This article discusses the family group conference (FGC) as a recovery model and its application in mental health nursing.
Tracy Wright, MA, PG Cert, PG Dip, RMN, RN, is consultant practitioner, South Essex Partnership NHS Foundation Trust.
Wright, T. (2008) Using family group conference in mental health. This is an extended version of the article published in Nursing Times; 104: 4, 34-35.
The chief nursing officer’s review of mental health nursing advocates the delivery of care in a recovery model approach (Department of Health, 2006). This article discusses the family group conference (FGC) as a recovery model and its application in mental health nursing. Mental health FGC is unique in that it engages both professionals and family and other support networks to help clients to manage their condition. It promotes social inclusion and reduces stigma in an often isolated group of people. The model is used in many adult care settings and children’s services, such as domestic violence centres, learning disabilities and older adult services.
The roots of the family group conference (FGC) lie in the culture of New Zealand’s Maori people, who identified that western culture was having a negative effect on family life. When a child or family had a problem and the authorities intervened, the traditional reaction was to place the child in care. The Maori people challenged this by demanding the child’s community be consulted first, as they would care for and support the child if there were family difficulties. They used a ‘family meeting’ involving the child’s entire network and developed a ‘family plan’ on how the child was to be supported (Doolan, 1999).
The emphasis on family involvement in planning and decision-making led to reforms in New Zealand legislation, with the advent of The Children, Young Persons and their Families Act 1989. Central to the act was family group conferencing, which was to be applied in both child welfare and youth justice. Marsh and Crow (1998) referred to it as ‘a new and radical innovation’.
Internationally, the use of FGCs has spread to Australia, Canada, France, Ireland, Israel, Norway, the US, South Africa and Sweden, where the model has been adapted and developed in various contexts. It is applied nationally and internationally to education, domestic violence, young carers and adult offenders. In the UK, any child involved in the child protection process has an FGC (Nixon, 1999).
The introduction of FGC in the UK also coincided with reforms in the Children Act (1989), which stressed the need for partnership in child welfare. The national body Family Rights Group (FRG) introduced FGC in 1993, and continues to play a role in its introduction throughout the UK. The model seems to have been introduced within a cultural change in both the UK and New Zealand, to involve families in finding solutions to problems. Previously there was an assumption that professionals know best and that the ‘experts’ have all the answers – the idea that service users have the answer to their problems was new. The introduction of FGC also coincided with the realisation that too many children were being taken into care, which is linked with a poor outlook for their future.
Traditional community mental health team services
People with mental illness can experience social isolation and stigma due in some part to the fact that friends and family do not understand their condition. Traditionally, community mental health services offer clients appointments with a psychiatrist and treating team as well as access to individual or group therapy. They receive education on mental illness and symptom management, along with a contingency plan should the condition return. Their immediate carers may also receive a carer’s assessment and information about the client’s illness.
The Care Programme Approach (CPA) (DH, 1996) is the national framework in which all health and social care mental health services work. CPA meetings offer opportunities for service users, family members and support agencies to put together a care plan and contingency plan for when a client’s condition deteriorates. However, it does not involve other people who may come into contact with clients when their condition deteriorates, such as neighbours who may notice the volume of music increasing, the child left with a pile of ironing when their mother is admitted to hospital, or the friend who is unsure what to say when a client cuts her wrists.
Mental health FGC
The FGC philosophy has moved into mental health care and offers an opportunity for all the client’s ‘family’ to have the condition explained – the word ‘family’ is used in a generic sense to mean anyone a client identifies as a support person. FGC also offers an opportunity to contribute positively to clients’ recovery and provides information on whom to contact/what to do should they become unwell.
Mental health FGC was introduced in Essex social care in 2000. The model complements traditional services and has the following benefits (Mirsky, 2003b):
• Clients and family members have the opportunity to meet a professional at a convenient time and place, which can include evenings or weekends. They are given the information they need, and can have more than one session if they need more time to ask questions.
• The process is client-led and socially inclusive. Clients identify the issues they wish to discuss and the family members they wish to be included. Plans to return to education, voluntary work and employment can be included.
• The family meeting is in clients’ time and not professionally led, which is far less intimidating than a ward round or CPA meeting.
• The meeting can help improve clients’ and family members’ understanding of each others’ perspectives and support needs.
• The model identifies resources outside the usual mental health network, which also promotes social inclusion.
• It improves communication within the support network. Further work may be agreed on in family therapy settings.
• As the family plan is produced by clients and their support network, there is a feeling of ownership and commitment.
• We seek to work with all professionals involved so the process is totally inclusive of all relevant networks.
• The results are then integrated into the CPA framework (Mirsky, 2003c).
Currently, there are two full-time and one sessional psychiatric nurses working as mental health FGC facilitators in our service. They establish whether clients have been given all the information they need on the process and that they wish to proceed. The care coordinator is invited to attend as often as clients wish them to or they are able to. The facilitator keeps care coordinators informed of all meetings and discussions.
The next step is to carry out an initial assessment with clients and help them to identify what they wish to discuss and, more importantly, what they do not want to have discussed. This may be done over a couple of sessions. A recovery plan is useful at this point as it highlights the strengths and gaps in the client’s life and focuses them towards a goal.
Once the initial assessment is completed, a family information sheet can be formulated (most clients like this to include an explanation of their illness) and clients agree which issues are to be addressed so they know what will be discussed with their identified network. Clients then draw up a list of people they want involved and their contact details. The facilitator contacts those on the list and arranges a visit at a time and place suitable to them, to explain the process and what is expected of them. It also gives them a chance to consider how they can realistically contribute to the family plan.
Mirsky (2003a) states children of the family should be included in this process but they may choose to have a letter read out at the conference by another family member, FGC facilitator or advocate.
All documentation is presented in clients’ own words – staff do not ‘professionalise’ it.
There is also an opportunity for an advanced directive to be drawn up if clients wish; this is particularly useful for those with early-stage dementia or those who have been detained under the Mental Health Act 1983.
Once all family members have been visited and are clear about the issues, a conference date is set. A venue is selected that is big enough to hold all family members and can accommodate disabled members if necessary. Any professionals that clients wish to attend are invited to the first part of the session to explain their role and what can or cannot be offered and to discuss any ideas or concerns (Mirsky, 2003a). The professionals, including the facilitator, then withdraw and the family spends up to an hour’s ‘family time’ deciding on a complete ‘family plan’, during which they can call on the facilitator at any time to clarify information. The facilitator then returns and shares food with the family. Once this process is completed the facilitator reviews the family plan and clarifies any issues it raises.
The plan is then typed up (using the client’s language) and circulated for comments by clients, family and professionals. The client and care coordinator then sign up to the plan, which can have a family crisis plan attached to it, containing contact details of all involved and details of their agreed role in a crisis.
This case study gives an example of the FGC in action. Mary (not her real name) was 40 years old and had a depressive illness. Her grandmother died three years previously and Mary found this difficult to come to terms with. Her motivation for an FGC was to make contact with relatives she had lost touch with since her illness began, and to increase her social contacts. She had five siblings, and was in contact with her father and one sister.
FGC initial assessment
The assessment revealed that Mary had felt isolated from her family since her grandmother died unexpectedly. She enjoyed going out to line dancing but had been unable to do this since her bereavement. Mary’s illness had deteriorated and she had episodes in which she would shout and scream at home.
Family information sheet and family plan
The family information sheet noted that Mary wanted to enjoy her social life again, as she enjoyed day trips with her support worker, and to start her line dancing again.
She still had contact with her parents but felt her grandmother was being ‘forgotten’ as they changed the subject when she was mentioned. Mary’s contact with her sister and brother-in-law was positive but not as frequent as before her grandmother’s death. She had tried to visit when other relatives were there, but found she had ‘just missed them’. She found this upsetting and wondered if her family was ashamed of her.
The issues Mary identified for discussion were:
• She and her family needed a better understanding of her illness and its impact on them all;
• She needed to become more integrated in the family and to stay in regular contact;
• She needed to go out more as she identified that it would help her recovery – and needed to know how her family could support her in this.
Eleven people were identified to help with this process: eight family members, one friend and two community health team workers. Each was contacted with the family information sheet and invited to give their views. Most relatives were surprised that Mary felt isolated as they felt they had tried to include her in family celebrations and kept in regular telephone contact. They were willing to attend a conference to explore the issues further. The community psychiatric nurse and support worker also agreed to attend.
The conference was held at Mary’s brother’s home on a Saturday morning. Seven relatives, the community psychiatric nurse (CPN) and the support worker attended. All issues in the family information sheet were revisited and the points highlighted. None had altered since the facilitator had met with Mary after visiting all family members.
The family was allowed to ask questions of the professionals and seek clarity about any concerns they still had. After all issues had been discussed, the facilitator, CPN and support worker withdrew to allow the family their ‘family time’.
During this time the family identified the following solutions:
• Improving understanding of Mary’s illness and its impact.
Mary mentioned how much she missed her grandmother and the nightmares she was suffering. The family responded, explaining how much they all missed their grandmother and that they dealt with it by talking about her and Mary must feel included in this, although they did point out that they often worried about exacerbating Mary’s illness if she became upset.
The agreement was to encourage Mary to discuss her problems and not keep them from the family. Mary was able to explain the difference between her illness and normal grief reaction.
• Integrating Mary in the family and staying in regular contact.
Mary’s family urged her to use them more for support, and to use their parents for trips to shops as they could provide company and extra support. They pointed out that in the past she had not taken up opportunities and, as much as the family wanted her to be included, they had other family commitments and could not always ‘run after her’.
The agreement was for Mary to go shopping with her parents once a week, and her father also suggested they visit her grandmother’s grave once a week together. Mary agreed to give it a try.
• Helping Mary to get out more.
All family members contributed to this and spoke of Mary’s achievements before her grandmother’s death. It seemed that Mary also used to be involved in church activities and her parents mentioned how much they felt she had sacrificed.
Her brother said she was always welcome to join him and his wife for tea but he found it difficult when Mary accepted an invitation but then did not turn up; they wanted her to say what she really wanted. Mary admitted she accepted invitations to make others happy. Her relatives reaffirmed that she must say what she wanted to do as they were still her family and would not reject her.
Mary admitted she had fears around eating out as she could never be sure if the food was contaminated. This made it difficult for her to attend family gatherings as she was not reassured the food was edible unless she had prepared it. Other family members tried to reason with her and stated that the food was fresh. However, through the FGC process they were able to understand that Mary’s illness would not let her accept this at present.
It was therefore decided that Mary would bring and prepare her own food for any family gatherings. The family agreed not to put pressure on her to accept their food or deal with it differently. They also agreed to give her time to decide whether she would attend these events and not to feel slighted if she declined.
The professionals then joined the family for lunch (Mary helped to prepare the food), and shared the plan.
Once it had been typed up the completed family plan was signed by Mary, the care coordinator and facilitator, and then shared with all participants. A review of the plan with participants was arranged for three months’ time.
Review of family plan
Three months later, all participants were given the opportunity to review the family plan and make any necessary contributions and changes. Mary had certainly managed to make some changes – she had gone line dancing, attended some church activities and attended family gatherings and celebrations, preparing her own food. She had also visited her grandmother’s grave with her father, and found some comfort in talking about her more with relatives.
Mary’s improvement was also evident in her mental health and the psychiatrist was able to discharge her back to her GP, while the community mental heath team could start discussing discharge from the service.
Most importantly, Mary was able to say that she knew her family was not ashamed of her.
Traditional CMHTs and mental health FGC
This example of an FGC raises much debate in CMHTs, with questions such as ‘Why can’t a care coordinator do this?’ and ‘Surely we do this anyway?’ However, FGC does not replace the CPA process and should be viewed as complementary to it.
Families may already have experienced ward rounds and CPA meetings and can feel traumatised by the experience (Jones, 2004). This means it often takes time to convince the family that the FGC is their meeting and that the plan formulated by them is then put into practice by professionals.
The model is led entirely by the client and family, and encompasses the philosophy of social inclusion (Partners in Care, 2004). The care coordinator does not normally have that sort of capacity to follow this amount of work through (Chand and Thoburn, 2005).
Since the FGC model was introduced in adult mental health, the framework has had to be adapted to deliver services in a timely manner to meet clients’ and their families’ needs. This has allowed referrals to be dealt with in 16 weeks. The framework has been adopted in other settings, which demonstrates that it is flexible (Brown, 2003). It can be also adapted for clients with less family support.
The area requiring most work when introducing the model is gaining professionals’ participation. They need to understand that they are working within the process and are not excluded. Some are intimidated by the concept of a care plan designed and led by service users. The facilitators have to work hard to ensure profesionals fully understand the framework (Gallagher and Jasper, 2003), but once this is achieved, it can influence their practice positively. It is important that the care coordinator reviews family plans in line with CPA meetings and ensures they remain relevant.
After each FGC, questionnaires are sent to clients and participants on their experience of the service. Below are some of the responses we have received.
Comments from family members
‘All members of my family found this to be a helpful, positive event. I feel it has provided a ‘supported’ way to move forward.’
‘I feel stronger in myself and can see an improved future.’
‘The conference made us closer and clarifies issues that I couldn’t explain, but became clearer to the family during the process.’
‘It helped all of us, instead of issues being just my problem as I was the one with mental [health] problems.’
‘The family realises that support is available, if required, and that they can work together, they are not on their own.’
‘All in all, this has been a positive, helpful part of my recovery process. I have been treated with respect all the way through, which has empowered me.’
Comments from family members
‘I just wanted to say thank you for coming to our house and bringing my family even closer together.’
‘I feel the meeting answered questions I was not sure about, also questions I did not feel comfortable asking my family.’
‘Understanding and sharing a problem makes it easier to tackle and gives an insight as to how to help.’
‘It gets things out into the open. [There is a] greater sense of support.’
‘I feel it gave time for most of the family to meet on neutral ground and speak more openly with one another.’
These responses are consistent with the findings of Mutter (2005), who reported increased confidence among clients and families that was still evident one year later.
Mental health FGC has introduced a way of working in mental health that is totally service user and family led. The process is socially inclusive and has a positive impact on clients’ mental health.
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The Children Act (1989)