The family and therapy

The term family therapy can be misleading. ‘Family’ is open to many interpretations, if not attacks, because it is frequently read as implying a two-parent, heterosexual couple with two children, with the woman primarily the ‘homemaker’ and the man the ‘breadwinner’, with occasional backup from the grandparents. Such a picture would seem to marginalise or exclude other family forms, such as childless couples, single parents with children, gay or lesbian couples and unattached elderly persons. However, the reality is that family therapists treat many different forms of committed relationships and friendships. As to the term therapy, it tends to imply the presence of illness or dysfunction, located in the family rather than one of its individual members, and may thus be quite unacceptable to families who often believe that it is the patient and not them whom requires help. Being at the receiving end of family therapy can have strong connotations of blame. Practitioners therefore increasingly use the term systemic therapy, which is also more informative because some of the work often involves the wider system. The systemic approach is essentially a contextual approach – seeing and treating people in context.

It is entirely possible that most readers will have been ignorant of community rehabilitation orders with or without requirements of psychiatric treatment until reading the article by Clark et al (2002, this issue). It is valuable as an educational article and is applicable to the work of both general adult and forensic psychiatrists.

Solution-focused brief therapy is an approach to psychotherapy based on solution-building rather than problem-solving. It explores current resources and future hopes rather than present problems and past causes and typically involves only three to five sessions. It has great value as a preliminary and often sufficient intervention and can be used safely as an adjunct to other treatments. Developed at the Brief Family Therapy Center, Milwaukee (de Shazer et al, 1986), it originated in an interest in the inconsistencies to be found in problem behaviour. From this came the central notion of ‘exceptions’: however serious, fixed or chronic the problem there are always exceptions and these exceptions contain the seeds of the client's own solution. The founders of the Milwaukee team, de Shazer (1988, 1994) and Berg (Berg, 1991; Berg & Miller, 1992), were also interested in determining the goals of therapy so that they and their clients would know when it was time to end! They found that the clearer a client was about his or her goals the more likely it was that they were achieved. Finding ways to elicit and describe future goals has since become a pillar of solution-focused brief therapy.

Over the past century war and organised violence have led to the displacement of large populations and threatened or resulted in genocide of many ethnic or cultural groups. Although many people are internally displaced within their own country, some flee and seek asylum in other countries. The United Nations High Commission on Refugees (UNHCR) defines a refugee as someone who:

Homeless families are defined as all adults with dependent children who are statutorily accepted by local authorities (housing departments) in the UK, and are usually accommodated for a brief period in voluntary agency, local authority or housing association hostels. This period varies from a few days to several months, although the target for rehousing is usually around 4 to 6 weeks. Some housing departments, particularly in London, also use bed and breakfast accommodation.

The terms ‘clinical audit’ and ‘clinical governance’ elicit a variety of responses, including boredom, frustration, incomprehension and, rarely, enthusiasm. This paper sets out to persuade the reader that clinical audit, as an integral component of clinical governance, will be reborn as an activity that clinicians will find interesting, developmental and a useful part of their everyday clinical practice. Under clinical governance, clinical audit will at last be able to achieve important and measurable improvements in patient care as a matter of routine.

‘Security holds the key’ was the title of a newspaper article concerned with e-commerce (D. Sumner-Smith, The Sunday Times, 6 February, 2000, p. 3.13). However, it applies just as readily to the health sector. The need to safeguard the confidentiality of information that patients share with clinicians is as fundamental as the principle of consent. This issue has come to the fore in the context of the rapid developments and applications of information and communication technologies within society in general and within the health sector in particular. There are also changing societal expectations regarding access to information, confidentiality and disclosure. The emerging scenarios present significant challenges in relation to the traditional methods used to deal with the privacy and confidentiality of personal information (Anderson, 1995). In addition to the impact of new technologies, consideration also needs to be given to the impact of changes in health care organisation and practice, for example multidisciplinary and multi-agency working. Mental health services are in many respects at the vanguard of these changes, where the ideals of community care, shared care and seamless care depend fundamentally on good communication and information sharing. Failures in communicating information, particularly across sectoral boundaries, have led to significant problems in patient care, as revealed in several recent enquiries into homicides (Northamptonshire Health Authority & Northamptonshire Social Services, 1999)

Depressive disorders are more common in patients with physical illness than in those without, with up to one-third of medical in-patients reporting mild to moderate symptoms of depression (Rodin & Voshart, 1986). Some medical conditions have a stronger association with psychiatric illness than others, for example the prevalence rates of depressive illness in patients with diabetes, cardiac or neurological disease is about 25%, but not much more than the general population in those with hypertension. Medical in-patients are more likely to have depression than are out-patients. There are a number of potential factors that may contribute to this increased risk of depression in people with physical illness, as outlined in Box 1.

In the first two articles of this series (Williams & Garland, 2002; Wright et al, 2002), we looked at the different areas of human experience that alter during times of mental illness. The Five Areas Assessment model (Williams, 2001; see also Fig. 1 of Williams & Garland, 2002) provides a clear summary of the range of problems and difficulties faced by the individual in each of the following domains:

1. 1 life situation, relationships, practical problems

2. 2 altered thinking

3. 3 altered emotions (moods or feelings)

4. 4 altered physical feelings/symptoms

5. 5 altered behaviour or activity levels.

Knowledge management sounds superficially like yet another of those topical expressions describing something that has been developed outside medicine and is possibly ill-suited for application within the field, but offering an excuse for yet more change. However, one of the distinguishing features of every profession is that it applies a body of specialist knowledge and skills to a defined purpose. Knowledge in medicine is growing exponentially. In a recent survey of just 22 general practices, the practice guidelines identified weighed 28 kg (Hibble et al, 1998)! In psychiatry, about 5500 papers which potentially have clinical relevance are published annually. Keeping pace with knowledge as it grows is a major challenge for all clinicians. This is reflected in the National Health Service (NHS) information strategy, which identifies three specific needs of clinicians (NHS Executive, 1998). These are:

1. • fast, reliable and accurate information about patients in their care;

2. • access to knowledge to inform clinical practice;

3. • access to information to underpin evaluation of clinical practice, planning and research, clinical governance and continuing professional development.

As the arsenal of antidepressant drugs increases with time so, concurrently, does the list of caveats that must be considered when using these agents in patients with other physical illnesses and using other medications. MacHale's (2002, this issue) overview of the management of depression in physical illness serves as a crucial update for clinicians providing psychiatric services for patients with comorbid physical illnesses. Appropriate emphasis is placed on the usefulness of non-pharmacological treatments in such patients, although the reality of modern practice is that drug treatment is most often considered first-line owing to limited psychological service resources.