Delivering cognitive-behavioural family interventions for schizophrenia
Open accessAbstract
BackgroundIn 1993, Kavanagh and colleagues outlined outcomes from a training programme designed to equip mental health practitioners to deliver evidence‐based cognitive‐behavioural family interventions within routine care. The authors highlighted how the training had not been able to deliver notable increases in the numbers of families being seen by the trained clinicians. There were significant issues in the translation and provision of family interventions within clinical settings, specifically difficulties with the integration of family interventions and caseload demands, and insufficient time within job plans and service settings to undertake the work. The authors posed the question: what can the matter be? Interestingly, the same question was being asked over a decade later.ObjectiveThe current article provides a narrative review of the issues on implementation of family interventions in psychosis.ResultsCurrent evidence suggests that while there exist pockets of good practice and provision for family interventions, it was a mistake to assume that care coordinators would be able to include these family interventions as part of their role, effectively to add duties without significant modification to their current roles and duties. It also seems to have been an underestimate of the skills required for delivering family work in psychosis and the ongoing requirements for high‐quality supervision.ConclusionWe argue for carer specialists to be involved in mental health teams, particularly early intervention teams, and for a triage system to offer families a range of evidence‐based support, as well as family interventions for more complex problems and presentations.
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Claims the paper makes
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- Premisecitation§ Caregiving Experiences
Caregiving in psychosis can be particularly stressful and burdensome.
“Data spanning several decades confirm that caregiving in psychosis can be particularly stressful and burdensome”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Boydell et al., 2014
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- cites Flyckt et al., 2013
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- Premisecitation§ Caregiving Experiences
High expressed emotion in informal caregiving relationships predicts more service user relapses and hospital admissions.
“Informal caregiving relationships characterised by high levels of caregiver criticism, and/or hostility, and/or emotional over involvement, commonly described as high expressed emotion (EE), are predictive of a greater number of service user relapses and hospital admissions.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Bebbington & Kuipers, 1994
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- Premisecitation§ Introduction
Informal caregiving relationships can reduce the need for and length of inpatient admissions.
“informal caregiving relationships can reduce the need for and length of inpatient admissions”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Norman et al., 2005
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- Premisecitation§ What this paper adds
Almost 25% of trained therapists in Kavanagh et al.'s sample reported finding it extremely difficult or impossible to use the family intervention.
“Almost 25% reported finding it extremely difficult or impossible to use the intervention”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Kavanagh et al. (1993)
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- Premisecitation§ Caregiving Experiences
Carers of people with psychosis report burnout and emotional exhaustion at levels equivalent to those reported by paid psychiatric staff.
“Carers also report feelings of burnout and emotional exhaustion, at equivalent levels to those reported by paid psychiatric staff”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Angermeyer, Bull, Bernert, Dietrich, & Kopf, 2006
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- Premisecitation§ Introduction
Service users with informal caregiving relationships report better health outcomes, including quality of life, than those without such relationships.
“Service users with informal caregiving relationships compared to those without can report better health outcomes, including self-reported levels of quality of life”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Stowkowy, Addington, Liu, Hollowell, & Addington, 2012
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- Premisecitation§ Caregiving Experiences
Positive family interactions, such as carer warmth, reduce relapse risk in individuals with psychosis.
“positive family interactions, such as reports and expression of carer warmth, reduce relapse risk in individuals with psychosis”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Bebbington & Kuipers, 1994
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- cites Lee, Barrowclough, & Lobban, 2014
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- Premisecitation§ Caregiving Experiences
Carer criticism is the strongest predictor of relapse even after several years.
“Carer criticism has been proven to be the most predictive of relapse even after several years”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Cechnicki, Bielanska, Hanuszkiewicz, & Daren, 2013
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- Interpretationnone given§ What this paper adds
Difficulties with service implementation and provision of family interventions have persisted across different countries for the last two decades.
“In different countries, difficulties with service implementation and provision of family interventions have persisted for the last two decades.”
Quote in the paperSubstantial claim - Premisecitation§ What this paper adds
More than half of trained therapists cited difficulties with the time available to undertake family work and combine it with other responsibilities.
“more than half cited difficulties with time made available to undertake the work and combine with other responsibilities.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Kavanagh et al. (1993)
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- Premisecitation§ Introduction
Ten-year follow-up data from first-episode psychosis service users suggest mortality rates are much improved for those with informal carers.
“Recent evidence taken from 10-year follow-up data of first-episode psychosis service users suggests that mortality rates are much improved for those with informal carers.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Revier et al., 2015
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- Premisecitation§ Family Interventions-The Evidence Base
Family interventions for psychosis share the stress vulnerability framework for the development, maintenance, and exacerbation of psychosis.
“they share common underlying principles, namely the stress vulnerability framework for the ontogeny, maintenance, and exacerbation of psychosis”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Barrowclough & Tarrier, 1992
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- cites Falloon, Boyd, & McGill, 1984
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- cites Kuipers, Leff & Lam, 2002
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- Premisecitation§ Introduction
Unnatural deaths among service users with psychosis were reduced by 90% in those whose families had input at initial contact with services.
“Cases of unnatural death in service users with psychosis were reduced by 90% in those with input from their families on initial contact with services”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Revier et al., 2015
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- Premisereasoning§ Delivering Family Interventions: Workforce and Organisational Issues
The whole-service training approach has not been possible in most areas where overstretched teams focus on crisis management.
“However, this training approach has not been possible in most areas where overstretched teams have been understandably focused on crisis management.”
Quote in the paperNot a substantial claim - Premisecitation§ Delivering Family Interventions: Workforce and Organisational Issues
In Kavanagh et al.'s study, 13% of staff worked with 60% of the families.
“in the Kavanagh et al. study, 13% of the staff were recorded as having worked with 60% of the families.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Kavanagh et al. (1993)
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- Premisecitation§ Family Interventions-The Evidence Base
Recent data offer encouraging evidence about the benefits of family interventions for at-risk psychosis groups.
“Recent data have also offered encouraging data about the benefits of family interventions for at-risk psychosis groups”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites O'Brien et al., 2014
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- Premisereasoning§ Delivering Family Interventions: Exploring New Ways of Working
Outside full family interventions, families and carers can benefit from less intensive, brief, targeted interventions such as relapse prevention planning or psychoeducation about psychosis.
“Outside of the full family interventions, families and carers can benefit from less intensive, brief, and more targeted interventions, such as developing a relapse prevention plan or psychoeducation about psychosis.”
Quote in the paperSubstantial claim - Premisecitation§ Family Interventions, So What Is the Matter?
In Germany, Austria, and Switzerland, only 1 in 50 families were receiving family interventions.
“only 1 in 50 families were receiving interventions in Germany, Austria, and Switzerland”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Rummel-Kluge, Pitschel-Walz, Bauml, & Kissling, 2006
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- Premisecitation§ Family Interventions-We Know What the Matter Is
Lessons from cognitive-behavioural therapy for psychosis indicate that staff in care coordination roles found it difficult to deliver interventions.
“some of the recent evidence on implementation suggests that it was predominately staff acting in care coordination roles who found it difficult to deliver interventions”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Jolley et al., 2012
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- Premisecitation§ Delivering Family Interventions: Workforce and Organisational Issues
A greater proportion of families tended to be seen by a small subgroup of practitioners.
“The pattern emerged that a greater proportion of families tended to be seen by a small subgroup of practitioners.”
Quote in the paperNot a substantial claim - Premisecitation§ Family Interventions-The Evidence Base
Economic analyses confirm that family interventions are cost-effective.
“Economic analysis confirm they are cost-effective”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Christenson, Crane, Bell, Beer, & Hillin, 2014
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- cites Mihalopoulos, Magnus, Carter, & Vos, 2004
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- Premisecitation§ Family Interventions-We Know What the Matter Is
The main difficulty for care coordination staff delivering cognitive-behavioural therapy for psychosis was insufficient time, despite high-quality training and acquired competency.
“The difficulty was mainly due to 'having insufficient time,' and this remained the case despite accessing highquality training and reaching the acquired competency in delivery.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Jolley et al., 2012
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- Premisecitation§ Family Interventions-The Evidence Base
Family interventions have proven effective in real-world clinical services.
“Family interventions have proven effective in real-world clinical services”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Kelly & Newstead, 2004
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- cites Ruggeri et al., 2015
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- Premisecitation§ Delivering Family Interventions: Exploring New Ways of Working
Not all families need or want the full standalone family intervention for psychosis.
“It is increasingly argued that not all families will need, or indeed want, the full standalone FIp”
Quote in the paperSubstantial claim0 of 3 sources checked- cites Cohen et al., 2008
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- cites Kuipers, 2010
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- cites Onwumere et al., 2011
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- Premisecitation§ Family Interventions, So What Is the Matter?
In the UK, at least 44% of staff had been given training to deliver family interventions for psychosis.
“records confirming that at least 44% of staff had been given training to deliver the therapy”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Haddock et al., 2013, as cited in Haddock et al., 2014
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- Premisecitation§ Family Interventions-The Evidence Base
Family interventions have proven efficacy during the early illness phases of psychosis.
“Interventions have proven efficacy during the early illness phases”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Bird et al., 2010
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- cites Gleeson et al., 2010
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- Premisecitation§ Family Interventions-The Evidence Base
The fixed effects odds ratio for family interventions to reduce relapse at 12 months compared with standard treatment was 0.55.
“The authors reported a fixed effects odds ratio of 0.55 for the interventions to reduce relapse at 12 months compared with standard treatment.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Pharoah, Mari, Rathbone, & Wong, 2010
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- Premisecitation§ Family Interventions, So What Is the Matter?
Accumulating evidence confirms surprisingly disappointing application, implementation, and provision of family interventions across the globe despite rhetoric about their need and benefits.
“Accumulating evidence confirms the surprisingly disappointing application, implementation, and provision of family interventions across the globe, despite the rhetoric about the need for and benefits of the intervention”
Quote in the paperSubstantial claim0 of 3 sources checked- cites Dixon, 1999
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- cites Fadden, 2009
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- cites Glynn, 2012
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- Premisecitation§ Family Interventions-The Evidence Base
Very early indications suggest that brief family interventions of five sessions or less might improve family understanding about psychosis.
“There are very early indications that brief interventions (five sessions or less) might confer some positive benefits for improving family understanding about psychosis”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Okpokoro, Adams, & Sampson, 2014
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- Premisecitation§ Delivering Family Interventions: Workforce and Organisational Issues
Burbach and Stanbridge reported an average of 3.5 families seen by staff over an average of 26 months after an accredited course.
“The authors' review of the average numbers of families seen by staff, following completion of an accredited course and over an average of 26 months since the course ended, was 3.5.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Burbach and Stanbridge (2006)
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- Interpretationcitation§ Family Interventions-We Know What the Matter Is
The initial aim of improving implementation and widening access to family interventions is not adequately achieved by mass up-skilling of frontline mental health staff in the absence of organisational and role revision.
“It seems clear from the evidence that the initial aim of improving implementation and widening access to family interventions is not adequately achieved by, or indeed, linked to, the mass up-skilling of frontline mental health staff, in the absence of organisational and role revision.”
Quote in the paperSubstantial claim - Premisecitation§ Delivering Family Interventions: Exploring New Ways of Working
Only a small proportion of families require the full multicomponent family interventions that form the evidence-based manuals and require expert-level therapists.
“Consequently, only a small proportion require the full, multicomponent family interventions, which form the basis of the evidence-based manuals (e.g., Kuipers et al., 2002), and require therapists trained to expert levels.”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Cohen et al. (2008)
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- cites Kuipers et al., 2002
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- Premisecitation§ Delivering Family Interventions: Exploring New Ways of Working
Preliminary findings suggest that the IAPT-SMI model significantly increases access to family interventions.
“The preliminary findings suggest much more promising results in significantly increasing access”
Quote in the paperSubstantial claim0 of 1 sources checked- cites IAPT-SMI
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- Premisecitation§ Family Interventions-We Know What the Matter Is
Implementation difficulties were more apparent in staff without master's-level education and without therapy experience prior to training.
“Implementation difficulties were also more apparent in those without master's-level education and without therapy experience prior to training”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Jolley et al., 2012
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- Premisecitation§ Family Interventions-We Know What the Matter Is
When frontline staff in care coordination roles experienced minimal implementation difficulties, it tended to be when they had negotiated specific role changes within their management system and organisation.
“When staff at the front line of mental health delivery and in care coordination roles experienced minimal difficulties in implementation, this tended to be when they had negotiated specific role changes within their management system and organisation that supported them to undertake the specialist work.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Jolley et al., 2012
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- Premisecitation§ Delivering Family Interventions: Workforce and Organisational Issues
Fadden (1997) reported that 8% of their sample provided family work for 40% of cases.
“Fadden (1997) reported that 8% of their sample provided family work for 40% of cases.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Fadden (1997)
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- Premisecitation§ Delivering Family Interventions: Exploring New Ways of Working
Pilot data from a South London family work service initiative using a stepped care approach showed encouraging results.
“Pilot data from a recent family work service initiative in South London, UK, offered a stepped care approach to working with families with encouraging results”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Grice, 2014
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- Interpretationcitation§ Conclusion
Provision of family interventions for psychosis remains lower than expected given the prevalence rates for psychosis.
“we also know, as seen with other psychological therapies in psychosis, that the provision of FIp remains lower than one would expect given the prevalence rates for psychosis”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Haddock et al., 2014
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- Interpretationnone given§ Conclusion
Successful implementation does not seem to depend only on offering and expanding training initiatives, as evidence dating back almost 25 years shows.
“cessful implementation does not seem to be dependent only on offering and expanding training initiatives; evidence dating back almost 25 years shows this clearly.”
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Interpretationnone given§ What this paper addsInnovative service models that use triage and target specific needs and presentations appear to have value.
“Innovative service models utilising a triage approach and targeting specific needs and presentations seem to have value.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ Caregiving ExperiencesCarers of people with psychosis are nearly 10 times more likely to be isolated than matched non-caring samples.
“recent figures suggest carers are nearly 10 times more likely to be isolated compared with matched non-caring samples”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Hayes et al., 2015
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Premisenone given§ What is already known on this topicFamily interventions for psychosis have a strong, long-standing evidence base and are recommended treatments in several countries.
“Family interventions for psychosis have a strong and long evidence base and are recommended treatments in several countries.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ What is already known on this topicFamily interventions for psychosis are acceptable to service users, carers, and families.
“Family interventions are acceptable interventions to service users and carers.”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Budd & Hughes, 1997
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- cites Nilsen, Frich, Friis, Norheim, & Rossberg, 2014
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- cites Stanbridge, Burbach, Lucas, & Carter, 2003
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Premisecitation§ Caregiving ExperiencesApproximately 40% of carers of people with psychosis report depression and emotional dysfunction.
“with approximately 40% of carers reporting depression and emotional dysfunction”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Dyck, Short, & Vitaliano, 1999
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- cites Hayes, Hawthorne, Farhall, O'Hanlon, & Harvey, 2015
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- cites Kuipers & Raune, 2000
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Interpretationreasoning§ Delivering Family Interventions: Exploring New Ways of WorkingDigital and technological interventions may offer more cost- and time-efficient approaches to meeting the needs of service users with psychosis and their families and improve accessibility.
“They may offer far more cost- and time-efficient approaches to meeting the needs of service users with psychosis and their families and improve accessibility.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ Family Interventions-The Evidence BaseUK NICE 2014 guidelines recommend that family interventions be offered to families of service users with psychosis who are living with or in close contact with them, with a minimum of 10 sessions over 3 to 12 months.
“The recent UK NICE (2014) psychosis and schizophrenia guidelines recommend that family interventions should be on offer to families of service users with psychosis who are living with (or in close contact 1 ), and include a minimum of 10 sessions over a 3- to 12-month period (NICE, 2014).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites NICE, 2014
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Interpretationreasoning§ Family Interventions, So What Is the Matter?The combination of organisation and workforce issues, specifically training, supervision, and opportunities to practise, seems most relevant to implementation of family interventions.
“It is, however, the combination of organisation and workforce issues, specifically as they relate to training, supervision, and opportunities to practise, that seems most relevant.”
Quote in the paperSubstantial claimMay combine two claims.
Premisecitation§ Delivering Family Interventions: Exploring New Ways of WorkingThe UK IAPT-SMI service model delivers family interventions by clinicians trained at expert level, receiving regular high-level supervision, and working in dedicated therapy posts.
“family interventions are delivered by clinicians trained at the expert level, receiving regular high-level supervision, but recruited to and working in dedicated therapy posts.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites IAPT-SMI
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Premisecitation§ Family Interventions-The Evidence BasePerceived benefits reported by service users and carers include improved communication between family members and problem-solving skills.
“The perceived benefits, as reported by service user and carers, have included improved communication between family members and problem-solving skills”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Nilsen et al., 2014
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Premisecitation§ Delivering Family Interventions: Exploring New Ways of WorkingBrief family interventions lend themselves to delivery by frontline mental health staff and are less dependent on role or service redesign.
“These brief interventions lend themselves to delivery by frontline mental health staff and are less dependent upon role and/or service redesign to undertake the work”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Roddy, Onwumere, & Kuipers, 2014
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Premisecitation§ Delivering Family Interventions: Exploring New Ways of WorkingThe South London service approach enabled highly trained staff to focus on delivering family interventions for psychosis and coordination-role staff to deliver brief standalone interventions, with the latter still requiring dedicated protected time and supervision.
“The approach actively enabled the more highly trained staff to focus on delivering Fip, and those in coordination roles to deliver brief, standalone interventions; the latter still required agreement for dedicated and protected time to undertake the work and access supervision”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Grice, 2014
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Interpretationreasoning§ Family Interventions-We Know What the Matter IsApplying similar principles to family interventions for psychosis, poor implementation after training is attributable to laudable but overambitious goals from service providers.
“If we apply similar principles to FIp, where the picture is arguably more complicated, since the interventions often rely on having two staff members and out of hours work to support the attendance of family members, it could be argued that poor implementation post-training is attributable to laudable, but overambitious goals from service providers.”
Quote in the paperSubstantial claim- Rests on an assumption: The implementation difficulties and lessons from cognitive-behavioural therapy for psychosis can be generalized to family interventions for psychosis.
May combine two claims.
Premisecitation§ Family Interventions-The Evidence BaseReported benefits of family interventions to carers include significant decreases in care burden and increased positivity about caregiving and willingness to continue.
“the reported benefits of family interventions to carers have included significant decreases in reports of care burden and increased positivity about caregiving and willingness to continue”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Berglund, Vahlne, & Edman, 2003
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- cites Devaramane, Pai, & Vella, 2011
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- cites Lobban et al., 2013
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Premisecitation§ Family Interventions-We Know What the Matter IsIt is not realistic to expect staff who are not in therapy roles to complete the work without role revisions and protected time.
“The authors concluded that it was perhaps not realistic to expect staff who are not in therapy roles to complete the work without role revisions and protected time.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Jolley et al., 2012
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Interpretationcitation§ Family Interventions, So What Is the Matter?The gap between published treatment recommendations and actual delivery of family interventions is evident and owes little to the style in which treatment guidance is prepared.
“The gap between published treatment recommendations and what is actually delivered and implemented is evident and owes little to the style in which treatment guidance is prepared”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Ince, Tai, & Haddock, 2015
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Premisecitation§ Family Interventions-The Evidence BaseA Cochrane review found that family interventions significantly reduce relapse, hospital admissions, and high expressed emotion, and improve patient social functioning and treatment engagement.
“A Cochrane review of studies conducted worldwide confirm that family interventions can significantly reduce levels of relapse, hospital admissions, and high EE, and lead to measurable improvements in patient social functioning and treatment engagement”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Pharoah, Mari, Rathbone, & Wong, 2010
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Premisecitation§ Family Interventions, So What Is the Matter?In the UK, only 1.6% of eligible people are offered family interventions for psychosis and 1.1% receive them.
“data suggest only 1.6% of those eligible are offered FIp and 1.1% received it”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Haddock et al., 2014
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Premisecitation§ Family Interventions, So What Is the Matter?Implementation barriers for family interventions include organisational issues, workforce issues, and family factors.
“These have included organisational issues (e.g., competing priorities for staff and services, resource shortages, reduced capacity, and high caseloads for staff), workforce issues (e.g., poor understanding about family interventions and recovery, training and supervision access), and family factors (e.g., service user and carer engagement issues”
Quote in the paperSubstantial claim0 of 3 sources checked- cites Burbach & Stanbridge, 2006
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- cites Casacchia & Roncone, 2014
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- cites Fadden, 2006
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Premisecitation§ Family Interventions, So What Is the Matter?Access to evidence-based health interventions is problematic and is poorer for people with psychosis.
“Access to evidence-based health interventions are problematic and are poorer for people with psychosis”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Rowlands, 2004
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Premisecitation§ Delivering Family Interventions: Workforce and Organisational IssuesThe largest provision of family work was delivered by a small group of trained practitioners, and those completing longer-term training appeared to yield better findings than brief models.
“The largest provision was delivered by a small group of trained practitioners, and those completing longer term training (e.g., 1 year or higher) appeared to yield much better findings compared with brief models”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Mairs & Bradshaw, 2005
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Premisecitation§ Delivering Family Interventions: Exploring New Ways of WorkingThe benefits of family-led and peer-supported interventions are attracting attention.
“Similarly, the benefits of family-led and peersupported interventions are also attracting attention”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Duckworth & Halpern, 2014
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Premisecitation§ ConclusionFamily interventions in psychosis were described nearly 20 years ago as effective but underused.
“Family interventions in psychosis were described nearly 20 years ago as effective but underused interventions”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Anderson & Adams, 1996
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Interpretationnone given§ ConclusionTo find the most efficient and cost-effective ways for staff to provide the full range of evidence-based interventions to service users, families, and carers alone, training additional practitioners is not enough.
“Identifying the most time-efficient and cost-effective strategies for the workforce to deliver the range of evidencebased interventions to both service users and their families, and carers on their own, requires more than simply training more practitioners.”
Quote in the paperNot a substantial claim- Rests on an assumption: A large proportion of people with psychosis have informal carers living with them or remain in regular contact with such carers, especially soon after first onset.
- Rests on an assumption: Relationships with informal carers can improve outcomes for service users and help mental health services in their work.
Probably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ NoteEvidence from general caring population studies supports that 10 hours per week or more of caring contact indicates a greater level of strain for carers.
“Although no specific criterion was offered, evidence in support of 10 hr per week or greater caring contact being indicative of a greater level of strain for carers has been reported in general caring population studies (e.g., Smith et al., 2014).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Smith et al., 2014
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The paper relies on this without support.
The implementation difficulties and lessons from cognitive-behavioural therapy for psychosis can be generalized to family interventions for psychosis.
“If we apply similar principles to FIp, where the picture is arguably more complicated”
The paper relies on this without support.
It is feasible for each psychosis mental health team to have access to at least one specialist therapist in a dedicated therapy role.
“At the very least, we suggest that each psychosis mental health team should have access to at least one specialist therapist.”
The paper relies on this without support.
A large proportion of people with psychosis have informal carers living with them or remain in regular contact with such carers, especially soon after first onset.
“Despite the deleterious effect of psychosis on social networks, many service users with psychosis will live with or maintain regular contact with informal carers, particularly in the early years following first onset.”
The paper relies on this without support.
Relationships with informal carers can improve outcomes for service users and help mental health services in their work.
“Informal caregiving relationships can optimise service user outcomes and support the work of mental health services.”
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Care is often associated with high distress and perceived burden, as well as feelings of confusion, guilt, embarrassment, and exhaustion.
“Care is often associated with high distress and perceived burden, as well as feelings of confusion, guilt, embarrassment, and exhaustion (4, 5).”
From Internet-based psychoeducation and support programme for relatives of young people with early psychosis: results of the first German-language intervention (2024) · cites this paper as [4]
The Caregiving Experiences section says caregiving in psychosis can be stressful and burdensome, and reports psychological distress and emotional exhaustion among carers. It does not substantiate the specific feelings of confusion, guilt, or embarrassment in the claim. Page numbers are unavailable in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe ePSP content is based on scientific evidence and psychological interventions, mainly cognitive-behavioural therapy, communication and problem-solving skills learning programmes, self-care interventions including Mindfulness, and peer-support principles in the context of family interventions for psychosis.
“The content is based on scientific evidence and psychological interventions (mainly cognitive-behavioural therapy, CBT), communication and problem-solving skills learning programmes, self-care interventions (including Mindfulness), and peer-support principles in the context of family interventions for psychosis (3, 4, 13–15).”
From Internet-based psychoeducation and support programme for relatives of young people with early psychosis: results of the first German-language intervention (2024) · cites this paper as [4]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredCarers' burden and stress can lead to a more critical and hostile attitude in caregiving.
“Carers’ burden and stress can also lead to a more critical and hostile attitude in caregiving (4), with detrimental effects on the person cared for and their recovery outcomes (8).”
The caregiver role is often difficult and exerts a significant impact on the carer's own mental health.
“The caregiver role is often difficult and exerts a significant impact on the carer’s own mental health (3, 4).”
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What Do Relatives of People With Schizophrenia Find Helpful About Family Intervention?
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Somerset's family interventions in psychosis service: an update
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The NICE schizophrenia guidelines: the challenge of implementation1
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Social networks and support in early psychosis: potential mechanisms
Sündermann, O., Onwumere, J., Bebbington, P., & Kuipers, E. (2012) · Epidemiology and Psychiatric Sciences · doi:10.1017/s2045796012000601 · Cited by 33 · see citing works
Self-citationNilsen, L., Frich, J. C., Friis, S., et al. (2014) · Early Intervention in Psychiatry · doi:10.1111/eip.12153 · Cited by 32 · see citing works
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Family Intervention in routine practice: it is possible!
KELLY, M., & Newstead, L. (2004) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/j.1365-2850.2004.00689.x · Cited by 30 · see citing works
Telepsychiatry and carer education for schizophrenia
Haley, C., O’Callaghan, E., Hill, S., Mannion, N., Donnelly, B., Kinsella, A., Murtagh, A., & Turner, N. (2010) · European Psychiatry · doi:10.1016/j.eurpsy.2009.12.021 · Cited by 29 · see citing works
The humanistic and economic burden of providing care for a patient with schizophrenia
Csoboth, C. T., Witt, E. A., Villa, K. F., & O’Gorman, C. (2015) · International Journal of Social Psychiatry · doi:10.1177/0020764015577844 · Cited by 29 · see citing works
The Meriden Family Programme: Lessons learned over 10 years
Fadden, G., & Heelis, R. (2010) · Journal of Mental Health · doi:10.3109/09638237.2010.492413 · Cited by 28 · see citing works
Lowenstein, J. A., Butler, D., & Ashcroft, K. (2010) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/j.1365-2850.2010.01564.x · Cited by 25 · see citing works
A study of family contact with clients and staff of community mental health teams
Krupnik, Y., Pilling, S., Killaspy, H. T., & Dalton, J. (2005) · Psychiatric Bulletin · doi:10.1192/pb.29.5.174 · Cited by 25 · see citing works
Family interventions in schizophrenia: Issues of relevance for Asian countries
Chakrabarti, S. (2011) · World Journal of Psychiatry · doi:10.5498/wjp.v1.i1.4 · Cited by 24 · see citing works
A pilot investigation of a brief, needs‐led caregiver focused intervention in psychosis
Roddy, S., Onwumere, J., & Kuipers, E. (2014) · Journal of Family Therapy · doi:10.1111/1467-6427.12054 · Cited by 21 · see citing works
Self-citationA preliminary study of the impact of long term psychotic disorder on patients' families
de Silva, D., & Silva, S. D. (2014) · Ceylon Medical Journal · doi:10.4038/cmj.v46i4.6429 · Cited by 20 · see citing works
Family Interventions in Schizophrenia: Promise and Pitfalls over 30 Years
Glynn, S. M. (2012) · Current Psychiatry Reports · doi:10.1007/s11920-012-0265-z · Cited by 20 · see citing works
Schizophrenia through the carers' eyes: results of a European cross‐sectional survey
Svettini, A., Johnson, B., Magro, C., SAUNDERS, J. R., Jones, K., Silk, S., Hargarter, L., & Schreiner, A. (2015) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/jpm.12209 · Cited by 19 · see citing works
Stress response symptoms in relatives of acutely admitted psychotic patients: A pilot study
Boye, B., & Malt, U. F. (2002) · Nordic Journal of Psychiatry · doi:10.1080/08039480260242732 · Cited by 19 · see citing works
Ince, P. G., Tai, S., & Haddock, G. (2014) · Journal of Mental Health · doi:10.3109/09638237.2014.958213 · Cited by 18 · see citing works
Family Intervention and Health Care Costs for Kansas Medicaid Patients with Schizophrenia
Christenson, J. D., Crane, D. R., Bell, K. M., Beer, A., & Hillin, H. H. (2013) · Journal of Marital and Family Therapy · doi:10.1111/jmft.12021 · Cited by 18 · see citing works
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Italian Families and Family Interventions
CASACCHIA, M., & Roncone, R. (2014) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000000149 · Cited by 14 · see citing works
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Challenges for group leaders working with families dealing with early psychosis: a qualitative study
Nilsen, L., Norheim, I., Frich, J. C., Friis, S., & Røssberg, J. I. (2015) · BMC Psychiatry · doi:10.1186/s12888-015-0540-8 · Cited by 9 · see citing works
Family Work for Schizophrenia: A Practical Guide, 2nd ed
PRIDMORE, S. A. (1994) · American Journal of Psychiatry · doi:10.1176/ajp.151.4.613 · Cited by 9 · see citing works
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Polo-López, R., Salaberria, K., & Echeburúa, E. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.02.005 · Cited by 8 · see citing works
Family Interventions in Psychosis
Onwumere, J., Hunter, E. C. M., & Kuipers, E. (2014) · Springer eBooks · doi:10.1007/978-3-642-45257-4_13 · Cited by 4 · see citing works
Self-citationTj, B., Lovell, K., & Richards, D. A. (2000) · Cited by 4 · see citing works
Family intervention in psychosis
Onwumere, J., Smith, B. H., & Kuipers, E. (2008) · Oxford University Press eBooks · doi:10.1093/med:psych/9780199206315.003.0017 · Cited by 3 · see citing works
Self-citation
Flagged first, then by citations
3 of the 138 references couldn’t be matched to a known paper.
Research works printed but not linked: 6
- Barrowclough C., 1992, Families of schizophrenia patients: Cognitive behavioural intervention
- Bradshaw T., 2000, Mental Health Nursing, 20, 10
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Cited by
Sorted by citations
Do Family Interventions Improve Outcomes in Early Psychosis? A Systematic Review and Meta-Analysis
Claxton, M., Onwumere, J., & Fornells‐Ambrojo, M. (2017) · Frontiers in Psychology · doi:10.3389/fpsyg.2017.00371 · Cited by 165 · see citing works
“It is important to recognize that not all families will require intervention or find it acceptable (Cohen et al., 2010; Onwumere et al., 2016).”
BackgroundSelf-citationSchizophrenia: Impact on Family Dynamics
Caqueo‐Urízar, A., Rus‐Calafell, M., Craig, T., Irarrázaval, M., Alfonso Urzúa, M., Boyer, L., & Williams, D. R. (2017) · Current Psychiatry Reports · doi:10.1007/s11920-017-0756-z · Cited by 87 · see citing works
Fornells‐Ambrojo, M., Johns, L., Onwumere, J., Garety, P. A., Milosh, C., Iredale, C., PETERS, E. R., Webster, A., & Jolley, S. (2017) · British Journal of Clinical Psychology · doi:10.1111/bjc.12136 · Cited by 34 · see citing works
Self-citationMucci, A., Kawohl, W., Maria, C., & Wooller, A. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.00761 · Cited by 30 · see citing works
Digital Technology for Caregivers of People With Psychosis: Systematic Review
Onwumere, J., Amaral, F., & Valmaggia, L. (2018) · JMIR Mental Health · doi:10.2196/mental.9857 · Cited by 27 · see citing works
Self-citationMa, C. F., Chan, S. K. W., Chien, W. T., Bressington, D. T., Mui, E. Y. W., Lee, E. H. M., & Chen, E. Y. H. (2019) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/jpm.12567 · Cited by 25 · see citing works
Developing a guideline for structured content and process in mental health nursing handover
Cowan, D., Brunero, S., Luo, X., Bilton, D., & Lamont, S. (2017) · International Journal of Mental Health Nursing · doi:10.1111/inm.12337 · Cited by 24 · see citing works
Caregiver correlates of patient-initiated violence in early psychosis
Smith, L. M., Onwumere, J., Craig, T., & Kuipers, E. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2018.09.011 · Cited by 19 · see citing works
“However, the potential negative impacts of caregiving in psychosis can also be wide-ranging and variously effect caregivers’ health and wellbeing, finances and relationships with others (Onwumere et al., 2016; Jansen et al., 2015).”
BackgroundSelf-citationRole of poor sleep in determining distress in caregivers of individuals with early psychosis
Smith, L. M., Onwumere, J., Craig, T., & Kuipers, E. (2018) · Early Intervention in Psychiatry · doi:10.1111/eip.12538 · Cited by 19 · see citing works
Self-citationMorrison, A. P., Pyle, M., Byrne, R. E., Broome, M. R., Freeman, D. H., Johns, L., James, A. C., Husain, N., Whale, R., MacLennan, G., et al. (2021) · Health Technology Assessment · doi:10.3310/hta25040 · Cited by 13 · see citing works
Mabunda, N. F., Mangena-Netshikweta, M. L., Lebese, R. T., et al. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph191710511 · Cited by 8 · see citing works
“Families may also experience varying levels of negative effects, such as stress, exhaustion, and physical health problems [5].”
BackgroundImplementing a family‐inclusive practice model in youth mental health services in Australia
Poon, A. W. C., Harvey, C. A., Fuzzard, S., & O’Hanlon, B. (2017) · Early Intervention in Psychiatry · doi:10.1111/eip.12505 · Cited by 8 · see citing works
“*Statistical significance of at least .05. a means reversed coded items that are changed to similar direction as other items. practitioners’ anxiety about working with families (O'Hanlon, 2015; Onwumere et al., 2016).”
BackgroundKavanagh, D. J. (2016) · Australian Psychologist · doi:10.1111/ap.12205 · Cited by 8 · see citing works
Iswanti, D. I., Nursalam, N., Rizki Fitryasari, P. K., Mendrofa, F. A. M., & Kandar, K. (2023) · Journal of Psychosocial Nursing and Mental Health Services · doi:10.3928/02793695-20231018-02 · Cited by 14 · see citing works
Rus-Calafell, M., Teismann, T., Kullmann, F., Alatas, D., Ballero-Reque, C., Holewa, J., Rüsberg, M., Brüne, M., Paino, M., & Schneider, S. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1248526 · Cited by 5 · see citing works
“Care is often associated with high distress and perceived burden, as well as feelings of confusion, guilt, embarrassment, and exhaustion (4, 5).”
BackgroundState of the art in psychological therapies for psychosis: Family interventions for psychosis
Jolley, S., & Grice, S. (2023) · Psychology and psychotherapy · doi:10.1111/papt.12487 · Cited by 6 · see citing works
“…time, a service structure supporting referral and intervention, and, crucially, supervision that assesses ongoing adherence to the intended intervention (e.g., FIp specifically as opposed to other modalities of family work applied to psychosis; Jolley et al., 2012; Onwumere et al., 2016).”
Self-citationHsiao, C., Lu, H., & Tsai, Y. (2020) · Journal of Mental Health · doi:10.1080/09638237.2020.1818703 · Cited by 5 · see citing works
“To facilitate dyadic mutuality, resilience-based psychotherapeutic interventions should be implemented to help the dyads foster communication, find gratification, and discover the meaning of caregiving as well as satisfy their respective concerns (Onwumere et al., 2016).”
BackgroundUnderstanding the complex family experiences of Behavioural Family Therapy
O’Hanlon, B., Hayes, L., PERLESZ, A. J., & Harvey, C. A. (2016) · Journal of Family Therapy · doi:10.1111/1467-6427.12139 · Cited by 5 · see citing works
Shepherd, M., & Butler, L. (2020) · Journal of Family Therapy · doi:10.1111/1467-6427.12323 · Cited by 7 · see citing works
Fan, X., Zhao, X., Zhu, B., & Qin, H. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.00215 · Cited by 4 · see citing works
“Good family function can reduce the relapse rate and improve the prognosis of schizophrenia (16).”
BackgroundThe role of key workers in improving physical health in first episode psychosis: A scoping review
Lim, J., McCombe, G., Harrold, Á., Brown, K., Clarke, M., Hanlon, D., Hennessy, L., O’Brien, S., Lyne, J., Corcoran, C., et al. (2020) · Early Intervention in Psychiatry · doi:10.1111/eip.12937 · Cited by 3 · see citing works
Smith, L. M., Onwumere, J., Craig, T., & Kuipers, E. (2020) · Transcultural Psychiatry · doi:10.1177/1363461519900596 · Cited by 3 · see citing works
Self-citationThompson, O., Griffiths, M., Allen, J., & Jones, F. W. (2019) · Journal of Family Therapy · doi:10.1111/1467-6427.12264 · Cited by 3 · see citing works
“with attention to crisis management, family problem-solving, coping strategies and support (NICE, 2014) as well as psycho-education tailored to the information needs of the family (Onwumere et al., 2016).”
BackgroundBaena, E. (2023) · Journal of Biomedical Research & Environmental Sciences · doi:10.37871/jbres1841 · Cited by 1 · see citing works
Scoping Review of Family Interventions That Support the Physical Health of Caregivers
Poon, A. W. C., Lappin, J., Cassidy, A., & Breckenridge, J. (2020) · Research on Social Work Practice · doi:10.1177/1049731520974444 · Cited by 2 · see citing works
“Family therapeutic methods using cognitive behavioral or systemic approaches are some ways to help carers deal with the demands of caregiving, solve problems, and improve the family atmosphere (Onwumere et al., 2016; Thorning & Dixon, 2016).”
MethodTettamanti, M., Chantraine, F., Schmitt, P., & Curtis, L. (2019) · Annales Médico-psychologiques revue psychiatrique · doi:10.1016/j.amp.2018.10.019 · Cited by 2 · see citing works
A unique regional family interventions training programme
Burbach, F., Sherbersky, H., Whitlock, R., Rapsey, E. H. S., Wright, K. A., & Handley, R. V. (2018) · The Journal of Mental Health Training Education and Practice · doi:10.1108/jmhtep-03-2018-0015 · Cited by 2 · see citing works
Who Gets FIp ? Understanding Contextual Factors in EIP Provision
Ferner, H. S., Parkyn, G., Onwumere, J., & Fornells‐Ambrojo, M. (2026) · Early Intervention in Psychiatry · doi:10.1111/eip.70184
“These figures are likely an underestimate (e.g., Read and Fraser 1998) and align with a growing body of literature on health and social inequalities in psychosis (Onwumere, Grice, and Kuipers 2016; Shiers et al. 2015).”
Self-citationSmith, G., Cummings, A. J., Bain, H., et al. (2025) · International Journal of Mental Health Nursing · doi:10.1111/inm.70143
Ma, C. F., Chien, W. T., Chan, S. K. W., & Wong, C. L. (2022) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd014970
Craig, T. (2022) · doi:10.1093/med/9780198861478.003.0035
Tettamanti, M., Bessero, S., & Curtis, L. (2021) · Annales Médico-psychologiques revue psychiatrique · doi:10.1016/j.amp.2021.09.020
Fekih, L. (2018) · International Journal of Education Culture and Society · doi:10.11648/j.ijecs.20180303.14
“According to Onwumere [34] it is wrong to consider the family interventions as a part of mental health worker’s effective role as current evidence suggests that the existence of good practice and provision for family interventions.”
Background
- Authors
- Onwumere, J., Grice, S., & Kuipers, E.
- Affiliations
- King's College London (GB)
- Corresponding author
- Onwumere, Juliana
- Venue
- Australian Psychologist
- Publisher
- Informa UK Limited
- Published
- 2016-02-01
- Volume
- 51
- Issue
- 1
- Pages
- 52-61
- ISSN
- 0005-0067 (ISSN-L)
- 1742-9544
- OpenAlex
- W2262793234
- Cited by
- 33
- References
- 138
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 1 · 2023: 3 · 2022: 3 · 2021: 2 · 2020: 7 · 2019: 3 · 2018: 5 · 2017: 5 · 2016: 2
- FWCI
- 6.70
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Australian Psychologist (publishedVersion)
- Research Portal (King's College London) (submittedVersion, cc-by)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Family Caregiving in Mental Illness
- Social Sciences › Psychology › Clinical Psychology › Counseling, Therapy, and Family Dynamics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Keywords
- schizophrenia, psychosis, early intervention teams, usual care
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