Family Interventions In Psychosis Research Articles

Understanding the provision of psychological interventions for psychosis in an Australian mental health service: a mixed methods study

ABSTRACT Objective To describe the provision of evidence-based psychological therapies for the treatment of psychosis in a large Australian mental health service; and to explore the barriers and facilitators to providing these therapies. Method Mixed-methods study including: 1) a retrospective audit of 100 clients with schizophrenia spectrum disorder to estimate adherence to guideline recommended psychological therapies; and 2) a cross-sectional survey of community based mental health practitioners, based on the Theoretical Domains Framework, to understand the barriers and facilitators to delivering psychological therapies to clients with psychosis. Results Twenty-five percent (25/100) of the audited sample engaged with psychological services. Of those who did, two received the recommended dose of evidence-based therapy. Thirty-three percent (37/112) of mental health practitioners completed the survey. Barriers to the delivery of psychological therapies related to perceived lack of knowledge, skills, and confidence with the therapies, and beliefs about who will (and will not) benefit. Other barriers included lack of time, demanding caseloads, and a culture of risk and crisis management. Conclusions People with psychosis have poor access to evidence-based psychological therapies. The barriers to providing psychological therapies are multifactorial and should be systematically addressed to improve health and quality of life outcomes for people living with psychosis. Abbreviations: CBT: Cognitive behaviour therapy; CBTp: cognitive behaviour therapy for psychosis; CRT: cognitive remediation therapy; FIp: family intervention for psychosis; PORT: Patient Outcomes Research Team; RANZCP: Royal Australian and New Zealand College of Psychiatrists; NICE: UK National Institute of Clinical Excellence; TDF: The Theoretical Domains Framework; HoNos: Health of the Nation Scale; EBPIs: Evidence Based Psychological Interventions; ACT: Acceptance and Commitment Therapy.

State of the art in psychological therapies for psychosis: Family interventions for psychosis.

It is a half-century since the coalescence of social psychiatry and systemic family therapy approaches started to inform condition-specific therapeutic work with families to reduce relapse and hospital readmission for people with schizophrenia. Today, family interventions are a cornerstone of international guidelines for the treatment of psychosis, and of workforce development initiatives. Effect sizes for clinical and economic outcomes are large, and the evidence base is robust and reliable, not only for outcomes but also for the underpinning theoretical models, which are coherent and consistent. Few, if any, psychological therapies, have so powerful a framework to drive widespread implementation. Nevertheless, delivery in clinical services is variable, often lagging behind that of individual cognitive behavioural therapy, notwithstanding its considerably weaker implementation framework. Our aim in this article is to formulate this translation failure and offer potential solutions. We summarise the model/intervention and supporting evidence, then consider why delivery remains problematic. We highlight the inter-linked issues of conceptual confusion between and conflation of, different approaches to working with families; of addressing diagnostic uncertainty, complex comorbidity and adapting interventions for specific populations; and of translation from gold-standard research trial practice, through educational curricula and training programmes, to routine delivery in frontline services. We present our view of clinical, research and workforce development priorities to address these issues and continue the collective effort, moving into the next half-century, to work more effectively with people with psychosis and their families, to further improve outcomes.

Exploring service user perspectives of behavioural family therapy in early intervention in psychosis.

Family intervention (FI) is recommended in national guidance to be offered to all service users accessing an early intervention in psychosis (EIP) team, due to the consistent evidence base in reducing relapse and rehospitalisation rates. However, FI implementation is poor nationally. Although barriers have been identified at the level of staff member and the organisation, there is a paucity of research identifying service user perspectives. A qualitative questionnaire design was used to explore service user perspectives of behavioural family therapy (BFT) within a specialist EIP service in northwest England. Most participants contacted reported they lacked knowledge and understanding of BFT, with 54% reporting that this intervention had not been offered to them. This finding was unexpected and is inconsistent with the offer of BFT documentation in their clinical notes. Reasons for accepting BFT included to increase understanding of family members and for them to also be supported. Reasons for declining BFT included a preference for one-to-one interventions and not wanting family involved in their care. National guidance on FI for psychosis is not reliably being translated to clinical practice, with many participants reporting that they were not offered this intervention. A key factor in accepting or declining an offer of BFT appeared to be whether participants wanted family members to be involved in their care. A lack of understanding of the BFT approach was evident, it is recommended that the offer of FI in psychosis is improved for service users to make an informed decision.

Management of demographic equality of access to family intervention for psychosis in specialist community mental healthcare teams

Background/AimsUK mental health services must provide evidence-based psychological treatments, including family intervention, to every service user diagnosed with psychosis. Although healthcare managers are required to ensure equitable delivery of prescribed core treatments, in practice equality of access remains debatable. This study investigates equality of access to family intervention for psychosis. Subsequent treatment uptake and engagement are also examined. The role of healthcare records in equality management is considered.MethodsRetrospective analysis of electronic medical records of 244 service users across four specialist early intervention teams in London in 2018 was undertaken using binary logistic regression and multiple linear regression. Bonferroni adjustment was applied to control for type 1 errors.ResultsParticipants were found to have equal access to the nationally endorsed treatment across all demographic variables. Likewise, treatment uptake and engagement were equally distributed.ConclusionsAn overall compliance with national policies was shown, demonstrating that equal provision of core treatment for psychosis is achievable. As discrepancies in record keeping were shown to impede the data extraction process, suggestions were made for the management of electronic medical records in mental healthcare services.

Psychosis REACH: Effects of a Brief CBT-Informed Training for Family and Caregivers of Individuals With Psychosis.

Psychosis Recovery by Enabling Adult Carers at Home (Psychosis REACH) is a training for families of individuals with psychosis that consists of recovery-oriented psychosis psychoeducation, caregiver self-care, and skills training informed by cognitive-behavioral therapy for psychosis (CBTp). The authors assessed the effects of a 1-day and a 4-day training on the natural supports (i.e., family and other caregivers) of individuals with psychotic disorders. Attendees of a 1-day (N=168) and a 4-day (N=29) Psychosis REACH training were surveyed at three timepoints: pretraining, posttraining, and 4-month follow-up. Longitudinal changes across the full sample were evaluated by paired-sample t tests or a one-way repeated-measures analysis of variance (ANOVA). Two-way mixed ANOVAs were conducted with training condition, time, and the training condition × time interactions entered into the model. Reductions were noted in self-perceived depression, anxiety, negative aspects of the caregiving experience, and expressed emotion. Trainees also showed more prosocial attitudes toward psychosis immediately and at 4 months after the training. This evaluation of the launch of Psychosis REACH in the United States suggests that the training can improve the mental health, attitudinal, and relational outcomes of family and caregivers of individuals with psychosis. Given the dearth of CBTp and family interventions for psychosis in mental health services in the United States, short-term, intensive training that supplements clinical services has intuitive appeal as a means of surmounting the barriers that have plagued family interventions.

A Delphi survey to explore best practice for practitioners offering family intervention for psychosis to families with children

Parents experiencing psychosis can face challenges in addition to those usually associated with being a parent, with their children at increased risk of negative outcomes. Although a strong evidence base has shown that family interventions for psychosis (FIp) can mitigate distress for adult relatives, techniques described in the systemic and parenting literature to facilitate the inclusion of children in family therapy are largely absent from the FIp literature and training. This study used a three‐round Delphi survey to investigate what experienced FIp clinicians consider to be best practice regarding the inclusion of children in parental FIp. Findings demonstrated support for including children, with high levels of consensus regarding methods of facilitating their involvement, as well as organisational factors that would support this. The results have important clinical implications given that many FIp practitioners work with families, following brief psychosis specific training, without exposure to the broader literature.

Effectiveness of Family Intervention for Preventing Relapse in First-Episode Psychosis Until 24 Months of Follow-up: A Systematic Review With Meta-analysis of Randomized Controlled Trials.

Relapse risk during the early years of first-episode psychosis (FEP) considerably increases the risk of chronicity. The effectiveness of family intervention for psychosis (FIp) for preventing relapse after FEP remains unknown. We assessed the effectiveness of FIp until 24 months of follow-up for preventing relapse and other relapse-related outcomes in patients following FEP. We searched the Cochrane, PubMed, PsycINFO, and ProQuest databases in June 2018. A systematic review with meta-analysis of randomized controlled trials (RCTs), sensitivity analyses, and publication bias were performed, comparing to treatment as usual (TAU) or TAU plus other psychosocial interventions. Outcomes assessed were relapse rates, duration of hospitalization, psychotic symptoms, and functionality. Risk ratios (RRs) and (standardized) mean differences (SMD; MD) were calculated. Of the 2109 records retrieved, 14 (11 RCTs) were included. Pooled results showed that FIp was effective for preventing relapse (RR = 0.42; 95% CI = 0.29 to 0.61) compared to TAU and/or other psychosocial interventions. It also proved effective when compared to TAU alone (RR = 0.36) and TAU plus other psychosocial interventions (RR = 0.48). FIp showed benefits in reducing duration of hospitalization (TAU, MD = -3.31; other interventions, MD = -4.57) and psychotic symptoms (TAU, SMD = -0.68), and increased functionality (TAU, SMD = 1.36; other interventions, SMD = 1.41). These findings suggest that FIp is effective for reducing relapse rates, duration of hospitalization, and psychotic symptoms, and for increasing functionality in FEP patients up to 24 months. The study's main limitations were the inclusion of published research only; authors were not contacted for missing/additional data; and high heterogeneity regarding relapse definition was observed.

The Views of Mental Health Manager Towards the Use of a Family Work Model for Psychosis in Guangzhou, China.

Family Interventions in Psychosis (FIP) have been promoted internationally but have been criticised for being based on western cultural models. This paper reports on a focus group study with 10 Integrated Mental Health Service Managers in Guangzhou, China using thematic analysis. Managers believed FIP might benefit families but identified potential difficulties due to (a) families avoiding services due to the 'shame' of mental illness (b) unrealistic expectations of services amongst families (c) deferral to 'key decision-makers' within families when discussing family issues with workers. The findings indicate that FIP work should focus on interaction between carers in the first instance with service users being introduced into sessions at a later date and that more attention needs to be given by the research community to how FIP may be adapted to cultural norms within China.

Do Family Interventions Improve Outcomes in Early Psychosis? A Systematic Review and Meta-Analysis.

Family interventions for psychosis (FIp) are effective in reducing service user relapse and carer distress in people with schizophrenia-spectrum conditions. Several treatment and best practice guidelines recommend FIp for all people with schizophrenia. However, outcome findings in relation to early psychosis groups have been inconsistent. The current paper reports a systematic review and meta-analyses of articles that evaluated FIp in early psychosis with a clearly defined comparison group. A combination of electronic database searches (using PsychINFO, Medline, and CENTRAL), citation searches and hand searches of key journals and reviews was conducted. Peer-reviewed articles published in English from database inception to June 2016 were included. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). Seventeen papers from 14 studies met inclusion criteria for review, the overall quality of which was moderate. Meta-analytic synthesis showed that FIp improved service user functioning and reduced the likelihood of relapse by the end of treatment. Psychotic symptoms were significantly reduced in the FIp group at follow up, but this was not evident at end of treatment. In terms of FIp target mechanisms, carers receiving FIp were more likely to shift from high to low expressed emotion and less likely to report patient focused criticism or engage in conflict communication than carers randomized to standard care. Carer burden and well-being were improved by the end of treatment but gains were not sustained at follow up. FIp had no impact on carer emotional over-involvement. The findings indicate that FIp is an effective intervention for early psychosis service users and their relatives. However, further research is required to establish which key therapeutic components of FIp are most effective for whom, in addition to understanding the mechanisms by which FIp might affect positive change.

Family Interventions in Psychosis: A Review of the Evidence and Barriers to Implementation

ObjectiveFamily interventions for schizophrenia are recommended psychological interventions worldwide. The National Institute for Care and Clinical Excellence (UK) and the Royal Australian and New Zealand College of Psychiatrists recommend family interventions as a first‐line treatment and “treatment essential,” respectively, at all stages of psychosis and with all aspects of care. However, the success of the integration of these interventions into routine clinical services has been problematic and remains a major challenge.MethodsWe outline the national guidelines on family interventions for schizophrenia and review the evidence for this approach. Drawing on recent systematic reviews and through searching electronic databases for relevant articles, we review the barriers and facilitators associated with implementing family interventions into routine clinical services.ResultsNational guidelines continue to recommend psychological interventions for schizophrenia, reflecting the evidence base to support the provision of this approach across the psychosis spectrum. Reported estimates of implementation rates remain low and vary between 0% and 53%. Barriers to implementing family interventions exist at the service user, clinician, and organisational level. Factors that facilitate implementation of family interventions have been reported to a lesser extent.ConclusionsImplementation of family interventions for schizophrenia remains poor and is below recommended levels, with wide variation of implementation rates reported. This reflects inequality in the provision of family interventions for schizophrenia. Barriers at the service user, clinician, and organisational level have influenced the implementation of family interventions. A research agenda for improving consistent implementation of family interventions for schizophrenia is discussed.

What do We Know about Family Interventions for Psychosis at the Process Level? A Systematic Review.

The evidence regarding effectiveness of family interventions for psychosis (FIP) is strong and consistent. However, there is a gap in the research on the process of these interventions, and little is known about their active ingredients. This review aims to identify the active ingredients of FIP. We conducted a systematic literature review, focusing on qualitative research, and analyzed 22 papers in total. We found a single study comprehensively exploring the process of FIP. All other studies focused on particular aspects of process-related variables. The key elements of FIP seem to be the so-called "common therapeutic factors", followed by education about the illness and coping skills training. This review supports the value of a stepped model of intervention according to the needs of the families. However, the evidence reviewed also reveals a gap in the research findings based on the limited research available. FIP are complex, psychosocial interventions with multiple components, and more intensive, qualitative research is needed to establish linkages between process and outcome.

Family intervention for psychosis: Impact of training on clinicians’ attitudes, knowledge and behaviour

ObjectivesTwo family intervention (FI) training models – Psychosocial (Thorn) and Behavioural Family Therapy (BFT, Meriden), were provided to clinicians working in a London mental health service, with an aim to boost FI implementation and family/carer collaborative working.Methods and proceduresA survey study that used a self-rated questionnaire to evaluate clinicians’ attitude, knowledge and behaviour following FI training, is reported. Data collection was conducted at three time-points: pre and post-training and at five months follow-up after the FI training.ResultsOver an 18-month period from 2010 to 2011, four cohorts of FI training were provided to 55 clinicians working in psychosis services. The results conveyed a positive change in clinicians’ attitude towards collaborative working with families/ carers and most reported that the FI training equipped them with the knowledge and competency required to provide FI. However, participants also identified some implementation challenges.ConclusionsThis survey showed effective outcomes from both Thorn and Meriden training. However, beyond the issue of staff training and skills development, there are wider issues to address for FI to become routine. Organisational support and FI practice development strategies alongside FI training, as highlighted in the BFT training project, are necessary to support clinicians’ FI practice.

Cognitive behavioural therapy and family intervention for psychosis – evidence-based but unavailable? The next steps

National Institute for Clinical Excellence updated guidelines for schizophrenia (2009) recommend two psychological treatments – cognitive behavioural therapy for psychosis (CBTp) and family intervention for psychosis (FI). Despite these recommendations being in place for nearly a decade, implementation problems remain, particularly for FI. It is argued that these problems can be overcome, if services prioritise improving access to psychological therapies for psychosis, and that carers in particular need their own services to be developed.

Family interventions in psychosis: a scale to measure therapist adherence

The efficacy of family interventions in psychosis is well documented. UK and USA schizophrenia treatment guidelines advocate the practice of family interventions within routine clinical services. However, less attention has been paid to the study of treatment fidelity and the tools used in its assessment. This study reports the inter‐rater reliability of a new scale: Family Intervention in Psychosis‐Adherence Scale (FIPAS). This measure is designed to assess therapist adherence to the Kuipers et al. (2002) family intervention in psychosis treatment manual. Reliability ratings were based on a sample of thirteen audiotapes drawn from a randomized controlled trial of family intervention. The results indicated that the majority of items of the FIPAS had acceptable levels of inter‐rater reliability. The findings are discussed in terms of their implications for the training and monitoring of the effectiveness of practitioners for family interventions in psychosis.

Carers' attributions about positive events in psychosis relate to expressed emotion

BackgroundRelapse is increased in people with psychosis who live with carers with high expressed emotion (EE). Attributional style has been used to understand EE at a psychological level. Previous studies have investigated carer appraisals for negative events in the patient's life. We therefore aimed to examine spontaneous carer attributions for both negative and positive events. Further, we distinguished between high EE based on critical comments, and that based on emotional-overinvolvement. MethodAudiotapes of the Camberwell Family Interview (CFI) (N = 70) were rated using the Leeds Attributional Coding System (LACS). Raters were blind to previous ratings of EE. ResultsIn our sample, low EE carers made significantly more attributions about positive events, and less about negative events than high EE carers. This is because criticism, but not overinvolvement, was strongly associated with responsibility attributions for negative events, while overinvolvement, but not criticism, was inversely associated with responsibility attributions for positive events. ConclusionCarers' attributions for both positive and negative events may be a useful target for improving family interventions in psychosis.

A study of families' satisfaction with a family interventions in psychosis service in Somerset

Although research has shown the efficacy of family interventions in psychosis, there has been little research into families' own experience of services in routine clinical settings. Fifteen of the first twenty‐two referrals to a Somerset Family Interventions Service agreed to take part in semi‐structured interviews regarding family satisfaction and clinical outcome. High levels of engagement and satisfaction with the service were reported in spite of initial apprehension regarding family sessions. Family members thought that the sessions had helped them deal more effectively with problems and relatives' symptoms. They valued the opportunity for open discussion, developing new perspectives and problem‐solving, as well as liaison/closer working with mental health services. Positive therapeutic qualities/skills (e.g. empathic, non‐judgemental approach; mutually agreed goals) were highlighted. This study also indicated that successful engagement in family work requires referral at an early stage. The findings of this study, particularly those relating to the therapeutic relationship, are discussed, including their relevance for future research.

Family intervention in psychosis

The efficacy of psychoeducational family interventions in schizophrenia is well established with clear evidence that they result in reduced relapse rates and costs of care. Gaps remain in our knowledge with regard to their applicability to early psychosis or psychoses other than schizophrenia. Questions as to how they can be implemented in routine clinical settings remain unanswered. development of these interventions has been a decline in research on family burden or caregiving. The needs of family caregivers is their own right rather than as agents of rehabilitation received little attention in the 1970s and 1980s, although there has been a welcome revival of interest in the present decade. The challenge of the next century is to look at how the different 'camps' can be integrated to produce better services for those with psychosis and their families, as comprehensive services which meet the needs of all of those involved are rare worldwide.

The münsteraner familienbogen (MFB)—An instrument to examine expressed emotion (EE)

Relapse is increased in people with psychosis who live with carers with high expressed emotion (EE). Attributional style has been used to understand EE at a psychological level. Previous studies have investigated carer appraisals for negative events in the patient's life. We therefore aimed to examine spontaneous carer attributions for both negative and positive events. Further, we distinguished between high EE based on critical comments, and that based on emotional-overinvolvement.Audiotapes of the Camberwell Family Interview (CFI) (N = 70) were rated using the Leeds Attributional Coding System (LACS). Raters were blind to previous ratings of EE.In our sample, low EE carers made significantly more attributions about positive events, and less about negative events than high EE carers. This is because criticism, but not overinvolvement, was strongly associated with responsibility attributions for negative events, while overinvolvement, but not criticism, was inversely associated with responsibility attributions for positive events.Carers' attributions for both positive and negative events may be a useful target for improving family interventions in psychosis.