Cognitive Behavioural Therapy and Family Interventions for Psychosis.
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).
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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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 approach to care, decreases the frequency of relapse and hospitalisation over periods of seven months to two years. It encourages compliance with medication and may help people stay in employment'. Despite the overwhelming evidence regarding the effectiveness of family intervention, however, Anderson & Adams (1996) have rightly pointed out that this psychosocial intervention is not being used to its full potential in clinical practice. Training is a necessary first step in addressing this problem, but until services have structures in place to support family work it seems likely that it will remain difficult to implement.
COGNITIVE-BEHAVIOURAL THERAPY FOR PSYCHOSIS
Cognitive Behavioural Therapy is a structured psychological therapy originally applied to the management of depression (Beck et al 1979; Barlow 1988). According to the cognitive therapy model, behaviour and actions are determined by the way an individual interprets or appraises situations. For example when a person is emotionally distressed, some negative evaluative thinking is involved in the negative emotional response (Beck et al 1979). The patient is encouraged to recognise patterns of distorted thinking and dysfunctional behaviour. Cognitive therapy assumes that there is a set of psychological constructs that apply to all persons including those with and without a psychiatric disorder. The CBT model challenges the 'gap' between psychosis and normality (Strauss 12969; Chadwick & Lowe 1994). It is generally accepted that 'normal' psychological processes are implicated in the maintenance of specific psychotic symptoms (Buchanan et al 1993; Drury et al 1996a; Kuipers 1996). CBT focuses on altering the thoughts, emotions, and behaviours of patients by teaching them skills to challenge and modify beliefs about their delusions and hallucinations. The importance of both environmental stress and emotional distress is central to the cognitive behavioural treatment of psychotic symptoms. Instability in arousal levels and emotional regulation is a typical pathway to exacerbation of psychotic symptoms. CBT aims to reduce the emotional consequences of delusions and to alleviate the consequences of environmental stress through enhanced coping strategies. Haddock & Tarrier (1999) is an example of a clinical heuristic which describes the factors contributing to psychotic symptoms and in addition provides a framework to guide a CBT model of therapy addressing emotional, behavioural and cognitive consequences of a psychotic episode.
The aim of CBT is to help patients gain knowledge about schizophrenia and its symptoms, to overcome hopelessness, to reduce distress from psychotic symptoms, to reduce dysfunctional emotions and behaviour and to help them analyse and modify dysfunctional beliefs and assumptions (Slade & Haddock 1996). Since the 1970s, researchers have tried to modify psychotic symptoms using cognitive-behavioural techniques including psychoeducation, coping responses, delusional belief modification, re-labelling psychotic experiences, dealing with dysfunctional assumptions, and goal setting. Effective treatment, however, may depend on the patient's motivation, the distress associated with positive symptoms, the type and structure of the symptoms and the patient's cognitive deficits (Sellwood et al 1994).
The available literature on psychological treatments for positive psychotic symptoms is mainly in the form of individual case studies or series of case studies, and few large, controlled trials have been compared with traditional or routine treatments. The majority of treatment reports have been on the treatment of hallucinations or delusions including operant procedures, counter-stimulation (e.g. distraction), use of ear plugs, thought stopping, focusing (e.g. content and beliefs about voices) and systematic desensitisation. The treatment interventions of some researchers have focused on particular symptoms rather than addressing all the psychotic symptoms experienced by patients (e.g. Bentall, Haddock & Slade 1994, Chadwick & Birchwood 1994). Cognitive-behavioural intervention for psychotic symptoms can be summarised into two main groups: cognitive rehabilitation and content approaches (Penn & Mueser 1996).
Cognitive rehabilitation proposes that relapse could be prevented by addressing the cognitive deficits of patients, and it aims at the remediation of basic information-processing skills. Most of the research on cognitive rehabilitation has focused on remediation through repeated practice or related techniques. A number of case studies have suggested that this approach is associated with improved attention, greater cognitive flexibility and reduced paranoia. Studies have a number of characteristics in common, all focused on a specific cognitive deficit (e.g. vigilance) and training was conducted on an individual basis. The studies to date have not provided any consistent conclusions regarding the efficacy of cognitive rehabilitation (Penn & Mueser 1996). Content approaches focus on residual positive symptoms (i.e. hallucinations and delusions) and stress management of these symptoms. These approaches aim at changing the nature of the content of dysfunctional thoughts and the patient's response to these thoughts by modifying thoughts or beliefs associated with delusions (e.g. that one's thoughts are being broadcast to others), and teaching ways to cope with auditory hallucinations (e.g. listening to music) (Penn & Mueser 1996).
There are various techniques used in CBT including 'coping strategy enhancement', which is aimed at building on the coping strategies that patients already have when they experience residual symptoms (Tarrier et al 1990, 1993). The procedures to help patients cope with these symptoms include explaining the treatment rationale, describing each psychotic symptom through a structured interview, assessing the frequency, duration, antecedents and consequences, assessing the interference of the symptoms, and the patient's beliefs and preoccupation; assessing the coping methods already used by the patients; identifying a target symptom and appropriate coping strategy; practising coping strategy during sessions; homework; and reassessment of the symptoms. Results from case studies suggest that coping strategy enhancement is effective in improving residual auditory hallucinations (Tarrier et al 1990). Coping strategy enhancement and problem-solving therapy have also been found to be superior in reducing positive symptoms compared with waiting list controls (Tarrier et al 1993). Bentall, Haddock & Slade (1994) have used a different approach to deal with psychotic symptoms by looking at the fundamental cognitive bias underlying hallucinations (i.e. misattribution of internally generated events to an external source). Results of their studies have shown a reduction in the frequency and distress of auditory hallucinations in patients.
The cognitive-behavioural approach for psychosis used by Fowler, Garety & Kuipers (1995) includes improving coping responses, psychoeducation and belief modification. The main goals include the reduction of the distress and interference that arises from the experience of persistent psychotic symptoms, increasing the patient's understanding of psychotic disorders and fostering motivation to engage in self-regulation behaviour; and reducing the occurrence of dysfunctional emotions and self-defeating behaviour arising from feelings of hopelessness, negative self-image or perceived psychological threat (Kuipers, Garety & Fowler 1996). Research by Garety and colleagues is still ongoing, and preliminary results are promising. Haddock & Slade (1996) have maintained that patients' distress is related to their beliefs about the origin and content of their voices. Chadwick & Lowe (1990, 1994) have used non-confrontational verbal challenge and reality testing to reduce delusional beliefs. Delusions are assessed based on the available information including interpretation of the beliefs, and behavioural experiments to invalidate the delusions. Results suggest that CBT reduces patients' conviction in and preoccupation with delusional beliefs. Moreover, there is evidence that some patients may reject their delusional beliefs completely (Chadwick et al 1994).
More recently, Nelson (1997) has provided a comprehensive practical manual to guide clinicians in their work with patients with schizophrenia. This manual provides information about treatment strategies with delusions including assessment, lessening the impact/distress of delusional ideas, promoting insight, modifying and challenging delusions, and long term strategies. Treatment strategies with hallucinations include assessment and setting the goals of therapy, practical ways of reducing the voices, promoting insight, CBT with non-psychotic beliefs, disempowering the voices, modifying and challenging the delusional beliefs about the voices, and long term strategies. However, despite the encouraging findings of these studies, some patients can be reluctant to engage in therapy because of their strong beliefs and feelings about their voices. Fortunately, some researchers have developed a number of techniques to deal with the resistance shown by some patients by looking at the connections between the perceived benevolence or malevolence and resistance and engagement in relation to the voices (Chadwick & Birchwood 1996). In conclusion, the results from studies on psychotic symptoms have provided strong evidence of the effectiveness of CBT in helping patients to cope with psychotic symptoms (Haddock & Slade 1996). However, some of these benefits may be temporary, and patients may need continued intervention to maintain any improvements.
How effective is CBT?
Schizophrenia is a progressive debilitating illness characterised by hallucinations, delusions, emotional withdrawal and poor social functioning (Kane & McGlashan 1995). Many patients with schizophrenia have residual psychotic symptoms and impaired social functioning that persists well into adulthood (Bustillo et al 1999). Pharmacological treatments have traditionally been the treatment of choice. However, while the effectiveness of anti-psychotic medication has made it central to the treatment of schizophrenia (Schwartz 1993), there is increasing knowledge that pharmacological treatment alone is rarely sufficient for optimal outcomes.
There are a number of reasons for this claim. First, the issue of compliance has demonstrated that the social and cognitive context in which pharmacological treatment is delivered has a major impact on its success (Bebington & Kuipers 1994). There is also evidence to suggest that young people in their first episode are both sensitive to its therapeutic and adverse effects (Remmington 1998). Second, the actual effectiveness of anti-psychotic medication has been challenged since up to 40% have a poor response to medication and continue to demonstrate moderate to severe psychotic symptoms (Kane 1996). Furthermore, a recent meta- analysis has suggested that the benefit of new atypical anti-psychotics is less than that previously thought (Geddes 2000).
A number of systematic reviews and meta- analytical studies of psychological treatments for schizophrenia have been performed over recent years (Mari & Streiner 1994; Mojtabi et al 1998; Adams 2000; Dixon et al 200; Gould et al 2000; Bustillo et al 2001; Pitschel et al 2001; Rector & Beck 2002). All of the above papers vary in the methodology and focus. Only Gould et al (2001) and Cormac et al (2002) have concentrated on randomised controlled trials of cognitive therapy for schizophrenia. The results of the former study suggest that cognitive interventions are a promising approach for targeting the positive symptoms of persistent delusions and hallucinations in schizophrenia.
For example, Drury et al (1996) demonstrated a high level of engagement using this approach, which they suggested was linked to the clients feeling that their beliefs were addressed directly and not ignored or dismissed. Unlike a biomedical approach which tends to focus on the form of psychotic symptoms, CBT addresses content. Psychotic beliefs are not directly challenged (Fowler et al 1995a). The aim is to enhance natural coping mechanisms which the patient may already have (Tarrrier 1992). During the treatment process the emphasis is on applying rationality to the patient's attitudes and underlying cognitive assumptions. Active problem solving strategies are promoted that address day to day problems and an attitude of acceptance is fostered toward the patient and the patient's experiences which is maintained throughout the therapy. Hallucinations, delusions, negative symptoms and depression have all been shown to be responsive to CBT (Sensky 2000). In addition , Turkington et al (2002) demonstrated that the benefits of CBT translate into community settings, whereby community psychiatric nurses were trained in this therapy and given weekly supervision . This approach allowed them to engage collaboratively with patients and achieve significant reductions in overall symptoms and improvement.
Nevertheless given the diversity of trials exploring the efficacy of CBT for psychosis and increased interest in this approach in recent years a number of questions remain; 'How generalisable are the results of studies investigating the efficacy of CBT for psychosis? Are there methodological issues which limit the conclusions drawn from such studies ? Finally how can we combine the results of diverse outcome studies in meaningful ways to draw reliable conclusions about its effects'? Healy's (2003) meta-analysis of eight independent controlled studies involving 888 participants suggests that a cognitive behavioural intervention is an effective and a promising therapeutic approach in the treatment of psychotic symptoms. Moreover, three of the studies followed patients up to a 9 month period. The result of these follow-ups is important in that a primary aim of therapy is to prevent relapse and if early benefits of treatment can be maintained over time, such psychological treatment should be encouraged and implemented.
One of the studies included in Healy's review did demonstrate that the benefits of CBT can also be implemented in a community setting. Turkington et al (2002) found that when community trained psychiatric nurses were trained in CBT for psychosis over a 10- day period and given weekly supervision , this intervention was found to be effective in reducing overall symptoms and depression. Levels of insight also improved. Such findings have positive implications for economic evaluations of psychological therapy for psychosis. However while these results suggest promising effects, a number of questions still need to be addressed. There has been a significant paucity of controlled studies investigating the efficacy of cognitive behavioural therapy for psychosis. All of the trials have been conducted in the UK, whereas none of the recent trials have taken place in the US. It is uncertain whether the results found would generalise to a different culture such as the US with a predominance of many ethnic minorities.
Schizophrenia is associated with a number of cognitive deficits such as difficulty in concentrating, problem solving and other attentional deficits. Such impairments have significant implications for the success of cognitive behavioural therapy and there has been a long held view that psychotic patients are not amenable to cognitive therapy. Lack of insight is another reason that is also posited for their failure to engage. The results of other meta - analyses (Cormac et al 2002, Gould et al 2001) clearly demonstrate that this is not the case. For example Garety et al (1997) found that cognitive variables were not related to treatment response. Nevertheless given the nature of cognitive behaviour therapy, a certain degree of insight and willingness to disclose symptoms are necessary prerequisites to engage in cognitive therapy (Chadwick et al., 1996). Thus those patients who are more severely deluded and suffering from marked negative symptoms of depression and withdrawal may not benefit from such a psychological approach. This hypothesis is supported by findings from Garety et al (1997) where he found that a greater insight did predict a better outcome among patients randomised to CBT therapy.
Identification of therapeutically relevant factors is very important in order to be able to implement them in clinical practice. A recent study by Andres et al (2003) investigated the significance of coping as a therapeutic variable for the outcome of purely psychoeducational and behavioural therapy in schizophrenia. They demonstrated that better outcomes in terms of psychopathology and social outcome was best predicted by the patient's mastery of active problem focused strategies, levels of cognizance about the disorder, and levels of social functioning. While the treatment intervention employed in this study is not CBT per se, such significant predictors of outcome can be readily mapped onto a CBT approach where levels of insight as previously discussed is an important variable to consider.
A criticism sometimes levelled at a cognitive behavioural approach to psychosis is that the focus of treatment is typically on target symptoms of hallucinations and delusions. Other symptoms such as affective state and psychosocial functioning have not been specifically addressed. This issue has been addressed in a very recent study by Gumley et al (2003) which looked at CBT for relapse. Significant improvements in two social functioning domains, (shopping, managing finances etc.) and pro-social activities were found. As opposed to using withdrawal or avoidance oriented coping with perceived relapses, participants exposed to a psychological intervention appeared to adopt more adaptive coping strategies which enhance social and interpersonal functioning. This represents a further promising role for the efficacy of this treatment approach and should be pursued in future studies.
Concluding Remarks
Considerable progress has been made in the development of psychological treatment for schizophrenia. Traditionally patients and relatives with schizophrenia have been rather passive recipients of care delivered by the mental health service. A cognitive behavioural approach radically changes this dyadic relationship in that both patients and carers become active participants in the management of their psychotic symptoms. The therapy fosters a collaborative relationship and dialogue which affords patients with some control over their care management and an opportunity to identify individual relapse signatures. The trials reviewed here provide encouraging results for the efficacy of cognitive behavioural intervention in the treatment of psychosis. However many issues remain to be clarified including the identification of the therapeutic processes activated by such treatment interventions. In addition some trials suffer from a number of methodological limitations which have been discussed. Future studies should address these issues.
Finally, the Department of Health, NHS Executive (1999) now acknowledge the importance of psychological interventions. Clearly there is a need for a new approach to treatment if the needs of individuals with schizophrenia are to be fully met. Such an intervention should also be readily incorporated into the training and subsequently integrated into routine clinical practice.
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Smith J, Birchwood M 1990 Relatives and patients as partners in the management of schizophrenia: the development of a service model. British Journal of Psychiatry 156:654-660
*Smith T E, Bellack A S, Liberman R P 1996 Social skills training for shizophrenia: review and future directions. Clinical Psychology Review 16(7):599-617
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Tarrier N 1996 Family interventions for schizophrenia. In: Haddock G, Slade P D (eds) Cognitive - behavioural interventions for psychotic disorders. Routledge, London pp 212-234
Tarrier N, Barrowclough C 1995 Family interventions in schizophrenia and their long-term outcomes. International Journal of Mental Health 24(3):38-53
Tarrier N, Harwood S, Yusopoff L, Beckett R, Baker A 1990 Coping strategy enhancement (CSE): a method of treating residual schizophrenic symptoms. Behavioural Psychotherapy 18:283-293
Tarrier N, Lowson K, Barrowclough C 1991 Some aspects of family interventions in schizophrenia. II: ?nancial considerations. British Journal of Psychiatry 159:481-484
Tarrier N, Beckett R, Harwood S, Baker A, Yusopoff L, Ugareburu I 1993 A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients, I: outcome. British Journal of Psychiatry 162:524-532
Trower P, Bryant B, Argyle M 1978 Social skills and mental health. Methuen, London
Vaccaro J, Liberman R, Wallace C J, Blackwell G 1992 Combining social skills training and assertive case management: the social and independent living skills program of the Brentwood Veterans Affairs Medical Center. New Directions for Mental Health Services 53:33-41
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*Fadden G 1998 Family intervention. In: Brooker C, Repper J (eds) Serious mental health problems in the community: policy, practice and research. Baillière Tindall, London, pp 159-183
*Falloon I R H 1995 Family management of schizophrenia. Johns Hopkins University Press, Baltimore
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Haddock G, Sellwood W, Tarrier N, Yusupoff L 1994 Developments in cognitive behaviour therapy for persistent psychotic symptoms. Behaviour Change 11(4):200-212
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Halford W, Hayes R 1995 Social skills in schizophrenia: assessing the relationship between social skills, psychopathology, and community functioning. Social Psychiatry and Psychiatric Epidemiology 30:14-19
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Hughes I, Hailwood R, Abbati-Yeoman J, Budd R 1996 Developing a family intervention service for serious mental illness: clinical observations and experiences. Journal of Mental Health 5(2):145-159
Kavanagh D J 1992 Family intervention for schizophrenia. In: Kavanagh D J, (ed) Schizophrenia: an overview and practical handbook. Chapman & Hall, London pp 407-423
Kavanagh D J, Piatkowska O, Clark D et al 1993 Application of cognitive behavioural family intervention for schizophrenia in multidisciplinary teams: what can the matter be? Australian Psychologist 28(3):181-188
*Kuipers L, Leff J, Lam D 1992 Family work for schizophrenia: a practical guide. Gaskell, London
Kuipers E, Garety P, Fowler D 1996 An outcome study of cognitive - behavioural treatment for psychosis. In: Haddock G, Slade P D (eds) Cognitive - behavioural interventions for psychotic disorders. Routledge, London pp 116-136
Lam D 1991 Psychosocial family intervention in schizophrenia: a review of empirical studies. Psychological Medicine 21:423-441
Lancashire S, Haddock G, Tarrier N, Baguley I, Butterworth C, Brooker C 1997 Effects of training in psychosocial interventions for community psychiatric nurses in England. 48(1):39-41
Leff J, Vaughn C 1985 Expressed emotion in families: its signi?cance for mental illness. Guilford, New York
Leff J, Gamble C 1995 Training of community psychiatric nurses in family work for schizophrenia. International Journal of Mental Health 24(3):76-88
Liberman R 1992 Handbook of psychiatric rehabilitation. Macmillan, New York
Liberman R, Mueser K, Wallace C, Jacobs H, Eckman T, Massel H 1986 Training skills in the psychiatrically disabled: learning coping and competence. Schizophrenia Bulletin 12:631-647
McCreadie R, Phillips K, Harvey J, Waldron G, Stewart M, Baird D 1991 The Nithsdale schizophrenia surveys. VIII: do relatives want family intervention, and does it help? British Journal of Psychiatry 158:110-113
McFarlane W R, Stastny P, Deakins S 1992 Family-aided assertive community treatment: a comprehensive rehabilitation and intensive case management approach for persons with schizophrenic disorders. New Directions for Mental Health Services 53:43-53
McKeown M, McCann G, Bentall R 1997 Time for action: a new system for training mental health practitioners. Mental Health Care 1(5):158
Midence K, Marshall L, Bell R, Leff J 1995 Community psychiatric nurses: their role as trainers in schizophrenia family work. Journal of Clinical Nursing 4:335-336
Midence K, Gamble C 1995 Family work and attitudes to schizophrenia. Nursing Times 290:12
Mueser K T, Wallace C, Liberman R P 1995 New developments in social skills training. Behaviour Change 12(1):31-40
*Nelson H 1997 Cognitive behavioural therapy with schizophrenia. Stanley Thornes, Cheltenham
Oppong-Tutu A, Price V 1997 Working with the mentally ill and their families. Mental Health Nursing 17(4):8-10
*Penn D L, Mueser K T 1996 Research update on the psychosocial treatment of schizophrenia. American Journal of Psychiatry 153(5):607-617
Sellwood W, Haddock G, Tarrier N, Yusupoff L 1994 Advances in the psychological management of positive symptoms of schizophrenia. International Review of Psychiatry 6:201-215
Slade P D, Haddock G 1996 A historical overview of psychological treatments for psychotic symptoms. In: Haddock G, Slade P D (eds) Cognitive - behavioural interventions for psychotic disorders. Routledge, London pp 28-44
Smith J, Birchwood M 1990 Relatives and patients as partners in the management of schizophrenia: the development of a service model. British Journal of Psychiatry 156:654-660
*Smith T E, Bellack A S, Liberman R P 1996 Social skills training for schizophrenia: review and future directions. Clinical Psychology Review 16(7):599-617
Tarrier N 1996 Family interventions for schizophrenia. In: Haddock G, Slade P D (eds) Cognitive - behavioural interventions for psychotic disorders. Routledge, London pp 212-234
Tarrier N, Barrowclough C 1995 Family interventions in schizophrenia and their long-term outcomes. International Journal of Mental Health 24(3):38-53
Tarrier N, Harwood S, Yusopoff L, Beckett R, Baker A 1990 Coping strategy enhancement (CSE): a method of treating residual schizophrenic symptoms. Behavioural Psychotherapy 18:283-293
Tarrier N, Lowson K, Barrowclough C 1991 Some aspects of family interventions in schizophrenia. II: ?nancial considerations. British Journal of Psychiatry 159:481-484
Tarrier N, Beckett R, Harwood S, Baker A, Yusopoff L, Ugareburu I 1993 A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients, I: outcome. British Journal of Psychiatry 162:524-532
Trower P, Bryant B, Argyle M 1978 Social skills and mental health. Methuen, London
Vaccaro J, Liberman R, Wallace C J, Blackwell G 1992 Combining social skills training and assertive case management: the social and independent living skills program of the Brentwood Veterans Affairs Medical Centre. New Directions for Mental Health Services 53:33-41
Kavanagh D J 1992 Family intervention for schizophrenia. In: Kavanagh D J, (ed) Schizophrenia: an overview and practical handbook. Chapman & Hall, London, pp 407-423
Kavanagh D J, Piatkowska O, Clark D et al 1993 Application of cognitive behavioural family intervention for schizophrenia in multidisciplinary teams: what can the matter be? Australian Psychologist 28(3):181-188
*Kuipers L, Leff J, Lam D 1992 Family work for schizophrenia: a practical guide. Gaskell, London
Kuipers E, Garety P, Fowler D 1996 An outcome study of cognitive-behavioural treatment for psychosis. In: Haddock G, Slade P D (eds) Cognitive-behavioural interventions for psychotic disorders. Routledge, London, pp 116-136
Lam D 1991 Psychosocial family intervention in schizophrenia: a review of empirical studies. Psychological Medicine 21:423-441
Lancashire S, Haddock G, Tarrier N, Baguley I, Butterworth C, Brooker C 1997 Effects of training in psychosocial interventions for community psychiatric nurses in England. Psychiatric Services 48(1):39-41
Leff J, Vaughn C 1985 Expressed emotion in families: its signi?cance for mental illness. Guilford, New York
Leff J, Gamble C 1995 Training of community psychiatric nurses in family work for schizophrenia. International Journal of Mental Health 24(3):76-88
Liberman R 1992 Handbook of psychiatric rehabilitation. Macmillan, New York
Liberman R, Mueser K, Wallace C, Jacobs H, Eckman T, Massel H 1986 Training skills in the psychiatrically disabled: learning coping and competence. Schizophrenia Bulletin 12:631-647
McCreadie R, Phillips K, Harvey J, Waldron G, Stewart M, Baird D 1991 The Nithsdale schizophrenia surveys. VIII: do relatives want family intervention, and does it help? British Journal of Psychiatry 158:110-113
McFarlane W R, Stastny P, Deakins S 1992 Family-aided assertive community treatment: a comprehensive rehabilitation and intensive case management approach for persons with schizophrenic disorders. New Directions for Mental Health Services 53:43-53
McKeown M, McCann G, Bentall R 1997 Time for action: a new system for training mental health practitioners. Mental Health Care 1(5):158
Midence K, Marshall L, Bell R, Leff J 1995 Community psychiatric nurses: their role as trainers in schizophrenia family work. Journal of Clinical Nursing 4:335-336
Midence K, Gamble C 1995 Family work and attitudes to schizophrenia. Nursing Times 290:12
Mueser K T, Wallace C, Liberman R P 1995 New developments in social skills training. Behaviour Change 12(1):31-40
*Nelson H 1997 Cognitive behavioural therapy with schizophrenia. Stanley Thornes, Cheltenham
Oppong-Tutu A, Price V 1997 Working with the mentally ill and their families. Mental Health Nursing 17(4):8-10
*Penn D L, Mueser K T 1996 Research update on the psychosocial treatment of schizophrenia. American Journal of Psychiatry 153(5):607-617
Sellwood W, Haddock G, Tarrier N, Yusupoff L 1994 Advances in the psychological management of positive symptoms of schizophrenia. International Review of Psychiatry 6:201-215
Slade P D, Haddock G 1996 A historical overview of psychological treatments for psychotic symptoms. In: Haddock G, Slade P D (eds) Cognitive-behavioural interventions for psychotic disorders. Routledge, London, pp 28-44
Slade P D, Haddock G 1996 A historical overview of psychological treatments for psychotic symptoms. In: Haddock G, Slade P D (eds) Cognitive - behavioural interventions for psychotic disorders. Routledge, London pp 28-44
Smith J, Birchwood M 1990 Relatives and patients as partners in the management of schizophrenia: the development of a service model. British Journal of Psychiatry 156:654-660
*Smith T E, Bellack A S, Liberman R P 1996 Social skills training for schizophrenia: review and future directions. Clinical Psychology Review 16(7):599-617
Tarrier N 1996 Family interventions for schizophrenia. In: Haddock G, Slade P D (eds) Cognitive - behavioural interventions for psychotic disorders. Routledge, London pp 212-234
Tarrier N, Barrowclough C 1995 Family interventions in schizophrenia and their long-term outcomes. International Journal of Mental Health 24(3):38-53
Tarrier N, Harwood S, Yusopoff L, Beckett R, Baker A 1990 Coping strategy enhancement (CSE): a method of treating residual schizophrenic symptoms. Behavioural Psychotherapy 18:283-293
Tarrier N, Lowson K, Barrowclough C 1991 Some aspects of family interventions in schizophrenia. II: financial considerations. British Journal of Psychiatry 159:481-484
Tarrier N, Beckett R, Harwood S, Baker A, Yusopoff L, Ugareburu I 1993 A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients, I: outcome. British Journal of Psychiatry 162:524-532
Trower P, Bryant B, Argyle M 1978 Social skills and mental health. Methuen, London
Vaccaro J, Liberman R, Wallace C J, Blackwell G 1992 Combining social skills training and assertive case management: the social and independent living skills program of the Brentwood Veterans Affairs Medical Centre. New Directions for Mental Health Services 53:33-41
Smith J, Birchwood M 1990 Relatives and patients as partners in the management of schizophrenia: the development of a service model. British Journal of Psychiatry 156:654-660
*Smith T E, Bellack A S, Liberman R P 1996 Social skills training for schizophrenia: review and future directions. Clinical Psychology Review 16(7):599-617
Tarrier N 1996 Family interventions for schizophrenia. In: Haddock G, Slade P D (eds) Cognitive-behavioural interventions for psychotic disorders. Routledge, London, pp 212-234
Tarrier N, Barrowclough C 1995 Family interventions in schizophrenia and their long-term outcomes. International Journal of Mental Health 24(3):38-53
Tarrier N, Harwood S, Yusopoff L, Beckett R, Baker A 1990 Coping strategy enhancement (CSE): a method of treating residual schizophrenic symptoms. Behavioural Psychotherapy 18:283-293
Tarrier N, Lowson K, Barrowclough C 1991 Some aspects of family interventions in schizophrenia. II: ?nancial considerations. British Journal of Psychiatry 159:481-484
Tarrier N, Beckett R, Harwood S, Baker A, Yusopoff L, Ugareburu I 1993 A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients, I: outcome. British Journal of Psychiatry 162:524-532
Trower P, Bryant B, Argyle M 1978 Social skills and mental health. Methuen, London
Vaccaro J, Liberman R, Wallace C J, Blackwell G 1992 Combining social skills training and assertive case management: the social and independent living skills program of the Brentwood Veterans Affairs Medical Center. New Directions for Mental Health Services 53:33-41
Annotated further reading
Fadden G 1998 Family intervention. In: Brooker C, Repper J (eds) Serious mental health problems in the community: policy, practice and research. Baillière Tindall, London
This chapter provides a comprehensive and up-to-date review of the research literature on family intervention.
Nelson H 1997 Cognitive behavioural therapy with schizophrenia. Stanley Thornes Publishers, Cheltenham
This is an excellent book for anyone who wants to develop an understanding of CBT in the management of psychosis.
*Haddock G, Slade P G 1996 Cognitive-behavioural interventions for psychotic disorders. Routledge, London