Family intervention for psychosis

Mental Health Nursing,  Nov 2003  by Holmes, Sophie

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In this article by Sophie Holmes, family intervention for psychosis is described and a brief overview of the evidence base is given. Staff training in psychosocial skills is widely available but staff frequently return unable to implement their skills. A service was set up in Weston-super-Mare with no extra resources and some of the reasons for its success are discussed

Family Intervention for people with psychosis has a long and well researched history, showing good evidence of effectiveness in reducing relapse of people with a diagnosis of schizophrenia and reduced length of stay in hospital (Leff et al, 2001).

Mental health nurses, in particular, have been encouraged to further their skills in the care of people with psychosis (Tredget, 1999). Given the evidence that supporting families can improve the outcome for people with schizophrenia, nurses are increasingly expected to work with carers.

In addition, the Government has taken a lead in prioritising psychosocial interventions for people with severe mental illness. The launch of the National Service Framework for Mental Health (Department of Health, 1999) set out standards of care that are expected to be in place over the following 10 years. Of particular relevance to family intervention for psychosis were the standards stating that all mental health users must have access to psychological therapies and readmission to psychiatric wards must be reduced. It was also specified that all carers should be offered an assessment of their own needs and carers had a right to access services in their own right.

The main aim of family intervention for schizophrenia has been to reduce Expressed Emotion (EE), as high EE is associated with increased chance of relapse (Wearden et al, 2000). Family interventions have been refined, researched and key components identified. It has been established, for instance, that simply offering education alone, is not enough to reduce the impact of psychosis (Barrowclough and Tarrier, 1992; Lam, 1991). In addition, treatment should be integrated into the overall case management (Bradshaw et al, 2000) and aim to improve medication concordance (Barrowclough and Tarrier, 1992).

The majority of therapeutic interventions offered to families involve communication training, problem solving skills and education. The style of therapy emphasises the positive aspects of the family's coping style and avoids judgmental or blaming comments. The aim is for collaboration between family members and workers over goals for change and a greater emphasis on the needs of the family. Fadden (1998a) has criticised the narrow focus on relapse prevention at the expense of addressing the family's wider needs. Increasingly, family workers are using techniques drawn from cognitive therapy and from systemic family therapy (Burbach and Stanbridge, 1998).

There have been strong criticisms made about family intervention, based on beliefs that it blames families for schizophrenia (Johnstone, 1993). To a greater extent, family support services have moved away from a position of explicitly trying to reduce EE and giving a message that stress exacerbates schizophrenia rather than causes it. Clearly, there is a contradiction in teaching families that reducing criticism lessens the chance of relapse yet taking a blame free approach and teaching families that schizophrenia is an illness not caused by the family. Families are quick to pick up on the implicit message that services see them as being instrumental and, therefore, responsible for their relative's relapse (Johnstone, 1993). The focus of family intervention on families described as 'high EE' is also flawed. We now know that EE is not a stable trait but, rather, fluctuates over time and may more accurately be described as reflecting the interactions between the client and their carer (Patterson et al, 2000).

More recently research has focused on other outcomes of family intervention other than simply relapse. Tarrier et al (1999) reviewed studies and concluded that there was some evidence that relatives' distress and burden could be decreased and that social functioning improved. Family intervention has been shown to improve a number of aspects of clients' social well being such as employment and leisure activities (Lam, 1991). Family intervention has also been proven to be effective not only in research settings but also in routine clinical care (Barrowclough et al, 1999).

Staff training in family intervention

The large body of evidence demonstrating the effectiveness of family intervention for psychosis has highlighted the need for staff training in these skills. These intervention skills are still not routinely taught as part of most mental health workers' professional training. In response to this, courses have been set up in different parts of the country.

The Thorn nursing programme, as described by Lancashire et al (1996), for example, has attempted to equip mental health workers with skills needed for working with people with schizophrenia. The Thorn training is a year long day release course which covers case management, family intervention and cognitive behavioural interventions (Tarrier, 1999). The outcome for clients seen by Thorn trained staff has been shown to be significantly improved for positive and affective symptoms (Lancashire et al, 1996).