P&B Lecture 5 - Working with Families PDF

Current Research for Working with Families with Psychosis: Domenico Giacco (Warwick) Class Prep: Intro to FI What is Family Intervention? Family intervention is a psychological intervention which is evidence-based for...

Current Research for Working with Families with Psychosis: Domenico Giacco (Warwick) Class Prep: Intro to FI What is Family Intervention? Family intervention is a psychological intervention which is evidence-based for people experiencing psychosis and their families. There are different types of family intervention but all work to include family members directly in the therapy Clinicians, family members and service users have sessions together Often in people’s home NICE Recommendations 1.3.7.2 Family interventions should: Include the person with psychosis or schizophrenia if practical Be carried out for between 3 months and 1 year Include at least 10 planned sessions Usually every-other week Take account of the whole family’s preference for either single-family intervention or multi-family group intervention Take account of the relationship between the main carer and the person with psychosis or schizophrenia Have a specific supportive, educational or treatment function and include negotiated problem-solving or crisis management Who is a carer? Carers can be anyone who has regular close contact with adults with psychosis and schizophrenia, including advocates, friends or family members, although some family members may choose not to be carers [Psychosis and schizophrenia in adults (NICE guideline CG178)] Family members include carers and family members who the person with psychosis or schizophrenia lives with or is in close contact with. [Psychosis and Untitled 1  schizophrenia in adults (NICE guideline CG178)] Carers as a resource People with psychosis who have carers will usually have better outcomes and quality of life than those who don’t Accessing relevant services during the early phases of psychosis (Jansen et al., 2015; Morgan et al., 2006) Improving treatment/medication adherence (Garcia et al., 2006) Identifying early signs of relapse (Guest & Burns, 2001) Reducing admission and relapse rates (Normam et al., 2015) Gains from psychological therapy (Garety et al., 2008) Improved reasoning skills and flexibility in thinking (Jolley et al., 2014) Experience of caregiving in psychosis High levels of burden: ~80% (Magliano et al., 2003; Patel et al., 2004) Feel their caring role has adverse effects on other parts of their life, e.g. emotional well-being, social functioning, financial burden and physical health High levels of burnout (Onwumere et al., 2015; Angermeyer et al., 2006) Exhaustion, feelings of negativity towards the person they’re caring for 30-40% report clinical levels of depression (Raune & Kuipers, 2004) 30-40% report PTSD symptoms (Kingston et al., 2015; Loughland et al., 2009) High levels of loss and grief (Patterson et al., 2005) Victim of violence and aggression – 52.9% (Onwumere et al., 2014) Social isolation (Hayes et al., 2015) Stigma and shame associated with mental health difficulties can reduce the social networks of carers (Magliano et al., 2005; Gutierrez-Maldonado, Caqueo-Urızar & Kavanagh, 2005) Expressed Emotion (EE) Untitled 2  EE = a measure of the family environment Considers the family interactions to be either positive or negative Being critical, hostile, overinvolved, may not be helpful ways of responding but these are very common ways of interacting Being ‘overinvolved’ may be an adaptive response in early psychosis (Van Os et al., 2001) High EE has been identified as common in caregiving relationships across multiple disorders (Wearden et al., 2000) ‘High EE carer’ is a shorthand to describe carers in a high EE relationship, not a fixed quality of the carer Understanding EE It was developed as a research measure It is measured by scoring an interview (the CFI), with the carer talking about the client, on 5 different dimensions (criticism, hostility, emotional overinvolvement, warmth, positive remarks) Untitled 3  It is a measure of a particular relationship at a particular point in time It can change It is not situated ‘in’ a person but in the interaction between people Impact of EE High EE has the potential to impact both client and carer High EE is a predictor of outcomes in schizophrenia: 21% relapse in those in low EE relationships 50% for those in high EE relationships High EE is strongly correlated to carer burden Burden is related to poor carer outcomes including: stress, distress, low self-esteem and less effective coping strategies. The role of Beliefs Carer beliefs are linked to expressed emotion (hostility, criticalness, overinvolvement). Cognitive theory suggests that it is not events in themselves which cause us distress, but the way we think about those events which leads us to feel distressed ABC model – Activating event, Belief, Consequence Carers’ appraisals of the situation and their perception of the resources they have to cope impact on carer burden and are independent of the severity of the experiences of the client (Scazufca & Kuipers, 1996) Overinvolved Relationships Untitled 4  Critical/Hostile Relationships Positive Relationships Untitled 5  Beliefs about Psychosis Leventhal’s Illness Perception Beliefs Model Identity – the symptoms, the name of the illness Cause – the aetiology of the illness Cure/control – the extent to which the illness can be cured or managed and what that might be like in real terms Consequences – the impact (e.g. personal, social, financial) on the individual experiencing psychosis, as well as the carer themselves Timeline – the perceived length of time the illness with continue These dimensions will impact on the emotional and practical responses of carers and people experiencing psychosis Cognitive Model of Caregiving (Kuipers et al., 2010) Summary & How this links to FI? Caring for someone who is experiencing psychosis can be a difficult and stressful experience for family members Untitled 6  Carers have may have different responses to caring due to factors such as expressed emotion and appraisal styles Interventions can include helping carers to understand psychosis in relation to their loved one, acknowledge the carers own difficulties and provide them emotional support, work on the relationship between the family and the individual and think about the impact that psychosis has had on that We include family members in our work because intervention has been shown to help the clients we work with and also the carers themselves Additional Read: Understanding the Needs of Carers of People with Psychosis in Primary Care Read: Effectiveness of Family Intervention for Preventing Relapse in First- Episode Psychosis Until 24 Months of Follow-up: A Systematic Review with Meta- Analysis of Randomised Controlled Trials Cognitive Model of Caregiving in Psychosis Notes: Family Interventions for Psychosis: the Models, the Evidence, the Implementation Family Interventions for Psychosis Models of family interventions (‘how to work with families?’) Evidence on FI for psychosis (‘Do family interventions work’? FI implementation in mental health services (‘How are family supported in practice and what are the barriers?’ FI in acute mental health care settings (general inpatient care, people treated under the Mental Health Act) Models of Family Intervention Systemic-oriented family interventions Psychoeducational approaches to family with the patient Psychoeducational interventions to the family without the patient Integrated interventions (separate interventions for patients and the whole family) (Models/Evidence, reference ‘Rodolico et al., 2022, Lancet Psychiatry’) Untitled 7  Systemic-Oriented Family Intervention The whole family is the target of the intervention Family considered as a self-governing cybernetic system → family have their own dynamics and mechanisms that may be related to symptoms Therapists focus on relationships between members; their interactions, and dynamics Requires lots of training, skill and understanding of cultural and psychological model Psychoeducation Talk to the family members of someone with psychosis and discuss (in user friendly language) what the disorder is, why they have to take medication & how it works. With the Patient W/out the Patient - Relatives’ Psychoeducation Focused on information provision and family emotional climate Can be done individually or in family groups Different groups of carers or Team the family and patient how to families → peer support and communicate effectively → in some exchange families communication can be disrupted - particularly when there’s Carer groups → those who lots of stress provide significant emotional and physical support Joint crisis care planning - what are the early signs of crisis → when Very effective when the patient people relapse, they present at the refuses to engage in beginning with signs and symptoms support/intervention (e.g. disturbed sleep, changes to feeling / eating) Relapse prevention - pick up on these signs for patient and families Plan in place if these signs appear Untitled 8  Focus on Emotional Climate → researches found (50s/60s) in families with more Expressed Emotion (e.g. critical/over emotionally involved) - can impact the risk of relapse Integrated Intervention Separate Psychoeducation Interventions Provided separately to patients and relatives FPsy + patient behavioural or skills training FPsy to all family training only to patients Community-based care intervention Family support provided as part of a wider community-based provision (e.g. Assertive Outreach - not done much anymore) → EIS use assertive outreach methods NICE recommends offering everyone in EIS Family Intervention The Evidence Rodolico et al., 2022 - Meta-Analysis Almost all interventions models were associated with a lower probability of 12- month relapse than TAU Exception: brief (less than two sessions) psychoeducation and interventions only focused on crisis planning - evidence is still unclear regarding its effectiveness → suggests the need for more sessions of family involvement Relapse rate: Family psychoeducation alone (10%), FPsy + behav/skills training and mutual support (17%) and systemic oriented (16%) Relapse rate in TAU was 37% Reflecting on the Evidence FI work and reduce relapse. Everything is effective but needs to be done for more than a couple of sessions. Untitled 9  FI effective because - family can understand more about diagnosis, medication (adherence & potential side-effects) and support & encouragement to seek help / better understanding for clinician regarding the patients environment. Crisis plan-focused and brief interventions fail to show effectiveness → too brief to get to know the families & dynamics and engage effectively → intervention may not be implemented properly Implementation Given the effectiveness of family interventions, they should be implemented in practice (see The National Institute for Care and Clinical Excellence, UK, and the Royal Australian and New Zealand College of Psychiatrists) However, their implementation is still limited Systematic Review Question: How is the involvement of families is implemented in the treatment of patients with psychosis? Methods: systematic review including both qualitative and quantitative studies. Analysis method: Thematic analysis of data from papers Implementation reference is ‘Eassom, Giacco et al., 2014, BMJ Open’ Identified Evidence Over half of the studies were based on UK findings Approaches were FPsy primarily, but also Open Dialogue, Systemic Psychotherapy and purely Behavioural Therapy Vast majority were cross-sectional and staff-focused studies (e.g. Open Dialogue) More attention to barriers than to facilitators Themes Red = Don’t Work Green = Make it Work 1. Training Needs Untitled 10  Get training but move out of service or don’t get the right supervision → doesn’t work for FI 2. System-wide Approaches and Attitudes Consider the organisation culture → what their priority is E.g. focus on medication may result in FI being a lower priority Even if staff are trained for FI - if colleagues don’t agree with it, may be less inclined to refer into it or agree with its outcomes Should be a shared focus in the team for FI to be implemented effectively 3. Reservations About 4. Problems with Engaging Families Involving Families Untitled 11  Families still need to be engaged but consider different ways to engage. Critical period of engagement with families → engaged early on = better outcome Important to have a shared message across the service about Family Involvement 5. Complex Needs Can be difficult if there are complex relationships within the family Important to be willing to share power/control with family regarding intervention & crisis-planning (e.g. what the patient wants to happen when they’re unwell) 6. Working Relationships Active use of effective communication skills → also possible to be trained FI = 3 way meeting → need to learn to navigate this dynamic Continuity of care is important → having the same person deliver the intervention (E.g. having a point-of-contact for the families) Untitled 12  7. Individualisation Listen, be curious of individual and culture Relinquish control a little bit Also consider delivery → e.g. if families are busy — meeting outside of working hours, via video calls etc. Helps with engagement with intervention → assist with barriers to treatment Reflection Is there something that research has not captured so far and would be worth investigating? What do you think the implications for practice are? Inpatient Care Background: service user and carer voices are often not heard in implementation research on family involvement Question: How can we improve implementation of family involvement in inpatient care? Focus groups with patients, carers, staff Giacco et al., 2017 Implementation in Inpatient Settings Practical Challenges of Carer Involvement: What should carer involvement entail: Identify carers → information not The right time for involvement regularly obtained (particularly in Providing carers with information crisis) Untitled 13  Involving carers in all aspects of care Problems in assessing and obtaining planning and discharge patients’ consent/capacity Adopting a supportive approach Complexities of information sharing towards carers Difficulties with engaging carers Valuing the personal knowledge of Systemic and organisational cares on patient’s condition constraints Kaselyonite et al., 2019 - Pathway of Family Organising a Topics for discussion in Engagement meeting/discussion the meeting: Obtaining consent from with the patient, their Reason for admission the newly admitted carer and clinician patient for carer within 7 days of Information provision involvement admission - hospital processes, legal rights, visitation policy etc. Ways of working together in care and discharge planning Family Support - Involuntary Care Admittance under the Information about mental health laws: MHA: “I would have loved to be able to have somebody else jus Previous research* - to help me understand all the legality of it, what my family/friends of patients rights were” carers felt isolated and Continuous support: unsupported by “A confidential adviser or a buddy assistant to talk to services. over the phone or in a private safe room, one-to-one, Mental Health Act not in coffee mornings but like regular get-togethers or (MHA) review - provide session” support to informal Specificity of peer support: carers (family and friends) of people who “a professional’s been education to know those things are detained but a carer would have gone through it themselves personally. …sometimes real-life events give you better Jankovic et al., 2011 knowledge.” Untitled 14  Gaps No interventions available focused on one-to-one and situation-specific support for carers (particularly when they have a relative in hospital under the MHA) Why one-to-one? Issues are sensitive, need for information is specific to MHA Evidence-based solution Peer support programme, tested successfully in Germany, adapted and tested for England OPAL project https://fundingawards.nihr.ac.uk/award/NIHR201707 Family Involvement in ‘service transitions’ - inpatient & outpatient care Interventions Evidence Implications 1. Psycho-education in Interventions including Comprehensive/sustain hospital → works a carers that take place interventions have the little both in the hospital and best evidence the community have the 2. Discharge planning → Rational for clearest evidence for doesn’t work well on implementation/resourc benefit on relapse its own reduction 3. Psychoeducation/discharge planning/community follow-up → most effective Petkari et al., 2020 A Positive Example: Early Intervention Teams 1. Family intervention is offered to all eligible patients 2. Explicit standard of care, monitored regularly 3. All staff trained Untitled 15  4. Meta-analytic synthesis: FPsy improves service user functioning and reduces relapse Claxton et al., 2017; Singh et al., 2021 Final Reflection FI are effective in reducing relapse. There are implementation challenges. All staff can be trained to FPsy (e.g. in EIT); more intensive approaches (systemic family therapy, specific forms of psychoeducation / behavioural skills training) need specialist training. At present, whole team approach and continuity of care seem to be key for both effectiveness and implementation. Peer support could be one of the possible key future ingredients of FI. Untitled 16