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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

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

talk about
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

The impact of care in psychosis– in first


  • “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

and in subsequent episodes

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

families as a resource
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

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

care giving has a clear impact on family members
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

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

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


EKuipers, KCL, IOP 16/05/07

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

cross cultural issues in ee research some evidence of cultural specificity
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

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


Families at first episode have similar issues (Raune et al


High EE carers more likely to attribute blame and responsibility

to patients and be more distressed (Barrowclough & Hooley


EKuipers, KCL, IOP 16/05/07

This evidence base has informed family

interventions in psychosis. Several manuals now


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

NICE Guidelines (2003)

18 RCTs included (N = 1458)

FI reduces relapse and can improve carer


EKuipers, KCL, IOP 16/05/07

pfammatter et al 2006 schizophrenia bulletin 32 s64 s80
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

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


FI for psychosis is broadly efficacious.

Can improve relapse rates, and outcomes for


Some evidence that carers can also feel better.

Longer treatments recommended by NICE


EKuipers, KCL, IOP 16/05/07

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

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

psychological prevention of relapse in psychosis theoretical studies
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.


EKuipers, KCL, IOP 16/05/07

some evidence supporting this from barrowclough et al 2003
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

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

kuipers et al 2006b british journal of psychiatry 188 173 179
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

discrepant illness perceptions kuipers et al 2007
Discrepant illness perceptionsKuipers et al (2007)

Carers and patients both had negative illness

perceptions, but carers tended to have more


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

hooley et al 2005 biological psychiatry 57 809 812
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

kiecolt glaser j k et al 2005 archives of general psychiatry 62 1377 84
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

clinical implications for fi in psychosis
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

clinical implications for fi in psychosis cont
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

department of psychology research day applying science to the real world

Department of Psychology Research Day Applying Science to the Real World

14th September 2007