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Family intervention in psychosis - Coggle Diagram
Family intervention in psychosis
Evidence base
Systematic reviews and meta-analyses in early/first-episode psychosis
FEP: Camacho-Gomez & Castellvi 2019
Key finding: higher relapse reduction
58% reduction in RR of relapse
Reduced hospitalisation duration
Reduced symptom severity vs pharmocology/psychoeducation alone
But CBT etc might be better - consider multicomponent integrated therapy based on prognosis
But lots of heterogeneity
Increased functionality
vs TAU/other psychosocial interventions
EP: Claxton et al. 2017
Service user outcomes
Reduced relapse
Reduced symptoms
Improved functioning
Mechanisms of change: carers moved from high to low EE, less critical of client
Carer outcomes
No change in carer emotional over-involvement
Improved carer burden/well-being
vs any clearly defined comparator group
Like Camacho-Gomez, but more outcomes
But impact on relapse and general functioning isn't sustained at follow-up - need booster sessions? [or grow up and away from parents?]
Limitations of trials, e.g. high dropout, so those that finish maybe benefitted unusually well from the intervention
Effects on carers: Ma, 2018
Reduced carer burden (all follow-up periods)
Improved caregiving experience (short term)
Improved use of formal support and family functioning (longer-term follow-up)
Vs TAU
Comparing types of FI
Mutual support was more effective than psychoeducation for family functionning at 1-2 year
Both had same effects of service utiliisation
*EP: Bird et al. (2010)
Review of 3 trials
Lower relapse and hospital admission at end of treatment
Compared to standard care
Impact of psychosis on carers
Who is 'carer'?
Anyone > 18 yo most involved in client's care
Ask client who they consider most involved
Impacts
Increased burden, distress, burnout (Magligano, 2005; Onwumere, 2017)
Increased rates of mental disorder (Gupta, 2015)
Including clinical depression (Kuipers & Raune, 2000)
Increased worry (Tennakon, 2000)
Isolation, social withdrawal, stigma (MacInness, 2000; Hayes, 2015)
Feelings of loss like bereavement (Patterson, 2005)
Self-blame, guilt (McCann, 2009)
Verbal/physical aggression & PTSD (Nielssen & Large, 2010; Loughland, 2009; Kingston, 2016)
At onset
Overwhelming, confusing (McCann, 2011; Lavis, 2015)
Exposed to behaviours they can't make sense of/cope with
Emotional impact
And yet family members are very influential on client outcomes
NICE guidelines
To be offered to families of people with psychosis or SCZ who live with or are in close contact with service user
Features
Include the client if possible
3 months - 1 year
At least 10 planned sessions
Take relationship with main carer into account
supportive, education or treatment function with negotiated problem solving and crisis management
Confidentiality and risk management
Check at pre-meetings
Carer feels safe?
Carers blocking treatment?
Stress from FI might increase risk of relapse?
Dependents in the home at risk of violence etc?
Assess levels of risk (violence, aggression, substance misuse in the presence of a child, bringing strangers into the home)
Discuss any concerns at zoning meeting, supervision
Devise a crisis plan, raise safeguarding alert, involve social services, as appropriate
Consent
If client refuses consent, ethical dilemma
Capacity may not be present
And relationship with the carer can influence the course of the disorder (Raune et al, 2004)
Don't want to break client confidentiality but need to support carers
Requirements
Seek client's consent to disclose on need-too-know basis
Review consent regularly
Record info accurately
Use clinical judgement
Cognitive model for caregiving (Kuipers, 2010)
Carer appraisal of client’s behavior and the illness
Cognitive & affective changes
Affects relationship with client, services
Can lead to social withdrawal
Affects coping strategies used
Illness perceptions predict carer outcomes better than actual illness severity
Appraisals = targets for intervention
Emotionally over-involved
Service user not to blame
Carer has to return to parental role
Initial relationship was typically good
Positive
Service user not to blame but has problems that need support
Critical
Service user to blame due to personality
Service user need to get better and control their problems
Poor early relationship - client often has substance misuse
Formulation within this model
Identify unhelpful appraisals
Summarise areas of strength/in need of development in communication and problem-solving
Identify key information needs/misunderstandings
Agree intervention plan with carer
e.g. identify day-to-day trigger points
Intervention
Emotionally overinvolved
Provision of facts unhelpful
need to learn to care differently
problem-solving approach
offer respite
Critical/hostile
Carers may not engage -> discontinue FI
Information is crucial - over longer time period
Peer groups where can ask questions
need to reattribute control and consequences
Negotiated problem-solving
Demonstrate the negative effects of this style on client
1/3 carers with this style have depression, so work on that
Benefits of FI
Families help clients engage with services/interventions (de Han et al 2002)
Increase client social functioning (Pfammater et al 2006)
Promote medication compliance (Pharoah et al, 2010; Pilling et al, 2002)
Improved experience of care (Giron et al, 2010)
Nilsen 2016
Psychoeducation needed because most people have stigmatising beliefs
Developing a shared understanding
Enhancing problem solving
Improving communication skills
Learn about behaviour pattern
Improve carer empathy and engagement style (Giron, 2015)
Garety et al (2001)
Reduces environmental stress, improving affect and social functioning
Changes in cognitive processes will be a byproduct
Helps family support client by giving them alternative explanations
Though this paints them as acting like therapists, which it's unlikely they can/will
Potentially problematic family characteristics
Expressed emotion
Emotional over-involvement
Exhausting for client and carers
Hostility
Criticism
Stress for both client and carers
High in c. 50% FEP families (Kuipers & Raune, 2004)
Higher risk of relapse within 9 months of returning to high EE family (50% vs 21% for low EE) (Bebbington & Kuipers, 1994)
Contraindications of FI
Exacerbation of risk to self or others
Too unwell/requiring MHA/admission
No main carers
Client wants CBTp first to manage symptoms
Delivery
Meeting structure
Client approached first
Then 10+ family meetings over 10 months
Set ground rules
Co-therapist helps implement them
Session 1
Develop shared problem/goal list
Reframe goals so they're inclusive and focus on communication, not behaviours of the client
Session 2: start psychoeducation booklet
Encourage all to talk to each other about how they find it
Only to be read in sessions
Doesn't criticise existing views but offers other views
Communication skills addressed throughout sessions
Problem-solving: 6-step process
Carers then practice this with an everyday problem
Relapse prevention plans
Early warning signs/relapse signature
Card sort technique
Collaborative
What can family and services do at each stage?
Print out plan so ready in an emergency
Set homework re: communication, spending time together
Transparency about consent
Find out who they want included
Meet each member individually
Identify their needs, goals, hopes, how they would like communication to be different
Refer for separate support if necessary
qualified therapist and co-therapist
Therapeutic style
Model warmth, encouragement
Family may be hypervigilant for signs of blame
Use a lot of normalisation
Identify the intention underpinning carer communication/behaviour
Use to reframe their behaviours
If carer are critical and won't respect ground rules, may need to terminate FI, but usually working out the intention helps them move beyond that
Check understanding
Watch out for signs of affect
Ask about feelings
Ask how other felt hearing it
Helps facilitate understanding and emotional processing
Complexities
Comorbid Autism/Learning Disability
Substance Misuse
Violence & aggression
Cultural factors
Sexuality
Lack of insight
How to involve carers in EIS?
Invite to initial assessments
CPA reviews
Discharge planning
Sharing relapse prevention plan
Sharing crisis plan
Offer Carers assessment
Offer Family meeting
Common themes in FI
Guilt
Blame
Grief & loss
Lack of understanding of psychosis
Can affect both client and carer's appraisals of what's going on
Poor communication skills
Essential to build these up
Hostility, criticism, tone
Need to improve to increase trust by client
Poor problem solving
Impaired limit setting