Family Burden of Psychosis
Family burden can be measured
The experience of families
Families are an important resource of information on the behavior of the psychotic person! See
Trajectory to a first episode of psychosis: a qualitative research study with families, Cheryl Corcoran, Ruth Gerson, Rachel Sills-Shahar, Connie Nickou, Thomas McGlashan,Dolores Malaspina, and Larry Davidson,
How to assist families?
An example on how family members can be involved from the very first start is the Open Dialogue practice in Finland. Look not only to the therapy method but also the organizational aspects! Family and the acute psychotic person are visited by the a team every day. The team keeps assisting all people involved as long as needed!
Video 1 play
Video 2 play
How to apply open dialogue? And what is the evidence of the working of Open Dialogue?
This approach is carefully researched and the outcome is better than anywhere in the world. How come? Read
Reviews and Endorsements
'...The book carefully explains the theoretical basis for dialogical communication, drawing heavily on the work of Mikhail Bakhtin, but its great strength is the way these principles have been transformed into a practice of community meetings. Because the authors are drawing on years of experience as well as outcome research studies, they present a framework for a model that is proven and they describe the techniques that make it work. For example, there are helpful sections that spell out what questions to ask a psychotic patient, how to respond to delusions and how to approach other professionals when the network is becoming stuck in its task.’
'Although the book describes their model in detail, many practitioners find that their ideas about dialogic communication can be applied across a wide range of clinical settings, such as family therapy, but they are particularly useful when multi-disciplinary or multi-agency teams meet to devise treatment for patients...’
'This Finnish team is widely recognized for the work they are doing, as shown by their writings and presentations at conferences, and this book gives them the space to explain their thinking and practice in greater detail than ever before. It is a major step in bringing their work to the attention of the English speaking community.' - David Campbell and Ros Draper, from the Editorsʼ Foreword
'What I particularly appreciated in reading this work is that we are introduced in both Open Dialogues and Anticipation Dialogues to important elements of Bakhtinʼs dialogical theory, together with fresh ideas about networks talking with networks... On a smaller scale, this book feels to me like a trumpet blast, not just in announcing the achievement of a more contextualized approach to human dilemmas, but in offering some solid proof of its efficacy.'
- Lynn Hoffman, from the Foreword
Psychodynamic work with families
Psychosis: Psychodynamic work with families
This article contains a very interesting historic overview on this issue, also addressing the accusations of that family therapy provokes guild in families. It ends with an example of psychodynamic work with a man with psychosis, his wife and his children.
Family psycho education
What is family psychoeducation?
Family psychoeducation is not telling families what to do, but a form of family behavior therapy, which has the aim of finding solutions for the practical problems which are caused by living with psychosis. Founders like Ian Falloon were family therapists. It can be given to single families but also be given in a family group. It is the best researched family approach of all. The main outcome is less hospitalization. ISPS members may not like the information part which is often given: schizophrenia is an brain disease not caused by family members. The information part can in my experience easily be replaced by: ‘we still do not know what caused psychosis, - there are maybe many causes- but we do know what family members can do to make the prognosis better’ and ‘psychosis is not only stressful for the person who is suffering from it but also for family members’. This is a statement every person will agree with. Therefore this type of family intervention is also accepted in very medical settings and recommended as a guideline by mainstream psychiatric forums. In the meanwhile family members, including the person who is suffering from psychosis can learn to communicate in a clear way, solve conflicts and so on. FPE can prevent or diminish so-called Expressed Emotions, a measurement of the worrying and angriness in a family. And in my experience it also prevents the silence and the evading of any confrontation in a family, which makes that people with psychosis live in a void. I teach this method to clinicians who are working in a medical setting. See for an example of the FPE approach:
Expressed Emotion in families, its significance for mental illness. Leff, J. and Vaughn - 1985 Guilford New York
This is the classic book about the Expressed Emotion theory. The founders Brown, Leff and Vaughn explain the basic research on which this theory is based. The research is replicated all around the world. Today the EE concept is criticized, calling a parent high EE is stigmatizing too, while the intention of the founders was to destigmatize families. Clinicians who are familiar with working with families understand that angry and worried reactions of families are a result of the stress that unsupported families who live with a mentally ill member, experience.
Families as Partners in Mental Health Care: A Guidebook for Implementing Family Work. D. Froggatt, Fadden, G Johnson, D.L, Leggatt M. & Shankar R. - 2007 Toronto: World Fellowship for Schizophrenia An excellent guide for working with families from the famous British Meriden institute, based on the approach of Ian Falloon.
Family Work for Schizophrenia Leff, Julian, Lam, Dominique, and Elisabeth Kuipers - 2002-2004 The Royal College of Psychiatrists _ This is a very practical manual for working with families. The authors belong to the founders of the method of the family psycheducation.
Advanced Family Work for Schizophrenia: An Evidence-Based Approach Julian P. Leff, Gaskell - 2005 Journal of Family Therapy From comprehensive records of about 150 families discussed during supervision, Julian Leff has distilled 19 anonymised case histories illustrating the most difficult problems encountered in such work. Each family is described in detail as presented by the supervisee. Then, the author gives his understanding of the problems in a social and cultural context, and makes recommendations for ongoing family work.
A Casebook of Family Interventions for Psychosis, Fiona Lobban, Christine Barrowclough - 2009 John Wiley and Sons A practical guide to implementing family interventions for psychosis, which discusses different family needs and illustrates different approaches to offering the interventions.
Bipolar Disorder: A Family-Focused Treatment Approach, David J. Miklowitz PhD, 2008 David Miklowitz worked with Michael Goldstein a pioneer in the family psychoeducation approach especially for first psychosis. In his opinion the strategy is somewhat different with persons with a bipolar disorder, it is more psychological.
Multi-Family Group Therapy
What is MFG?
Psychosis and multiple family group therapy, Eia Asen and Heiner Schuff. Asen has a somewhat different approach than Mc Farlane, mentioned below (les medical), but also a lot in common: shaping a community of people with the same problem.
Multifamilygroups in the Treatment of Severe Psychiatric Disorders McFarlane William R. - 2002 NY: Guilford Press, v This very clearly written book can be used as a manual for running Multi Family Groups.The unique advantage of MFT's is the phenomena of the forming of cross-relationships between parents and children who are vulnerable for psychosis from other parents and the other way around. McFarlane calls it changing from family relationships to neighbor relationships. More distance helps group members to use their wisdom, which surely isn't lacking. MFT is an evidence based practice.
Family Psychoeducation Evidence-Based Practices (EBP) KIT CD-ROM/DVD Version, available for free on Samsha
The evidence for family psychoeducation,
FPE is in fact the most evidence based psychological treatment for psychosis. But the evidence according to the very strict Cochrane rules is diminishing See Family intervention for schizophrenia Pharoah F, Mari JJ, Rathbone J, Wong W - 2010 Cochrane Database of Systematic Reviews The Cochrane institute has a rule that study must be blinded, which is almost not possible to accomplish. It is also working in the long term. In fact FPE has not very different results in the short term in family friendly institutes but it makes a difference after 5 years! See
Needs-based cognitive-behavioural family intervention for patients suffering from schizophrenia W. Sellwood, A. Wittkowski, N. Tarrier, C. Barrowclough - 2007 Wiley A 5-year follow-up of a randomized controlled effectiveness trial Acta Psychiatrica Scandinavica
Patients were less likely to relapse over the 5-year follow-up when they received the needs-based family intervention, especially in relation to exacerbations of symptoms not requiring inpatient admissions: 86.7% of control participants relapsed compared with 53.3% (P = 0.01). Survival analysis indicated that the relapse risk was 2.5 times higher for patients receiving routine care, compared with those receiving family intervention. A similar trend was observed for the final 4 years of follow-up. Comment Margreet. In this study family intervention was compared with a condition in which families were supported by an experienced family member.
The social and symptomatic course of early-onset schizophrenia. Five year follow-up of a psychosocial intervention. Like in Sellwood’s study: it seems that family support alone has a benevolent effect, while a therapeutic way of working has more effect on the long term. I know from Ria, that family members did not like the intervention, so the clinicians decided to stop this intervention, years after their decision it appeared that the intervention really worked!!!
Early intervention services, cognitive–behavioural therapy and family intervention in early psychosis: systematic review, V. Bird, P. Premkumar, T. Kendall, C. Whittington, J. Mitchell and E. Kuipers
Latest information from IEPA conference Dr Juliana Umniware: identifying moderators and predictors of treatment outcome in caregivers, an RCT, go to 43,28 minutes.
Some informative websites of family therapy institutes
Recovery for cares
Recommendations from the Meriden Institute. A comprehensive list of literature of the Meriden Institute. See page