Community Mental Health Journal, Vol. 28, No. 5, October 1992

CLINICAL CARE UPDATE Clinical Issues in Social Network Therapy for Clients with Schizophrenia Donald Wasylenki, M.D. Susan James, O. T Carrie Clark, O. T Joan Lewis, O. T Paula Goering, Ph.D. Laurie Gillies, Ph.D.

A B S T R A C T : Social networks are viable foci for therapeutic interventions. A social network t h e r a p y program for clients with schizophrenia was developed by a community-based m e n t a l h e a l t h agency. This paper presents four of the most common clinical issues encountered a n d illustrates each with a case example.

The term social network refers to relationships and how they are arranged. Social networks are described in structural and functional terms. Structure refers to network size, density, and kin versus non-kin composition. Functional characteristics include reciprocity, accessibility, homogeneity, multiplexity and others. Networks typically are arranged in separate, highly connected clusters, with or without linkages between clusters. Supported clusters are clusters which are connected to other clusters. The authors are all on staff of the Continuing Care Division at the Clarke Institute of Psychiatry in Toronto. Dr. Wasylenki and Dr. Goering are associate professors in the Department of Psychiatry at the University of Toronto. Address correspondence to Dr. Wasylenki, Clarke Institute of Psychiatry, 250 College Street, Toronto, Ontario, Canada, M5T 1R8. The Social Network Therapy Program is operated by Community Occupational Therapy Associates in Toronto and funded by the Community Mental Health Branch of the Ontario Ministry of Health. (Grant 0861). 427

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Several researchers have described the social networks of people with schizophrenia as different, both structurally and functionally, from '~normal" social networks (Mueller, 1980). These networks have been shown to be smaller, denser and more heavily kin-dominated, with few separate clusters (Pattison et al., 1975). A "cluster" refers to a sub-set of interconnected relationships. In addition, relationships have been shown to be less reciprocal, and less multiplex (Sokolovsky et al., 1978). Reciprocity is the extent to which relationships are characterized by giving as well as receiving, and multiplexity refers to the number of separate functions provided by relationships. Tolsdorf (1976) has shown that young people with schizophrenia have a '~negative network orientation", i.e., they do not tend to view the people with whom they have contact as potential sources of support. Pattison (1975) has argued that small, dense, kin-dominated networks not only do not provide support, but in themselves become sources of stress. Studies of interactions among family members of some people with schizophrenia lend support to Pattison's observations (Left, 1976). In addition, negative symptoms in schizophrenia have been shown to correlate with smaller, more dysfunctional social networks (Hamilton et al., 1989). Social networks have been seen as viable foci for therapeutic interventions (Greenblatt, Becerra & Serafetinides, 1982) as well as relevant outcome measures (Cutler, Tatum & Shore, 1987). Assessment techniques have been developed to measure both the subjectively perceived social network (Pattison, Llamas & Hurd, 1979), and the objectively determined network (Silberfeld, 1978). Strategies for increasing network flexibility and stability for "revolving door" patients have been described (Morin & Seidman, 1986). These strategies include increasing network size by adding clusters or by adding individual members, increasing multiplexity, reducing negative effects and generating connections and spans. Schoenfeld and colleagues (1986), in a very encouraging report, showed dramatic decreases in subsequent hospital utilization among 20 participants in a network therapy program, compared with 20 nonparticipants. Eleven of the 20 network clients were described as psychotic or schizophrenic. THE P R O G R A M

A Social Network Therapy (SNT) Program for clients with schizophrenia was developed by Community Occupational Therapy Associates, a community-based mental health agency in Toronto. Six occupational therapists, who formed the SNT team, received specialized

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training in the psychosocial needs of individuals with schizophrenia and models of network therapy practice. Subsequently, as the project evolved, they received ongoing support and technical assistance, including regular supervision, conference and workshop attendance, and sessions devoted to refinement of the network therapy approach. Referrals to the SNT Program come from mental health practitioners across Metropolitan Toronto, in accordance with published criteria. During an initial assessment visit, the client and one other network member map out significant relationships, using a modified version of the Psychosocial Network Inventory (Pattison et al., 1975), and an ecomap which provides a concrete '~picture" of the client's social network. There are three principle subsets of goals pursued most frequently in the SNT Program. The first is to increase network size, particularly the size of the non-kin sector. The second is to create distinct clusters in the network with a moderate degree of linkage. The third is to minimize "encapsulation" of the client's social network by someone else's network. In order to achieve these objectives, therapists employ activities such as increasing contact with valued network members, removing or decreasing dependency on negative social ties, and reinforcing existing supportive ties while increasing the number of functions provided by these relationships. Principle network intervention strategies include network construction, which involves adding new members to a depleted network; network convening, which involves consultation between the therapist and network members to effect change; and network coaching, wherein the therapist assumes the role of educator or trainer for the network. Further details regarding the program's operations are presented elsewhere (Gottlieb & Coppard, 1987). Thus far, the program has dealt with several hundred referrals, each of which was seen by the referring source as involving some sort of network dysfunction requiring intervention. A detailed analysis of a sub-set of these referrals is in preparation. This paper presents four of the most common clinical issues encountered in working with the networks of clients with schizophrenia, and illustrates each with a case example taken from clinical practice. Successful working through of these issues has resulted in good outcome with high levels of both client and network satisfaction. Sources of the data reported for each case include client interviews conducted by a research assistant, involving both structured interviews and rating scales, and "contact sheets" completed in uniform fashion by all therapists following each client contact. Scales used included the 18-item Brief Psychiatric Rating Scale (Overall & Gorham, 1962) and a Social Handicaps Scale developed for the project.

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E N V I R O N M E N T A L CHANGE Some young people with schizophrenia experience a great deal of stress from spending most of their time with critical or emotionally overinvolved network members. This interpersonal environment has been described as high in Expressed Emotion (EE) (Left, 1976). High EE is a common characteristic of small, dense, kin-dominated networks with few alternative clusters. People are unable to escape from these oppressive networks because they have great difficulty in negotiating independence. As a result, they do not move away from their families, develop social relationships or discover vocational interests, activities which normally lead to the creation of balanced networks with both kin and non-kin clusters. Not uncommonly, the network therapist encounters a situation wherein the client spends most days in close contact with a few family members, interrupted solely by admissions to hospital. The task is to begin to assist the client to discover new living, learning, working or social environments within which he or she can begin to form new network clusters. This involves moving from kin-dominated to non-kin networks, and entails support from the therapist, both in altering old connections and in taking new initiatives and developing new relationships in new environments. Casual rather than intense social situations, low in expressed emotion, often provide optimal settings for the development of new clusters (Lakoff, Snyder & Ventura, 1984). The challenge, as Hammer (1981) points out, lies in discovering environments which provide a balance of stimulation so as to reduce feelings of being intruded upon while avoiding excessive social withdrawal. The objective is to enable the client to occupy several different social environments and to move freely among them. Once the client is established in a new environment, and some degree of cluster formation has occurred, then therapist and client may begin to work at connecting clusters, i.e., building spans, so as to enable clusters to support one another. Supported clusters have been shown to be more durable than unsupported clusters, particularly during episodes of hospitalization (Hammer, 1964). Building spans may include linking clusters within the client's naturally occurring network with community support programs or formal mental health services. The following case history illustrates several aspects of the environmental change process in social network therapy. Case One Mr. M, a 23 year old man diagnosed with schizophrenia, was admitted to the SNT Program because of poor motivation and negative feelings towards family members. His social network consisted of his mother, father, sister, brother, psychiatrist and

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social worker. Family relationships were described as negative, and relationships with the psychiatrist and social worker were slightly positive. He did not work or attend school, and spent nearly all of his time at home with his family. Both parents were described as emotionally over-involved and unable to set appropriate limits. The client had a history of many hospital admissions and several suicide attempts. He was extremely agitated during initial assessment sessions, and stated that he disliked living at home but knew of no alternatives. He complained of an inability to meet people, and the SNT therapist ascertained that most relationships were non-reciprocal and highly dependent. He demonstrated a number of social handicaps, including pressured speech, preoccupation, vagueness, and an inability to make eye contact, and six symptoms were present on the 18 item Brief Psychiatric Rating Scale (BPRS) in moderate to severe categories. When asked, he stated that he was dissatisfied with the amount of support available from family and friends, and that he did not turn to people he knew for assistance. Initial meetings with the family network resulted in a decision to assist the client to locate an alternative living environment. Mr. M's brother agreed to work with the client to collect housing information. The client's history of violent and suicidal behaviour and substance abuse blocked access to several supervised settings. In addition to helping to direct the search for a suitable environment, the SNT therapist convened a number of family meetings to deal with the parent's covert resistance to the move. One successful strategy involved linking the parents to a support group for families of people with schizophrenia. The therapist also worked with the client and his psychiatrist and social worker to achieve better stabilization of his clinical state through an increase in medication and a shift to regular weekly injections. In addition, the therapist worked with the network to provide strong advocacy with a supervised, cooperative housing program, to secure admission for the client. After admission, she supported the building of new relationships with housemates as well as working to connect the family network with the developing cluster in the housing environment. On follow-up, one year after entering the SNT Program, the client and his family expressed a great deal of satisfaction with the intervention. The client spent much less time with his family network, and felt much more positively about family relationships. He identified four new relationships in the housing environment, all of which were positive. He stated that he was anxious to make new friends, and complained of feelings of loneliness when his housemates were away. In order to qualify for the housing program, he had enrolled in a day program, and he reported no problems with the use of spare time. There were no social handicaps identified on follow-up, and no symptoms on the BPRS. When asked, he stated that he was very satisfied with the support he received from family and friends, and that when he experienced difficulties in future he would turn to people he knew for help.

RELATIONSHIP COUNSELHNG Many people with schizophrenia complain of feelings of loneliness. Social impairments and social skills deficits are prominent features of chronic mental illnesses. Social skills refer to the ability to make appropriate responses in interpersonal situations, and include such things as the ability to express feelings, to make requests, to obtain information and to be suitably assertive. With regard to schizophrenia, social skills may be lacking for a number of reasons: the illness may

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have had its onset in adolescence, so that skills have not developed; features of the illness may alienate potential network members; episodes of illness and periods of hospitalization may erode social skills; the client may assume anti-social roles; and social anxiety may be a prominent aspect of the illness. This makes it difficult for patients to develop and maintain close personal relationships, and absence of such relationships characterizes the social networks of people with schizophrenia. In particular, many young clients express a strong desire to establish heterosexual relationships, and experience a great deal of frustration when they are not able to succeed. Some clients are able to develop and sustain heterosexual relationships even though the relationships often have a quality of detachment and, at times, of unreality, when compared to the relationships of healthier individuals. Despite these limitations, such relationships frequently are observed to have a stabilizing effect on the client's previously chaotic existence. As noted above, a central relationship problem for many people with schizophrenia is lack of reciprocity. Reciprocity refers to the give and take in healthy relationships, which allows both participants to feel they are receiving as well as contributing important interpersonal supplies. In a non-reciprocal relationship, one member is typically highly dependent upon and demanding of the other, and lacking in the ability to identify and respond to the other's needs. Because of a lack of reciprocity, many members or potential members of clients' networks experience relationships with the client as extremely burdensome. This, along with various instrumental demands, contributes to the heavy burden of illness associated with schizophrenia. Learning to become more reciprocal in relation to others is an important skill which many people with schizophrenia must learn if they are to succeed at expanding and normalizing their networks. A second important feature of many clients' relationships is nonmultiplexity. Multiplexity refers to the number of different functions that a given relationship may provide. For example, two friends may share collegial concerns at work, spend time pursuing recreation together, and socialize together, along with other members of one anothers' families. Multiplexity is seen as an indication of mature, functional, durable network bonds, and it is assumed that as a relationship develops over time, it will take on added functions, i.e. become more multiplex. Healthy social networks are characterized by numbers of multiplex relationships. Many of the relationships of people with schizophrenia, on the other hand, are described as non-multiplex or unidimensional. They provide only one function for the client and clients

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often experience g r e a t difficulty in e x p a n d i n g t h e f u n c t i o n s or e v e n in r e c o g n i z i n g t h a t a g i v e n r e l a t i o n s h i p h a s t h e p o t e n t i a l to m e e t m o r e t h a n one need. D e v e l o p i n g m u l t i p l e x i t y becomes a n i m p o r t a n t focus of r e l a t i o n s h i p c o u n s e l l i n g in order to i m p r o v e t h e q u a l i t y of clients' networks. T h e presence or absence of a c o n f i d a n t h a s b e e n s h o w n to be a n i m p o r t a n t d e t e r m i n a n t of t h e s u p p o r t i v e capacity of social n e t w o r k s . A c o n f i d a n t is s o m e o n e w h o provides a n d experiences a confiding relationship w i t h a n o t h e r . C h a r a c t e r i s t i c s of a c o n f i d a n t r e l a t i o n s h i p include e m o t i o n a l i n t e n s i t y , reciprocity a n d availability. B r o w n a n d colleagues (1975) s h o w e d t h a t t h e p r e s e n c e of a confidant, who w a s e i t h e r a spouse, b o y f r i e n d or close friend, conferred p r o t e c t i o n in a group of w o m e n p r e d i s p o s e d to depression. L o w e n t h a l a n d H a v e n (1968) also h a v e s h o w n t h a t t h e presence of a n i n t i m a t e r e l a t i o n s h i p is a n i m p o r t a n t d e t e r m i n a n t of q u a l i t y of life a n d m o r a l e in t h e elderly. W i t h r e g a r d to schizophrenia, however, H a m m e r (1981) p o i n t s o u t t h a t t h e issue m a y be m o r e complex. She r e p o r t s t h a t a n i m p o r t a n t correlate of EE is d i s a p p o i n t m e n t by t h e f a m i l y in t h e p a t i e n t ' s r e f u s a l to confide. She s u g g e s t s t h a t ~'what is i m p o r t a n t h e r e is not t h a t t h e p a t i e n t acquire a confidant, b u t t h a t t h e p a r e n t s stop t r y i n g to be one." N e v e r t h e l e s s , m a n y y o u n g people w i t h s c h i z o p h r e n i a are v e r y a n x i o u s to develop closer r e l a t i o n s h i p s outside of f a m i l y clusters, a n d m a n y do express d i s a p p o i n t m e n t a b o u t lack of i n t e r e s t in t h e i r lives on t h e p a r t of f a m i l y m e m b e r s s u c h as siblings a n d o t h e r relatives. P a r t of t h e c h a l l e n g e for t h e S N T t h e r a p i s t , in w o r k i n g to e s t a b l i s h o p t i m a l i n t i m a c y b e t w e e n client a n d significant others, involves a s s e s s m e n t of t h e degree of intensity t h e client needs a n d can tolerate. The following case h i s t o r y illust r a t e s several aspects of t h e r e l a t i o n s h i p c o u n s e l l i n g f u n c t i o n of Social Network Therapy.

Case Two The client, Ms F, a thirty year old female diagnosed with schizophrenia was referred to the SNT Program because of difficulties with her parents, feelings of stress at work and a lack of close relationships with men. Her social network was relatively dense and kin dominated, consisting of mother, father, two brothers, sister-in-law, several aunts and cousins, one male and one female friend, a psychiatrist and a social worker. She had attempted to live on her own in an apartment, but felt too lonely and so had moved back home. She complained that her parents were too over-protective, and did not allow her to do things for herself or to take responsibility for jobs around the house. She did volunteer work at an animal shelter, but felt that they expected too much of her. Shortly before entering the SNT Program, she had joined a rehabilitation day centre for psychiatric patients. She hoped to meet people there. She was mildly depressed on

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admission to the program. She had no social handicaps, and only four mild symptoms on the 18 item BPRS. Her primary goals were to become more independent and to meet a man and eventually get married. Initially, the SNT therapist worked with Ms F around decreasing stress and improving relationships at work. The focus was on developing social skills. Ms F. learned to be less talkative, and to interrupt others less often at work. She also became more assertive in requesting a reduction in the number of volunteer hours she was contributing. Increased assertiveness resulted from role playing sessions with the therapist and discussions in small network sessions involving family members. The reduction in time spent volunteering enabled her to enroll in an educational upgrading course, which increased her self-esteem and provided an additional non-kin cluster. Soon after entering the SNT Program, the client met a man in whom she became very interested. This relationship persisted throughout her involvement in the program, and was a major focus of the therapist's interventions. The client's parents disapproved of the relationship because the boyfriend did not have a job and was disabled by a mental disorder. The therapist convened several sessions with the boyfriend and family members of the network to enable the family cluster to understand positive aspects of the relationship. These meetings were successful, and the relationship eventually was supported by the family. Later, on one occasion, the client learned that her boyfriend was abusing drugs and she was prepared to end the relationship. However, the SNT therapist was able to facilitate discussion which led to his decision to avoid drugs in future in order to maintain the relationship. Gradually, the client and her boyfriend expanded their range of shared activities, i.e. developed more multiplexity. They joined a fitness club together, which enabled them to share structured time, and to participate in a mutually enjoyable activity. With the therapist's help, they increased their abilities to meet one anothers' needs, i.e. they increased reciprocity. The boyfriend, for example, realized that the client would appreciate his taking on some household tasks, and so began to prepare meals, which gave him and the client a great deal of satisfaction. Throughout the courtship period, the SNT therapist monitored relationship intensity, and helped the couple to discover a degree of engagement which was soothing and supportive without being overwhelming. On follow-up, one year after entry into the program, the client was much happier. She was pleased with her accomplishments at school, and was engaged to be married. Her parents and other family network members approved of her fiancee. She was extremely satisfied with the SNT Program. She felt much more independent, as she was making arrangements for her wedding and preparing to move into her own apartment. She had expanded her social network significantly through the addition of classmates, friends of her fiancee and future in-laws. She reported that she was very satisfied with the support she received from her friends and family, and that in future she would turn to her fiancee for support. She appeared to have gained a confidant.

THERAPEUTIC ALLIANCE T h e t h e r a p e u t i c a l l i a n c e , a s d e f i n e d b y Z e t z e l (1956), is t h e w o r k i n g r e l a t i o n s h i p b e t w e e n c l i e n t a n d t h e r a p i s t . T h e c l i e n t is a n y o r a l l o f t h e network members in social network therapy. The therapist and network members must developed a set of agreements, understandings and bonds in order to encourage the alliance. In social network therapy,

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the therapist functions as a conductor or facilitator for the network as a whole (Halevy-Martini et al., 1984). The therapist is not meant to be aligned with any individual member of the network, but rather to act as a catalyst to promote alliances among network members. In practice, however, the therapist needs to establish some individual bonds, in order to achieve this goal. Relationships within networks are complex and unique. Thorough assessment to determine how and with whom the alliance will be established is required. There are several critical issues in this area. Characteristics of individual network members must be examined. If it is the network which is to be responsible for change in the client, the overall network must work collaboratively, and must possess sufficient resources to assist the client in achieving objectives (Hurd, Pattison & Llamas, 1981). Members of the network may need to feel accepted and supported by the therapist, in order to co-operate with the group. For example, some symptomatic traits of the client have been recognized as critical factors is establishing a working relationship. Gottlieb & Coppard (1987) point out that patients with a diagnosis of paranoid schizophrenia will require a specific type of approach due to their suspiciousness of others. The therapist, in this situation, must establish a trusting relationship with the client initially, in order for involvement of other network members to be tolerated. Aligning with the network too quickly may promote paranoid feelings in the client, leading to termination of the relationship. An assessment of previous relationships within the network is necessary. When relationships among network members are seen as too stressful and unrewarding, Turkat (1980) suggests the natural network may need to be abandoned. New networks are very difficult to create however, and may not be necessary. The therapist may be able to diffuse noxious relationships by offering support to several individuals. This may be sufficient to maintain the natural network while other interventions are being introduced. Networks characterized by high EE relationships lend themselves to this type of intervention. A therapist who has a strong therapeutic alliance with the client and network members can model positive patterns of support and teach new methods of communication. The assessment of the network should not only include the quality of relationships within the network, but also the number of relationships. As noted above, many individuals with a diagnosis of schizophrenia have small, kin-dominated networks in which members become burdened as sole providers of emotional, instrumental and informational

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support. Network members feel stressed, and their ability to provide support becomes threatened. They may become depressed, and their own resources may become depleted. The therapist needs to recognize this situation and help seek other supports for the client and network members. Case Three Mr. S, age 30, was referred to the SNT Program because he had become dependent on his family, and had isolated himself from other supports. He had a diagnosis of paranoid schizophrenia, and his doctor reported that he had become increasingly non-compliant with medical treatment. He lived alone in a small apartment, only venturing outside for basic supplies. His social network consisted of his three brothers and their wives, two family friends, and four casual acquaintances. His contact with these individuals was primarily by telephone. He described the relationship with his network as satisfactory, although he was aware of the need to become financially independent from his family. The family relationships, as described by his brothers, were very stressed. Family members found him demanding, verbally abusive, and manipulative. However, they continued to meet many of his basic needs. Their own marriages were stressed as a result. On admission to the program, the client demonstrated three social handicaps, and was rated as having six moderate to severe symptoms on the BPRS. The SNT therapist initiated individual meetings with the client. This served to establish a trusting relationship with the client, whose initial presentation was very paranoid. She focused on his identified goals of improving financial independence and developing increased social contacts. Referrals to social/recreation programs were completed, and active coaching was used to establish a few new relationships in these settings. Financial independence was promoted by reconnecting the client to previous vocational agencies who were responsible for providing opportunities to earn additional income. Once the alliance with the client was established, the therapist convened his family members. Having identified components of high EE within the network, initial meetings were held in the absence of the client. His agreement to this approach was possible due to the trust he had developed with the therapist. In his absence the therapist was also able to develop an alliance in the network, and immediately began to teach alternate communication patterns using role play. During subsequent and frequent network sessions, the therapist encouraged the family to withdraw the material supports, such as money and cigarettes. By having the client share information about his newly developed supports, the family was reassured that his needs were being met. The network sessions, although beneficial, were also perceived as threatening to the client. The SNT therapist introduced an advocate for the client by inviting his individual therapist from his day program to the network sessions. This helped him feel there was balanced support in the meetings. The creation of another therapeutic relationship for the client also allowed the SNT therapist to act more as a facilitator for the entire network. On follow-up, one year later, the client and his family felt very satisfied with the network approach. The client was receiving support from many sources, which meant the family was less drained, and thus able to provide more positive emotional support. The client reported an improvement in the quality of these relationships. He also added five new friends to his network, and increased his participation in social/recreational activities. He reported feeling positive about his financial independence, even though his budget was strained. Although he still had two social handicaps, symptoms on the BPRS had become very mild.

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READINESS Social network therapy is not successful in all situations. Often failed attempts to increase support provide greater understanding of the complexities of this approach. While some of these situations may have had positive outcomes had different strategies been used, there remain those individuals and/or networks which do not appear to be either ready, or appropriate, for this type of intervention. Although this case example focuses on issues of '~readiness" in relation to failure, at other times, despite the interest of all parties, the clinical objective may not be achieved. Such cases require a more careful analysis of alliance factors, hidden resistances and therapist techniques. As with any therapy, success requires the client's desire and willingness to participate. Therapist and client must be able to achieve consensus on the objectives of the interventions. At times, for example, on working with indigent clients, objectives may involve attempting to meet basic material needs. At other times, the referral source may identify a non-functional network, yet the individual client does not share the same perception. In such an instance, the client may not consent to the inclusion of other participants in the therapy approach. This barrier to intervention with the network also may exist if any key member of the network refuses access to other members (Gottlieb & Coppard, 1987). Such situations are particularly likely to occur if network members wish to protect themselves from exposing embarrassing secrets. In establishing criteria for admission to their program, Schoenfeld and colleagues (10) found that network members must be experiencing sufficient stress and separation to be willing to abandon their tendency toward self-sufficiency and family secrecy. As previously discussed, some networks are incapable of or unsuitable for the provision of support to individuals. Inclusion of network members is a key principal of social network therapy. If there is no network, then the first objective is to construct a network for the client, which, as Turkat (1980) suggests, is a difficult challenge for the practitioner. The most likely alternative to the natural network has been one within the mental health system, usually high in professional support. Clients do not always accept this alternative. A recent consumer driven trend toward greater integration within society means that many individuals reject the services of psychiatric programs. For the therapist to succeed in creating new relationships, while also maintaining collaboration with the client, supports from the non-psychiatric community must be sought. This, in turn, requires a level of social skills in the client, as non-professional resources are less tolerant of deviant behav-

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iours. Degree of pathology may therefore become a barrier to the successful development of a network. Severe psychotic symptoms may preclude attempts at network construction. Readiness for social network therapy also may be blocked by insufficient knowledge on the part of the therapist. The need for familiarity with norms, characteristics and dynamics of the network is essential. The existence of different cultural and ethnic groups may pose a problem for therapists (Gottlieb & Coppard, 1987). The assessment of network characteristics is critical to determining the appropriate course of action. An inability to accomplish this with Toreign' networks may pose such difficulties that social network therapy is untenable. Case Four Miss L is a 22 year old female, of Asian descent. She was admitted to the SNT Program because of dissatisfaction with her social network. When interviewed, she reported being unhappy in her living, working and social environments. She had two friends and three roommates with whom she shared very little support. Her goal was to develop more friends, in order to lessen her feelings of boredom and loneliness. She described herself as an extremely shy person who avoids contact with others. She felt this difficulty was the result of growing up in a very private family, where there was an absence of communication. As a result of these feelings, she reported severe difficulties with her family, and preferred to maintain independence. At the time of entrance into the program, she had four social handicaps, including minimal verbal responses, frightened expression, and flat, monotonous, yet pressured speech. She also experienced six symptoms in the moderate to severe category on the BPRS. The SNT therapist agreed to help the client seek alternative housing. Several referrals to supportive housing programs were made and many appointments arranged. The client was ambivalent about these environments, reporting that she wanted to avoid mixing with "crazy" people. Attempts to connect the client with social/recreational programs were met with the same reluctance, as the client believed she would become crazy herself. The therapist tried to encourage the involvement of the client's network. However she was denied access. In an attempt to construct a network, the therapist introduced a volunteer to the client. This individual was viewed as being outside the psychiatric population, and thus the client was agreeable to the creation of a relationship. At the same time, the client developed an exacerbation of her illness, and required hospitalization. The volunteer tried to maintain contact with the client. However, the admission to hospital was lengthy and the volunteer was not willing to wait for the client to recover. Thus, this new relationship was severed. The SNT therapist continued to meet with the client. However, it became increasingly difficult to achieve collaboration. The client's continued pathology made the formation of social relationships outside of the mental health system improbable. On follow-up, one year after admission to the program, the client remained dissatisfied with her living, working and social environments. She had not established any new friendships, and continued to feel negatively about the ones she had formed. The number of social handicaps she experienced had increased to thirteen, and on the BPRS she had an additional symptom in the severe category. Although the client reported positive feelings about the SNT therapist, and her attempts to develop a social network, she continued to feel lonely and stated she would not turn to other people for help in the future.

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CONCLUSION Social networks have the potential to provide individuals with protection and support. Individuals with schizophrenia often have small, kindominated networks which may not be able to provide sufficient support on an ongoing basis. Social network therapy aims to enhance networks, through the formation of new relationships and/or improved quality of existing relationships. Although there is considerable information about the structure and function of networks of individuals with schizophrenia, there is limited knowledge about the processes involved in changing networks. Social network therapy is defined differently by some groups, and does not have well-defined or standardized techniques for practitioners to follow. Goals of social network intervention have been related to directly improving structural or functional characteristics of networks, e.g. increasing network size, developing reciprocal relationships. However, the strategies used are complex and ill-defined. The evaluation of a therapy technique that is so diverse is difficult. Numerous factors may contribute to success or failure. Through qualitative analysis of successful and unsuccessful cases, it has been possible to identify issues and techniques which have an effect on outcome. Although the literature has discussed some factors which may promote or hinder the success of social network therapy, these have not been grouped as clinical issues. The issues discussed in this paper, i.e. environmental change, relationship counselling, therapeutic alliance and readiness, are commonly discussed factors for many psychosocial therapies. It is the interplay of these issues within the social network therapy model which is integral to the success of the intervention. The case examples illustrate techniques which may be used to effect positive change in networks of individuals with schizophrenia. If these issues are not addressed by the therapist, the chances of developing a more caring and responsive network are diminished and, in turn, a therapy technique which has proven useful may be unnecessarily discarded.

REFERENCES Brown, G.W., Bhrolchain, M.N., Harris, T. (1975). Social class and psychiatric disturbance among women in an urban population. Sociology, 9, 225-254. Cutler, D.C., Tatum E., Shore, J.H. (1987). A comparison of schizophrenic patients in different community support treatment approaches. Community Mental Health Journal, 23, 103-113.

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Clinical issues in social network therapy for clients with schizophrenia.

Social networks are viable foci for therapeutic interventions. A social network therapy program for clients with schizophrenia was developed by a comm...
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