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Cited by 225Family Caregiving in Mental IllnessCounseling, Therapy, and Family DynamicsSchizophrenia research and treatment

Cognitive model of caregiving in psychosis

Open access
Kuipers, Elizabeth, Onwumere, Juliana, Bebbington, Paul·2010·British Journal of Psychiatry
DOI 10.1192/bjp.bp.109.070466
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Abstract

BACKGROUND: There is a long history of research into the attributes of carers of people with psychosis, but few interventions target their distress or their difficulties. AIMS: To describe an empirically based model of the relationships of those caring for people with psychosis to inform clinical and theoretical advances. METHOD: We developed a model of informal carer relationships in psychosis, based on an integration of the literature elaborating the concept of expressed emotion. The model accounts for divergent outcomes of three relationship types: positive, overinvolved and critical/hostile relationships. RESULTS: Good evidence supports a number of hypotheses concerning the origin and maintenance of these relationship outcomes, which relate to specific differences in carer attributions, illness perceptions, coping behaviour, social support, distress, depression and low self-esteem predicted by our model. We propose that interventions aimed at modifying the specific maintenance factors involved in the different styles of relationships will optimise therapeutic change both for service users with psychosis and for their carers. CONCLUSIONS: Family work in psychosis, which improves relationships through problem-solving, reduces service user relapse. It is now time to consider theory-based interventions focused on improving carer outcomes.

Integrity signals

Registry

Crossref · 10.1192/bjp.bp.109.070466

Cites

76 of 76 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 117 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Service users with carers demonstrated better outcomes from cognitive-behavioural therapy or family intervention.

    “Our own intervention study showed that service users with carers demonstrated better outcomes from cognitive-behavioural therapy or family intervention.70”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [70] 70. Garety PA, Fowler DG, Freeman D, Bebbington P, Dunn G, Kuipers E. Cognitive-behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: randomised controlled trial. Br J Psychiatry 2008; 192: 412-23.

      Not checked in the free run.

  • Premisecitation

    Carers' evaluations of their circumstances and resources matter more to carer and service-user outcomes than the apparent severity or scope of the problems they face.

    “Carers' appraisals of their situation and of the resources they have to cope with it are more crucial to both carer and service user outcomes than the apparent severity or scope of the problems faced.6”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] 6. Scazufca M, Kuipers E. Links between expressed emotion and burden of care in relatives of patients with schizophrenia. Br J Psychiatry 1996; 168: 580-7. source

      Not checked in the free run.

  • Premisecitation

    Perceptions of carer criticism are linked to poorer service-user functioning.

    “and perceptions of carer criticism have in turn been linked to poorer service user functioning.27”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27] 27. Onwumere J, Kuipers E, Bebbington P, Dunn G, Freeman D, Fowler D, et al. Patient perceptions of caregiver criticism in psychosis links with patient and caregiver functioning. J Nerv Ment Dis 2009; 197: 85-91. source

      Not checked in the free run.

  • Premisecitation

    High-criticism carers are more likely to make controllable and personal attributions, both in psychosis and in other disorders such as diabetes.

    “Since then it has become clear that high-criticism carers are more likely to make 'controllable' and 'personal' attributions, both in psychosis and in other disorders such as diabetes.23,24”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [23] 23. Barrowclough C, Hooley JM. Attributions and expressed emotion: a review. Clin Psychol Rev 2003; 23: 849-80.

      Not checked in the free run.

    • cites [24] 24. Wearden AJ, Ward J, Barrowclough C, Tarrier N, Davies R. Attributions for negative events in the partners of adults with type I diabetes: associations with partners' expressed emotion and marital adjustment. Br J Health Psychol 2006; 11: 1-21.

      Not checked in the free run.

  • Premisecitation

    Active and proactive strategies are better at reducing carer burden, even in the early stages of illness.

    “Active and proactive strategies seem better at reducing the impact on levels of carer burden, even in the early stages of illness.19,43,46”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [19] 19. Raune D, Kuipers E, Bebbington PE. Expressed emotion at first-episode psychosis: investigating a carer appraisal model. Br J Psychiatry 2004; 184: 321-6. source

      Not checked in the free run.

    • cites [43] 43. Scazufca M, Kuipers E. Coping strategies in relatives of people with schizophrenia before and after psychiatric admission. Br J Psychiatry 1999; 174: 154-8. source

      Not checked in the free run.

    • cites [46] 46. Magliano L, Fadden G, Economou M, Held T, Xavier M, Guarneri M, et al. Family burden and coping strategies in schizophrenia: 1-year follow-up data from the BIOMED I study. Soc Psychiatry Psychiatr Epidemiol 2000; 35: 109-15.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims. 27
  • Classified as probably not a substantial claim. 18
  • The quote only partly states this claim. 2

  • May combine two claims.

    Findingcitation

    In an analysis of prospective studies, high expressed emotion is a reliable predictor of patient outcomes in schizophrenia; relapse was 21% in low-EE families versus 50% in high-EE families.

    “We have shown, in an analysis of prospective studies, that high levels of this expressed emotion (EE) are a reliable predictor of patient outcomes in schizophrenia: overall, the relapse rate for those returning to families with low EE was 21% compared with a 50% relapse rate in families with high EE.18”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] 18. Bebbington P, Kuipers L. The predictive utility of expressed emotion in schizophrenia -an aggregate analysis. Psychol Med 1994; 24: 707-18.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Coping depends on accurate appraisal of situations, on one's resources, and on how these are marshalled.

    “This is based on the ideas of Lazarus & Folkman that coping itself depends on accurate appraisal of situations, on one's resources and on how these are marshalled.45”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [45] 45. Lazarus RS, Folkman S. Stress Appraisal and Coping. Springer, 1984.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The model accounts for divergent outcomes of three relationship types: positive, overinvolved, and critical/hostile.

    “The model accounts for divergent outcomes of three relationship types: positive, overinvolved and critical/hostile relationships.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    In psychosis, avoidant coping may be useful for problems that resolve naturally, but not for more enduring or worsening problems.

    “In psychosis, avoidant coping (a style of emotional response characterised by 'hoping problems will go away') may be useful for problems that resolve naturally, but not with more enduring or worsening problems.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Critical carers' attributions relate to greater carer distress and more negative evaluations of the caring role.

    “This in turn relates to greater carer distress and negative evaluations of the caring role.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Few interventions target carers' distress or difficulties.

    “There is a long history of research into the attributes of carers of people with psychosis, but few interventions target their distress or their difficulties.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    High expressed emotion and burden are related to poorer carer outcomes such as stress, distress and low self-esteem, and to less effective avoidant coping, even at first episode.

    “It was also related to poor carer outcomes such as stress, distress and low self-esteem, and to less effective, avoidant coping, even at first episode.19,20”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] 19. Raune D, Kuipers E, Bebbington PE. Expressed emotion at first-episode psychosis: investigating a carer appraisal model. Br J Psychiatry 2004; 184: 321-6. source

      Not checked in the free run.

    • cites [20] 20. Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, Watson P et al. Influence of carer expressed emotion and affect on relapse in non-affective psychoses. Br J Psychiatry 2006; 188: 173-9. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Carers' appraisals of and reactions to their role affect their own well-being and may improve or impede recovery in those they care for.

    “Carers' appraisals of and reactions to their role not only affect their own well-being, but also may improve or impede recovery in those they care for.18”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] 18. Bebbington P, Kuipers L. The predictive utility of expressed emotion in schizophrenia -an aggregate analysis. Psychol Med 1994; 24: 707-18.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Family work in psychosis improves relationships through problem-solving and reduces service-user relapse.

    “Family work in psychosis, which improves relationships through problem-solving, reduces service user relapse.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [54] 54. National Institute for Health and Clinical Excellence. Schizophrenia (Update). Clinical Guidelines CG82. NICE, 2009 (http://www.guidance.nice.org.uk/ CG82).

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [55] 55. Pharoah F, Mari J, Rathbone J, Wong W. Family intervention for schizophrenia. Cochrane Database Syst Rev 2006; 4: CD000088. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Caring for a family member with psychosis is demanding, often prolonged, and linked with higher stress and distress.

    “Caring for a family member with psychosis is demanding, often prolonged, and associated with increased levels of stress and distress.6,[9][10][11]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [6] 6. Scazufca M, Kuipers E. Links between expressed emotion and burden of care in relatives of patients with schizophrenia. Br J Psychiatry 1996; 168: 580-7. source

      Not checked in the free run.

    • cites [9][10][11]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    If carers feel they are not in control of their relative's illness and that it will last a long time, they experience more stress and depression and have more negative views of the impact of care.

    “if carers feel that they are not in control of their relative's illness and that it will last a long time, they experience more stress and depression and have more negative views of the impact of care.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [30] 30. Lobban F, Barrowclough C, Jones S. Assessing cognitive representations of mental health problems. II. The illness perception questionnaire for schizophrenia: relatives' version. Br J Clin Psychol 2005; 44: 163-79. source

      Not checked in the free run.

    • cites [31] 31. Onwumere J, Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, et al. Caregiving and illness beliefs in the course of psychotic illness. Can J Psychiatry 2008; 53: 460-8. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    As many as one third of carers meet criteria for post-traumatic stress disorder.

    “Recent evidence suggests that as many as a third of carers meet criteria for post-traumatic stress disorder.12”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] 12. Barton K, Jackson C. Reducing symptoms of trauma among carers of people with psychosis: pilot study examining the impact of writing about caregiving experiences. Aust N Z J Psychiatry 2008; 42: 693-701. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Social support reduces distress and encourages more proactive coping in carers.

    “The importance of social support in reducing distress and encouraging more proactive coping in carers has been confirmed.51,52”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [51] 51. Joyce J, Leese M, Kuipers E, Szmukler G, Harris T, Staples E. Evaluating a model of caregiving for people with psychosis. Soc Psychiatry Psychiatr Epidemiol 2003; 38: 189-95.

      Not checked in the free run.

    • cites [52] 52. Magliano L, Fiorillo A, Malangone C, Marasco C, Guarneri M, Maj M, et al. The effect of social network on burden and pessimism in relatives of patients with schizophrenia. Am J Orthopsychiatry 2003; 73: 302-9.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    Carers in critical/hostile relationships are likely to be angry, upset, anxious and depressed, may have low self-esteem, and feel that nothing they do makes a difference.

    “In this relationship type, carers themselves are likely to be angry, upset, anxious and depressed.They may have low self-esteem, and feel that nothing they can do will make any difference.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationreasoning

    In critical/hostile relationships, a longer duration of untreated psychosis is likely, associated with poor role performance.

    “In this relationship style a longer duration of untreated psychosis is likely, associated with poor role performance.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    These appraisals engender carer cognitive and affective reactions and lead to carer behaviours towards service users and services and to different carer outcomes.

    “It is these appraisals that engender carer cognitive and affective reactions, and lead to a range of carer behaviours towards service users and towards services, and to different carer outcomes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    This depression is associated with more avoidant coping, low self-esteem and pessimism.

    “This is associated with more avoidant coping, low self-esteem and an understandable pessimism.20”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] 20. Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, Watson P et al. Influence of carer expressed emotion and affect on relapse in non-affective psychoses. Br J Psychiatry 2006; 188: 173-9. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    In overinvolved relationships, carers experience worry, stress, anxiety, depression and guilt.

    “Worried, stressed, anxious, feels depressed and guilty”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [35] 35. Grice SJ, Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, et al. Carers' attributions about positive events in psychosis relate to expressed emotion. Behav Res Ther 2009; 47: 783-9. source

      Not checked in the free run.

    • cites [63] 63. Leff J, Vaughn C. Expressed Emotion in Families. Guilford, 1985.

      Not checked in the free run.

    • cites [64] 64. Bentsen H, Notland TH, Munkvold OG, Boye B, Ulstein I, Bjorge H, et al. Guilt proneness and expressed emotion in relatives of patients with schizophrenia or related psychoses. Br J Med Psychol 1998; 71: 125-38. source

      Not checked in the free run.

    • cites [65] 65. Peterson EC, Docherty NM. Expressed emotion, attribution, and control in parents of schizophrenic patients. Psychiatry 2004; 67: 197-207. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    In overinvolved relationships, carers take over adult roles and responsibilities, and the service user can become childlike.

    “Takes over adult roles and responsibilities, service user can become childlike”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [35] 35. Grice SJ, Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, et al. Carers' attributions about positive events in psychosis relate to expressed emotion. Behav Res Ther 2009; 47: 783-9. source

      Not checked in the free run.

    • cites [63] 63. Leff J, Vaughn C. Expressed Emotion in Families. Guilford, 1985.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [64] 64. Bentsen H, Notland TH, Munkvold OG, Boye B, Ulstein I, Bjorge H, et al. Guilt proneness and expressed emotion in relatives of patients with schizophrenia or related psychoses. Br J Med Psychol 1998; 71: 125-38.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [65] 65. Peterson EC, Docherty NM. Expressed emotion, attribution, and control in parents of schizophrenic patients. Psychiatry 2004; 67: 197-207. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    In critical/hostile relationships, earlier relationships between service users and carers will often have been poor, with a long history of adolescent turmoil and poor school performance.

    “Earlier relationships between service users and carers will often have been poor, with the service user perhaps displaying a long history of adolescent turmoil and poor performance at school.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Emotional overinvolvement in carers of people with psychosis is a strong marker of poor current psychological and physical health and may indicate poor future health.

    “Emotional overinvolvement in those caring for people with psychosis is a strong marker of poor current psychological and physical health.The evidence suggests that it may also be an indicator of poor future health. 62”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [62] 62. Breitborde N, Lopez S, Chang C, Kopelowicz A, Zarate R. Emotional over- involvement can be deleterious for caregivers' health. Soc Psychiatry Psychiatr Epidemiol 2010; 44: 716-23. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Study design and conductnone given

    The typology of caregiving characteristics is based in empirical research.

    “Although our typology of the characteristics of caregiving can never be exact, it is based in empirical research, and we think it will be of use in shaping interventions to the needs of caregivers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Critical and hostile attitudes are the more common negative reactions to the stresses of the caring role in psychosis.

    “Critical and hostile attitudes are the more common negative reactions to the stresses of the caring role in psychosis”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Critical and hostile attitudes can be found in all types of carer, whether parents, partners, children or siblings.

    “be found in all types of carer, whether parents, partners, children or siblings.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Interpretationreasoning

    Three different caregiving styles or types are supported by evidence: positive, overinvolved, and critical/hostile.

    “Given the overall model, we suggest further that three different styles or types are at present supported by the evidence, interpreted in the light of clinical experience of intervention with families dealing with psychosis.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    In critical or hostile relationships, carers have low self-esteem, depression and frustration.

    “Low self-esteem, depression, frustration”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] 19. Raune D, Kuipers E, Bebbington PE. Expressed emotion at first-episode psychosis: investigating a carer appraisal model. Br J Psychiatry 2004; 184: 321-6. source

      Not checked in the free run.

    • cites [20] 20. Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, Watson P et al. Influence of carer expressed emotion and affect on relapse in non-affective psychoses. Br J Psychiatry 2006; 188: 173-9. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Long-standing carers may be more optimistic than those caring for people at an early stage of illness.

    “When asked, long-standing carers may be more optimistic than those caring for people at an early stage of their illness.31”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] 31. Onwumere J, Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, et al. Caregiving and illness beliefs in the course of psychotic illness. Can J Psychiatry 2008; 53: 460-8. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    In critical or hostile relationships, carers experience anger, stress, anxiety and worry.

    “Angry, stressed, anxious, worried”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] 19. Raune D, Kuipers E, Bebbington PE. Expressed emotion at first-episode psychosis: investigating a carer appraisal model. Br J Psychiatry 2004; 184: 321-6. source

      Not checked in the free run.

    • cites [20] 20. Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, Watson P et al. Influence of carer expressed emotion and affect on relapse in non-affective psychoses. Br J Psychiatry 2006; 188: 173-9. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    In critical or hostile relationships, longer duration of untreated psychosis is likely because the service user may withdraw and not discuss problems.

    “Longer DUP likely, as service user may withdraw and not discuss problems”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationreasoning

    More problems then occur, confirming that the only solution is the struggle to get better treatment.

    “More problems then occur, confirming that the only solution is the struggle to get better treatment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    In critical or hostile relationships, carers believe the service user needs to get better and to control problems.

    “Service user needs to get better and to control problems”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [23] 23. Barrowclough C, Hooley JM. Attributions and expressed emotion: a review. Clin Psychol Rev 2003; 23: 849-80. source

      Not checked in the free run.

    • cites [35] 35. Grice SJ, Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, et al. Carers' attributions about positive events in psychosis relate to expressed emotion. Behav Res Ther 2009; 47: 783-9. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    In critical or hostile relationships, the carer may be a parent, spouse, sibling or child.

    “Carer may be parent, spouse, sibling or child”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    Families may become stuck at initial stages, unable to adapt to current reality or new problems, because it feels like defeat or giving up.

    “Families may also become 'stuck' at these initial stages, finding it impossible to adapt to the current reality or to new problems, because this feels like a defeat, giving up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    In critical or hostile relationships, carers are critical of the service user's behaviour and may reject the service user.

    “Critical of service user's behaviour, may reject service user”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] 19. Raune D, Kuipers E, Bebbington PE. Expressed emotion at first-episode psychosis: investigating a carer appraisal model. Br J Psychiatry 2004; 184: 321-6. source

      Not checked in the free run.

    • cites [20] 20. Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, Watson P et al. Influence of carer expressed emotion and affect on relapse in non-affective psychoses. Br J Psychiatry 2006; 188: 173-9. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    In critical or hostile relationships, carers appraise the service user as to blame, with personality seen as a problem (e.g. lazy).

    “Service user to blame, personality a problem (e.g.lazy)”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [23] 23. Barrowclough C, Hooley JM. Attributions and expressed emotion: a review. Clin Psychol Rev 2003; 23: 849-80.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [35] 35. Grice SJ, Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, et al. Carers' attributions about positive events in psychosis relate to expressed emotion. Behav Res Ther 2009; 47: 783-9. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    In critical or hostile relationships, previous problems are likely, including comorbid substance misuse and long duration of untreated psychosis with poor social functioning.

    “Previous problems Likely to have comorbid substance misuse Likely to have long DUP, characterised by poor social functioning”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Families who pass through the initial shock and stigma may find a way of seeing caregiving as enriching.

    “Families who pass through the initial shock and stigma may find a way of seeing caregiving as enriching.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    In critical or hostile relationships, the service user's psychotic episode may be dramatic, with more refusal of help and severe symptoms before services are involved.

    “May be dramatic presentation, as service user more likely to refuse help, symptoms may have to be severe before services can be involved”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Interpretationreasoning

    Carer exhaustion, exasperation with the service user and frustration with inadequate services may lead to no one in the family managing, with shared pessimism and cynicism.

    “The result may be that no one in the family is managing, and all that its members share is pessimism and cynicism.”
    Quote in the paperSubstantial claim
39 of 39

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • 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).”

    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 [3]

    The Impact of care section says caring for a family member with psychosis is demanding and associated with increased stress and distress. The paper explicitly limits its evidence to carers of people with psychosis, so it does not establish the claim for caregiving generally. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • The 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 [3]

    The Social support and Conclusions sections describe family interventions for psychosis that use problem-solving, and the Not clinically depressed section discusses changing negative communication patterns. The paper also recommends contact with other carers and attention to carers’ own wellbeing, but it does not describe ePSP content, mindfulness, or CBT as the main basis of these family interventions. The indexed passages provide no page numbers. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

Cites

Flagged first, then by citations

4 of the 80 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. Kuipers, 2005, Families and Mental Disorder: From Burden to Empowerment
  2. Breitborde, 2010, Emotional overinvolvement can be deleterious for caregivers' health, Soc Psychiatry Psychiatr Epidemiol, 44
  3. 2009, Schizophrenia (Update)

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Authors
Kuipers, E., Onwumere, J., & Bebbington, P.
Affiliations
  • King's College London (GB)
  • University College London (GB)
Corresponding author
Kuipers, Elizabeth
ORCID
Venue
British Journal of Psychiatry
Publisher
Royal College of Psychiatrists
Published
2010-04
Volume
196
Issue
4
Pages
259-265
ISSN
  • 0007-1250 (ISSN-L)
  • 1472-1465
DOI
10.1192/bjp.bp.109.070466
OpenAlex
W2160092944
Cited by
225
References
80
Citations by year
2026: 14 · 2025: 7 · 2024: 13 · 2023: 13 · 2022: 11 · 2021: 12 · 2020: 11 · 2019: 15 · 2018: 13 · 2017: 20 · 2016: 14 · 2015: 21 · 2014: 19 · 2013: 15 · 2012: 10
FWCI
1.91
Type
journal article
Language
en
Open access
Licence
www.cambridge.org/core/terms (unspecified, 2833 d)
Locations
  • The British Journal of Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Research Portal (King's College London) (submittedVersion)
Funders
  • South London and Maudsley NHS Foundation Trust
  • National Institute for Health and Care Research
  • King's College London
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
psychosis, informal caregivers, caregiver distress, expressed emotion, caregiver relationships, illness perception, coping behaviour, social support, family responsibilities, theory-based intervention, relapse prevention
MeSH terms
Adaptation, Psychological, Attitude to Health, Family Health, Humans, Interpersonal Relations, Models, Psychological, Psychotic Disorders, Caregivers, Expressed Emotion

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