The Role of Family Therapy in Mental Health

Charlotte EngelbrechtUniversity of KwaZulu-NatalSouth AfricaIFTA, Slovenia, March 2009

Introduction• Mental health is not only the absence of mental disorders and

emotional discomfort• Mental health is a multi-dimensional construct including people’s

– Intellectual well-being• Their capacity to think, perceive and interpret adequately

– Psychological well-being:• Believe in own self-worth and abilities

– Emotional well-being• Affective state of mood (Petersen: 2008)

• Social well-being– Ability to interact effectively in social relationships with other people and

the environment• Spiritual well-being

– Ability to express meaning of life in relationship with self as well as God (or “Higher Power”) (RAU: 2000)

Primary Health Care

• Alma Ata declaration 1978– Primary health care

• Mechanism for achieving health for all in low to medium income countries

• Goal :– Providing integrated health services (including mental health)

within walking distance from each person’s home– Eradicating poverty– Reducing child mortality – Improving maternal health– Achieving universal primary education– Combating diseases with pandemic effects (HIV, Malaria,

Cholera).– Mental health not an isolated goal, but an important undertone

in all the above

Mental illness , physical illness and poverty

• “Poor mental health deepens poverty” (Petersen, 2008)

• Poor mental health increase a persons vulnerability for risk behaviours with increasing effect on physical health

• Socially destitute families are influenced – Limited access to resources– Individual and family underdevelopment– Lack of positive experiences, – Chronic exposure to stressful environments– Disengagement from civic life (Rojano: 2004)

Context: KwaZulu-Natal, South African

• Research on experiences of families living with mental illness shows 1.Families experiences with schizophrenia (Mohlahle, et al.

2003)

• Different ways in handling and effected by the illness of their member.

– Some families low tolerance levels – Critical– Hostile objecting negatively to what ever the sufferer says or does.– Other families opposite– Extreme reaction with high tolerance – Too caring and accepting – Overprotective– Showing understanding of the mental illness of the family member– Perpetuate the “sick role” – Taking over the responsibility of mental ill member

» Alleviating stress» Hoping that family member will become well again

Context (cont)

2. IsiZulu families living with Severe Mental Illness

– Caring for Mentally in the community includes• Challenges of the Burden of Care• Challenges embedded in the community life

– Extreme poverty – High vulnerability to

» crime » Stigma

– Multiple family responsibilities– Lack of social support

• Within a neo-liberal governmental system of public health

(Engelbrecht, 2008)

Family therapy

• Research produced evidence – family therapy

• an effective intervention to provide care and facilitate care to families living with mental illness (Tilden, 2008).

• was associated with a decrease of $586 in general medical costs through other treatment.

• the total indirect effect of family intervention on hospitalization costs and general medical costs were also in the hypothesized direction and showed that a one unit increase in family therapy was associated with a $796 and $580 savings, respectively (Christenson, Crane, & Hillin: 2008)

Family Therapy in South Africa• Still family therapy is not widely known or practiced in

Mental Health Services• In South Africa, family therapy is only practiced by health

care specialist who qualified as on masters and PhD level: – not registered as family therapist, but in profession of origin (e.g.

psychology, social work, psychiatry , psychiatric nursing, pastoral therapy)

– in pockets of health care but not as a standarized method of choice in all services

• Little family therapy teams are available in the community (as opposed to private practice) of KwaZulu-Natal– Human resources

• Staff shortage social work, nursing and psychiatry– Financial resoures

• Funding for occupational therapy and psychotherapy limited

Family therapy in the community

• To use family therapy as tool for both health promotion and illness prevention

• Family therapy as we know it traditionally should be moulded and applied to the needs of the resource poor settings

• Family therapy should move from glamorous five star settings with one way mirrors and video technology to the community setting, to the shacks, to the long rows in community health clinics

• Family therapy should exchange her ballroom dress and dancing shoes for working clothes and ground herself in the core of every day community life

Professional alignment

• Family therapy should be acknowledged as a skill and profession of its own in South Africa.

• Decentralising and deconstructing discources of difference in the professional groupings.

• Enforcing the strength of family therapy teams by putting emphasis on interdisciplinary team work (Tilden: 2008)

Training

• Capasity building by increasing training of all professional groups in the primary health care teams to participate in some levels or to some extent in the therapeutic team process – E.g. collaborative work between family therapists and general

practitioners– Including psychiatric nurses, (advanced psychiatric nurse

certificate) (Smith: 2008), pastoral councelors social workers occupational therapists into these collaborative teams

– community health care workers and community volunteers (working with NGO) to

• Identify and to report symptoms of mental illness • Identify vulnerable families • Give psycho-education on mental illness and mental health to the

community in general• Assisting in holistic care of the families in need (physical, medication

compliance, emotional suport

Community Awareness

– National Mental health day: • activities of family therapy psycho-education• De-stigmitizing and unmasking myths about mental illness in

the communities (being cursed, spiritual misinterpretations, labeling and disabling use of language)

– Networking with NGO’s and participating with NGO’s in community development projects

• referring families for skills training and • work opportunities • other resources (soup kitchens, recreation and sport)

– Negotiating and encouraging the development and implementation of community support structures,

• like support groups, • day centres and consumer groups, • accomodation and • reintegration in social activities.

Inovation• Inovative application of the rich family therapy models into a cultural

compatible and cultural acceptable way• Sensitivity to the multicultuaral and multilingual nature of the South

African society • Implementing the inovative family centered intervention stategies in

the communities– E.g. inovative implementation of family therapy in

• The family home (less intimidating and ‘Western for our indiginous cultural groups)

• Use of multfamily therapy strategies• Use of narrative theatre (Sliep)• Use of community development strategies to empower and educate

communities • Evaluate family centered activities in the community

– generate evidence–based practice and measuring outcomes of interventions scientifically

Research• International and national research

projects supporting and evaluating the inovative process necessary for the interventions mentioned.

• The effect of research projects • A raise in awareness and knowledge of

family therapy in • the society • Community of care• Governing bodies

– country – professional boards

South Africa with vast spacesParticipation in community activities

Language and Terminology development

Encouraging Small business

Local seamstress

Home visits

Barriers of family therapy interventions in the community

1. Overwhelmed by the needs of families– Physical,

• “I am ill, I have too much to do to care for this brother”

– Emotional• Feelings of anger, blame, helplessness and hopeless

– Intellectual• “he (son with mental illness) refuses to go back to school”

– Economic• “I do not have a job, my grant for child care expired, I anm

living on the mercy of the church and others˝

– Spiritual levels• “ God is punishing me”

Strategy to overcome

• Identifying core problems with the family, prioritising the problems and ensure the team give attention to needs on different levels (Tilden: 2008; Sliep)

Barriers

2. Language and cultural• isiZulu speaking clients • Mixed teams with English dominance• Cultural practices and processes in families

hidden to the “outsider”

Strategy to overcome

• Multilingual teams

• Presentation of a cultural consultant – (Just therapy)

• Use of interpreters trained in the family therapy process

Barriers

3. Perceived and real danger:

• The townships around Durban (and South Africa) are known for the prevalence of violent crimes like high jacking of vehicles, armoured robbery.

• “Strangers” are not encourage to go to the area by themselves

Strategy to overcome• Building relationships within the community as a

compationate listener (Weingarten) and a co-author (White) of community stories

• Make sure you know exactly where you are going and do not get lost

• Use a guide from the area if you do not know your way• Decrease your own vulnerability by avoiding the display

of valuables• Network with the police services and other organisations

within the community• Ensure that the local governing leaders know you are

working in the area.

Barriers

• Finances and physical area to use as a venue

• Strategy to overcome:– Fundraising strategies (e.g. reserach and

community development grants)– Networking with NGO’s that are already

involved in the community

Questions or comments?

Reference list• CHRISTENSON, J. B., CRANE, D. R. & HILLIN, H. H. (2008) Family Intervention and Health

Care Costs for Kansas Medicaid Patients with Schizophrenia. Kansas, Brigham Young University Topeka, Kansas

• ENGELBRECHT C (2008) experiences of families living with mental illness in an African community. Paper delivered at the International Social Work Association conference, 2008, Durban, unpublished

• MOHLAHLE, S. J., CALITZ, F. J. W., VAN RESBURG, P. H. J. J., VERSCHOOR, T., JOUBERT, G. & NEL, M. (2003) The family system of Schizophrenic state patients compared with other schizophranic patients. Acta Criminologica, 16, 10-18.

• PETERSEN, I. (2008) Mental Health for all in South Africa? from science to service. Inaugural lecture. University of KwaZulu-Natal, Durban, unpublished

• RAND AFRIKAANS UNIVERSITY (RAU) SCHOOL OF NURSING (2000) Theory of health promotion and illness prevention. Johannesburg, Rand Afrikaans University

• ROJANO, R. (2004) The practice of Community Family Therapy. Family Process, 43(1)

• SMITH, A (2008) Family therapy assignment, UKZN: Durban unpublished

• TILDEN, T. (2008) Integrative Practice: presentation of an inpatient family therapy program. Journal of Family Psychotherapy, 19, 379-403.

• WEINGARTEN

• WHITE