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WAP / Vocational training for community based psychiatric nursing

Further Training of Ambulatory Psychiatric Service Providers

TRAINING MODULE

FAMILY INTERVENTION TECHNIQUES AUTHORS Nilgün SARP Professor Ankara University, Faculty of Health Sciences Ruhi Selçuk TABAK, Ph. D. Associate Professor Muğla University, Fethiye School of Health Sciences Deniz Kader Şarlak, M Sc Muğla University, Fethiye School of Health Sciences

Muğla/Fethiye/Ankara

September - 2008

Contents Instructions for Trainers Introduction Family

FAMILY INTERVENTION TECHNIQUES

Objectives: 1. Trainees will understand the conceptual basics of family intervention techniques in the frame of mental health. 2. Trainees will understand the family dynamics in multilateral perspectives. 3. Trainees will have knowledge and skills about the leading and new approaches and models of family interventions 4. Trainees will improve their awareness about family mental health various problems and their causing factors, 5. Trainees will have knowledge and skills about the specific mental health problems of the family, and of their causing factors. 6. Trainees will improve their skills on the family evaluations, care plans and interventions. Learning Outcomes Cognitive:
 Nurses will list the kinds of families.

 Nurses will count the risk factors of mental health in the family.  Nurses will count the family interview techniques.  Nurses will count the family intervention techniques. Affective
 Nurses will express their willingness to carry out community based mental health services to the families.

 Nurses will accept to employ the holistic approach for the mental health problems of
families.

Psychomotor  Nurses will employ the family interview techniques.  Nurses will employ the family intervention techniques in the frame of community
based mental health services.

For the trainer: In this handbook you will find the whole content of the module “Family Intervention Techniques”. In addition in blue letters there are written down instructions for the trainer. In many chapters it can be helpful to let the trainees work together in groups. In the following you find an overview about the idea of working in groups. Philosophy of group learning Group learning, or working in groups, involves shared and/or learned values, resources, and ways of doing things. Effective groups learn to succeed by combining these factors. However, each group, and each individual, will only be as effective as they are willing to embrace and/or respect differences within the group. Interaction within the group is based upon mutual respect and encouragement. Often creativity is vague. A group's strength lies in its ability to develop ideas individuals bring. Conflict can be an extension of creativity; the group should be aware of this eventuality. Resolution of conflict balances the end goals with mutual respect. In other words, a group project is a cooperative, rather than a competitive, learning experience. The two major objectives of a group project are: What is learned: factual material as well as the process What is produced: written paper, presentation, and/or media project Role of trainers The success of the outcome depends on the clarity of the objective(s) given by teachers, as well as guidelines on expectations. The group's challenge is to interpret these objectives, and then determine how to meet them. The process of group work is only as effective as trainers manage and guide the process. Group projects are not informal collaborative groups. Students must be aware of, and prepared for, this group process. Cooperative group projects should be structured so that no individual can coast on the efforts of his/her team-mates. You will find explanations concerning the exercises for the trainees at the end of each chapter. During the chapter you will find remarks if necessary and proposals of the parts you could present by some kind of projection (PowerPoint, overhead projector, etc.). These parts are marked by a blue frame.

INTRODUCTION Theory: - Introduction by the trainer Practise: - ex1: concepts and different kinds of family interventions Requirements in equipment: paper, pen beamer, laptop

50 minutes for this part in total 20 minutes 20 minutes 30minutes 30 minutes

INTRODUCTION Audio-Visually supported presentation. Family In general, family, which is considered a core structure within the community based mental health care, is the environment for the individual to gain the social experiences. Beside its unignorable importance for mental health for individuals, family is a quite fragile institute due to mental disorders and/or hard life conditions. Literally, family is social institute which consists of individuals who have close relations trough blood, marriage and/or adoption, who live in the same house; share the incomes, and who interact each other in the frames of their roles. Psycho-social and legal ties build up the power in families rather than organic ties. The professionals in mental health services are expected to be aware of the family dynamics. All families have basically same functions each family and every individuals in families are unique. They all have different backgrounds and traits. A family can be analyzed in 4 dimensions according to structural-functional approach:

a) Values system: The factors that constitute are the social norms such as culture,
moral, law, religion (beliefs, traditions, punishments). Values are not stable. They change continuously. While values guide the behaviours, they lead the necessities for norms and rules in families. For example, if an individual feels him-/herself as necessary for the family he/she will surely take care of him-/herself more and adopt better health behaviours.

b) Role structure: Role is the expected behaviour of an individual who has a position in
a group. Roles in a family are both formal and informal. Among the formal roles are provision of incomes, responsibility for care, parentship, spouseship, etc. The informal roles are encouragement, share, partnership, friendship, governing, sacrifaction, agreement, etc.

c) Power structure: Money providing and decision making are the sources for the
power. Love, security, clarity bring the family members closer. Toughness weakens the relations, destroys the power structure.

d) Communication structure: Samples of the relations such as democratic, share,
emphatic, pressure, tough, irrespective etc. are important in being healthy or unhealthy of families. General specifications of families: Family  is universal,  is based on emotions,  has the character of formation,  is the smallest of social structures, and has limited capacity,  has the core specificity in social life,  members have responsibilities,  is surrounded by social norms and rules,

has both tentative and permanent natures.

Common characteristics of family;     Each member can be stimulated by the behaviours of others. Interactions in family affect the behaviours of family members. Each family has its own structure and functions. Families have specific strategies for dealing with conditions such as stress, crisis, conflicts etc.

Family has some functions beside these characteristics. Fulfilment of these functions prevent conflicts and ensures the harmony. Characteristics of a Functional Family A family which carries out its functions;  is social and efficient in establishing relations with others.  has members with proper identity feelings and self-values.  gives chances to its members for self-expression and self-disciplines.  encourages its members’ independency and sufficiency.  gives freedom to children according to their development levels.

For a healthy family, mental well-being of parents is especially important as the basic members of a family. Mental well-being of parents is affected by the;          acceptance of mother her identity as a woman. preparedness for the parenthood. relationships with their own parents. relationships as spouses. use of alcohol, drug, cigarette; abuse, unemployment, immigration, diseases. sickness of a family member. missing or divorce of a family member. marriages between relatives. situations of fear, anxiety, depression.

Family and its life are important and prior constructions in the primary prevention approach. There three basic family types in the present Turkish society: Rural Family, City Family, Squatter (Transition) Family. There are specific factors in these family types which are affecting the arousal of mental disorders. These are;     endogamies, premature and matchmaking style marriages, especially in rural families, functions of women and their increasing responsibilities, payments to bride’s families, especially in eastern region, increasing divorces in city families,

adaptation problems, conflicts, weakening relationships in squatter families.

There are, in general, four approaches in defining the concept of a family: 1. Defining the family considering the opinions, feelings and fantasies of a member of a family. This approach is commonly used in psychiatry as the way for identifying and defining the family 2. Cultural approach which considers family as social institute with its cell and large dimensions. This definition is used generally in sociology and social psychology. 3. The approach which considers family as social unit. According to this approach, family is a system constructed by various segments. It is taken into account as a small group and studied by social-psychology in terms small group behaviours. 4. The approach which accepts family as a group limited by the social values. According to this approach, beside rules defined by and in the laws, each family has its own clear or unclear norms and rules. Today, the term ‘family intervention’ is used for two concepts: The first concept is used in situations where a member of family is need of definition and treatment of a mental health disorder. In this case, family intervention comprises the approaches and types of explanation and treatment in defining and management of dynamics in family. The second concept includes the approach and treatment types in defining and management of conflicts, troubles and complaints in and about the relations in family. This second one is also called as ‘marriage therapy’. Family intervention is not solely to give amateur speeches and advices based on the nurses own common-sense through gathering the family members. Even, it does not consist of the self-expressions of family members to overcome the symptoms or problems appeared in one or all members of a family after a group discussion. It requires sufficient psychotherapy training and experience as well as the awareness of family intervention techniques and clinical efficiency to an extent.

Effects of Mental Disorders to Family As interactions among the family members affect the mental health of each member individually, a disorder appeared in a member may easily affect the whole family and cause some defects in family functions. While, sometimes, the problem is created through overtaking the patient role a member by another member of the family, generally feelings and thoughts of the member with a mental disorder such as the refusal of sickness, feeling guilty, fearing from the environment affect the whole family. However, families can create another balance to carry out the basic functions by learning to live with the problem or finding new solutions for the mental troubles. Whatever they employ as techniques, family interventions have the following aims:  To deal with to decrease the symptoms mental and functional disorders of individuals in the frame of the family relations.  To solve the conflicts in family and spouses as well as the conflicts of the family with its proximal environment and community,  To define and mobilize the sources and behaviours to be used by family in solving their mental health complaints.

 To ease the perception and satisfaction of the emotional needs of family members.  To improve problem solving skills and communication competencies of families and its individual members in case of hardening life conditions and mental disorders.  To ensure the development of independency of family members as well as their skills for healthy relations.  To help for promotion of compliances among family members in terms of role distribution by gender and generation.  To facilitate the integration of the family to the community.

Group discussion on on the effects and improtance of family dynamics on mental health.

To remember

Family is social group which has its own unique characteristics, norms, rules, dynamics and life style.

Questions and assignments List and describe the different kinds of families. Give examples for each.

Exercise: Let the nurses write down the different kinds of families and 1-2 examples for each. After they have finished let them present to each other what they have written down and discuss the results. The aim is to let them understand the categories and to “translate” them in concrete crisis situations from the daily life. If necessary you can help them giving examples.

Questions:

1- A family can be analyzed in 4 dimensions according to structural-functional approach.
Which of the concepts given below is not included among these dimensions?  Beliefs system  Values system  Role structure  Power structure  Communication structure

2- Which of the items given below is not included among the general specifications of
families?  Family is based on emotions,  Family has the character of formation,  Family is the smallest of social structures, and has limited capacity,  Family has the core specificity in social life,  Family is local,  Family is surrounded by social norms and rules.
3- For a healthy family, mental well-being of parents is especially important as the basic

members of a family. Mental well-being of parents is not affected by the;  acceptance of mother her identity as a woman.  preparedness for the parenthood.  relationships with their own parents.  relationships as spouses.  use of alcohol, drug, cigarette; abuse, unemployment, immigration, diseases.  softness of a family member.  missing or divorce of a family member.  marriages between relatives.  situations of fear, anxiety, depression.
4- Which of the items given below is not included among the aims of family interventions?

 To ease the perception and satisfaction of the emotional needs of family members.  To improve problem solving skills and communication competencies of families and its individual members in case of hardening life conditions and mental disorders.  To control the development of independency of family members as well as their skills for healthy relations.  To help for promotion of compliances among family members in terms of role distribution by gender and generation.  To facilitate the integration of the family to the community. FAMILY AND RISK FAMILY AND RISK Theoretical knowledge Theoretical explanation by the trainer 50 minutes in total 20 minutes 20 minutes

Practice Group discussion on fundamental risk factors regarding mental health Equipment required Paper, pen Beamer, laptop Audio-Visually Supported Presentation.

30 minutes 30 minutes

Information to be gathered about the psycho-social status of the family constitute data to be used in planning treatment and cure. Individuals under psychiatric treatment have been away from their family and interaction with the family members (at least for a while) due to their individual psychopathological reasons. Nurses working in the field of mental health will often work with patients and their families. A family with a member who suffers from Alzheimer, a family with an inner-family violence, a family with a child suffering from lack of concentration, and families with members who have chronical mental disorder constitute much of families at risk mental health nurses face. There are many risky situations which damage biopsycho-social and moral balance and mental health of the families. Family Development Periods and Risky Life Changes Developmental Tasks Development of language skills----------Development of impulse control---------School age-----------------------------------Early literate---------------------------------Development of social skills------------------Puberty--------------------------Interest in opposite sex----------------Development of independence-------Leaving home---------------------------High education--------------------------Selecting a job------------------------Marriage------------------------------Birth------------------------------------Becoming parents---------------------Becoming parents to a school child----Becoming parents to a child in the early adolescence---Becoming parents to a child who left the family--------Becoming parents to a child to a child who is just married--------Providing treatment to sick parents-----------------------------Becoming grand parents----------------------------------------Adolescence School child Life Periods Healthy birth---------------------------------------------------Babyhood and early childhood

Early Adolescence

Middle Age

Retirement---------------------------------------------------Busy with sicknesses-----------------------Looking after a sick spouse--------------Coping with death of the spouse--------Coping with death of one of the peers-----One way of planning primary preventive measures and organizing them systematically is to consider developmental tasks required in every period of life and life changes. Risk Factors Damaging Mental Health of the Family: a) Family Factors; - Lack of harmony in the family - Mental illnesses in the family - Abuse in the family - Economical problems in the family and unemployment - Low level of education - Overcrowded family - Marriage with relatives - Lack of parents - Rigit family - Poor communication Old age

b) Environmental and Social Factors; -Homelessness -Discrimination -Deprivation -Migration -Earthquake -Fire -Floods -Environmental pollution -Weak social support -Education difficulty of the family with disabled child Mental health nurse should evaluate the family with totalitarian (integrated) approach. Woman and Risk: Women of our country are those who have problems in productivity, enterprising, self-expression, and satisfaction and problem solving skills. The fact that women apply health services due to depression often met in women and somatic complaints support this view. Protection of this group suffering due to their psychological social status is very important in the development of healthy families and generations. As the psychological satisfaction or dissatisfaction of women is important, problems or

failures in the satisfaction levels given below and problems seen in those contexts are the risky situations for the mental health of women. Satisfaction Love relationships Contents - To love and be loved Individual achievement Satisfaction in sexual life Relationship with the loved ones

-Success in life -Job satisfaction - Self-awareness and acceptance - Individual development

Physical health

-nutrition -general health and physical attractiveness

-Physical activity -Being parents Parents-child relation -Relation with children Personal time Setting the balance in issues concerning work, family, home and environment -Relations with close friends Social relations -Relations with colleagues -Social life with highly valued individuals Sparing time for oneself

Motherhood: The motherhood period is rather stressful for women. Pregnancy and post-natal period may bring about some crises. The following are the main causes of stress: 1. Hormonal changes 2. Changes in body features 3. Psychologicdal conflicts concerning pregnancy

4. Not being prepared for the role of motherhood. These causes of stress frequently lead to depression during the pregnanacy and post-natal period. It is possible to recognise women who are under the risk of depression during their pregnancy and postnatal period. Very young unemployed women who have not received a good education and have children are under the risk of developing depression. These risk factors enables the nurses diagnose the depression and gives them the opportunity for an early treatment, thus enhancing the physical and mental health of the mother to be. Working Mothers: Due to their economic situation and their personal choice of carrier, the number of working women is increasing. Having a job may give a woman positive feelings and a sense of security and independence. However, it may, at the same time, develop a guilty conscience and anxiety in working women who think they ignore their husbands and children. It is a well-known fact that the working woman in the family is held responsible for everything which goes wrong. Undertaking a role, being uncertain and inefficient and having contradictions are problems which working women face frequently. Mental Symptoms among the Working Women: 1. Women staying at home for a long period and suffering from anxiety when they go back to work 2. Fear and anxiety in connection with turning of a carrier success into a social failure 3. Conflict between what are expected from them socially, and their own necessities and rights 4. Conflict between being a woman and her professional identity and feelings which threaten her marriage and family independence Three defence mechanisms are seen among such women : In rationalisation: she sees the behaviour of a mother as an issue which is socially accepted. For example, (she may say) “ If I were at home I would find a work which I could do voluntarily”, or “I am a working woman, I have no time for doing the cleaning.” When revealed: she constantly blames others. In compensation: she tries to make up for it by other things. For example, constantly buys gifts for her children. Nurses can help working mothers who cannot cope with their roles. First of all they should be helped to understand their conflicts. The mother should be provided with the information that she should understand that in the mother-child relation quality is more important than quantity. Child – Adolescent and Risk The source of problems for many adults is the childhood period. The period of childhood and adolescence is the time for attaining the learning capacity for coping. The following are the assessment of the primary protection attempts in childhood: 1. Anti-social behaviour a. Physical aggressiveness ( fighting, being destructive) b. Other anti-social behaviours 2. Learning disorder 3. Mental retardation 4. Childhood schizophrenia 5. Suicide 6. School failure 7. Addiction 8. Neurotic disorder

Some of these problems may be related to the biological development. Others may have to do with the mental development and the family and social circle. The risk factor concerning these situations may be related to separation of parents and child, loss of parents, abuse of children and divorce of parents. Factors concerning the childhood and adolescence period protection can be regarded as a capacity for solving problems, social skills, a pleasant relation and achieving positive experiences outside the child’s home. Group discussion on the practical effects of risk factors from the point of view of mental health.

VISITING THE FAMILY ___________________________________________________________________________ 50 minutes total Theorethical Information 20 minutes - Theoreticl explanation of the specialist 20 minutes ___________________________________________________________________________ Application 30 minutes _________________________________________________________________________ Group discussion on realistic applictions in 30 minutes family visiting techniques Necessary Materials: Paper, pen Projector, laptop VISITING THE FAMILY

From the point of view of therapeutic intervention to the family, among the qualities a nurse should have, priority is given to the following skills : º Communiction Skills º Problem- Solving Skills º Consultancy Skills º Discussion Skills º Adult (mother and father) Education º Psychiatric Care and Training (especially in connection with serious mental disorders like schizophrenia) Therapeutic Techniques in Communication Therapeutic communication techniques are verbal and non-verbal communication techniques which make it easy for the person seeking consultancy to express his/her feelings, ideas and intention. They are used in the meeting of the public mental health nurses with their patients or persons seeking consultancy.

The attitude that sets the basis for curatory communication is predicated on protecting the Larson self respect of the parties involved. The understanding, emphaty and helping skills of the society mental health specialist nurse are transmitted to the consultee. The consultee feels that he or she is respected, trusted and valued. This, in turn, helps the individual to feel “good”, “precious” and “special”. It’s crucial that the individual is assured taht he or she won’t be punished, laughed at or accused of his or her expressed feelings and thoughts. There’s open communication when the consultee can voice his or her feelings, thoughts and needs and which technnique is used is not that important. Here, the aim and responsibility of the society mental health specialist nurse is to provide and maintain an open communication. The communication techniques and approaches presented below are the communicative skills that are affective in reaching the consultee and keeping an open communication with him or her. They provide feedback to the consultee and makes it easier for him or her to express himself or herself. (Smitherman, Colleen (1981) Larson 2000). 1. Transmission of observations : These observations can be about the consultee or the situation due to the fact that it has the means for observing many facts about the consultant. In either case, it is important that these observations are displayed. Observations about the consultee: These are useful for starting a conversation. Expansions based on observations makes it easier for the individual to express himself or herself. “You got up early today” “You look troubled today” “In my last visit last week, you didn’t seem enthusiastic about talking when you were with your mother-in-law” Observations about the situation: You can use them to “make a prologue” to the topic the individual wants to talk about. These also are useful for starting a conversation. “I would like to talk to you about your reaction about using psychiatric medicine.” 2. Encouraging the conversation: This is useful especially in the beginning phase of the relationship. With short expressions meaning “Continue, I’m listening” the person is encouraged to continue talking. “Please continue”, “Yes”, “Hıh hı”, “Really?”, “What happened then?” In addition to these expressions, the use of body language – nodding, bending towards the consultee, reveals the willingness of the nurse in showing interest and listening. 3. Discovering: This technique encourages the consultee to know about himself / herself and his / her problems in depth. “Would you tell me about your job?” “You mentioned that there’s a patient diagnosed with schizophrenia in your family” 4. Recognitive attitude: This doesn’t mean that we approve the attitude or agree with the thoughts of the consultee. We accept that the individual has the right to feel the way he or she feels and he or she acts the way he/ she does. 5. Concentrating on emotions: In stating what the consultee’s emotions might be, the society mental health specialist nurse has to prepare questions in such a way that they help him/ her to concentrate on topics important for the consultee. Consultee : “This is unacceptable” Nurse : “You seem to distressed of all these” 6. Demystifying: This is used when what the consultee talks or complains about are not clearly understood. “You tell me you’re distressed. Could you please explain how you feel.” “Have I understood you right? You tell me whatever you’d done your father didn’t think you were successful. Is it so?”

7. Summarizing: This is to highlight the basic counsels of the topic discussed with the consultee. It helps to to revise the basic issues discussed during the interview. It’s useful to summarize the previous session at the beginning so that the consultee remembers previous issues and the nurse has the opportunity to see how he or she synthasizes. Summarizing helps the parties not to miss the aim of the session. “In our last meeting you had concerns about how your wife would respond to you” “Today you asserted three main points. These are....” 8. Listening: This is far beyond hearing and is the action of catching the meaning of what’s told. It’s important that, during the interaction, the nurse mostly listens and the consultee mostly tells. Listening is standing still however it is not a passive process. The nurse has to continue observing and try to understand the meaning of what he / she hears and observes. 9. Reflecting the scope: This iterates the basic thought in the consultee’s scope. It resembles the self iteration with words technique. “You think everything will be all right soon” “You say finding a part-time job will be good” 10. Reflecting the emotions: This is used to to give voice to the evident and implicit emotions in consultee’s statements. Whether the individual understands is displayed and also empathy, interest and respect is communicated. “As far as I understand you seem to be angry with your brother” 11. Informing: It is sufficient to respond to the queries of the consultee by giving direct and desired information. “I’ll visit you once in a forthnight on Tuesdays” 12. Restating with oneselves own words: This is repeating the main thought of what the consultee talked about with your own words. “That is to say you’re not comfortable with their treating you like a child” “You tell me that your mother left you when you were five.” Checking the perceptions: The perception of the consultee about his or her behaviors, thoughts and feelings is shared and the nurse checks whether his or her understanding is correct. “You’re smiling but I feel that you’re angry with me.” 13. Asking questions: It is necessary to collect all the information so as to help the consultee. 14. Feedback: This, informs the consultee about how his or her attitude affects others and develops open and confidence inspiring relationships. The main principles of interviews for the purposes of family and mental health service (therapeutics – educational intermeddling) are as follows: 1. Starting the education in accordance with interview principles (greeting the family) 2. Asking open - ended questions so that family members express their concerns about medicine use at home (Could you tell me about your concerns about the use of medicine? What difficulties do you have in using medicine?...) 3. Learning about the knowledge level of the person/people who will provide patient care about medicine (What do you know about the medicine the patient takes?) 4. Supporting the existing valid knowledge of the family members about medicine. 5. Explaining the family why that particular medicine is prescribed and how it will affect treatment.

6. Explaining how important it is to use the medicine regularly so that positive effects of it can be realized. (Especially emphasizing that initial effect will be seen after a week or 10 days) 7. Explaining that in the initial use of the medicine before the expected positive effects side effects might occur and the side effects and their strength may vary from person to person. 8. Explaning the necessary changed the patient needs to make in his or her daily routine to the family (driving, alcohol-drug interaction, the effect of the drug on motor skills) 9. Explaining what to do in the case of side-effects (depending on the type of the medicine) 10. Explaning the family that they should consult the doctor if the side-effects are seriously affecting the patient (drug intoxication, acut dystonia) 11. Giving the family a chance to ask questions 12. Answering the family's questions 13. Finalizing the interview within the principles of interview LISTENING TO THE FAMILY EFFECTIVELY EFFECTIVE LISTENING SKILLS Theoretical Information - Theoretical instructions Practice Group discussion on listening to the family effectively Required materials Pen and paper Projector and laptop computer OBJECTIVES Distinguishing between listening and hearing Raising awareness for the mistakes committed during listening Finding out different listening types Evaluating self-listening behaviour Evaluating effective listening bahaviours during interpersonal relations LISTENING Listening is to understand what one wishes to express exactly in the same way as it is transmitted. Listening is, rather than hearing something somebody utters, to hear what somebody expresses. Listening requires active involvement. We should show attentive behaviour to the speaker’s words through both verbal and non-verbal responses. For effective listening we need a quiet place and appropriate time. The number of people are quite high who try to offload their worries and give advice through some immature responses, who think they have found out the root of the problem after a few spoken words and make comments and guesses impatiently. Functions of listening 1. Listening shows that people understand or try to understand you. A total of 50 minutes 20 minutes 20 minutes 30 minutes 30 minutes

2. Listening encourages you to see what other people tell you and to be aware of your own experiences 3. While listening, you can create openness both for yourself and the speaker. This will reveal some important issues in the situation and the problem. This will also lead to openness regarding the situation. As a result, you can raise some awareness to help others solve their own problems. Principles of Listening Listening should show genuine attention. It is not possible to have an understanding of the conversational issue through pretended listening. Open statements are needed during listening. This will allow us to understand the purpose of the listener. Eye contact: It is a way to show we pay attention and show interest to the other person. Show your interest though your body posture Your body posture will impress others. It is very important that you have an open posture and your body faces the other person. Encouraging talk The important points in this section can be clarified with two examples: While talking on the phone, you expect the other person to indicate attentive listening using affirmative words such as yeah, yes. This sort of affirmation though verbal and non-verbal behaviour is also important in face to face communication. It encourages the speaker and also helps the listener to follow the conversation. Asking for clarification for lack of understanding Asking for clarification when you have not understood something is not perceived negative. On the contrary it produces positive outcomes. We can try to clarify some issues through confirmation checks such as "What did you mean exactly?" or "could you tell me what the important point is?" Do not hesitate to ask about the details of the problem While talking to somebody, try to understand exactly what they mean. Listen and ask for the details through questions such as "What kind of experiences did he/she enjoy?, What does he/she expect?', Does he/she have any fears? These sort of questions will help if you want to find out what the exact problem is? Instead of trying to elaborate on what you have told, lısten to the other person because you will only find out what the he/she means through listening. You need to be an active listener for not only understanding the messages conveyed but their contextual and emotional meanings. Questions should be posed only to understand the speaker not to satisfy the listener's curiosity.

Summarizing the present When especially jumping from one topic to another or diverging from the topic, it is important to put the conversation together in a summary form. Control your feelings

Everybody's opinion is right for himself. You should be able to accept this point even though others' opinions are different from yours. Being overwhelmed by your opinions, you may not hear what the other person is saying. Never hurry up Do not act in a hurry while listening. Checking the time or tidying up indicates impatience when you talk to people stuttering or groping for words. Frequently made mistakes Inattentive listening Among the effective listening behaviours are eye contact and attentive listening. Sometimes people watch TV when somebody is talking to them. Some do not reveal any facial expressions. These are examples of some ineffective listening behaviours. Another ineffective listening behaviour is to get engaged with another activity while somebody is talking to you. For example playing with a pen or a paper clip or doodling. Failure to allow others to finish conversation Another frequent mistake while listening is to interrupt others before they have a chance to finish their speech. This usually occurs when we know what the other is going to say and when we think it is unnecessary for the other person to continue. Another reason is that we prefer to hear what we say instead of listening to others. This happens when the topic of conversation is emotional and relevant to our personal life. This is also common in group discussions when people do not allow to finish each other's conversation. People may wait for a short time, but afterwards they will get a chance to interrupt. Beginning to tell our own story: One of the characteristics of listening is to provide the opportunity for someone else to tell their story. This story is sometimes unavoidable because it reminds us of our relationships and certain other things. When someone tells you about the emotions they experience and ask you how you feel about it, you tend to say that you have also experienced something like that and then tell your own story. Inability to remember: You may not be interested in the other person s story, and may not be able to continuously keep that information in your memory. We often experience inadequacies in telling other people that we are not in a position to listen. We give them the opportunity to talk and murmur something in return, pretend to be listening but in fact, can not. If you do not have time or if you do not feel well enough to listen to someone, it is best to tell them. Listening behaviour should always be practiced genuinely. Categories of Listening: There are a variety of listening categories. The most widespread is “apparent listening”. Sometimes, the person opposite you looks as if he\she is listening on the outlook but their inner world is somewhere else or has a more important issue on their mind than what you are saying. Some people are not interested in things other than what they will say or have said. You would think they talk to the person in front of them. They appear to be talking but are in fact not. The aforementioned is not a dialogue, but is the person talking to themselves, a form of lecture. The society names this as “Lecturing”. Some people only hear the part of what has been said which only interests them, and not the other parts. Such listeners can be categorized as selective listeners. These people remain to be “apparent listeners” until a word or an expression which attracts their attention is revealed. EFFECTIVE QUESTIONING SKILLS IN INTER-FAMILY COMMUNICATION

QUESTIONING SKILLS IN INTER-FAMILY COMMUNICATION Theoretical Knowledge -Theoretical explanations of the educator Application Group discussion and dramatization of the skills in effective questioning in inter-family communication Materials required Paper, pencil Projector, laptop

Total of 50 minutes 20 minutes 20 minutes 30 minutes 30 minutes

TARGETS: 1. Understanding the function of asking questions 2. Being able to discuss the importance of asking the right questions 3. Being able to discuss question types 4. Being able to ask new questions appropriate for the answers given EFFECTIVE QUESTIONING SKILLS IN INTER-FAMILY COMMUNICATIONS We can have more time for others and ourselves and gather more useful information related to the issue by asking effective questions. In this way we can make our encounter more effective. We can gather the correct information we need when we collect data by asking questions effectively. The helping relationship with the family members develops with questioning skills. We can obtain objective information focused on the family member with appropriate questions. In provisions of a quality care for the family member or the individual who need psychiatric help in the family, special data can be obtained by means of asking appropriate questions. Categories of Questions Open-ended questions These are questions that can not be answered with “Yes” or “No”. Basically, they are geared towards understanding the individual’s views, thoughts and feelings in relation to a specific issue. Their use is particularly appropriate at the beginning of the communication and makes transition to the later stages of communication easier. Open-ended questions clarify expression without any prejudgment. It is imperative to move onto complete listening with open-ended questions in order to understand the person in front of us. This type of questions is necessary for introduction to the issue and for changing it. We facilitate the spontaneous expression of the patient’s story by asking open-ended questions.

Closed-ended questions Open-ended questions are useful in moving onto listening and understanding in communication. However, there can be unclear emotions and thoughts within the answers given to an open-ended question which require clarification. In such situations, closed-ended questions come into play in order to clarify the concepts provided in a general and unclear manner or to gather relevant information. Closed-ended questions are used with the aim of clarifying unclear concepts which can be interpreted in different ways. Closed-ended questions are important in the provision of clarity to the information transferred. Such questions, which transform the information transfer to data, should be asked without too much detail and should not be threatening. 1. The questions we ask should be in such a way as to reveal all the necessary details within the encounter. The place, quality, quantity, chronology, environment, conditions and the variables related to the issue should be clarifying. 2. The questions asked should be understandable by the person in front of us. Medical language should not but a simple and clear language should be used. The answer to a question should not be obviously present within the question. “You must be feeling happy for being released from the clinic?”. “You must be in belief that children should not be smacked?”. 3. The questions should not be directed at overcoming our curiosity; piercing questions should not be asked. “Why did your husband leave you?”. 4. Numerous questions should not be asked at the same time. “Have you conformed to the suggestions I made?, Have you been careful with your diet?, Did you go for your check-ups?” 5. The questions should not start with expressions such as why and what for. The family member should not feel that he or she is being questioned. “Why didn’t you come for your check-up all this time? Why are you not following your diet?” The questions we need to ask ourselves before we pose it to someone else. WHY did you choose this question? WHAT exactly did you want to ask? HOW did you want to ask it? TO WHOM do you want to ask? WHEN should it be asked? WHERE should it be asked? Questions which does not involve personal interest The person is prevented from talking about his/her personal life unless it is absolutely necessary. The interest indicated by health service staff can be professional, not personal. For example, health service staff might be interested in knowing whether or not the patient’s wound has healed, the abscess has got better, his/her situation has improved. Interest in such matters indicates that the health service staff cares for the patient (counseled individual), is interested in the patient, and is following the improvements in the patient’s condition. Such attitudes contribute to the patient’s well-being and self-worth. “Why did your wife leave you?” “Why aren’t you still married at this age?”

Such questions are not appropriate since they are directed at satisfying the curiosity of the person asking the question rather than gathering information about the individual being counseled. However, if you need to gather information about such issues, it would be more appropriate to reformulate the questions above in the following manner: “Would it be useful to talk about your wife’s leaving?” “What do you think about marriage?”

FAMILY INTERVIEW QUESTIONS Family Interview Questions Theoretical Information - Educator’s theoretical explanations Practice - Presenting family interview questions to the group Required Materials: - Paper, Pencil/Pen - Projection Equipment - Lap Top FAMILY INTERVIEW QUESTIONS These sample questions below have necessary qualities to submit for the health care personnel during the interview. It is necessary to remind that open-ended questions has advantages on patients who has high-functioning level. But, close-ended questions which we can answer with “yes”or “no”, are advantageous for deorganized patients with low-level of functioning. However, close-ended questions can include an extra questions, such as “Can you give me some more details about it?” in order to gain more information about the patient. PSYCHOLOGICAL DIMENSION: 1) Do you have any specific problem that you think on frequently and openly lately? 2) Is there any relationship between your current problem and your problems from the past? Do you have any example for it? Is this example close to your conflicts with your parents in the past? 3) Did you experience many changes in your life lately? 4) How you view yourself now? Did your experiences effected your self-esteem? SOCIAL DIMENSION: 1) 2) 3) 4) 5) 6) 7) Do you usually spend many times with other people? Do other people respond you in a different way? Is there any changes in your close relationships lately? What are your friends thinking about your situation? Do you criticize yourself much? What do you think about the things that you can be with in this life (on the earth)? Do you feel that, other people are responsible from your problems today? Total 50 minutes 20 minutes 20 minutes 30 minutes 30 minutes

8) Are you behaving with other’s influences or with your own values? BIOLOGICAL DIMENSION: 1) Does any member of your family is experiencing the same or similar problem with you? Did any member of your family hospitalized because of having a psychiatric disorder? 2) Do you notice any change in your appetite and sleep lately? Do you experience an excessive sadness and happiness lately in your life? 3) Did you have any extreme experience in your life which you had difficulty in explaining to others? Do your thoughts seem that are changing very rapidly or very slowly from general? 4) Have you ever had the feelings of not having control of some of your thoughts? 5) Do you feel yourself under pressure because of other’s expectations from you? 6) How often (and how much) do you drink alcohol? Do you use any other substances? Do you have any problem related with alcohol and other substances? 7) Are you using any recommended/prescribed drug? CULTURAL DIMENSIONS: 1) How different is your life now from the time when you were raising? Do your family and your friends have problems that you can be able to understand and advise? 2) How were the responses of people from your previous culture which you were living in for these kinds of problems? How they are explaining this kind of situation and how they feel toward it? BEHAVIORAL DIMENSION: 1) Do you have any specific behavior which causes problems in your life? Do you have any behavior that you want to stop or prevent yourself not to do it? Do you have any difficulty In case of behaving in a manner which you really don’t want to do? 2) How others respond you? Is it easy to have a friend? PSYCHOLOGICAL (SPIRITUAL) DIMENSIONS: 1) Do you believe that you have any superior or exalted power for something? What is your view on these kind of feelings and beliefs? 2) Does your religion in this life (on the earth) can be able to understand you? EVALUATION OF THE EMOTIONAL STATES OF THE INDIVIDUALS AND THEIR FAMILY MEMBERS Evaluation of the emotional states of the Total : 50 minutes individuals and their family members Institutional Information 20 minutes - The conceptual acknowledgements of the 20 minutes educator Application 30 minutes -The discussion of the evaluation of the emotional 30 minutes states of the individuals and their family members in the group Necessary materials: Paper, pencil, overhead projector, laptop GOALS 1. The properties of the emotional state evaluation

The Emotional State Evaluation(ESE) The ESE is a recognition tool from the medical view.The aim of the evaluation is to define the psychopatalogical symptoms and then to evaluate the emotional states of the patient/applicant as well as his/her mental and emotional functions. This tool is very efficient in defining the patient’s acute psychotic characteristics and, also, in making a distinction between his/her functional states and organic states. As in all other data collecting and evaluation tools, ESE can be best realized when the applicant’s history is connected with his/her sociocultural status and physical condition. Nurses should prepare the ESE questionairre according to the patients’cultural background, personality, needs, desires, and interaction levels. a) Projective Tests: Projective tests are organized by focusing the verbal expressions of the patients on their interpretations of some vague shapes, and these tests project the patient’s mental functions. Projective tests define the samples of the non-standardized thoughts and also the behaviors which are based on real or predictory situations. APPEAREANCE: General appearence, psycho-motor behaviors, attitude and speech, posture, is observed and evaluated and finally, recorded as the general impressions. BEHAVİOR: Speech samples, tone, slang usage, fluency, eye contact, body language, and reactions to the environment and other stimuli are observed and compared with the behavioral data of the applicant. ORIENTATION: The awareness of the reality of the connection with other people, places, time and situations is observed with direct questioning. MEMORY: Previous memory, recent memory, and far memory is evaluated through direct questioning. SENSUOUSNESS: Sensing the inner and outer stimuli, concentration, getting interested in things is evaluated through direct questioning. PERCEPTIVE PROCESS: The examining of the data obtained perceptively, involves self-awareness and the thoughts of others, reality and fantasy. b) Personality Survey Forms: Personality Survey Forms measure the attitudes, habits and tendencies behind the actions, and they are objective tests which are standardized. They are generally in the form of questionairres.The difficulty of these surveys come from asking the questions in artificial situations and necessity of choosing the answers from the given,limited answers.These can create cultural bias. However, thses tests consist the secure samples of the potential acts and opinions. c) Intelligence Tests Intelligence Tests measure the mental functions in verbal and non-verbal levels.These tests are standardized according to the age. Generally, the effects of the individuals’ sociocultural characteristics on the logic can not be evaluated in intelligence tests.The aim of the intelligence tests is to identify the role of the mental functions causing the problems in the mind of a patient. Orientation: 1. Have you ever had any problems with realizing where you are or what is happening around you? Can you tell where you are now? COGNITIVITY:

1. Are you worrying for yourself? Memory 1. Do you remember what you have had for breakfast this morning? 2. What was the day yesterday? The content of thoughts: 1. Do you have any recent thoughts which are reoccuring to you often? 2. Do your thoughts travel in your mind slower or faster than usual? 3. Do you feel like empty-minded lately? 4. Do you experience any problems with proceeding or understanding your thoughts? 5. What is my name? 6. What is the name of the college that you graduated from? Sensitivity: 1. Do you have any concentration or focusing problems? Can you read a book or watch a film till its end? 2. Do you experience any problems while you are communicating with others? Perception: 1. Are there things that other people can not see or hear, but you can do?

Pages 30-32

2.
3. 4.

Do you think you have extraordinary abilities and experiences recently? Do you believe there are some people who say completely wrong things? Do you believe there are people who try to hurt you? Are there any situations lately in which you see a person like a shadow or something as it is something else?

Insight: 1. 2. Criticism: 1. 2. What would you do if a policeman stops you for an exceeding speed? What would you do if you received a 10.000 dollar check from mail? What do you think is the real problem for being here today? How do you interpret the situation at the moment and what are your feelings about it?

Nature and Affect: 1. History: 1. How many sisters and brothers do you have? Where were you born? When you were a small child how were your parents like? What do you remember about your childhood? How would you define your recent emotional-condition? Are you more emotional or less emotional compared to the normal situation?

2.

Were you successful in your school life? What was your success level? Were you playing too much (a lot) with other children? What were the things that you liked at home? What was your primary school like? What did you like about it? How were your grades? Did you have any problems? Lisede size neye okudunuz sorusunu anlayamadim

3.

Intellectual Knowledge: 1. 2. 3. What is the name of your mayor? What is the most important recent news? Can you deduct 7 from 100 until I say “stop” (can you count 7 by 7 backwards starting from IA)? What do you understand from the saying “It does no good to cry over a spilled milk”?

Result: 1. 2. 3. Is there anything you want to tell me which will help me to understand you better? Is there anything you want to add to this session? Can you tell me what this session is like or mean to you? Are there any questions you want to ask me?

Counseling with the Family Counseling with the Family Institutional Information -Institutional information given by the educator Application -Group discussion between the family and the counselor Necessary Materials Paper, pens/pencils Projector, laptop Goals: 1. 2. Being able to explain the principles of counseling. Being able to apply the principles of counseling. Total 50 minutes 20 minutes 20 minutes 30 minutes 30 minutes

COUNSELING Counseling can be defined as providing help to the applicants who need help by those who experts in the field to encourage the individuals applicants to gain the necessary knowledge and skill to become conscious about their own ideas, choices and decisions. The aim of counseling is: to provide information to the applicant and the family to provide answers to the questions of the applicant and ease the worries to explain what the applicant’s next step will be

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to give information about any possible unpleasant situation(s)

-Duration of Counseling Counseling must be provided confidentially under a comfortable and secure environment where the member(s) of the family feel secure and the communication techniques are used effectively. This environment must be quiet and clean and it must have appropriate lighting and heating. Characteristics of the Counselor: The counselor must be reliable and protect confidentiality of the individuals. The counselor must possess the essential knowledge. The counselor must be able to use the communication skills effectively. Principles of the counselors are: to treat the family member(s) well to create a strong communicative environment to give appropriate information to the family member(s) when necessary to help to the family member(s) to understand and remember

Counselor Evaluating the Interview (Session) with the Family Member(s) Pages 33-35

Did the counselor form proximity/communication with the client? Did the counselor reflect the client’s feelings? Did the counselor share the client’s feelings? Did the counselor communicate with the client without any judgement? Did the counselor form an association between the stressors and the client’s emotional responses? Did the client and the counselor agree on the definition of the problem? Did they understand each other about the definition of the problem? Did the counselor allow the client to talk and define himself/herself clearly? Did the client reach the helpful choices or solution at the end of the session?

Intervention to the individual or family having the crisis

Intervention to the individual or family having the crisis

Total 50 minutes

The Theoretical Information The theoretical explanations of the trainer

20 minute 20 minute

Application Discussion with the group about the intervention to the individual/family having the crisis.

30 minute

30 minute

Necessary Materials Paper, pencil, projector, laptop

Aims 1. Understand the crisis’s reason 2. Understanding of how to deal with the individual/family with appropriate 3. Direct the individual or family, who having the crisis to the proper place

Intervention to the individual or family having the crisis Crisis is the position that an individual’s mental state needs to be restructured again, and it is the temporary situation that the individual’s expectations from himself/herself suddenly change. Even, it can be defined that it is a turning point in our life. The crisis threats the individual/family, and destroys the balanced situation. If the individual can not cope with the problem, this creates an opportunity for the personal development. Caplan defined four steps, which lead the crisis. 1. Individual is face to face with the crisis’s situation. Individual uses the past experiences to cope with the tension and the anxiety. 2. The crisis situation continues cause of anxiety and creates tension.

3. It is used urgent problem solving mechanisms. The individual looks for help. All the internal/external resources are started to move/activate. The problem is redefine again if it has any similarities with the past experiences. Individual organizes himself/herself according to the problem and can abound some of the goals. Sometimes the problem is solved and balance is provided. If they can not solve the problem, the tension starts to increase and individual might have of depression.

4. It will be resulted with the active crisis if the problem can not solved and continue to increase. In this crisis situation the individual feels himself/herself helpless and h/s can not know what h/s can do. The individual’s emotional state might be destroyed. Using of inappropriate coping strategies to decrease his/her tension might risk his/her future social functioning.

After the crisis was happened, it can be finished during the 2 days or 2 weeks. Mostly, the crisis takes place 24-56 hours, but sometimes it can be continue 5-8 weeks. Every individual can live the crisis situation during their life. The individual, who is in the crisis situation, it does not mean that has a psychological problem. The individual does not have pathology that leads the diagnosis. Individual can live temporary tension because of the conditions that h/s is living. Baldwin defined six different types of crisis to provide a plan for care and evaluation. Specific Crisis: In this situation individual faces with problem which is appear /come up with the result of specific situation. For example, individual has an alcoholic wife. Vital Crisis: This crisis is divided form the specific crisis because they are related with the psychological problems. To be a partner and father, divorce and cronical illness can be given as an example.

Traumatic stress crisis: They appear when individual can not wait or control any kind of situations/conditions. The unexpected death of family members, natural disaster, and rape are traumatic crisis. Developmental Crisis: Developmental crisis appears when individual could not solve the problem which is happened in the past. For example, addiction, value conflicts, sexual identity conflicts. Psychopathological Crisis: Refers to crisis, which have happen at the end of the previous psychopathology, such as neurosis and personality disorder. Psychiatric Urgent/Emergency: In this crisis the individual’s psychological, social, and emotional functions are seriously destroyed. For instance, like attempted suicides or acute psychosis circumstances. The Interference to the Crisis There are two aims interference the crisis. The first one is to reduce the pain of the individual and the environment with an immediate first aid and the second aim is working to increase individual’s power of harmony and fight during the crisis. Crisis in the work of the first step is to define the meaning of ‘crisis’ for people and for the relatives of them. The crisis assessment of the present time problem story begins with the involvement. “When have these symptoms started? How are they defined by the patient? What has begun in the patient’s life at the same time?” Receiving information about the past story and the coping with mechanism: “Has the similar crisis incident been experienced before? Are there similar crisis situations in the life of important somebody for the patient? How did the patient cope with out the past crisis situations? What are the results of using the present dealing with methods? Is there anybody who causes to continuing of the problem?” The social support level assessment of the family

“To whom did you apply during the crisis? Who is the most important and available person in the individual life? How is the home environment? How is the patient's business environment and social environment?” Some ways should be followed to explain the crisis situation by the nurse. The Therapeutic Intervention Approaches to the Family Psychodynamic and Insight Oriented Approaches The fundamental concepts of this school have been taken from the individual patients’ psychoanalytic treatments. The family now existing problems are explained by unconscious conflicts of the man and woman and associations of the reflections stemming from the family in the past. For example, a mother who finds the world unsatisfying with her unconscious conflicts can place her own child in a feeling of desperation and guiltiness to fulfil her narcissistic delight. Three criteria are suggested psychoanalytically to be considered for a family therapist. The first one is the assessment of the dynamics of the relations between people based on the psychoanalytic theory. The second, the awareness of the respondents for their unconscious conflicts and providing the possible solutions for them. And the third is therapeutic framework is the fact that psychoanalytical. The family therapists using this approach aim to make a change on the family system to help the individuals and couples to gain insight by using confrontation, interpretation, clarifying techniques. Thanks to this therapy, it is aimed to provide the autonomy and the proximity needs of individuals in a more advanced form, to enable having more empathetic relations, to decrease emotional reactions and to advance cognitive mechanism. The Structuralism Approaches In the structuralism model, the family system interplays various and more complex behaviour patterns which is accepted as a whole integral. The family therapy is a helpful theory tries to understand the complex patterns of behaviour processes. 3 basic concepts of this theory as follows: 1. Family structure 2. Lower systems and 3. Borders

The family structure is ingrained behaviour patterns occurred as a result of the family behaviour patterns. It also supplies the interaction between family members by putting arrangements related to this relation. The structure of a family of the system completes its functions with the infrastructure systems formed by the individuals. Within a family each individual on his own is accepted as a lower system, three general lower systems can be mentioned about. These lower systems are; husband and wife sub system, father and mother sub system, brothers and sisters sub system. There is a border of existing subsystems and systems. The borders are divided into three dramatic borders regarding solidity, uncertainty and certainty according to how much emotion and knowledge will be conveyed from a lower system to another; who has a relationship with whom and how. Due to the lack of permeability between lower systems and systems restricted by solid borders, the individuals cannot assist each other and cannot learn despite having independence. If it remains uncertain border a kind of inside to go through appears and although the infrastructure systems/systems help each other, learning another they cannot protect their haecceities and differences. On the other hand, in the families who have considerable border characterics, the individuals remain split succeed to have a relationship without breaking out from each other. To the situations in which the limitations and hierarchy are destroyed as an example of over protective, supervisory parents’ sub-system and passive or rebellious child a family structure may be given. It aims to increase of the structuralist therapeutic parental intervention in relations and sorting triangulation out. Among the techniques used can be respected animation, focusing and the creation of border. During the therapeutic intervention in the family of problems of the revival, representing the problem of a situation and refocused on clarification of borders (daughter of for example speaking on behalf of the mother, daughter to help but where it's daughter that he should do to speak) are provided.

Cognitive-behavioural Approaches This therapeutic approach intervenes in the learning principles. Communication skills, problem solving skills, consolidating bilateral and computational conditioning techniques are used. Therefore, rewarding the appropriate behaviour with a prize, unrewarding the inappropriate ones is one of these techniques. The focus of the initiatives is the behaviours that cause to problems. A nurse who is expert at communication teaches the family members to describe their opinions and behaviours in a clear way. Problem solving consists of five phases: identification of the problem, the determination of the goal, making a proposal of possible solutions, application of these proposals, and assessment of the results. For behaviour changes positive reinforcements and home tasks are used.

Pages 39-41 Strategic Approaches The approaches focus on the complaint or the problem that causes the rise of complaints in the family. According to this approach some reason of the symptoms are failing to solve problems, inability to adjust to changes life brings and malfunctioning hierarchy in the family. In order for the family to solve the problem they have to change this pattern and adopt a new pattern. This goal entails subgoals, prevention of strong feedback, changing the continuity of the symptom with new results and a clearer definition of hierarchy. Family structure is kept intact; yet the family is free to reorganize itself. Reframing the problem, behavioral assignments are some techniques used to provide change. Communication-language and meaning are especially important in this approach. Systemic Approach Family is a system of information exchange and active communication. The fact that psychological symptoms are related with the individual’s social environment is emphasized, which helps treatment. Psychological problems arise from the system and the people sharing the same system in which the individual lives. In etiological approach, members of the family or malfunctioning family are not responsible for the symptoms, it is rather tha “family game”. The family is imprisoned in the vicious circle of permanent interactive patterns. This approach takes for granted that the systems evolve and improve, yet they appear to be stable. Systemic treatment helps the family develop an ability to change and frees the family’s potential for change. Instead of forcing the family to accept external solutions, it helps them develop their own solutions. Experimental/Humanistic Approach This approach defines family as an interactive communication system among the individuals. Communication demonstrates whether a family is healthy or not.Although communication is rather comlex, it is regarded as based on learning. This treatment also emphasizes self-respect. There three communication levels: 1. meaning (verbal communication/ words and meaning) 2. Association (body language and the voice carrying the message) 3. environment (where communication takes place and when) Apart from these there five types of communication between individuals: 1. Consolation: the self is not important, what’s important is the environment and the others. Here the individual agrees with everything. 2. Accusation: the others and the environment are not important, what’s more important is the self. The individual holds everything and everybody, even his/her own existence accountable. 3. Logical communication: the self and the other are not important, the environment is more important. In this type of communication, the individual is strict, objective and obssessive compulsive. 4. Indifference: the self, the others, the environment are not important. The individual simply does not communicate. 5. Proper communication: the self, the others and the environment are important. The first four of these communication types are used by malfunctioning families. The treatment has two goals: First, it helps every member express his/her feelings about himsel/herself and the others in the presence of other people. Secondly, it helps decisions made through negotiation/research rather than through force which is more appropriate in a selfrespecting environment.

Educational approaches New studies stress this approach. The families of the patients are told that they are not responsible for the problems just as they can’t be held responsible for illnesses such as diabetes or high blood pressure. Informative model replaces etiological-patogenic model. Workshop, texts, guides are used in informing. These approaches are applied in psychological cases as well as child development and communication. The characteristics of Treatment Family treatment comprises of meeting of all the family members and their interaction with the nurse. Some nurses find it helpful to bring all the members of the extended family (such as grandparents, uncles, aunts, et cetera) together and some think that single individual or the core family can be treated only because dealing with individuals and relationships is more important. In the treatment of a marriage, the couple (married or not) is treated together. It is important for the therapist or therapists and those who conduct the treatment to cooperate. The nurses who treat the family must have the ability to sympathize, must have psychiatric knowledge, must be strong enough to take complications and must be eager to contribute to and influence the process of treatment. During the evaluation phase, the nurse talks with a group who has a common past. Therefore, she has to understand the values of the family and their way of communication. She can use some techniques such as speaking the same language with them, emphasizing and praising the values of the family as a whole or each member, interactive questioning instead of judging (for eg. She can ask ‘when your wife does that, what do you do’ type of questions), which help her communication with the family. During the evaluation phase each member is asked to describe the problem and the history of the problem from their own perspective. The members should be all asked the same question. They are asked to use the “I” language. Each is asked to suggest solutions. When they talk to each other, it must be observed whether what they say is heard in the same way or not. Role-changing and psycho-drama are very helpful in understanding the ways in which the individuals are affected by each other. By observing the way individual people interact in the nurse consultation room, he specifies and comments on the problem. This sort of comment is usually one that turns the negatively impacted behavior to a positive one, providing a new perspective, focusing on the functional use of the behavior. In this way, the technique helps alleviate the impact of negative emotions in people and enables them to change. In family therapies focus should be on behavioral patterns. The individual behavior of the family members results in interactive changes in others. The period of change will materialize in the recognition of the consecutiveness of behavioral patterns. During the therapy the family is assigned certain homework which would help the individual members change. The homework intends to track down and show that they can be held in check. The nurse should also be an influential guide during the family consultation. For instance, she may propose certain changes in the way family members sit, the way they can communicate, and be prohibitive and restrictive in domestic violence. She might as well suggest that arguments should be limited to a certain time period and make sure that they can actually manage the problem. Communication skills are actually of crucial importance in enabling changes in behavioral patterns. Clear and lucid communication, the ability to ask questions are of methods will help with the way people understand what they each mean what they say. The nurse should set a good model that would provide family members with communication skills. Family Evaluation Form 1. Demographic Data 2. Roles Rules and Relations

Decision-making pattern, Communication pattern Rules and roles 3. Socio-economic and cultural factors Health care provision status Role, responsibility, values, Relationship between religion and health Value system 4. Environmental Factors 5. Health and health history Health and sickness history of the family Whether the family seeks for health care The way the family perceives health care providers Health priorities of the family. 6. Risk Families

Family with multiple problems Unhealthy family (dysfunctional) Immigrant Family Unregistered family Family with chronic illnesses Aged family Family with no socio-economic means Family with domestic violence 7. Evaluation of Domestic Violence Molested, abused children: observation of the problem, frequency of violence, and treatment Molested women. Observation of the problem, personality traits of the woman, sources/action. Molested elderly: observation of the problem, characteristics. PSYCHO-EDUCATIONAL NURSING PROTOCOLS FOR FAMILY AND INDIVIDUAL

1. Seeking for informed approval and suitability Participation of patients The way the family members define the patient Permission (Approval) of the family members 2. History based on records (information) Days of hospitalization within the last year Number of hospitalization First hospitalization. Health checks since the last hospitalization (clinical records) Psychiatric diagnosis Nurse diagnosis Medical history, anamnesis, Other medical problems. 3. Clinical Evaluation of the patient The way the patient perceives the illness The way the patient perceives the causes of hospitalization Recognition of the symptoms by the patient The methods the patient discovers in handling the symptoms The patient’s reaction to the illness Diagnosis of the nurse Psychiatric symptoms (scale of symptom evaluation) Patient’s objective Patient’s social and leisure activities. 4. The visitation of the family member (upon consent) The way the family member perceives the illness The way the family member perceives the causes of hospitalization Recognition of the symptoms by the family member The methods the family member discovers in handling the symptoms

The family member’s objectives vis-à-vis the treatment The time the family member allocates to the patient The family’s reaction to the illness The way the family perceives social and leisure activities and expectations 5. The information synthesis of the expert clinical nurse and psycho educational practice Reciprocal Objectives for psychological training (Patient, family planning and evaluation of the clinical nurse) Planning and developing psychological training for the patient and the family 6. Discharging the patient and its aftermath Interdisciplinary discharge plan Public health care, psychological health and contact with the nurse during domestic healthcare. Phone contact with the expert when needed Annual evaluation after the discharge Meeting the Family 14. Beginning the training with greeting principles (greeting the family) 15. Asking open-ended questions about the family member’s anxiety about medication (Would you like to talk about your reservations about medication? Do you have any problems with medication?) 16. Learning about the individuals who will provide the patient with medication (What do you know about the drugs the patient takes?) 17. Supporting the family members correct knowledge about the drugs 18. Explaining to the family members lucidly what the patient takes drugs and its effects in the treatment 19. Dwelling on the regular use of the drugs to optimize the effects of the drugs (Explaining that the effects of the drugs will be marked after a week or ten days) 20. Explaining that there is possibility that before the positive effects the side effects may appear

21. Explaining the family that there will be changes in the daily routine of the patient and rules the patient must abide by (driving, alcohol-drug interaction, and delicate motor skills 22. Explaining them what to do when side effects appear (according to the drug variety) 23. Advising them to certainly contact the doctor when the side effects are serious (drug intoxication, acute distony) 24. Giving the family the opportunity to talk 25. Responding to the questions of the family Concluding the meeting in accordance with the consultation principles TRAINING THE PATIENT ABOUT THE DISCHARGE 1. Helping the patient express their feelings about the discharge (in accordance with consultation principles) 2. Specifying the patients need for information 3. Explaining the patient status of the patient and effects of the treatment 4. Explaining the functionality, role and responsibility and their effect on the interaction with other people 5. Explaining how he will be living certain extraordinary circumstances with the illness at home, workplace. 6. Providing information on cases which might increase the illness (problems with the work and family life, ceasing to take drugs, unavailability of spouse or friend support 7. Explaining the suitability of the other prescribed drugs and treatment with other kinds of the symptoms 8. Explaining the symptoms of reappearance of the illness (sleep patterns, eating habits, emotional changes, introversion, suicidal thoughts or attempts, excessive uncontrolled behaviors) 9. Reminding that the patient should contact hospital when such symptoms appear 10. Letting the patient ask questions 11. Responding to the questions 12. Concluding the consultation in accordance with the consultation principles.