Mental illness and addictions: Our responsibility to support the family

Mental health and addictions is a field within the realms of social work practice that appears to be consistently growing. This article seeks to discuss the importance of social work practice with the families that come into contact with mental health and addiction services. It will also draw attention to the questions of whether social workers are effectively supporting and engaging family and how we can work alongside or in partnerships with family. It will seek to highlight the importance of having a clear understanding of the experiences of the family who have been affected by mental illness or addiction in order to more effectively work towards recovery. Note: For the purposes of this article I have chosen to use the term ‘family’ to represent two or more people who share goals and values and have long-term commitments to one another. The use of this term is not intended to exclude any other understandings or meanings.


Introduction
Mental health and addictions is and will continue to be an area of controversial associations within an interdisciplinary approach (Pritchard, 2006).But an integral part of this work is the understanding of and working within the client framework of reference for their illness and/or addiction.Therefore, there is no straightforward approach to success or recovery (Pritchard, 2006).One of the important aspects of this work, however, is the relationship developed with the family, as this has been acknowledged as a part of recovery.The active inclusion of family in the process of recovery, not only in support of the individual, also enables the individual to 'give back' to the family that may have been adversely affected during times of addiction or unwellness (UKDPC, 2007).There have been numerous references to the importance of a family-focused approach within service delivery and the evidence suggests that the focus of services remains on the individual, and families often play a very peripheral role (Copello & Orford, 2002).

Balancing the focus of the client with the needs of the family
Working with individuals who are experiencing periods of mental unwellness or addiction can be a very humbling experience.The strength and courage observed through the journey to recovery by the individuals is notable in a wide range of narratives (Barnett & Lapsley, 2006).An important aspect of this work to recovery, however, is also the courage shown by the family during the time of difficulty associated with the illness or addiction.It is very important to remember, as social workers, that although our 'client' is often identified as the individual who is unwell, the family is often just as much in need of assistance.Frequently the family's needs get overlooked as the focus can be on assisting the individual to recovery, which involves the family also playing a role in this (Mental Health Commission, 2000).
Although family involvement in recovery is important for the individual it is also important to note that the acknowledgement of the family's journey as possibly separate can assist in the expression of the needs of all concerned.Maybe not separate, as the journeys are inextricably linked, but they are in many respects parallel in their existence.The family may feel the need to 'be strong' for the individual as the individual's experiences appear so much more difficult at this time, yet the idea of being strong for long periods can be exhausting and lead to relationship breakdowns (Leibrich, 1999).This is particularly the case of partnership, where the relationship has been one of reciprocal supports and suddenly due to the illness or addiction of one partner, the reciprocal support becomes limited and is no longer providing the co-existing supports it once did.Pritchard (2006) refers to this in one of his case studies where his 'client' is a woman who has been experiencing depression for a sustained period of time.When he speaks to the husband he makes the comment that 'it must have been a difficult time for you' wherein the husband responded: The reciprocal relationship of husband and wife support appears to have changed.Pritchard talks about depression being contagious.However, rather than contagion it could be expressed as the family experiencing feelings of hopelessness when someone they love and care for becomes unwell due to illness or addiction and often they feel powerless to help.

Contribution of workers
During this time mental health and addictions services can sometimes contribute to this feeling of helplessness, as they can 'take control of the client's situation' in order to assist.This control can take the form of: focus on pharmalogical treatments, emphasis and focus on clinical understandings, individual responsibility of outcomes and the ideologies of expertness by professionals (Barnett & Lapsley, 2006;NCETA, 2006;Rapp, 1998).
Often the focus for the family is on the individual's needs and the individual's recovery.Rarely is focus put on, or time given, for the family to discuss and feel comfortable enough to express what they are going through, the range of emotions that exists during this time.This oversight can often be due to the given fact that most services operate within limited resources and client-focused treatments are prioritised over family-focused treatments (Copello & Orford, 2002).
The family of people who become unwell through mental illness or addiction may feel isolated in their own world.They can feel they do not have the right to talk about what is going on as this might be betraying a loved one's trust, and the 'illness' or the 'addiction' is not theirs, although it impacts on them.Families often experience a wide range of emotions such as grief, powerlessness, isolation and fear when supporting someone they love with a mental illness or addiction (SF Auckland, n.d).

Using systems theory to understand family responses
So how do we, as social workers, effectively assist family in finding a safe place to talk about how the illness or addiction is impacting and affecting them and their relationships?A consideration of systems theory provides us with an insight into the impact a mental illness or addiction can have on a family.Two of the key assumptions of systems theory are that individuals function as a part of many systems -they are affected by these systems and affect the systems, and because systems are in dynamic interchange, a change in one part of the system will have consequences for other parts of the system (Mitrani, Feaster, McCabe, Czaja & Szapocznik, 2008).Therefore, when one person within a family is affected by illness or addiction then this effect can, and will, influence and place pressure on the interaction of the family systems through the interchange of all involved (Payne, 2002).But if we are dealing with a system that is, or has been profoundly affected by, changes internal (mental illness/addiction) and external (services) and is continually confronted by the unexpected inherent in these changes then the consistency of behavior becomes less important than the persistence of the relationships within (Holling, 1978).Mitrani, et al. (2008) view the family as an organism regulated by 'structures', and repetitive patterns of interaction within these structures.These then determine the manner in which family members communicate, manage disagreements, distribute leadership roles, form alliances and negotiate distance or closeness.These interaction patterns are relatively stable across different situations, and homeostatic processes make them resistant to change.However, during times of stress these structures, in response to the changing needs of family members, can become rigid or disorganised therein impacting on the family system (Mitrani, et al., 2008).The impact of mental illness and/or addiction can cause stress for all family members within the system and as a response alter the dynamics and interactions of the family.Therefore, an understanding of the interplay of the family system and the impacts of mental illness or addiction can improve family functioning and lead to a possible reduction of the harm that may be experienced as a result (Copello & Orford, 2002).

Working with the family for the family
Kina Trust (2009) identifies that many services already provide programmes for children and families, but these are typically limited, under resourced and marginalised.When children and family present to other specialised services the focus is typically on the individual presenting rather than the family issue of mental illness or addiction.They go on to say that contemporary research identifies both the need for, and effectiveness of, family-inclusive practice.
Family-inclusive practice acknowledges that in order to fully assist a 'client' a social worker needs to be aware of and work with the feelings and emotions of the family.Family have a right to participate in and receive services, as this leads to more effective interven-tions (Kina Trust, 2005).Whether this is alongside the existing worker/client relationship or ensuring the family has alternative supports put in place for them.
The family needs time to experience their own journey, so that their own journey to recovery can be alongside and interwoven within the individual's recovery.
The World Health Organisation acknowledges this by stating that the needs and rights of family should be balanced with the needs and rights of the individual who is experiencing the mental illness or addiction (World Health Organization, 2003).Aotearoa New Zealand's Mental Health Commission also aligns itself with these concepts as presented in Te Hononga 2015: Connecting for greater well being.Here it recognises the importance of the family unit in being the continued foundation of support, strength, security and identity to build and maintain well-being (Te Hononga, 2007).In order for this to occur though, the importance of allowing the family the necessary time and resources to explore their experiences is important.Te Hononga highlights this in their recognition of the need for provision of direct services to meet the needs of family.Despite these recommendations the use of familyinclusive practice appears still not to be a standard practice (Whiteside & Steinberg, 2003).
Therefore, as social workers working within mental health and addiction services (or in fact within any service), it is hugely beneficial, not only to our clients but also to ourselves, in terms of long-term positive outcomes, that the family is not only included within the work we do, but also their experiences are actively expressed.A mother whose child has been affected by mental illness talks about how going to a counselor for herself offered her the chance to express her own anger and distress and how 'just talking about it really helped' (Mental Health Commission, 2000).

Strengths model
Current approaches mean that family should be seen, and supported, to be active partners in the care of people receiving treatment.The Mental Health (Compulsory Assessment and Treatment) Act 1992 states that consultation with family will occur during the assessment process and on an ongoing basis.This consultation may involve disclosure of personal information about the individual's health (Legal Services Agency, 2008).This implies that recovery and consultation is about how the family can provide support to assist the individual.Often what is needed for the family is to feel empowered enough to say what they are feeling and how this illness or addiction has also impacted on them as people and also as part of the wider family system.This can be viewed as detrimental to the journey of recovery as it changes the focus from concentrating on strengths of individuals.
The strengths model is a frequently used intervention when working within the mental health and addictions field and can be used effectively with the family as well.A part of the understanding of the strengths model is the view that suggests that the key conditions in the process of recovery are hope, healing, empowerment and connection (Jacobson & Greenley, 2001).The necessity to transfer this to the work with families will assist in the recognition of the integration of these internal conditions and the external relationship of functioning explicit in the strengths model.This recognition, interlinked with the understanding of the systems approach, provides a platform for sustainable relationships.The integration of hope, healing, empowerment and connection is the link to human rights and the creation of a positive culture of healing (Jacobson & Greenley, 2001).
But it has been noted that the telling and hearing of all the people affected and their realities within an illness or an addiction can be liberating for all parties.It enables a sense of honesty and openness to be explored without fear of recriminations and blame (Cowling, 1999).
As part of this strengths approach, the use of stories to assist the family in expressing their experiences can be very beneficial.Narrative examines the belief that stories shape experience, individual stories are embedded in and shaped by broader family and cultural narrative, and interactions invite the enactment of particular stories (Madsen, 2007).

The influence of the grief
Many families appear to experience symptomology reflective of the experience of grief.Historically, grief has been looked at as possibly occurring in stages.At the beginning the family may deny that anything is amiss, they can become angry, sometimes at the illness or addiction, sometimes at the individual, which can manifest in such ways as experiencing thoughts of blame and resentment; and then a resignation of acceptance, a 'where to from here' attitude (Kubler-Ross, 1969, as cited in Drewery & Bird, 2004).As social workers we are aware of the impact that trying to ignore grief may have.As Neimeyer (1998) seeks to explain, it is important for people who are grieving to be able to create a narrative of understanding around their grief.Allowing the family to experience what they need to in a safe environment is very important for the overall wellness of all involved.Giving the family the time to create this narrative of understanding may provide them with a sense of awareness and appreciation of the experience (Neimeyer, 2001).It is okay for the family to feel what they are feeling and expressing this will ultimately mean, for most clients and family, that the journey towards acceptance and recovery will be made a little easier by the acknowledgement that they are doing the best they can in the circumstances in which they find themselves (Tolan, 2003).

Raising awareness of family needs
Awareness of mental illness and addiction is growing evident as a result of different programmes, such as the 'Like minds, like mine' campaign, peer support movements and a wide range of other networks and programmes, that are providing education and seeking to reduce discrimination towards people with a mental illness and addiction.ALAC (1996) states that a family will provide reassurance, aroha, confidence, warmth, empowerment and mana to the client which will sustain the client, which is integral.However who will provide reassurance, aroha, confidence, warmth, empowerment and mana to the family to sustain them?An acknowledgement by industry workers can begin to provide this and lead to a constructive dialogue which can heighten awareness of and enable acceptance of mental illness and addiction as an issue that impacts everyone.Placing the role of the social environment as central in the focus makes it possible to incorporate a wider view of the problems and therefore increase understandings at a higher level (Copello & Orford, 2002).
There are organisations that provide specific support for families and these services provide the needed acknowledgement and assistance in order to meet the identified needs for the family.However, as social workers we also have a very important role in this, as often we may be one of the first points of contact a family has within the mental health and addiction services.This role can involve one of advocate for the family and understanding that families bear a considerable burden in their support of their relative (Pritchard, 2006).This understanding needs to communicate respect through listening, taking time, supporting and mostly acknowledging that families have a voice (Mental Health Commission, 2001).Therefore, one of the things we need to be able to communicate to families is that it is okay for them to feel what they are feeling and there are supports available for them so that they are able to safely experience either their own journey to recovery or at least better cope and/or understand their own role within their loved one's journey.

Conclusion
Mental illness and addiction impacts us all.Social workers who practise within the guidelines of the ANZASW are bound and committed to provide a service for the welfare and self-actualisation of their fellow human beings, which include the family (ANZASW, 2008).As part of this commitment it has been acknowledged, through guidelines, that the inclusion of family-focused practice become inherent within the provision of services within the mental health and addiction field.The actual delivery of these provisions can assist the work done with clients, in order to provide a duality of services that best meet the needs of all who are impacted upon by mental illness and addiction.Therefore, with acknowledgement and awareness of the family's experience of their journey, social workers can and often do engage in effective partnerships with family that facilitates more positive outcomes for all involved.
…you're the first person to ask about me.When my wife first became ill, I did not recognise what was happening and I thought my marriage was coming apart.It was the worst time of my life as I thought I'd failed her (p 33).