Participants' perceived benefits of family intervention following a first episode of psychosis: a qualitative study

Clinicians' perceptions of family involvement in the treatment of persons with psychotic disorders: a nested qualitative study

Background

Family involvement in mental health care ranges from basic practices to complex interventions such as Family psychoeducation, the latter being a well-documented treatment for psychotic disorders. The aim of this study was to explore clinicians' perceptions of the benefits and disadvantages of family involvement, including possible mediating factors and processes.

Methods

Nested in a randomised trial, which purpose was to implement Basic family involvement and support and Family psychoeducation in Norwegian community mental health centres during 2019-2020, this qualitative study is based on eight focus groups with implementation teams and five focus groups with ordinary clinicians. Using a purposive sampling strategy and semi-structured interview guides, focus groups were audio-recorded, transcribed verbatim, and analysed with reflexive thematic analysis.

Results

Four main themes were identified as perceived benefits: (1) Family psychoeducation-a concrete framework, (2) Reducing conflict and stress, (3) A triadic understanding, and (4) Being on the same team. Themes 2-4 formed an interconnected triad of mutually reinforcing elements and were further linked to three important clinician-facilitated sub-themes: a space for relatives' experiences, emotions and needs; a space for patients and relatives to discuss sensitive topics and an open line of communication between clinician and relative. Although far less frequent, three main themes were identified as perceived disadvantages or challenges: (1) Family psychoeducation-occasional poor model fit or difficulties following the framework, (2) Getting more involved than usual, and (3) Relatives as a potentially negative influence-important nonetheless.

Conclusions

The findings contribute to the understanding of the beneficial processes and outcomes of family involvement, as well as the critical role of the clinician in achieving these and possible challenges. They could also be used to inform future quantitative research on mediating factors and implementation efforts.

"The most important thing is that those closest to you, understand you": a nested qualitative study of persons with psychotic disorders' experiences with family involvement

Introduction

Family interventions constitute effective treatment for persons with psychotic disorders. However, the active ingredients and beneficial processes of these interventions are insufficiently examined, and qualitative explorations of patients` experiences are lacking. This study was nested in a cluster randomised trial that implemented national guidelines on family involvement in Norwegian community mental health centres, including family psychoeducation and basic family involvement and support. The aim of this sub-study was to explore how patients with psychotic disorders experience systematic family involvement, and its significance.

Methods

We conducted semi-structured, individual interviews with 13 persons with a psychotic disorder after systematic family involvement. The participants were recruited through purposive sampling. Qualitative content analysis guided the analysis.

Results

Participants reported overall positive experiences with systematic family involvement. It was significant that the relatives increasingly understood more about psychosis and their situation, while they themselves also gained more insight into the relatives` situation. The participants emphasised the need to enable both patients and relatives to safely share experiences in a containing space, led by professionals. Shared understanding and awareness of each other's situation further improved communication, coping with the illness, reduced stress, and stimulated a more caring family environment. The therapist seemed crucial to facilitate these beneficial communication processes, and also to provide continuous support to the relatives. Reported challenges included that the participants felt vulnerable in the initial phase, a need for tailored approaches, and too late start-up.

Conclusion

Findings from this study suggest that persons with psychotic disorders may benefit greatly from participating in systematic family involvement. This study also gives new insight into possible mediators of positive outcomes both for the patients and the relatives. Systematic family involvement should be implemented a standard approach in the early phase of the disease, using a step-wise and tailored process.

Exploring service user perspectives of behavioural family therapy in early intervention in psychosis

AIMS

Family intervention (FI) is recommended in national guidance to be offered to all service users accessing an early intervention in psychosis (EIP) team, due to the consistent evidence base in reducing relapse and rehospitalisation rates. However, FI implementation is poor nationally. Although barriers have been identified at the level of staff member and the organisation, there is a paucity of research identifying service user perspectives.

METHODS

A qualitative questionnaire design was used to explore service user perspectives of behavioural family therapy (BFT) within a specialist EIP service in northwest England.

RESULTS

Most participants contacted reported they lacked knowledge and understanding of BFT, with 54% reporting that this intervention had not been offered to them. This finding was unexpected and is inconsistent with the offer of BFT documentation in their clinical notes. Reasons for accepting BFT included to increase understanding of family members and for them to also be supported. Reasons for declining BFT included a preference for one-to-one interventions and not wanting family involved in their care.

CONCLUSIONS

National guidance on FI for psychosis is not reliably being translated to clinical practice, with many participants reporting that they were not offered this intervention. A key factor in accepting or declining an offer of BFT appeared to be whether participants wanted family members to be involved in their care. A lack of understanding of the BFT approach was evident, it is recommended that the offer of FI in psychosis is improved for service users to make an informed decision.

Interfamily Therapy, a multifamily therapy model settled in infant-juvenile mental health services of Havana (Cuba): A qualitative study from participants' perspectives

Interfamily therapy (IFT) is a specific model for multifamily therapy (MFT) of recent expansion in Latin American and European countries. In IFT a multifamily group becomes a community of learning where professionals and family members establish collaborative relationships and participate in dialogues. This study used a qualitative phenomenological approach to explore the participants' perspective of 14 members and ex-members of two IFT groups conducted in Infant-Juvenile Mental Health Centers in Havana (Cuba). In this study IFT was well accepted and effective, and it was perceived as beneficial due to its positive influence for participants, with benefits on a personal, family and social level. In addition, participants articulated a series of therapeutic elements of IFT that were essential to promote these benefits. In conclusion, IFT seems to be a useful therapeutic model in the treatment of children, adolescents and their families in a Cuban psychiatric setting.

Stigma of Treatment Stages for First-Episode Psychosis: A Conceptual Framework for Early Intervention Services

Early intervention services (EIS; in the United States, Coordinated Specialty Care) can lead to substantial improvements in psychiatric symptoms and social functioning for individuals with first-episode psychosis who engage in treatment. Nevertheless, stigma associated with early intervention services can limit their full potential benefits by preventing or reducing participation. Drawing from Corrigan's "why try" model positing relationships between public and self-stigma, engagement in treatment services, and the EIS treatment model, this article proposes a framework that delineates how distinct forms of stigma are linked to given stages of treatment engagement in first-episode psychosis. We identify three phases of engagement: (1) community outreach, which has associations with public stigma; (2) the referral and evaluation process, which primarily has associations with self-stigma; and (3) EIS, which have associations with self-stigma and its psychosocial consequences. For each phase, we describe evidence-based strategies typically provided by EIS programs, using OnTrackNY as an exemplary model, to illustrate potential linkages in our conceptual framework. By specifying how distinct forms of stigma are associated with EIS treatment stages, this framework is intended to guide EIS programs in explicitly addressing stigma to optimize recovery of individuals with first-episode psychosis.

First-Person Accounts of Change Among Young Adults Enrolled in Coordinated Specialty Care for First-Episode Psychosis

OBJECTIVE

This study investigated how clients of a coordinated specialty care (CSC) program for first-episode psychosis perceived how they changed while attending the program, what the most important changes were, and what mechanisms they believed helped bring about these changes.

METHODS

Study participants were 121 individuals (71 men and 50 women) from 35 CSC programs across 22 U.S. states. Responses to the primary questions of interest were procured through a semistructured interview. Data on the length of time in the CSC program were also obtained. The authors used systematic content analyses to analyze these qualitative data.

RESULTS

Participants reported a greater number of changes the longer they had received CSC services. Half of the participants reported improved psychiatric symptoms, and this change was the most important for almost one-third (31%; N=32) of the sample. In addition, 39% (N=45) of participants also reported improved social and interpersonal skills, changes in their attitude to and perspective on life, and more treatment engagement. Participants most frequently endorsed therapy as the mechanism underlying their improvement.

CONCLUSIONS

Standardized outcome measures allow systematic assessment of clinical and functional status, but they do not provide a nuanced understanding of the underlying mechanisms or the areas of improvement most important to individual clients. The findings reinforce the value of mixed methods in both research and quality improvement efforts as well as for greater integration of patient-selected outcome measures.

Parent strategies to support young people experiencing mental health problems in Australia: What is most helpful?

Parents are a critical resource in supporting young people who live with mental health problems. Qualitative research has identified that parents use a wide range of strategies to provide support. However, parents report being unsure which strategies are likely to be helpful, so often struggle in this role. Presently, little empirical evidence exists to assist parents to decide which strategies are likely to be most helpful. This study aimed to explore the parent-perceived helpfulness of parental strategies to support young people living with mental health problems. Data were collected from February to July of 2018, using a cross-sectional, online, anonymous, self-report survey of participants who identified as parenting a young person (15-24 years) diagnosed with a mental health problem (n = 70). Overall, the strategies perceived as most helpful were practical assistance and personal interactions aimed at promoting positive thoughts and feelings and obtaining appropriate treatment. Least helpful strategies tended to be control-type strategies, aimed at behaviour change. Overall, there was good alignment between strategies' helpfulness and frequency of use, however, there were exceptions. These exceptions are likely reflections of the specific context of particular situations as well as parental uncertainty regarding alternative strategies. Generally, perceptions of strategies' helpfulness were unrelated to parent or child characteristics. However, helpfulness of strategies was associated with parents' satisfaction with their relationship with the young person. Parents' collective experience-based perceptions about the helpfulness of strategies used to support young people experiencing mental health problems can be harnessed to inform mental health practitioners' advice to parents and contribute to better mental health outcomes for young people.

Caring for caregivers: Understanding and meeting their needs in coping with first episode psychosis

AIM

The first episode of psychosis is a challenging time for both patients and those who care for them. Although literature on treatment is plentiful, literature on how to best support caregivers is more scarce. This review was undertaken to better understand the caregiver experience, determine which interventions most effectively alleviate their burden and examine which other factors may affect outcomes.

METHODS

Articles were retrieved from PubMed and OVID using the following search terms: first episode psychosis (FEP), schizophrenia, caregiver, intervention and burden in various combinations. Only peer-reviewed articles germane to FEP caregiver experience and interventions written in English were included.

RESULTS

Caregivers can experience grief, guilt and anxiety during this time. While concerned for their loved one, their own lives take a back seat and their mental and physical health are adversely affected. Some are better prepared to cope and are typically warm, decisive, confident and optimistic. Their families are organized and flexible. Others are less prepared and are more likely to have poor self-esteem, use avoidant coping strategies and be overly critical. Their families are controlling and have difficulty with communication and balance. These caregivers stand to benefit most from interventions.

CONCLUSIONS

Effective interventions incorporate psychoeducation, problem solving strategies, peer support and clinician guidance. A higher level of interaction with facilitators and peers is associated with better results. Benefits include decreases in caregiver burden, depressive and anxious symptoms and feelings of shame and isolation. Although the literature has yet to isolate the key factors of a successful intervention, this review provides practical suggestions for clinicians and further illustrates the need for more research.

Understanding young peoples' and family members' views of treatment for first episode psychosis in a randomised controlled trial (MAPS)

BACKGROUND

There is limited evidence to inform treatment decision-making in adolescents experiencing first episode psychosis (FEP). In the MAPS trial (Managing Adolescent first Episode Psychosis: a feasibility Study), adolescents with FEP received either antipsychotic medication (AP), psychological intervention (PI), or both. We investigated treatment views of young people and family members across each treatment arm of MAPS.

METHODS

Thirteen adolescents participating in MAPS and eighteen family members attended in-depth audio-recorded interviews to discuss trial treatments. Interviews were analysed using inductive Thematic Analysis, identifying salient themes across these accounts.

FINDINGS

Family members in particular reported an urgent need for treatment regardless of type. Both AP and PI were broadly viewed as acceptable treatment approaches, but for differing reasons which participants weighed against a range of concerns. AP were often seen to reduce symptoms of psychosis, though participants expressed concerns about side effects. PI were viewed as interactive treatment approaches that helped improve understanding of psychosis and enhanced coping, although some found PI emotionally and cognitively challenging. Combining treatments was seen to maximise benefits, with a perceived interaction whereby AP facilitated engagement with PI.

INTERPRETATION

Acceptability of and engagement with treatments for FEP may differ between individual young people and their family/carers. In order to be able to offer fully informed choices, and determine an optimum treatment approach for young people with FEP, definitive trial evidence should be established to determine wanted and unwanted treatment impacts.

FUNDING

NIHR HTA programme (project number 15/31/04).

The Family Psychoeducation Fidelity Scale: Psychometric Properties

This study examined psychometric properties and feasibility of the Family Psychoeducation (FPE) Fidelity Scale. Fidelity assessors conducted reviews using the FPE fidelity scale four times over 18 months at five sites in Norway. After completing fidelity reviews, assessors rated feasibility of the fidelity review process. The FPE fidelity scale showed excellent interrater reliability (.99), interrater item agreement (88%), and internal consistency (mean = .84 across four time points). By the 18-month follow-up, all five sites increased fidelity and three reached adequate fidelity. Fidelity assessors rated feasibility as excellent. The FPE fidelity scale has good psychometric properties and is feasible for evaluating the implementation of FPE programs. Trial registration ClinicalTrials.gov Identifier: NCT03271242.

Systematic review (meta-aggregation) of qualitative studies on the experiences of family members caring for individuals with early psychosis

Despite the importance of the role of caregivers of people with psychosis being widely recognized, comprehensive understanding of their experience is limited. A thorough understanding of the experience of caregivers over the journey of the illness, particularly during its early stages, is crucial. Qualitative studies published between 1 January 1949 and 31 January 2018 were obtained from seven databases based on PICo search strategy. Meta-aggregation methodology of the Joanna Briggs Institute (JBI) was adopted to aggregate existing qualitative findings about caregivers' experiences. Twenty-eight qualitative studies on 635 caregivers and family members were included in the review. Six inter-related categories-'stigma', 'help-seeking', 'service encounter', 'emotional challenges', 'on becoming a caregiver' and 'making sense of experience'-were aggregated from 129 themes from the sub-acute stage, the acute stage and the recovery or residual stage. Three statements about caregivers' experiences of their relative's first episode of psychosis were synthesized from the findings. Results highlighted the need of incorporating caregiver intervention into the existing services to support the emotional challenges, uncertainty, and stigma-related burden along the caregiving journey.

Impact of a culturally adapted behavioural family psychoeducational programme in patients with schizophrenia in Egypt

OBJECTIVE

To study the effect of a culturally adapted, structured family intervention on symptom severity, medication attitudes and knowledge, social functioning and quality of life in patients with schizophrenia.

METHODS

Thirty subjects with schizophrenia were selected to receive 14 sessions of a culturally adapted behavioural family psychoeducational programme (BFPEP). Another 30 subjects received standard treatment as usual (STU) for 6 months. Pre- and post-intervention outcomes were assessed using the Positive and Negative Syndrome Scale (PANSS), Drug Attitude Inventory 10-item scale (DAI-10), Quality of Life Scale (QLS) and Social Functioning Questionnaire (SFQ).

RESULTS

There was a no significant difference between BFPEP and STU at baseline on all measures. There was a significant difference (p < .05) between pre- and post-treatment scores for BFPEP on all measures, a significant difference (p < .05) between pre- and post-treatment scores for STU on all measures (favouring pre-treatment scores) and a significant difference (p < .05) favouring BFPEP over STU on all measures post-treatment.

CONCLUSIONS

These results demonstrate the feasibility and effectiveness of implementing family therapy psychoeducational interventions in different cultural settings, with relatively minor modifications. This may have implications for mental health policy makers to make available such programmes for patients and mental health professionals.

Family intervention for caregivers of people with recent-onset psychosis: A systematic review and meta-analysis

AIM

We aimed to systematically review the evidence of the effectiveness of family interventions for caregivers of people with recent-onset psychosis compared with usual psychiatric care. A secondary objective was to directly compare the effects of different types of family interventions.

METHODS

MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL Complete and EBSCOhost were searched to identify relevant randomized controlled trials. Trial data were extracted following the procedures described in the Cochrane Handbook of systematic reviews. Random-effects models were used to pool the intervention effects.

RESULTS

Twelve studies including 1644 participants were included in this review. With the exception of a high risk of performance bias inherent to the nature of the psychosocial interventions, the studies had an overall low or unclear risk of bias, suggesting that sources of bias are unlikely to lower confidence in the estimate of intervention effects. Meta-analyses were conducted for 4 different participant outcomes reported in 9 studies. Compared with usual psychiatric care, family intervention was more effective in reducing care burden over all follow-up periods. Family intervention was also superior to usual care with regards to caregiving experience in the short term and improved utilization of formal support and family functioning over longer-term follow up. Mutual support is more effective than psychoeducation in improving family functioning when measured 1 to 2 years after the intervention but had equivalent effects on utilization of formal support services.

CONCLUSIONS

This review provides evidence that family intervention is effective for caregivers of recent-onset psychosis, especially for care burden where the positive effects are enhanced over time.

Family group interventions in an early psychosis program: A re-evaluation of practice after 10 years of service delivery

INTRODUCTION

The role of family in supporting service users in coping with illness and engaging in relapse prevention in early psychosis is important. Taking on this caring though is stressful and challenging, and it has been found that support and information for carers assists in their coping and reduces isolation.

AIMS

To evaluate the current utility of a psychoeducation group program in a public adult mental health service, for the families of people experiencing early psychosis.

METHODS

A purpose-designed pre- and post-intervention questionnaire was administered to quantitatively measure group participants' changes in perceptions of their understanding of mental illness and its treatment through attending the group. Additional qualitative items were used to determine other knowledge, benefits and any critical feedback.

RESULTS

The group program continues to result in highly significant improvements in family members' understanding of psychosis, recovery, medications, relapse prevention and substance co-morbidities. Additional feedback reaffirmed previous findings that family members find group peer support valuable and that this reduces isolation and the experience of stigma.

CONCLUSION

The current evaluation, conducted following 10 years of early psychosis group work, found there to be efficacy in family peer support groups and that it is important to provide family interventions in public early psychosis mental health services.

The Effects of Psychoeducation on the Expressed Emotion and Family Functioning of the Family Members in First-Episode Schizophrenia

The aim of this study was to determine the effects of the psychoeducation received by the family members of the patients with first-episode schizophrenia on the expressed emotion (EE) and the family functioning of the family members. This study has a quasi-experimental design with a control group. The sample of the study was 60 family members (30 experimental -30 control) of the patients with first-episode schizophrenia. The experimental group received 9 weeks of psychoeducation as a group. EE and family functioning were assessed at the beginning and at the end of the psychoeducation program. EE criticism/hostility and over involvement-protecting-intervention levels of the family members have decreased at the end of the psychoeducation (p < 0.05). Family functioning has changed too at the end of the psychoeducation (p < 0.05), and assessed as more healthy. Consequently, early psychoeducational groups may be effective in decreasing EE level and improving the family functioning for a family member of patient with first-episode schizophrenia.

Challenges for group leaders working with families dealing with early psychosis: a qualitative study

BACKGROUND

Family work is one of the best researched psychosocial interventions for patients with chronic psychosis. However, family work is less studied for patients with a first episode psychosis and the studies have revealed contradicting results. To our knowledge, no previous studies have examined qualitatively group leaders' experiences with family work. In the present study we wanted to explore challenges faced by mental health professionals working as group leaders for family interventions with first episode psychosis patients.

METHOD

A qualitative exploratory study was carried out based on digitally recorded in-depth interviews and a focus group interview with nine experienced mental health professionals. The interviews were transcribed in a slightly modified verbatim mode and analysed by systematic text condensation.

RESULTS

Challenges faced by group leaders was classified into six categories: (1) Motivating patients to participate, encouraging potential participants was demanding and time-consuming; (2) Selecting participants by identifying those who can form a functional group and benefit from the intervention; (3) Choosing group format to determine whether a single or multi-family group is best for the participants; (4) Preserving patient independence, while also encouraging them to participate in the intervention; (5) Adherence to the protocol, while customizing adjustments as needed; (6) Fostering good problem-solving by creating a fertile learning environment and choosing the most appropriate problem to solve.

CONCLUSIONS

Group leaders face challenges related to recruitment and selection of participants for family work, as well as in conducting sessions. Awareness of these challenges could help health professionals more specifically to tailor the intervention to the specific needs of patients and their families.