well as physical and mental health history. The process enables us to identify patterns of behaviour and relationships across generations. Figure 8.1 provides an example of how a genogram is recorded.

Fig. 8.1
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Example of a genogram

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Constructing the genogram may take one or a several sessions and remains a resource we refer back to throughout treatment. We build on the genogram work by obtaining a developmental history of the patient. Obtaining a clearer understanding of early childhood experiences and how the young person and family managed transitions from preschool to primary school to high school, provides insight into the evolution of the patient’s difficulties and how the family system has responded. As part of this exploratory process, family members are invited to share their thoughts and opinions on what they would like to see change or be different. A key aspect of this exercise is the building of an effective therapeutic alliance (Goplolan et al., 2010) which is necessary to hold and contain the family during difficult stages of the work, particularly when the young person is experiencing a set-back in their recovery. The family’s level of engagement and participation in the genogram exploration helps guide our treatment approach, as those who demonstrate openness, spontaneity and some reflective capacity are the most suitable for systemic work.

Ongoing sessions consist of both therapeutic exploration as well as the discussion of more practical matters such as medication changes, voluntary/involuntary admission status and weekend leave arrangements. However the main focus remains on the systemic process such as ongoing work on improving communication within the family, helping the family to problem solve difficulties arising during leave (self-harm, suicide attempts, absconding), and helping the parents to work collaboratively, re-instating the hierarchy (de-parentification of the identified patient). After one month of admission, the family is provided with a preliminary treatment plan that offers detailed information on the presenting issues, goals of treatment and estimated discharge date (see Chap. 5 for more detail). Care is taken to go through the plan with the patient and their family in a collaborative manner. All members are encouraged to give honest feedback with specific consideration given to anything that needs to be added or changed. In further sessions, we work with the family on systemic and relational goals that have been observed to contribute to the evolution of the young person’s difficulties or that play a part in perpetuating unhelpful dynamics.

A home visit is conducted at least once during the period of admission. The aim is to meet the family in their own environment to get a better sense of what it is like for the young person to be at home; it affords an opportunity to learn things that are not readily accessible by meeting the family on the unit. It can provide a rich source of information surrounding the level of emotional and physical care available which is often observed through how warm and welcoming the environment is. This includes levels of basic cleanliness, how light or dark the place is, whether there is sufficient and appropriate furniture and so on. It also gives information on the neighbourhood, proximity to community resources and the school, whether the household is permeable (drop in visits from neighbours, relatives) or impermeable (seemingly isolated). Moreover, we get to see and interact with the pets, we see artworks produced by the children stuck on the fridge door and other personal effects such as family photos that tell stories we wouldn’t otherwise know. Even the car journey with the young person can be very informative as we get to listen to their music and discuss matters that would not be discussed at the Unit. Home visits also allow for the therapy team to acknowledge the weekly effort made by families and provides an opportunity for us to meet with other members who have been unable to attend sessions in the hospital. This may be due to anxiety and avoidance, physical/mental illness or other practical matters such as work.

Leave is introduced in a gradual manner (see Fig. 8.2); owing to safety concerns, a young person’s home and community leave may have to be reduced or ceased. A central task of the Walker family therapy process includes the reintroduction of leave in a gradual and safe way. The home visit sets the groundwork for this process. In situations where there is high anxiety regarding leave at home, a visit can provide a necessary first step of exposure. Usually, the psychiatrist, family therapist, registrar and nurse attend the home with the young person and act as a containment team to buffer interactions with the family, and assist with any risk issues that might emerge for example, the young person absconding or engaging in self-harm. An important part of the family therapy at this stage includes assisting the family and young person to problem-solve difficulties that emerge, exploring how reactive responses may be contributing to the escalation of conflict and supporting members to tolerate challenging behaviours and difficult feelings aroused as a part of the leave. A family chain analysis may be conducted to better understand interactional sequences contributing to dysfunctional dynamics, thereby bringing awareness to unconscious patterns of behaviour and overall areas of being stuck. At times, it becomes necessary to support members to adjust their expectations regarding the amount of change that is possible within the scope of the admission, for example accepting a reduction in the level of serious self-harm rather than self-harm ceasing altogether.

Fig. 8.2
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Stages of leave

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In sessions, a variety of techniques can be used to gather information and to encourage members to reflect on their experiences such as role play, use of a white board, using figurines and drawings. Every effort is made to amplify family strengths and the positive changes that members are making, no matter how small. Tracking these changes across the admission can be helpful in assisting members to recognise their achievements and to observe the skill building that has developed over time. In the case of a young person being under the care of the Minister and living in an Out of Home Care arrangement, the family therapy team works closely with the carers and child protection case managers to support them in the safe transition back into their care.

School Integration (See Also Chap. 7)

Once the young person’s mental state has stabilised we begin exploring appropriate educational options for the young person. This can often involve applying to a school for specific purposes (SSP) for specialised emotional and educational support. When a suitable pathway has been identified the Walker teacher and treating team meet with the school (if possible in person) to discuss the young person’s needs and put together an integration plan. The family and young person also attend this meeting and equally contribute to the plan that is put in place. Much like home leave, attending an outside school is considered leave within the community and an integral part of the overall treatment programme.

Discharge and Handover

Throughout the young person’s admission, the treatment plan is periodically reviewed by the family and team to monitor progress and make necessary adjustments. This treatment plan includes the estimated discharge date and the decision if this should remain the same or change, depending on the young person’s progress and level of engagement in the programme. As discharge draws nearer it becomes vital that we prepare the family for this reality, and ensure that there is sufficient time within the therapy to effectively discuss concerns, and examine any remaining work that needs to be done.