Staff expressed emotion and causal attributions for client problems on a low security unit: an exploratory study

Differential correlates of criticism versus emotional overinvolvement towards patients with schizophrenia living in halfway houses or with their families

PURPOSE

This study systematically searched for differential correlates of criticism vs. emotional overinvolvement (EOI) towards patients with schizophrenia in families and halfway houses, which have only incidentally been reported in previous research. Identified patterns were compared across settings.

METHODS

We included 40 inpatients with schizophrenia living in halfway houses and 40 outpatients living with their families and recorded the expressed emotion (EE) of 22 psychiatric nurses or 56 parents, respectively, through Five Minutes Speech Samples. Each nurse rated 1-12 inpatients and each inpatient was rated by 2-5 nurses. Each outpatient was rated by one or both parents. As EE ratings had a multilevel structure, weighted Spearman correlations of criticism and EOI with various patient- and caregiver-related characteristics were calculated and compared with Meng's z-test.

RESULTS

Criticism was weakly negatively correlated with EOI in nurses but negligibly in parents. Distinct patterns of significant differential correlates arose across settings. Outpatients' aggressive behavior and parents' related burden were mainly associated with higher criticism. Inpatients' symptoms (agitation/aggression, negative and other psychotic symptoms) and nurses' burnout (Depersonalization) were mainly associated with lower EOI. Inpatients' perceived criticism and outpatients' previous suicide attempts were equally associated with higher criticism and lower EOI (mirror correlations). Finally, various inpatient attributes (older age, chronicity, unemployment and smoking) triggered higher EOI only. Inpatients' age, psychopathology (esp. agitation/aggression and negative symptoms) and perceived criticism survived adjustment for multiple comparisons.

CONCLUSION

Our findings suggest setting-specific pathogenetic pathways of criticism and EOI and might help customize psychoeducational interventions to staff and families.

Momentary displays of compassion and the relationship between psychosis, mood and risk incidents on inpatient wards: An experience sampling study

OBJECTIVES

Psychosis can be thought of as a threat-based experience. Compassion has been shown to be effective in reducing threat, although highly distressed individuals may struggle to be self-compassionate. This study explored the effects of compassionate interactions with staff on inpatients with psychosis.

METHOD

Experience Sampling Method (ESM) was used to investigate the relationships between compassion from staff and paranoia, voice hearing, distress related to psychosis experiences, affect and risk incidents in daily life. Twenty-two service users residing on inpatient mental health wards took part. Baseline measures of compassion, fears of compassion and affect were taken. Participants completed ESM assessments 10 times per day, over 6 days.

RESULTS

Compassion from staff was associated with a small increase in voice hearing, but was not associated with paranoia, paranoia-related distress, voice-related distress, negative affect, positive affect, or risk incidents in daily life. Baseline fears of compassion moderated the relationships between compassion from staff and some of the service user outcomes. For inpatients scoring low on fears of compassion, compassionate interactions were associated with increased positive affect and lower paranoia. However, for those scoring high on fears of compassion, this relationship was reversed, and compassionate interactions were associated with higher paranoia and lower positive affect.

CONCLUSION

People with psychosis who have fears of compassion may benefit from receiving support to address these fears in order to experience the benefit from the compassion of staff. The results should be interpreted with caution due to the low number of observations and limited statistical power.

Family in Crisis: Do Halfway Houses Perform Better Than Families with Expressed Emotion toward Patients with Schizophrenia? A Direct Adjusted Comparison

Expressed emotion (EE) toward patients with schizophrenia is typically reported to be lower in psychiatric halfway houses than in families. This is the first study directly comparing EE between these settings and investigating the pathways mediating EE differences. We included 40 inpatients in halfway houses and 40 outpatients living with their families and recorded 22 psychiatric nurses' and 56 parents' EE, respectively, through Five Minutes Speech Samples. Each inpatient was rated by 2-5 nurses and each outpatient by 1-2 parents. As EE ratings had a multilevel structure, generalized linear mixed models were fitted, adjusting for patient-related confounders and caregiver demographics. Mediatory effects were investigated in multilevel structural equation models. Outpatients were younger, less chronic, and better educated, with higher negative symptoms and perceived criticism than inpatients. Nurses were younger and better educated than parents. Before adjustment, EE rates were equally high across settings. After adjusting for patient-related confounders, emotional overinvolvement was significantly higher in parents. However, after also adjusting for caregiver demographics, only criticism was significantly higher in nurses. Patients' age, negative symptoms, and perceived criticism and caregivers' age and sex significantly mediated EE group differences. Our findings highlight pathways underlying EE differences between halfway houses and families and underscore the importance of staff and family psychoeducation.

Perceptions of learning disability nurses and support staff towards people with a diagnosis of schizophrenia

WHAT IS KNOWN ABOUT THE SUBJECT?: People with learning disability are more likely than the general population to develop schizophrenia. Personal recovery philosophies are based on positive attitudes and an optimism that recognizes and values people and their strengths and capacity to achieve goals. Little is known from previous studies about the illness perceptions of learning disability practitioners who work with people that experience both a learning disability and schizophrenia. The illness beliefs of learning disability practitioners about schizophrenia may mediate the potential for social exclusion and limit recovery outcomes. WHAT THIS STUDY/PAPER ADDS TO EXISTING KNOWLEDGE?: The findings show that the illness beliefs of learning disability practitioners and support workers regarding schizophrenia are pessimistic in terms of the consequences for people with schizophrenia and learning disability and their relatives as well as the chronic course of the illness. WHAT ARE THE IMPLICATIONS FOR CLINICAL PRACTICE?: This study identifies the nature of LD practitioner perceptions about schizophrenia and provides guidance about how personal recovery philosophies can be applied to the management of LD and schizophrenia. The beliefs of learning disability practitioners and support workers regarding schizophrenia need to be reframed to support better recovery outcomes and social inclusion for this group. The findings from this study can inform the development of training in bio-psycho-social models of schizophrenia, recovery approaches, family/carer interventions, clinical supervision, mentorship and reflection on clinical practice, which could be potentially useful strategies to help facilitate a reframing of beliefs.

ABSTRACT

Background and purpose of study The prevalence of schizophrenia in people with learning disability is 3-4%. This is the first study to investigate the illness perceptions of learning disability (LD) practitioners towards people with schizophrenia. Methods Learning disability practitioners (n = 210) that work with people with LD and schizophrenia completed a modified version of the Illness Perception Questionnaire Schizophrenia Carers Version (IPQ-SCV). Descriptive and correlational analyses were conducted for all of the IPQ-SCV subscales. Results A significant positive correlation was found between consequences relative and consequences patient (0.495, P < 0.001), and a negative correlation was found between timeline episodic and timeline chronic (-0.243, P < 0.001) subscales. Discussion Consistent with previous evidence found regarding negative staff attitudes to schizophrenia recovery outcomes, course and chronicity, the current investigation has extended and confirmed these observations to staff working with individuals with comorbid schizophrenia and learning disability. Implications for practice This study identifies the nature of LD practitioner perceptions about schizophrenia and contributes to the development of the recovery philosophy in relation to the management of LD and schizophrenia. The findings inform the design of training modules in bio-psycho-social models of schizophrenia, recovery approaches, family intervention, clinical supervision and reflection. These can help LD practitioners to reframe their schizophrenia/LD illness beliefs.

Hope-inspiring therapeutic relationships, professional expectations and social inclusion for young people with psychosis

OBJECTIVE

Personal recovery accounts suggest that a positive therapeutic relationship with an optimistic mental health professional may facilitate social inclusion. However, little empirical research has investigated the role of the therapeutic relationship in social outcomes or explored potential mechanisms of change within community psychosis care. This study investigated the direct predictive associations of the therapeutic relationship and professional expectancies for social inclusion and vocational activity for young people with psychosis, and indirect associations through hopefulness.

METHOD

Young people with psychosis and their main mental health professional (n=51 dyads) participated across two time points. Measures of therapeutic relationships, professional expectancies, and vocational activity were obtained at baseline. Measures of hopefulness, social inclusion and vocational activity were obtained at follow-up. Direct and indirect associations between variables were analysed using path modelling.

RESULTS

Directed path models were consistent with a positive therapeutic relationship and positive professional expectancies predicting social inclusion and vocational activity through mediation by increased patient domain-specific hopefulness. The professional-rated therapeutic relationship more directly predicts change in vocational activity status. Change in vocational activity status predicts increased patient hopefulness.

CONCLUSION

The therapeutic relationship between professionals and young people with psychosis appears hope-inspiring and important to patients' social inclusion and vocational outcomes. Vocational activity may produce reciprocal gains in hopefulness.

Feasibility of a ward-based psychological intervention to improve staff and patient relationships in psychiatric rehabilitation settings

OBJECTIVES

Recent inquiries highlight the anti-therapeutic nature of inpatient psychiatric care. We aim to assess the feasibility and potential efficacy of a ward-based psychological intervention to improve staff-patient relationships in psychiatric rehabilitation settings.

METHODS

A single-blind cluster randomized design compared the intervention with treatment as usual (TAU) on measures of relationships, staff well-being, and patient functioning. Assessments were carried out at baseline and at 6 months.

RESULTS

Fifty-one patients and 85 staff were recruited across 10 wards. Fifteen patients and 11 staff were lost to follow-up, with primary reason being ward discharge. Uptake to the intervention was variable but on average lower than anticipated (mean number of sessions 3.5, range 0-11). Despite this lower than anticipated uptake, compared with TAU, patients in the intervention arm felt significantly less criticized by their key workers and reported improvements in ward atmosphere. Staff in the intervention arm also reported significantly lower levels of depersonalization post-intervention. Although trend level data favoured the intervention group, in this relatively small feasibility study, we were not able to demonstrate statistically significant differences between the groups in terms of staff perceptions of relationships, staff stress, and longer-term patient outcomes.

CONCLUSIONS

This psychologically informed ward-based intervention shows potential in improving relationships, although findings and feasibility may be enhanced if further measures are put into place to ensure that all members of the team attend intervention sessions on a more frequent basis. Loss at follow-up due to discharge also needs to be factored into future power calculations.

PRACTITIONER POINTS

It is feasible to implement and trial a ward-based psychological intervention (team-based formulation) in long-stay psychiatric settings using a cluster randomized design. Developing psychological formulations with frontline ward staff around patients' needs has the potential to improve staff-patient relationships. The small sample size and loss of data at follow-up may have limited the power of the study to detect the full range of treatment effects. Larger trials are needed to assess the reliability and generalizability of our findings across different wards.

The client-caseworker relationship and its association with outcomes among mental health court participants

A portion of people with mental illnesses who are arrested are diverted to mental health courts (MHC) where they work with teams of treatment and court staff rather than serving time in custody. This study investigated the association between the relationship with caseworkers and outcomes. MHC participants were recruited to participate in structured interviews on their perceptions of the bond and conflict with their MHC caseworkers. Regression models tested associations between relationships with caseworkers and program retention, service use, and number of days spent in jail. Perceived conflict with caseworkers was higher among participants who were terminated or missing from the MHC. Participants who perceived less conflict with caseworkers utilized more services and spent fewer days in jail. The perceived bond was significantly associated with service use. Caseworkers with clients who are in the criminal justice system should be mindful as conflict arises and implement strategies to effectively manage conflict.

Effects of a recovery-oriented cognitive therapy training program on inpatient staff attitudes and incidents of seclusion and restraint

We investigated the feasibility of implementing a recovery-oriented cognitive therapy (CT-R) milieu training program in an urban acute psychiatric inpatient unit. Over a 1-month period, 29 staff members learned short-term CT-R strategies and techniques in an 8-h workshop. Trainees' perceptions of CT-R, beliefs about the therapeutic milieu, and attitudes about working with individuals with psychosis were evaluated both before the workshop and 6 months after the workshop had been completed. Incidents of seclusion and restraint on the unit were also tallied prior to and after the training. Results indicate that staff perceptions of CT-R and their beliefs about the therapeutic environment significantly improved, whereas staff attitudes towards individuals with psychosis remained the same. Incidents of seclusion and restraint also decreased after the training. These findings provide evidence that CT-R training is feasible and can improve the therapeutic milieu of an acute psychiatric inpatient unit.

The predictive validity of expressed emotions (EE) in schizophrenia. A 20-year prospective study

BACKGROUND

The level of expressed emotions in the family (EE) and components thereof (emotional over-involvement EOI, and critical comments CC) have been found to be related to treatment outcomes in psychotic patients. One point of interest is the dynamic of various outcomes in relation to initial EE, CC and EOI levels.

METHOD

43 individuals with diagnosis of schizophrenia were assessed at 1, 3, 7, 12 and 20-year follow-ups. The EE indicator was evaluated during the index hospitalization. Outcome indicators included: number of relapses, number and duration of in-patient rehospitalizations, and severity of psychopathological symptoms.

RESULTS

1) A high EE indicator was associated with a higher number of relapses in every follow-up and differences between the groups with low and high EE indicators proved significant after 3, 7, 12 and 20 years of the illness. 2) A high EE indicator was associated with a higher number of rehospitalizations after 3 and 7 years, and showed as a clear trend after 12 and 20 years. 3) A high level of CC was associated with a higher number of relapses. 4) The severity of positive symptoms increased only in the group with high CC. 5) The negative syndrome was not associated with EE, EOI or CC.

CONCLUSIONS

The EE indicator may be considered a valid prolonged predictor of relapses and rehospitalizations. A high level of CC was associated with a higher number of relapses and intensification of the positive syndrome in both the short-term and long-term course of the illness.

The prognostic role of perceived criticism, medication adherence and family knowledge in bipolar disorders

BACKGROUND

In schizophrenia, high levels of critical comments by significant others are associated with early relapse, especially if medication adherence is sub-optimal. Levels of criticism may be influenced by family knowledge about both the disorder and its treatment. No study has explored whether this combination factors influence outcome in adults with bipolar disorders.

METHODS

Medication adherence was assessed in 81 individuals with bipolar disorder of whom 75 rated perceived criticism by an identified 'significant other' as well as their own perceived sensitivity. 33 (of the 75) had a close family member who agreed to completed an assessment of their knowledge and understanding of bipolar disorders. Psychiatric admissions were then recorded prospectively over 12 months.

RESULTS

Perceived criticism and medication adherence were significant predictors of admission. In the patient-family member dyads (n=33), the odds ratio (OR) for admission was 3.3 (95% confidence intervals 1.3-8.6) in individuals with low levels of medication adherence, high perceived criticism, and a family member with poor knowledge and understanding.

LIMITATIONS

The small sub-sample of patient-family member dyads means those findings require replication. Sensitivity to criticism by professional caregivers may not equate to that by relatives.

CONCLUSIONS

Perceived criticism may be a simple but robust clinical predictor of relapse in mood disorders. High levels of perceived criticism, poor understanding of bipolar disorder by a significant other, and sub-optimal treatment adherence are risk factors for hospitalization in adults with bipolar disorders that are potentially modifiable through the use of strategic psychosocial interventions.

Carer and mental health professional views of a psychosocial treatment for negative symptoms in psychosis: a qualitative study

BACKGROUND

Trials of complex interventions should be preceded by in-depth piloting of the treatment in order to ensure clear definition of critical components and establish feasibility and acceptability.

OBJECTIVES

This study aimed to elicit views of extending behavioural activation, an evidence-based treatment for depression, to the negative symptoms observed in psychosis from the perspectives of carers of people with mental health problems and mental health professionals.

DESIGN

Qualitative study.

SETTING

School of Nursing, Midwifery and Social Work and carer support organisation, North West of England, United Kingdom.

PARTICIPANTS

Fifteen participants were recruited from a local carer support group. Nineteen mental health professionals were recruited from post-registration university based programmes.

METHODS

We used focus groups and semi-structured interviews. Thematic analysis using a constant comparative approach was employed to capture key concepts and themes.

RESULTS

There was support for behavioural activation for negative symptoms in psychosis from some mental health workers and many of the carers; however both groups identified barriers to its implementation. Professionals highlighted internal factors, the difficulty in engaging people with negative symptoms in psychosocial treatments and services more broadly while carers identified a number of external, practical barriers. For those who saw some utility in the treatment approach, the benefit of expanding the treatment to include community based sessions as well as formal behavioural activation meetings were recognised. However, a number of mental health professionals remained sceptical as to its potential to reduce negative symptoms. Professional and carer views generally concurred in relation to family involvement, indicating that restricted engagement could be helpful, but that further participation might actually be counterproductive.

CONCLUSIONS

Acceptability for many carers and some professionals was evident and support further evaluation of behavioural activation for negative symptoms. Significant issues to be addressed include the balance of formal talking based sessions and community based sessions to support activation for people with negative symptoms and mental health professional pessimism in relation to this symptom cluster. The current study supports the phased development and careful piloting of complex healthcare interventions before progression to large scale evaluation.

Effects of Severe Mental Illness Education on MSW Student Attitudes About Schizophrenia

Social work students (n = 60) in a master's-level course on severe mental illness participated in a quasi-experimental study examining the degree to which increased knowledge about and contact with individuals with schizophrenia during the course would impact their attitudes toward people with the disorder. Results revealed significant improvement in student knowledge and general attitudes after the course, and indicated that increased knowledge about schizophrenia was only related to general attitudinal improvement when accompanied by increased personal social contact. Implications for education on severe mental illnesses, and value and attitude development in social work education are discussed.

The role of expressed emotion in relationships between psychiatric staff and people with a diagnosis of psychosis: a review of the literature

The concept of expressed emotion (EE) has been extended to the study of staff-patient relationships in schizophrenia. A comprehensive review of the literature identified a total of 27 studies investigating EE in this group published between 1990 and 2008. The article aims to assess whether the concept of EE is a useful and valid measure of the quality of professional caregiver and patient relationships, given that staff may be less emotionally invested in relationships than relatives. In doing so, it summarizes methods of measuring EE, the nature of professional EE compared with familial EE, associations between high EE and patient outcomes, associations between EE and both patient and staff variables, and intervention studies to reduce staff high EE. The available evidence suggests that the Camberwell Family Interview is an acceptable measure of EE in staff-patient relationships, although the Five Minute Speech Sample may provide a less resource intensive alternative. However, in contrast to familial research, neither the EE status on the Camberwell Family Interview nor the Five Minute Speech Sample show a robust relationship with outcomes. The presence or absence of a positive staff-patient relationship may have more predictive validity in this group. There is relatively consistent evidence of associations between staff criticism and poorer patient social functioning. Consistent with findings in familial research, staff attributions may play a key role in driving critical responses, and it may be possible to reduce staff high EE by modifying negative appraisals.

Stigma, Reflected Appraisals, and Recovery Outcomes in Mental Illness

Drawing on modified labeling theory and the reflected appraisals process and using longitudinal data from 129 mothers and their adult children with schizophrenia, we estimate models of the effects of mothers’ stigmatized identity appraisals of their mentally ill children on reflected and self-appraisals, and how appraisals affect outcomes (symptoms, self-efficacy, life satisfaction). Results indicate that initial symptoms and functioning are related to how significant others think about their ill family members, how persons with mental illness think others perceive them, and how they perceive themselves. Part of the effects of initial symptoms and functioning on reflected appraisals are due to mothers’ appraisals. A small part of the effects of outcomes on self-appraisals are due to others’ and reflected appraisals. Stigmatized self-appraisals are related to outcomes, but reflected appraisals do not affect outcomes directly. Implications for modified labeling theory and social psychological processes in recovery from mental illness are discussed.

Working with women prisoners who seriously harm themselves: ratings of staff expressed emotion (EE)

BACKGROUND

Prison staff are repeatedly exposed to prisoners' suicidal behaviours; this may impair their capacity to care. Expressed emotion (EE), as a descriptor of the 'emotional climate' between people, has been associated with challenging behaviour in closed environments, but not previously applied to working alliances in a prison.

AIMS

To investigate the feasibility of rating EE between staff and suicidal women in prison; to test the hypothesis that most such staff-inmate alliances would be rated high EE.

METHODS

All regular staff on two small UK prison units with high suicidal behaviour rates were invited to participate. An audiotaped five-minute speech sample (FMSS) about work with one nominated suicidal prisoner was embedded in a longer research interview, then rated by two trained raters, independent of the interview process and the prison.

RESULTS

Seven prison officers and 8 clinically qualified staff completed interviews; 3 refused, but 17 others were not interviewed, reasons including not having worked long enough with any one such prisoner. Participants and non-participants had similar relevant backgrounds. Contrary to our hypothesis, EE ratings were generally 'low'. As predicted, critical comments were directed at high frequency oppositional behaviour.

CONCLUSIONS

EE assessments with prison staff are feasible, but our sample was small and turnover of prisoners high, so the study needs replication. Attributions about problem behaviour to illness, and/or traumatic life experience, tend to confirm generally supportive working relationships in this sample.

The relationship of case managers' expressed emotion to clients' outcomes

BACKGROUND

Expressed emotion (EE) has been studied in families of a relative with schizophrenia as well as other psychiatric disorders; and high EE (hostile, critical, and overinvolved) families have been found to be strongly related to relapse among their relatives. EE has been assessed on a limited basis among non-familial care providers and determined that providers can also have high EE which results in poor quality of life and negative consequences for their clients.

METHODS

The present study assessed 42 case managers serving clients with schizophrenia spectrum disorder regarding their EE for specific clients enrolled in a larger study examining the reliability and validity of two alliance measures. Case managers and clients were personally interviewed at baseline, 3, 6, 6 plus 2 weeks, and 9 months post-client entry into case management. The EE measure was inserted into the 6 months plus 2 week case manager interview. Generalized Estimating Equation analysis was employed to examine predicted outcomes of EE.

RESULTS

High EE was found to be related to client attitudes toward medication compliance and social contact.

CONCLUSIONS

Family psychoeducation interventions, an evidence-based practice, have been demonstrated to be effective in reducing relapse of relatives with serious mental illness. Given the clinical evidence that EE is modifiable, it is expected that such educational training for non-familial caregivers will have the same potential as for family caregivers. Providers dealing with challenging clients may also need support and skills to better handle difficult situations, especially direct support providers like case managers who are not clinically trained.

The use of the repertory grid technique to examine staff beliefs about clients with dual diagnosis

AIM

This paper reports a study exploring how individual psychiatric staff construes clients with psychosis who misuse substances.

BACKGROUND

A dual diagnosis of substance misuse is common in clients with psychosis. Previous studies have suggested that psychiatric staff feel ill-equipped to work with these clients, and hold negative views of them, affecting client care and recovery. Understanding staff attitudes can inform training and practice.

METHOD

Twelve psychiatric nursing staff working in an inpatient service for adults with enduring mental health difficulties in England were interviewed. Using a repertory grid technique, staff were asked to describe clients and acquaintances who did and did not misuse substances, themselves and colleagues.

FINDINGS

All staff made critical judgements of some clients, particularly clients with dual diagnosis, but were less judgemental towards acquaintances who misused substances. Staff who used fewer dimensions to construe people appeared to make a clear distinction between clients and non-clients. This distinction was not apparent for staff with more cognitively complex construct systems. Specific factors that could be implicated in the organization of individuals' construct systems included personal experience of services as a carer; these staff made less distinction between clients and non-clients.

CONCLUSION

Further training is needed for staff working with clients with a dual diagnosis. Training packages need to consider the personal experiences and views of staff. Reducing the boundaries between staff and clients might enable staff to better understand the actions of clients and improve client care.

What Influences Social Workers' Attitudes Toward Working With Clients With Severe Mental Illness?

A national random survey of 2000 NASW members in post-master's practice in mental health was conducted to investigate their experiences with and attitudes about working with individuals with severe and persistent mental illness (SPMI). Through a series of structural equation models, we examined the influence of different frustrations reported by the respondents on their attitudes toward working with individuals with SPMI. Results suggest that social workers' attitudes toward working with individuals with SPMI are primarily influenced by their frustrations related to client behaviors and treatment issues, rather than frustrations with system related issues. Implications for social work practice and directions for future research are discussed. (105 words).

An Investigation of the Relations Between Student Knowledge, Personal Contact, and Attitudes Toward Individuals with Schizophrenia

A survey of 118 MSW students was conducted to examine the relationship between social work students' knowledge about, contact with, and attitudes toward persons with schizophrenia. Hierarchical regression analyses indicated that students' knowledge about and contact with persons with schizophrenia were significantly related to better attitudes toward this population. Moderated multiple regression analyses revealed a significant interaction between knowledge about and contact with persons with schizophrenia, such that knowledge was only related to positive attitudes among students who had more personal contact with persons with the illness. Implications for social work training in severe mental illness are discussed (99 words).

Expressed emotion, attributions, utility beliefs, and distress in parents of young people with first episode psychosis

This study examined the relationship between expressed emotion (EE), attributions of control, beliefs about the utility of EE behaviors, and distress in parents of young people with first episode psychosis. Fifty-three parents completed self-report measures of EE, attributions of patient and parent control over the psychotic illness, and beliefs about the utility of EE behaviors in controlling the patient's symptomatology. Measures of parental distress and parental assessment of patient symptomatology were also completed. Parents high on criticism EE were more likely to make attributions that the psychotic illness was controllable by the young person, and to endorse the potential utility of person-focused criticism (i.e., telling the patient about the parents' dissatisfaction and frustration with them as a person) in controlling the patient's symptoms. Beliefs in the utility of person-focused criticism and self-sacrifice were significantly associated with distress, but attributions that the illness was controllable by the patient or the parent were not. Beliefs about the utility of criticism may play an important role in EE among parents of young people with first episode psychosis, and may provide further direction for interventions designed for this group.

A review of the role of adult attachment style in psychosis: Unexplored issues and questions for further research

Attachment styles reflect individual differences in beliefs about self and others, interpersonal functioning and affect regulation. We review and critically appraise studies suggesting higher levels of insecure attachment, and dismissing attachment in particular, in samples with psychosis compared to controls. We also review the role of social cognition, interpersonal factors, and affect regulation in the development and maintenance of psychosis, and specific symptoms associated with the diagnosis. We review studies showing that insecure attachment is associated with poorer interpersonal relationships and less integrative recovery styles and highlight how recent theories and empirical findings in the psychosis literature can be understood within the framework of attachment theory. In doing so, we argue that investigations of the nature of attachment styles in psychosis and how they relate to the cognitive, interpersonal and affective factors that have been implicated in psychosis will help develop theoretical knowledge in relation to the condition. We conclude by outlining the clinical implications of applying attachment theory to the understanding of psychosis and summarising the conceptual and methodological limitations of the theory which should be addressed, including the need for studies with longitudinal designs, larger, more representative samples, and more valid measures of assessing attachment styles in psychosis.

Expressed emotion and burnout: the experience of staff caring for men with learning disability and psychosis in a medium secure setting

This study examines the level of expressed emotion (EE) and burnout in staff caring for people with learning disabilities on a medium secure unit. The study aims to develop a baseline measure of EE and burnout in staff on the unit to be used for future service evaluation and to underpin interventions in the developing service based on psychosocial interventions. Ten staff participated in an audiotaped interview and completed a questionnaire. The Five Minute Speech Sample and Maslach Burnout Inventory were completed. High EE was evident in 31% of responses based on critical comments and negative relationships. Expressed emotion was higher in male staff and in Health Care Support Workers. No staff met all components for high burnout, but low personal accomplishment, high emotional exhaustion and high depersonalization were evident for some staff. There is evidence of high EE and some elements of high burnout within the staff team. A significant relationship was found between the level of high EE and the depersonalization element of burnout.

The impact of nurses' opinion of client behaviour and level of social functioning on the amount of time they spend with clients

The impact of nurses' opinion of client behaviour and level of social functioning on the amount of time they spend with clients For people afflicted with different kinds of psychiatric disorder, suffering is a common denominator. The time the nurses spend with psychiatric clients may mirror their attitudes towards and feelings for these clients. The aim of this study was to investigate the connections between the time spent together and the nurses' opinion of client behaviour and social functioning in community-based psychiatry. In this quantitative study, 29 clients were assessed by 30 nurses, who answered the Global Assessment of Functioning Scale (GAF) and the Positive and Negative Syndrome Scale (PANSS). At the same time, 11,200 non-participant observations of clients were registered using the Patient Activity Classification (PAC) to investigate how they spent their time at two psychiatric group dwellings. The PAC instrument revealed that clients spent an average of 60.8% of time alone, while only 20% of their daily time was spent with the nurses. Based on a factor analysis, indices were made by setting cut-off points for the PANSS and the GAF scores, and four small groups of clients were generated: a relatively high level of social functioning and a low degree of psychiatric symptoms (A); a relatively high level of social functioning and a high degree of psychiatric symptoms (B); a low level of social functioning and a low degree of psychiatric symptoms (C); and, finally, a low level of social functioning and a high degree of psychiatric symptoms (D). The clients judged as having a low level of social functioning in combination with high degrees of psychiatric symptoms, that is, the most vulnerable and dependent individuals, receive less staff attention (18%) and are the clients who spend the most time alone (71.4%). It might be possible to interpret the results of this study in the light of a process of dehumanization.

Expressed Emotion in the Client-Professional Dyad

Summary: Background: This article reports on a study of the concurrent validity between the standard expressed emotion instrument, the Camberwell Family Interview (CFI), and two alternative EE measures, the Level of Expressed Emotion (LEE) and the Perceived Criticism Scale (PCS). Methods: The research sample consisted of 56 schizophrenic clients, who were residing in sheltered residences, and 56 professionals. Results: Based on the results of the correlation matrix between all the subscales of the instruments, a significantly positive relationship was found between the criticism scale of the CFI, the total score of the LEE, and the client version of the PCS. These correlations, however, were rather weak, which implies that the three instruments have little in common with each other. The professionals' version of the PCS does not appear to be an EE instrument. Conclusions: The results suggest that the CFI still remains the best instrument for assessing EE in a therapeutic relationship (between a professional and a client). If there is insufficient time to administer the CFI, then the client version of the PCS and the LEE can be used with the qualification that the PCS and LEE also measure other aspects and thus cannot completely replace the CFI. Nevertheless, the research indicates that asking the clients would seem to provide a better indication of the level of the professionals' criticism rather than asking the professionals themselves directly.