Schizophrenia Article

Understanding the complex family experiences of Behavioural Family Therapy

Brendan O’Hanlon,a Laura Hayes,b

Amaryll Perleszc and Carol Harveyd

Family psychoeducational interventions including Behavioural Family Therapy have an impressive evidence base in the treatment of schizo- phrenia. While there are challenges in their implementation including the engagement of families, in the few qualitative studies of Behavioural Family Therapy, families report largely positive experiences. Under- standing more about families’ experiences of Behavioural Family Ther- apy could guide changes to practice to improve implementation. This qualitative study involved interviews with twenty clients diagnosed with schizophrenia and twenty relatives who participated in Behavioural Fam- ily Therapy in Australia. Participants valued sharing experiences between family members and their relationship with the practitioner. Unlike previous studies they reported discomfort in sessions and disap- pointment in aspects of Behavioural Family Therapy. Greater emphasis on addressing this discomfort and on therapeutic alliance may help over- come implementation challenges.

Practitioner points • Practitioners can use their therapeutic alliance with families to promote shared understanding by providing information as well as facilitating information sharing between family members

• Practitioners need to recognize and respond to the high levels of discomfort experienced by families and particularly the vulner- ability of the person with schizophrenia

• An increased focus on engagement and the therapeutic alliance may improve the implementation of BFT in services

Keywords: Adult mental health; psychosocial and psychoeducational approaches; therapeutic relationship; qualitative research.

a Mental Health Program Manager, The Bouverie Centre, La Trobe University, 8 Gardiner Street Brunswick, Victoria, 3056, Australia. [email protected].

b Research Specialist, Parenting Research Centre. c Adjunct Professor, The Bouverie Centre, La Trobe University. d Director, Psychosocial Research Centre, Department of Psychiatry, University of

Melbourne.

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Journal of Family Therapy (2018) 40: 45–62 doi: 10.1111/1467-6427.12139

Introduction

Behavioural Family Therapy (BFT) is a form of family psychoeduca- tion, a group of approaches that focus on providing information about mental illness and skills training to help families support the recovery of their mentally ill relative and reduce stress within the fam- ily. Family psychoeducation has been the subject of extensive interna- tional research indicating that it improves outcomes for people experiencing schizophrenia and their families (McFarlane, 2016; Pharoah, Mari, Rathbone and Wong, 2010). However, only a small number of British studies have sought to understand the actual expe- rience of families who have participated in BFT and similar forms of family psychoeducation (Budd and Hughes, 1997; Campbell, 2004; James, Cushway and Fadden, 2006). This qualitative study explores the experience of family participants in BFT in Australia.

BFT consists of components of individual goal setting, information sharing about mental illness and skills training in communication and problem solving in the context of a supportive relationship between a practitioner and a family where a member experiences mental illness (Mueser and Glynn, 1999). In a number of controlled trials BFT has been associated with a reduction in relapse for people experiencing schizophrenia (Berglund, Vahlne and Edman, 2003; Glynn et al., 1992; Randolph et al., 1994; Schooler et al., 1997). BFT has also been found to reduce symptoms and the use of psychotropic medication and improve the functioning of the person with the condition (Ber- glund et al., 2003; Magliano et al., 2005; Magliano, Fiorillo, Malan- gone, De Rosa and Maj, 2006b; Montero et al., 2001; Schooler et al., 1997). In relation to family members, BFT has been associated with reduced carer burden and improved carer coping and family func- tioning (Berglund et al., 2003; Magliano et al., 2005; Magliano et al., 2006b; Mueser et al., 2001).

While outcome research is vital in demonstrating the value of BFT, it provides less guidance about the practice of BFT and how the model might be improved (Mairs and Bradshaw, 2005). Further- more, despite impressive benefits, BFT and other forms of family psychoeducation are not provided in many jurisdictions (Fadden, 2006; Haddock et al., 2014; Rummel-Kluge, Pitschel-Walz, Bauml and Kissling, 2006). Implementation of BFT in mental health serv- ices has proven challenging, with low levels of uptake by practi- tioners following training (Fadden, 2006; Onwumere, Grice and Kuipers, 2016). Another challenge to increasing participation in

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BFT concerns difficulties in engaging and retaining families in BFT (Fadden, 2006; Harvey and O’Hanlon, 2013; Magliano et al., 2005; Magliano, Fiorillo, Malangone, De Rosa and Maj, 2006a; Onwumere et al., 2016).

Although a diverse range of factors influence the extent of imple- mentation of new practices, one useful avenue for addressing these dif- ficulties is to consider adaptations to intervention models and their associated training programmes. Such adaptations could be informed by a deeper understanding of families’ and clients’ experience of par- ticipating in BFTwith the potential to improve engagement of families, enhance the relationship between the family and mental health practi- tioners and reduce premature cessation of the intervention (Lambert, Skinner and Friedlander, 2012; Priebe and McCabe, 2006).

However, despite the potential value of understanding the family and client perspectives concerning participating in BFT, their experi- ence has been infrequently investigated. Previous research concern- ing family experience of BFT or similar interventions is limited to three studies conducted in the United Kingdom with largely English- speaking families (Budd and Hughes, 1997; Campbell, 2004; James et al., 2006). The common themes that emerged in these studies relate to the importance of practitioners’ personal qualities and the value of collaborative and supportive relationships between family and practitioners (which BFT enhanced). These accounts of the experience of BFT were almost exclusively positive, with families endorsing the value of the approach (Budd and Hughes, 1997; James et al., 2006).

Building Family Skills Together was a project based in Melbourne, Australia, that aimed to establish BFT in an adult community mental health service and research both the process of implementation (O’Hanlon, 2015) and the outcomes (Hayes, 2014). The research questions in this study were: What are the client and family experien- ces of BFT in an Australian mental health context? How do these experiences provide guidance about how the BFT model could be best practised and implemented in mental health services?

Method

Setting

Behavioural Family Therapy (BFT) was conducted at two community mental health centres located in disadvantaged urban and suburban

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areas of Melbourne, Australia. All the practitioners at each of the centres completed a five-day training programme and were provided with a practice manual developed by the Meriden Family Programme (Falloon et al., 2004). Practitioners were also provided with follow-up support in use of the model, including co-working as part of the Building Family Skills Together project.

Intervention

Families were usually seen for BFT sessions at weekly or fortnightly intervals for one hour at a home or office setting. The length of con- tact varied with an average of twelve sessions (68SD) conducted over six to nine months. Most sessions were conducted with two practi- tioners, one of whom was directly responsible for the client’s ongoing treatment and usually a novice practitioner of BFT. The other was an experienced family therapist and BFT practitioner from a specialist family mental health service that was supporting the implementation of the approach.

Participants

Forty-seven families who had participated in BFTwere approached to participate in interviews about their experience of the intervention. Nineteen clients and seventeen carers (ten parents, three spouses and four siblings) completed individual interviews; four family dyads (two parent/adult child, one husband/wife, and one sibling pair) completed the conjoint interviews. Three clients and one relative participated in both the individual and conjoint interviews. Overall twenty clients and twenty carers were interviewed.

The age of the clients ranged from 18 to 60 years. Fourteen were male and seventeen were never married. Seven were working at least part-time.

The relatives’ age ranged from 25 to 61 years. Thirteen were female, eleven were currently partnered, and ten were working at least part-time.

Fourteen of the clients lived with their relatives, and sixteen of the relatives lived with their family member who was a client. Three cli- ents and six family members were born overseas (three clients and five carers from Europe and one carer from Asia).

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Data collection

Two interview approaches were used. The first was in-depth hour- long interviews with the client and self-nominated family member interviewed together by the first author (BOH), six to twelve months after the conclusion of BFT sessions. Using combination purposeful sampling (Patton, 2002), clients and their families were identified, firstly, on the basis that they had participated in at least eight sessions of BFT. Secondly, families were selected to reflect the mix of cultural backgrounds and family constellations (partner, parental and sibling groupings) of the treatment group.

The second approach involved brief (10 to 15 minutes) semi- structured interviews, using an interview guide, and with a self- nominated family member and the client separately. The second author conducted these interviews immediately following the conclu- sion of BFTsessions.

The two different interview approaches maximized the opportunity to capture the widest variation in responses, due to differences in time after treatment (both immediate response and later reflections), analo- gous to post-testing and follow-up assessments in quantitative methods, interview length, interview structure and sampling strategy. The use of conjoint and split interviews allowed exploration of a wider range of responses to the family sessions. Shared experiences were discussed in conjoint interviews and split interviews allowed participants to freely state reflections on their experience that they might have been uncom- fortable expressing in front of other family members.

Interviews were recorded digitally and then transcribed or through field notes taken by the interviewer.

Data analysis

The data was thematically analysed (Salda~na, 2009). In-depth inter- views underwent an independent editing process to eliminate repeti- tions and redundancies. Material was descriptively coded, a methodology well suited to the analysis of different data formats (Sal- da~na, 2009). This involved using a word or phrase to summarize the basic topic of a segment of qualitative data. The coded data were then subjected to further categorization and reflective analysis by the first two authors to generate a series of themes. A third refinement was undertaken by these authors independently to demonstrate reliability in the thematic coding process where data from the first coding was

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independently categorized to the secondary themes. There was a very high concordance in classification and any differences in classification were discussed until consensus was obtained.

Ethical considerations

The research procedures and protocol were designed and carried out in a manner consistent with the Helsinki Declaration. Ethics approval for the conduct of interviews was obtained from the relevant hospital and university ethics committees.

Consent for the in-depth interviews conducted by the first author (BOH) was obtained by a research assistant. This was done to reduce the likelihood that families would feel obliged to participate in inter- views as a consequence of their relationship with the interviewer who had also been one of the experienced family therapists who had con- ducted BFTwith the family. For the briefer interviews, case managers approached eligible participants to obtain permission for a researcher to contact them. For both groups interviewed, consent was required from the client before family members were approached. Names of participants were changed to preserve anonymity.

Findings

The four major themes and the sub themes that emerged are described below. The interview contexts are identified as Family Interview (FI) and Brief Interview (BI).

Engagement and early sessions

Reflecting on their experiences of engagement, family members described their expectations about how BFT might help and their apprehensions about participation.

Hopes and expectations. Family members’ hopes for how BFT might assist their family varied. Frequently family members linked their expectations to specific components of the BFT model, most often information sharing and communication skills.

I know for me I just wanted more information about what was going on. (Paula, sister, (FI))

Yeah, I was hoping it would help with the family understanding and also knowing what to do as well. (Conor, client, FI)

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There was always a lot of sort of blame being shunted around . . . I thought . . . [BFT] was actually a good way of maybe rebuilding better communication. (Arthur, father, FI)

Apprehensions about BFT. Although family members generally had posi- tive expectations that BFTcould assist the family, this was balanced by a range of concerns about what might happen. Uncertainty about how others might respond in sessions and the potential for conflict were often reported.

Very nervous . . . I was a bit stressed and I was a bit anxious . . . I don’t know how the family are going to take it either . . . It was going to be tough, because I always find it [the illness] tough to talk about. (Conor, client, FI)

Oh there’s definitely some nervousness about it because . . . you don’t know what you’re going to fire at us, and . . . you have to bare your soul a little bit, and that’s not comfortable . . . I mean the session like that potentially could end up in a real bun fight. (Arthur, father, FI)

I was quite ambivalent about doing it because I thought it might stir up a hornet’s nest, and rock the boat . . . And I felt that I might be blamed for all the problems too (Irene, mother, (BI))

Participation in BFT

When families participated in sessions they described aspects of the sessions that they found uncomfortable as well as enjoyable or rewarding.

The client being in the hot seat. Clients reported high levels of discom- fort, although this commonly lessened over time. For Halime, this dis- comfort related to a sense of intrusion, while for Gerard this was feeling he had done something wrong which made him the focus of attention.

They were intruding into my space . . . but towards the end of it though, I . . . accepted them. (Halime, client, FI)

So I was feeling a bit like a child, a naughty child or something . . . I was in the hot seat so to speak . . . but after a few sessions it seemed that . . . I was no longer in the hot seat because I would somehow move to an easier position . . . some of the pressure was taken off me. (Gerard, client, FI)

In a similar vein to Gerard, Conor and Melissa described feeling uncomfortable, although for them this related to having to talk about their experiences. Melissa described talking about her addiction

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problems being especially difficult. For Conor, this was couched in terms of having to talk about painful past events, although his attitude to the sessions changed later.

There were some issues I was uncomfortable about, but my case manager said we have to talk about them . . . It was hard to talk about the addiction, I felt ashamed, in front of mum and dad and siblings. (Melissa, client, BI)

At first it was difficult to talk about the different things happening, but then after we did it was good . . . I was just nervous and stressful (sic) when asked to talk about it, but then afterwards in hindsight when I look back I thought it was good. (Conor, client, FI)

Challenging but helpful. Families identified that even though some aspects of BFTwere difficult, this was balanced by a view that it might be ultimately helpful and, to some extent, a necessary ingredient in the change process.

You are sitting there looking around at people, it felt a little bit like the heat was on . . . Oh I just think it’s good to have discussion . . . I know it helps because the more you involve people the better it is. (Liz, mother, BI)

Yeah I reckon it has to be full on and actually get people out of their comfort zone to actually bring a change about. (Arthur, father, FI)

There were a few awkward moments, like role playing. [But] the role playing is the most important because you learn from it. (Ivan, client, BI)

Enjoyable aspects of the process. Clients described features of BFT that they found enjoyable. This ranged from being part of a family con- versation to enjoying the humorous moments in sessions. Families frequently referred to humour and its importance seems to be in pro- viding relief or contrast to the seriousness of the reason that families are meeting.

No I actually liked those conversations even on days when I haven’t got that much to say or I find it difficult to put words together, I still always enjoy a con- versation or . . . listening in . . . (Gerard, client, FI)

I was a bit more relaxed actually because I knew [my brother] would say some- thing stupid, that was relaxing . . . but him being a bit stupid would make it even more shared around. (Conor, client, FI)

It was good, it was funny because my sisters and the two therapists all got along and we found we were laughing and getting along and communication and it was interesting, it was pretty good. (Judith, client, BI)

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The impact of BFT

Families reported both positive and negative impacts from participat- ing in BFT. The positive impacts were linked most often to the infor- mation sharing component of BFT and having more open discussions about their family member’s illness and improved understanding of the mental illness. Families’ disappointments were related to limita- tions in the delivery of anticipated benefits.

Talking more openly about mental illness. Families described how BFT had enabled them to talk more openly about mental illness. This could relate to specific symptoms such as suicidal thoughts or a more generalized idea of ‘things being out in the open’.

Sandra [case manager] came here and she said ‘Halime, are you suicidal today?’ ‘No’ and I’m thinking ‘Jeez, I think she’s [the case manager] putting things in her head’ and she says ‘No, no, no, that’s not the case, you need to be up front with them’. And I thought ‘she might be right. All right, I’ll take over’. . . We used to hide things, like we never used to say it openly . . .’. (Umit, partner, FI)

Well it sort of just got things off your mind . . . different things . . . got out in the open and everyone sort of discussed them more and then it was better. (Conor, cli- ent, FI)

Improved understanding of mental illness. Families commonly described how BFT had improved their understanding of mental illness. Two main processes were associated with this improved understanding. Firstly, the practitioner provided clients and family members with information about mental illness. This often led to changes for the cli- ent in managing their condition or for family members in how they responded to their relative’s illness.

It was helpful, it was constructive. I learnt about the illness, and about the ’nega- tive symptoms’ and I had heard of them, but never had it explained, so now I understood about negative symptoms and the depression and the whole thing. (Adam, client, BI)

We did a lot of stuff . . . One of my first ones when I’m getting sick was ‘what do I do? What triggers it?’ We did that session, it was good. I’m more aware of the talking voices problems, it’s helped. I get extra help now to deal with the voices, like going for a walk or listening to music. (Peter, client, BI)

Had I not had the sessions, I [would have] still thought yelling would help when in fact it makes it worse. (Jerry, brother, BI)

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Secondly, clients shared their experience of mental illness with family members. This typically occurs in BFT as part of a practitioner facilitated process that acknowledges the ‘client as expert’ in their ill- ness. These sessions deepened family members’ appreciation of their relative’s illness and were emotionally powerful moments for families.

Melissa talked about her feelings, and her symptoms and her experiences, for her to open up to the family was a turning point and a high point. (Amanda, mother, BI)

In one [of] the early sessions, the therapist asked me to explain my symptoms, and I told my mum I thought she had been the devil, and she was amazed, and I real- ized it was just silly thoughts, just symptoms and I got the insight just by talking about it, (Melissa, client, BI)

We didn’t realize she hears voices ALL THE TIME, it’s sad to think this goes on all the time. (Kerrie, sister, BI)

The extent of change. Families’ disappointments about the impacts of BFT related to limitations in the degree of change that occurred for the client, the extent to which improvements in family communica- tion were not sustained and the failure of BFT to prevent relapse as described by Paula.

Where we are at now where Frank [client] has gone a little bit backwards. . .. I think with me . . . if I’m going to be doing something . . . you want to know that yep . . . you wish it’s 100 per cent secure and it’s going to fix it, . . .. I think my point is did we actually really touch the surface of the real problem [sic] to start with from the word go? (Paula, sister, FI, whose consumer sibling relapsed after BFTsessions)

In my opinion Building Family Skills Together helps 60 per cent, the rest it doesn’t change. It helps, but it does not cure, it does not fix the person. (Lidio, husband, BI)

I mean the objective of these sessions is to bring about change, and you have to have that momentum to actually bring about the change, and then settle the change, and make it part of you. The danger is that if you don’t have that, you know people come along to the session and everything starts nicely, and you go away and it just disappears,and you don’t actually get to the point of where the change becomes internalized and becomes part of you. (Arthur, father, FI)

The role of the practitioner

Families frequently commented on the qualities and approach of the practitioners. This was noted at commencement and during

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participation in BFT. While clients and family members frequently described their experiences of practitioners in positive terms, they also identified circumstances in which they viewed the practitioner’s approach as less helpful. While practitioner attributes and the quality of relationships were important in the experience of BFT, participat- ing in BFT also had an impact on the ongoing relationship between practitioners and families.

Commencing BFT. The existing trust between the practitioner who was the case manager of the client and the family was important in the decision to commence BFT. Enthusiasm was also identified as an important attribute influencing the families’ willingness to be involved.

Well we trust them as professionals . . . I thought it would be O.K. It is something that is probably going to be O.K. because Susan [case manager and BFT practi- tioner] said, she was not going to put us somewhere that was silly. (Liz, mother, FI)

She was just enthusiastic, she said that they had a service, we could go there or they would come to our house and try and help the family and me and I thought it was a good idea. (Halime, client, FI)

The approach of the practitioners. Family members often commented on the attributes of the practitioners. These related to their manner, gen- uine caring and their acknowledgement of the importance of family members.

It was the way they spoke to you, they spoke nicely (Ivan, client, BI)

. . . In the previous experiences we’d just go through the process in and out you know, you don’t want a problem you just get rid of it, whereas with all the people that we’ve dealt [with] in this service over here it’s always been caring. (Arthur, father, FI)

The therapists really listened to you and were helping you, not just as an extra to the patient . . . I felt important and validated (Michelle, mother, BI)

While there was a general sense of appreciation and valuing of practitioners’ work with families, family members did not always agree with the way in which BFT was conducted. Areas of concern spanned questioning the extent to which their relative was encour- aged to talk in sessions, the focus being on family members rather than the client and the client’s participation when they were unwell.

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There is still a question in my mind about R (client) not being drawn out enough – whether we should just not talk and let him, or whether [we] should have said something. (Irene, mother, BI)

It was hard to get across to the therapists that why are you working on us, not him. We were doing [a] session when he was unwell, so there was no point to the discussions because he was paranoid and there were things in his head. (Renee, mother, BI)

Strengthening relationships. Families commented on how participating in BFT had broadened the practitioner’s relationship with the client to include the family. The quality of the relationship between family members and the practitioner was also improved.

The entire family has [a] good relationship with case manager now. (Melissa, cli- ent, BI)

Oh yeah, you probably do get closer with the case manager. She does know you more intimately now . . . you see her a bit more so you feel more confident and that with her. (Angelo, brother, FI)

Discussion

The analysis of post-intervention interviews revealed that family experiences of BFT in this study were both similar to, and different from, the experiences of families reported in previous studies. Consistent with the previous studies, the attributes of the practi- tioners and the relationship between families and the practitioner featured prominently. This was evident from the point of initial engagement as found by James et al. (2006). It was also significant in families’ positive experience of participating in BFT. BFT was also seen as improving the relationship between family and practi- tioner as found by Budd and Hughes (1997). Families’ observa- tions of the caring and interested manner of practitioners resonate with the earlier findings about genuineness as a particularly important attribute (Campbell, 2004).

More than in previous studies, the interviews highlighted that fam- ily members valued the information sharing component of BFT. Information about the client’s condition provided by practitioners was seen as useful in informing how both the client and their family members responded to the illness. The most profound experiences in understanding the impact of mental illness for families were when the client shared their personal experience of symptoms. This led to a

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richer appreciation by family members of the day-to-day reality expe- rienced by the client and enhanced empathy. These sessions were also seen as beneficial because they involved a process of ‘opening up’ dis- cussion in families about mental illness in circumstances where such conversations had been avoided. ‘Deep conversation’ can be thought of as a task that was achieved through the within-family alliance (Lam- bert et al., 2012; Priebe and McCabe, 2006) (the shared sense of pur- pose within the family that is nurtured by the practitioner (Lambert et al., 2012)) as participants increased the regard and empathy for each other as sessions progressed.

The practitioner’s attributes and their relationship with the family and the information sharing component of the model were important in how families perceived the benefits of family psychoeducation (Fife, Whiting, Bradford and Davis, 2014). In line with the conclu- sions of James et al. (2006), family members’ trust in practitioners, or the therapeutic alliance, created the context for families to benefit from BFT. In a reciprocal way, when clients are supported to share their experience of mental illness, relationships are strengthened within the family and between the family and the practitioner. This suggests the acquisition of skills and knowledge, the development of therapeutic alliance and the development of within-family alliance, family intimacy and capacity for deeper conversations developed hand in hand (Fife et al., 2014).

In contrast to the overwhelmingly positive previous accounts of BFT, families reported significant discomfort in sessions. Being involved in sessions was especially daunting for clients, particularly in the early stages when they felt they were the focus of attention and had to talk about their experiences. Family members also reported feeling uncomfortable, yet acknowledged that this discom- fort might be necessary for meaningful change to occur. Interest- ingly, then, the very experiences that made clients and family members feel uncomfortable, in particular talking about the illness directly, were also what they appreciated most about BFT. This has implications for how clients and their family members can be best supported so that initial discomfort does not lead to early withdrawal from BFT.

While these findings relate to those who have participated in BFT, they may also apply to those clients or family members who decline the intervention. For clients in particular, negative anticipation of what will happen in sessions may be an important factor in accounting

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for why families declined offers of BFT as described earlier. This is significant in an adult mental health context where practitioners often need to convince the family of the value of participating in BFT and where the families’ involvement is contingent on the willingness of the person with the diagnosed condition to participate.

Families’ disappointments about participating in BFT were more prominent in this study than in previous accounts. Families raised questions about whether there was sufficient time and attention paid to sustain new and beneficial skills. Family members themselves identified the importance of spending more time on these skills and of revisiting them in sessions. This may be the result of sessions led by practitioners new to BFT who may not have focused sufficiently on ensuring families had acquired these skills. In addition, working with families from non-English speaking backgrounds involved time- consuming use of interpreters. This may have made it harder to provide the required additional sessions needed to consolidate learning.

Family members were especially disappointed when BFT did not meet their expectations regarding improvement in their relative’s functioning or if a relapse occurred. This suggests the importance of achieving a balance between instilling hope through promoting the benefits of BFT and reminding families that it is not possible to guar- antee positive outcomes. More broadly, an appreciation of families’ differing experiences of BFT has implications for practice, training and research.

Implications

The value of ‘non-specific’ factors such as therapeutic alliance in manualized treatment approaches should be emphasized in the train- ing of practitioners in BFT. There is a need to balance content and process, structure and flexibility, depth and lightness in the family sessions (Falloon, 2015). Practitioners need to assist families to have the ‘difficult’ discussions that build intimacy, as much as build the skills that support these interactions.

In terms of engagement of families in BFT, there are a number of factors that may be helpful. As Flaskas (2016) notes, it is important for practitioners to factor in the ‘strangeness’ of family therapy for fami- lies and to recognize how anxious and vulnerable family members can feel. The current study highlighted the particular vulnerability of

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the family member diagnosed with a mental illness. This suggests that practitioners can help their clients and family members manage their anxiety by anticipating, normalizing and directly addressing feelings of discomfort.

There have been encouraging results in relation to the use of moti- vational interviewing techniques to improve family engagement in family psychoeducation (Sherman et al., 2009). Carer and consumer advocates, especially those with prior training or experience of BFT, may play a role in supporting families in joining sessions. Training in Family Sensitive Practice might help develop trust between practi- tioners and families that would make it easier for families to take the difficult first steps to participate in interventions such as BFT (Fur- long, 2001). There may also be a role for information sessions about BFT in which families who are considering BFT hear about ’navigat- ing the initial difficulties’ from families with lived experience.

Given the complexity of conducting family sessions, the training and supervision of practitioners may need to be enhanced to include skills in building the therapeutic alliance and in ‘containing’ anxieties (Falloon, 2015). Practitioners may need access to a variety of other practitioners and their corresponding therapy styles – thus there is value in co-working with several other practitioners, peer mentoring and supervision groups to provide such exposure.

Outcome studies of BFTand other forms of family psychoeducation should routinely include measures of therapeutic alliance, knowledge, satisfaction and within-family alliance. Process variables such as thera- peutic alliance might be considered more often in programme evalua- tion studies, especially as proximal (immediate) outcome measures. The link between tasks such as ‘in-depth’ conversations, family and therapeutic alliances and outcomes is a particularly important area for further empirical investigations (Smerud and Rosenfarb, 2008).

Conclusion

Although BFT is a manualized treatment, our findings suggest that greater emphasis on the value of ‘non-specific’ factors such as engagement and therapeutic alliance would be beneficial in the implementation, training, practice and assessment of BFT pro- grammes. In this way the current problems associated with initial engagement and retention of families in BFT may be addressed so

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that more families can experience the benefits of this and other effec- tive family interventions.

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