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Family Intervention in Psychosis

Family Intervention in Psychosis. Professor Elizabeth Kuipers King’s College London Institute of Psychiatry Department of Psychology Mental Health Social Work Conference: Highlights in Research & Practice, IOP, 16 th May 2007. Talk about :.

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Family Intervention in Psychosis

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  1. Family Intervention in Psychosis Professor Elizabeth Kuipers King’s College London Institute of Psychiatry Department of Psychology Mental Health Social Work Conference: Highlights in Research & Practice, IOP, 16th May 2007 EKuipers, KCL, IOP 16/05/07

  2. Talk about: • Background – the importance of relationships for outcomes. • Cross cultural issues. • Family intervention research. • Recent research findings. • Clinical implications. EKuipers, KCL, IOP 16/05/07

  3. The impact of care in psychosis– in first episodes • “What upsets me most is that I’ll never know what he would have been like if this illness had never happened” (father of 19 year old son with psychosis) • “I find myself asking for God to take it from her and give it to me. If I could do anything to take it from her, I would prefer that” (mother of 19 year old daughter with psychosis) EKuipers, KCL, IOP 16/05/07

  4. And in subsequent episodes: ‘we all get paranoid sometimes so I don’t understand why you can’t just dismiss it like everyone else does’ ‘the relapse has been a huge blow to me personally’ ‘you think everything is better and then bang, back to square one’ ‘we won’t feel any better until we find a cure’ (Carers from PRP trial) EKuipers, KCL, IOP 16/05/07

  5. Many people remain in contact with families after an episode of schizophrenia (20-40%) Emphasises community links Supplements reduced social contacts in psychosis Provision of an environment in which to recover Families as a resource EKuipers, KCL, IOP 16/05/07

  6. The impact of care Consistent finding in the literature that carers have to cope with a heavy impact of care. (Fadden et al, 1987; MacCarthy et al, 1989; Kuipers, 1993; Scazufca & Kuipers, 1996; 1997; Kuipers & Raune, 2000; Magliano et al, 2000; Raune et al, 2004; Kuipers et al, 2005). EKuipers, KCL, IOP 16/05/07

  7. Care giving has a clear impact on family members • Increased worry and strain. • Emotional upset. • Reduces social networks. • Isolation, stigma & shame. • Financial problems. • Worry about the future. • Loss. • Anger. • Guilt. • Denial. • Some symptoms particularly difficult for carers to cope with; disruptive behaviour, social withdrawal, poor understanding of difference between illness behaviour and personality. EKuipers, KCL, IOP 16/05/07

  8. The quality of relationship between client and carer • Initial reactions to demands of caring: - bewilderment, anxiety, denial - unrealistic (uninformed) expectations about recovery and role performance Can lead to: - frustration, irritation, criticism 2. Another response: - to try to ‘look after’ client & take over social roles - compensate for impairment (only helpful in acute phases) This can lead to: - loss of adult independence in clients - over burden & exhaustion in carers - emotional overinvolvement 3. Or carer can understand that there are difficulties and try to encourage the individual to deal with them. EKuipers, KCL, IOP 16/05/07

  9. Measuring the quality of a relationship Both criticism and overinvolvement are key components of Expressed Emotion (EE) Robust predictor of outcome in schizophrenia Kavanagh (1992) reviewed 26 studies Bebbington & Kuipers (1994) used data from 25 studies worldwide and confirmed - those returning to live with high EE families more likely to relapse in next 9 months - 50% relapse rate - compared to those going back to low EE families who had a 21% relapse rate Also confirmed by Butzlaff & Hooley (1998) Some evidence that warmth on its own, relates to better outcomes. EKuipers, KCL, IOP 16/05/07

  10. Examples of expressed emotion (EE) in relationships I take it as it comes… I think you can just show love and affection (Husband re. wife; example of warmth) I’d rather just leave him (in hospital)… There comes a point when you’ve just got to put your foot down. (Father re. son; hostility) It really irritates me how we can never sit through a family meal without Simon talking to those voices. (Mother re. son; critical comment) We don’t like leaving him on his own … ever. (Parent about son; emotional overinvolvement) He just goes on and on. Its irritating, he knows how to do it but he doesn’t do it. (Staff re. ‘key patient’ criticism) I feel comfortable with her, being very friendly and our relationship being very equal. (Staff re. key patient, warmth) High EE, critical, hostile or overinvolved relationships associated with poor outcome, can also be found in professional relationships (Kuipers & Moore 1995; Tatton & Tarrier 2000). Low EE relationships appear to be protective. EKuipers, KCL, IOP 16/05/07

  11. Cross cultural issues in EE research: some evidence of cultural specificity Rosenfarb, Bellack & Aziz (2006) Journal of Abnormal Psychology, Vol 115, 1, 112-120 - Compared associations between family interactions and illness course over 2yrs in African American (N = 40) & Whites (N = 31) patient-carer dyads - African American dyads: high levels of critical and intrusive behaviour in carers were associated with better outcome in patients Kopelowicz et al (2002) & Lopez et al (2004) - high EE predicted relapse only if caucasian - Negative behaviour must be see in context: may be perceived as a sign of caring and concern in some families EKuipers, KCL, IOP 16/05/07

  12. EE and impact of care ‘burden’, are linked (Smith et al 1993, Scazufca et al 1996; Raune et al 2004) EE is an assessment of the quality of the relationship, based on appraisal of problems. Both EE and burden more dependent on appraisal of clients problems than on actual deficits, and relate to poor outcomes. Low EE carers still feel burden but perceive as less problematic. Families at first episode have similar issues (Raune et al 2004). High EE carers more likely to attribute blame and responsibility to patients and be more distressed (Barrowclough & Hooley 2003). EKuipers, KCL, IOP 16/05/07

  13. This evidence base has informed family interventions in psychosis. Several manuals now available: Falloon et al (1984) Anderson et al (1986) Barrowclough & Tarrier (1992) Kuipers, Leff & Lam (1992, 2002) Addington & Burnett (2004) Based on helping families understand, improve communication, cognitively reappraise problems, negotiate problem solving, emotionally process loss, grief and distress. Optimal medication. EKuipers, KCL, IOP 16/05/07

  14. NICE Guidelines (2003) 18 RCTs included (N = 1458) FI reduces relapse and can improve carer burden. EKuipers, KCL, IOP 16/05/07

  15. Pfammatter et al (2006)Schizophrenia Bulletin, 32, S64-S80. Consistent finding that schizophrenia patients with relatives taking part in Family Intervention (FI) suffer from significantly fewer relapses and hospitalisation during follow-up, (31 RCTs). Pfammatter et al found “considerable shift from high to low EE, a substantial improvement in the social adjustment of the patients, a decline of inpatient treatment and an overall reduction in psychopathology during the follow-up” (p. 571). EKuipers, KCL, IOP 16/05/07

  16. Cochrane Review - Pharoah et al (2006); another 15 trials (+ previous 13) (N=4124) (2006) confirms that FI reduces relapse and hospital admissions, encourages compliance with medication, and may improve social impairment and reduce EE. EKuipers, KCL, IOP 16/05/07

  17. Summary FI for psychosis is broadly efficacious. Can improve relapse rates, and outcomes for patients. Some evidence that carers can also feel better. Longer treatments recommended by NICE (2003). EKuipers, KCL, IOP 16/05/07

  18. However, although we know FI works, we do not entirely understand how. eg. How do stressful (critical or over involved) family relationships relate to increased symptoms of psychosis such as delusions and hallucinations (relapse) in patients, and depression in carers? Can we improve outcomes for carers and patients by changing these mechanisms? EKuipers, KCL, IOP 16/05/07

  19. Model of social and cognitive processes in psychosisGarety et al (2001)Kuipers et al (2006a)Garety et al (2007) We have hypothesised that family relationships relate to affect in patients; patients with negative relationships with carers will have higher anxiety, depression and lower self esteem. EKuipers, KCL, IOP 16/05/07

  20. Psychological Prevention of Relapse in Psychosis: Theoretical studies • Grantholders: Philippa Garety, Elizabeth Kuipers, David Fowler, Paul Bebbington, Graham Dunn. • Research Co-ordinator: Daniel Freeman. • Research Therapists: Suzanne Jolley, Juliana Onwumere, Rebecca Rollinson, Ben Smith, Craig Steel. • Research Workers: Hannah Bashforth, Susannah Colbert, Ellen Craig, Amber Elliott, Jane Evans, Dite Felekki, Laura Fialko, Sarah Fish, Miriam Fornells-Ambrojo, Alison Gracie, Catherine Green, Amy Hardy, Louise Isham, Rosie Moore, Marta Prytys, Kathryn Ruffell, Philip Watson. • Advisory Group: Jan Scott, Max Birchwood, Tony Johnson, John Geddes, Mike Took. FUNDED BY THE WELLCOME TRUST EKuipers, KCL, IOP 16/05/07

  21. Some evidence supporting this from Barrowclough et al (2003) Association between high criticism in carer, low self esteem (negative self evaluation), and more symptoms in patients. EKuipers, KCL, IOP 16/05/07

  22. Also some anecdotal evidence from a participant in our current trial.Coping with ParanoiaA personal account 2004 “The most likely thing to trigger (my paranoia) is a comment or question that could have more than one meaning, or at least that’s how it seems at the time. It can be a comment that feels critical and that I dwell on afterwards. These comments are usually from people I know well, especially family.” EKuipers, KCL, IOP 16/05/07

  23. Kuipers et al 2006bBritish Journal of Psychiatry, 188, 173-179 N = 86 dyads. Negative relationships seem to have an impact via affect; significantly more depression and anxiety in patients in high EE dyads. Critical comments predicted anxiety in patients. Carers themselves could have low self esteem. This was related to feeling ‘burdened’, stressed, and depressed, having poor coping (avoidant) and to patient depression. Model partly supported. EKuipers, KCL, IOP 16/05/07

  24. Discrepant illness perceptionsKuipers et al (2007) Carers and patients both had negative illness perceptions, but carers tended to have more concerns. When carers and patients disagreed about the consequences of psychosis, patients were depressed; when they disagreed about control, carers were more stressed (N = 82 dyads) ie. discrepant views impacted on mood. EKuipers, KCL, IOP 16/05/07

  25. Hooley et al, (2005)Biological Psychiatry, 57, 809-812 9 controls and 7 remitted patients with depression listened to warm and negative comments from their mothers. Those previously depressed showed more negative mood change to negative comments, and less activation of DLPFC (dorsolateral prefrontal cortex). EKuipers, KCL, IOP 16/05/07

  26. Kiecolt-Glaser, J.K. et al (2005)Archives of General Psychiatry, 62, 1377-84 42 normal married couples. Hostile interactions reduced wound healing. Pathways for negative relationships to affect physical health. EKuipers, KCL, IOP 16/05/07

  27. Clinical implications for FI in Psychosis Suggests FI needs to concentrate on reducing family disagreements, improving understanding of problems and thereby reducing patient anxiety and depression. Also needs to reduce disagreements to improve carer self esteem and depression in carers to improve coping. These seem to be crucial ingredients for successful family interventions. EKuipers, KCL, IOP 16/05/07

  28. Clinical implications for FI in Psychosis cont. Seems important to replace stress, anxiety and criticism by calmer, more tolerant, and more effective reappraisal and problem solving, while boosting carer coping and self esteem. Some families might need specific support for active rather than avoidance coping styles. Some evidence that family support can improve outcomes, compared to isolation. EKuipers, KCL, IOP 16/05/07

  29. Department of Psychology Research Day Applying Science to the Real World 14th September 2007 www.iop.kcl.ac.uk/prd

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