Cognitive Behavioural Therapy and Family Interventions for Psychosis.

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Cognitive Behavioural Therapy and Family Interventions for Psychosis

Helen Healy, David Reader and Kenny Midence

INTRODUCTION

Psychosocial treatments for schizophrenia are not new in the research literature. Psychological treatments have been previously used in the treatment of schizophrenia. For example in terms of behaviour therapy, operant approaches such as token economy programmes were used in the 1960s and 1970s to improve the behaviour of patients in long stay hospitals. However, the evidence suggests that the clinical gains were limited and did not generalise beyond the therapeutic setting and also did not address delusional convictions (Alford 1986; Himadi et al 1991). Other psychological treatments for schizophrenia can be traced to early work devoted to studying the impact of the social environment on mental illness. A plethora of early studies focused on the role of the family environment in the maintenance of schizophrenia which in turn led to the concept of expressed emotion (Brown et al 1972; Brown & Rutter 1996). Family interventions were first developed as a method for reducing levels of expressed emotion among relatives and are now recognised as a significant aspect in the treatment of schizophrenia. This approach marked a paradigmatic shift in the way family members were viewed by clinicians and has led to efforts to improve communication between clinicians and carers. Recent years have seen such cognitive approaches expanded to interest in interventions that combine the principles of cognitive and behavioural approaches.

However, despite all the research available providing evidence of their effectiveness, these approaches are not widely available in routine clinical practice (Slade & Haddock 1996). It is now clear, however, that psychosocial interventions are necessary to help patients cope with their condition, and improve their quality of life. These interventions are also beneficial to relatives, and are effective in improving the quality of the family environment (Penn & Mueser 1996). Psychosocial interventions are aimed at empowering patients, and, as Slade & Haddock (1996) have pointed out, 'since the 1980s, the task of the therapist was no longer to "change the behaviour of the patient" but rather to "help the client to change their own behaviour, if they wish to do so"'.

This chapter provides an overview of family interventions and cognitive behavioural therapy (CBT) for psychotic symptoms. There has been a lot of research and clinical interest in the effectiveness of CBT for patients with psychosis. Unfortunately, the provision of family interventions in routine services has been disappointing, despite vigorous training programmes. Notwithstanding some notable exceptions in the UK, such as Bath (Smith & Velleman, 2002) and Somerset (Stanbridge et al, 2003), increasing the availability of family work remains a challenge for most service providers.

The aim is not to provide a comprehensive academic review of family interventions and CBT for serious mental illness. Instead, it is to give the reader an overview of the state of research and developments of recent research studies. This chapter also tries to condense the available evidence to help health care professionals get a general outlook of these exciting and promising new approaches. Recommended empirical, theoretical, or review papers, and books (in asterisks) are provided in the reference section for those readers who want a comprehensive description of the theoretical and empirical research of these interventions.

FAMILY INTERVENTIONS

Early research on Expressed Emotion (EE) carried out in the last 20 years by researchers in the MRC Social Psychiatry Unit at the Institute of Psychiatry, London, provided evidence of the negative impact of high EE families on the course of schizophrenia. According to Leff & Vaughn (1985), these high EE families not only experienced distress in coping with the condition, but they also showed behaviours that were either extremely critical or hostile, or both, and emotionally overinvolved with the relative with schizophrenia. During this period, the influential vulnerability-stress model proposed by Zubin and Spring (1977) drew attention to the importance of environmental factors, such as the family, on the course and prognosis of schizophrenia. According to this model, exacerbations of a person's symptoms are the product of the interaction between environmental stress and the person's predisposition for the illness. In this way, effective management of environmental stress might reduce the risk of an individual's symptoms re-occurring and, as Tarrier and Barrowclough (1992) say, 'this supposition has been the driving force behind family interventions'. Thus the development of family intervention programmes to reduce the effects of schizophrenia on patients (e.g. relapse, hospitalisation), to increase patients' social functioning, and to reduce family burden and improve the quality of life of sufferers and their families (Tarrier & Barrowclough 1995). Family interventions are based on broad psycho-educational and/or behavioural approaches, and research examining the effectiveness of these approaches has been mainly carried out by Falloon and colleagues, and Hogarty and colleagues in the USA; and Vaughan and colleagues in Australia. In the UK, research has been conducted by Leff and colleagues in London, and Tarrier, Barrowclough and colleagues in Manchester.

What are the components of family intervention?

According to Kavanagh (1992), the components of family intervention include engagement of families, education, communication training, goal setting, problem solving, cognitive-behavioural self-management, increasing family well-being and maintenance of skills. Bellack & Mueser (1993) have suggested that four main aspects of the psychosocial treatment of patients should be emphasised. These are the need for a comprehensive and long term treatment including drugs, individually tailored treatment programmes, an active participation by patients and relatives and the acknowledgement of patients' cognitive limitations. Reviews by Lam (1991) and Fadden (1998) have identified common features of successful family interventions which include the development of a therapeutic alliance between family and therapists, the provision of education and information about the disorder, a behavioural or cognitive-behavioural approach to problems, an emphasis on enhancing skills in problem solving and communication and promoting activities and interests outside the family.

Lam (1991) has also identified three possible mechanisms underlying the

better outcome of patients who receive family therapy:

. lower negative family affect (i.e. EE)

2. improved patient adherence with medication and

3. better patient monitoring by the treatment team.

The techniques used in these family intervention approaches have been

published by the researchers responsible for their development (e.g. Anderson, Reiss & Hogarty 1986, Barrowclough & Tarrier 1992, Falloon 1995, Kuipers, Leff & Lam 1992). The techniques involved include initial assessment of relatives' and patients' needs, educating families, stress management and coping responses, issues about engaging and maintaining the family involvement, dealing with violence and suicide risk, assessment of psychotic symptoms, and coping strategies (cognitive and behavioural) (e.g. Barrowclough & Tarrier 1992). Family intervention by Kuipers, Leff & Lam (1992) includes assessing the relative and their family, engaging the family, education about schizophrenia, improving communication, identification of stressors, setting realistic goals, dealing with emotional issues (e.g. anger, conflict, rejection), dealing with overinvolvement, getting everyone in the family involved, employment, cultural issues, special issues (e.g. substance abuse, suicide, incest) and running a relatives' group.

This approach with single families has been adapted to include multiple families in a group setting. This approach appears to combine the benefits of family work with the experience and advantages of participating in a group, such as mutual support, shared learning and reduced isolation. According to McFarlane and colleagues (1995), multiple family groups can be as effective as family interventions for individual families in reducing relapse rates and, in first episode psychosis, they can contribute to enhanced knowledge and understanding (Mullen et al, 2002).

How effective are family interventions?

The positive results of the studies on family interventions have provided strong evidence for the effectiveness of these psychosocial approaches. Overall, research findings indicate that these approaches are more effective than routine treatment, and are beneficial for patients and their relatives. Family interventions are effective in reducing EE in relatives, family burden and relapse rate in patients over 1 to 2 years, and in improving patients' social functioning, especially when families change from high to low EE. Moreover, long term family intervention seems to reduce patients' relapse rate, and treatment gains are stable and can be maintained for as long as 2 years. The duration of the treatment is related to the outcome of the intervention, and this means that the longer the treatment the better is the outcome; short term interventions show less beneficial effect on relapse rate. Furthermore, the financial savings to the mental health service in providing family intervention for 9 months has been reported to be as high as 27%, including less social work contact and hospital admission (Tarrier, Lowson & Barrowclough 1991).

Fadden's (1998) review of family interventions showed the effectiveness of these approaches. She points out that 'family interventions have been shown to result in at least a fourfold reduction in relapse rates at one year post-intervention, and even though relapse increases in the second year, the rates are still only half what they are when no such intervention is provided'. However, we still do not know which family intervention model provides the best benefits for patients and their families, what aspects of family intervention are most effective, and the characteristics of patients and their families who do not benefit from family intervention. Furthermore, not all families are willing to engage in family intervention. The difficulty in engaging relatives in family work has been investigated by McCreadie et al (1991). In their study, half of the families invited to take part refused the treatment (almost half were low EE families), the main reasons given included 'things are fine at the moment', 'it is the patient who needs help, not me', and 'the patient doesn't want anyone else to know he has been ill'. The STEP clinical team in Wales found that 26% of families did not take part in the family intervention (Hughes et al 1996). According to Smith & Birchwood (1990), between 7 and 21% of families tend to refuse family intervention, the range of families withdrawing from treatment range between 7 and 14%, and between 8 and 35% of families do not adhere to the treatment.

Implementing family intervention in routine clinical practice

Using family intervention for schizophrenia in routine clinical practice is a difficult task. A number of obstacles to implementation have been identified by follow-up studies of the impact of training programmes (e.g Kavanagh et al, 1993; Fadden, 1997). These relate mainly to organisational and structural barriers such as failures to provide time to practitioners to carry out family work and receive clinical supervision and difficulties integrating family work with existing clinical responsibilities. To implement family work, service managers need to understand the demands it makes on staff time and provide the conditions to support them (Leff, 2000). Hughes et al (1996) have described their experience of providing family work in a management culture of 'benign neglect' and yet they report the service provided was highly valued by families themselves (Budd & Hughes, 1997).
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Budd & Hughes (1997) consulted families regarding what they found most helpful in family work and found the following elements emerged: knowledge/ understanding of schizophrenia, feeling supported, reassured and encouraged, and having someone to call in emergencies. Families also said that the intervention had helped them to become more tolerant of their relative's behaviour, and to improve communication between family members.

In conclusion, there is no doubt that the effectiveness of family interventions is well established. Indeed, Mari and Streiner's (1997) recent meta-analysis of family intervention studies concluded that 'family intervention, as part of a multi-dimensional ...

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