Family intervention for Asian Americans with a schizophrenic patient in the family

An unexpected visitor and a sword play: a randomized controlled trial of collective narrative therapy groups for primary carers of people with schizophrenia

BACKGROUND

Most family carer support programs focus on supporting carers with caregiving-related knowledge and skills to help their family members who suffer from schizophrenia in their recovery process while carers' inner resources and preferred identities are less emphasized in the existing studies.

AIMS

The present study uses collective narrative therapy groups (CNTG) to promote the inner strengths and agency of family carers and help them to explore their preferred identities while caring for family members with schizophrenia.

METHOD

To ensure an evidence-based intervention, 89 Chinese family carers of people with schizophrenia took part in this three-wave longitudinal program evaluation study using a randomized controlled trial design.

RESULTS

Compared with the control group, family carers in CNTG reported better family relationships, a lesser caregiving burden, and more perceived inner resources. Repeated one-way ANOVA revealed that CNTG improved family relationships, the caregiving burden, the level of hope and inner resources in the posttest, and a statistically significantly better mental health condition in the follow-up.

CONCLUSION

This study shows that collective narrative psychotherapy is effective in supporting family carers of people with schizophrenia in Hong Kong. Based on the research findings, we discuss the strengths of the program and its implications for practitioners.

Family functioning and negative emotions in older adults: the mediating role of self-integrity and the moderating role of self-stereotyping

OBJECTIVES

The objective of this study was to examine a possible mediator role of self-integrity and a moderator role of self-stereotyping in the relationship between family functioning and negative emotions in older adults.

METHOD

A total of 1186 older adults participated in the current study. They completed measures related to family functioning, self-integrity, self-stereotyping, depression, anxiety, and loneliness.

RESULTS

Older adults with family dysfunction experienced more negative emotions than those with healthy family functioning, a finding which could be explained by the levels of self-integrity. Older adults with high levels of self-stereotyping, unhealthy family functioning, and low self-integrity were significantly more likely to be depressed and anxious than those with low levels of self-stereotyping.

CONCLUSION

Family functioning negatively predicted negative emotions, self-integrity mediated the link between family functioning and negative emotions, and self-stereotyping moderated the direct and indirect effects of family functioning on depression and anxiety via self-integrity.

Experiences of self-stigmatization and parenting in Chinese mothers with severe mental illness

Mental health stigma has serious ramifications on people with a severe mental illness (SMI). Stigma damages self-esteem, recovery outcomes, family relationships, socialization abilities, access to housing, and career prospects. The cultural tendencies of Chinese people have been shown to be associated with particularly high levels of stigmatization. These cultural tenets can result in high levels of self-stigma due to experiencing shame and a perceived need to keep mental illness a secret. Although there is a lack of existing evidence, it is possible that such experiences present unique challenges to Chinese mothers diagnosed with SMI when they parent their children. Therefore, this qualitative study explored the experiences of parenting and self-stigmatization of Chinese mothers with SMI. Individual semi-structured interviews were conducted with 15 mothers who were direct carers of their children aged under 18 and who were receiving community-based care in Hong Kong. Manual inductive thematic analysis was used to analyse the interview data. Three main themes related to self-stigmatization emerged from the interviews: (i) distancing and being distanced; (ii) doubting myself; and (iii) struggling for control. The experiences of self-stigmatization appeared to damage these mothers' self-efficacy, which may negatively affect their parenting self-esteem, tendency to seek professional help, and ability to manage their own mental health. Strategies to improve self-efficacy, including psychoeducation, and additional childcare support/resources are required for mothers with SMI so they can better manage and balance the demands of motherhood and their mental healthcare needs.

A Randomized Controlled Trial on Mutual Support Group Intervention for Families of People With Recent-Onset Psychosis: A Four-Year Follow-Up

Introduction: Recent research in Western countries has indicated that family interventions in schizophrenia and other psychotic disorders can reduce patient relapse and improve medication compliance. Few studies have addressed Chinese and Asian populations. This study tested the long-term effects of a 9-month family-led mutual support group for Chinese people with schizophrenia in Hong Kong, compared with psycho-education and standard psychiatric care. Methods: A randomized controlled trial of Chinese families of patients with recent-onset psychosis (≤5 years of illness) was conducted between August 2012 and January 2017, with a 4-year follow-up. Two hundred and one Chinese families of adult outpatients with recent-onset psychosis were randomly selected from the computerized patient lists and randomly assigned to either mutual support, psycho-education, or standard care group (n = 70 per group). Family caregivers were mainly the parent, spouse, or child of the patients. Mutual support and psycho-education group consisted of 16 two-hour group sessions and patients participated in three sessions. The standard care group and the two treatment groups received the routine psychiatric outpatient care. Results: Patients and families in the mutual support group reported consistently greater improvements in overall functioning [family functioning, F (2, 203) = 8.13, p = 0.003; patient functioning, F (2, 203) = 6.01, p = 0.008] and reductions in duration of hospitalizations [F (2, 203) = 6.51, p = 0.005] over the 4-year follow-up. There were not any significant increases of medication dosages or service use by both the family support and psycho-education groups over time. Conclusions: The peer-led family support group can be an effective psychosocial intervention in early psychosis indicating long-term benefits on both patient and family functioning and re-hospitalizations. Clinical Trial Registration: NCT00940394: https://register.clinicaltrials.gov.

Culturally adapted Family Intervention (CaFI) for African-Caribbean people diagnosed with schizophrenia and their families: a mixed-methods feasibility study of development, implementation and acceptability

Background

African-Caribbean people in the UK experience the highest incidence of schizophrenia and the greatest inequity in mental health care. There is an urgent need to improve their access to evidence-based care and outcomes. Family intervention (FI) is a National Institute for Health and Care Excellence-approved psychosocial intervention. Although clinically effective and cost-effective for schizophrenia, it is rarely offered. Evidence for any research into FI is lacking for ethnic minority people generally and for African-Caribbean people specifically.

Aims

(1) To assess the feasibility of delivering a novel, culturally appropriate psychosocial intervention within a ‘high-risk’ population to improve engagement and access to evidence-based care. (2) To test the feasibility and acceptability of delivering FI via ‘proxy families’.

Design

A mixed-methods, feasibility cohort study, incorporating focus groups and an expert consensus conference.

Setting

Two mental health trusts in north-west England.

Participants

We recruited a convenience sample of 31 African-Caribbean service users. Twenty-six family units [service users, relatives/family support members (FSMs) or both] commenced therapy. Half of the service users (n = 13, 50%), who did not have access to their biological families, participated by working with FSMs.

Interventions

An extant FI model was culturally adapted with key stakeholders using a literature-derived framework [Culturally adapted Family Intervention (CaFI)]. Ten CaFI sessions were offered to each service user and associated family.

Main outcome measures

Recruitment (number approached vs. number consented), attendance (number of sessions attended), attrition (number of dropouts at each time point), retention (proportion of participants who completed therapy sessions), and completeness of outcome measurement.

Results

Of 74 eligible service users, 31 (42%) consented to take part in the feasibility trial. The majority (n = 21, 67.7%) were recruited from community settings, seven (22.6%) were recruited from rehabilitation settings and three (9.7%) were recruited from acute wards. Twenty-four family units (92%) completed all 10 therapy sessions. The proportion who completed treatment was 77.42% (24/31). The mean number of sessions attended was 7.90 (standard deviation 3.96 sessions) out of 10. It proved feasible to collect a range of outcome data at baseline, post intervention and at the 3-month follow-up. The rating of sessions and the qualitative findings indicated that CaFI was acceptable to service users, families, FSMs and health-care professionals.

Limitations

The lack of a control group and the limited sample size mean that there is insufficient power to assess efficacy. The findings are not generalisable beyond this population.

Conclusions

It proved feasible to culturally adapt and test FI with a sample of African-Caribbean service users and their families. Our study yielded high rates of recruitment, attendance, retention and data completion. We delivered CaFI via FSMs in the absence of biological families. This novel aspect of the study has implications for other groups who do not have access to their biological families. We also demonstrated the feasibility of collecting a range of outcomes to inform future trials and confirmed CaFI’s acceptability to key stakeholders. These are important findings. If CaFI can be delivered to the group of service users with the most serious and persistent disparities in schizophrenia care, it has the potential to be modified for and delivered to other underserved groups.

Future work

A fully powered, multicentre trial, comparing CaFI with usual care, is planned.

Trial registration

Current Controlled Trials ISRCTN94393315.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 32. See the NIHR Journals Library website for further project information.

A Randomized Controlled Trial of Clinician-Supported Problem-Solving Bibliotherapy for Family Caregivers of People With First-Episode Psychosis

Family interventions for first-episode psychosis (FEP) are an integral component of treatment, with positive effects mainly on patients' mental state and relapse rate. However, comparatively little attention has been paid to the effects of family interventions on caregivers' stress coping and well-being, especially in non-Western countries. We aimed to test the effects of a 5-month clinician-supported problem-solving bibliotherapy (CSPSB) for Chinese family caregivers of people with FEP in improving family burden and carers' problem-solving and caregiving experience, and in reducing psychotic symptoms and duration of re-hospitalizations, compared with those only received usual outpatient family support (UOFS). A randomized controlled trial was conducted across 2 early psychosis clinics in Hong Kong, where there might be inadequate usual family support services for FEP patients. A total of 116 caregivers were randomly selected, and after baseline measurement, randomly assigned to the CSPSB or UOFS. They were also assessed at 1-week and 6- and 12-month post-intervention. Intention-to-treat analyses were applied and indicated that the CSPSB group reported significantly greater improvements in family burden and caregiving experience, and reductions in severity of psychotic symptoms and duration of re-hospitalizations, than the UOFS group at 6- and 12-month follow-up. CSPSB produces moderate long-term benefits to caregivers and FEP patients, and is a low-cost adjunct to UOFS.

Ethnic and gender variations in the associations between family cohesion, family conflict, and depression in older Asian and Latino adults

To examine the associations between family conflict, family cohesion and late-life depression in Latino and Asian populations and test if these associations vary by race/ethnicity and gender. We used a subsample of older adults from the National Latino Asian American Study (N = 395). All analyses were weighted and adjusted for individual and clinical characteristics. Greater family cohesion was associated with decrease in risk for depression in Latino and Asian older adult populations (OR: 0.68, 95% CI: 0.54, 0.84). These associations varied by gender, with men being more sensitive to family cohesion and family conflict than women. Asian older adults were more sensitive to family conflict, whereas Latino older adults were more sensitive to family cohesion. The quality of family relationships is strongly associated with late-life depression. Further research is needed to better understand the complex interplay between social support, ethnicity, and gender in latelife depression outcomes.

Family Interventions for Schizophrenia and the Psychoses: A Review

Family psychoeducation as a treatment for schizophrenia was developed 40 years ago almost simultaneously and independently by investigators who at the time were not family therapists. Although the original goal was to decrease high expressed emotion as a means of preventing relapse, later variations have gone beyond to focus on social and role functioning and family well-being. Explicitly disavowing the earlier assumptions that family pathology caused relapse and deterioration, family psychoeducation seeks to engage family members as more sophisticated partners, complementing interventions by clinicians with specialized interactions and coping skills that counter the neurologic deficits inherent to the disorder. It has proved to be one of the most consistently effective treatments available. Reports on outcome studies now number more than 100, while meta-analyses put relapse rate reduction at 50-60% over treatment as usual. The most recent application in first episode and prodromal psychosis, combined with other evidence-based interventions, is yielding perhaps the most promising results yet achieved-substantial return of functioning and avoidance of psychosis altogether. Reviewed here are its scientific, theoretical, and clinical sources, a description of the most commonly applied version-the multifamily group format, selected clinical trials spanning those four decades, international and ethnic adaptations, and studies on mechanisms of efficacy.

Understanding complexity of Asian American family care practices

This article describes, from mental health providers' perspectives, strengths and challenges in Asian American (AA) family management of mental illness in a member. AA family strengths included loyal engagement in care and creating productive roles for patients. Challenges included transitions to professional care, intense family involvement, care that overlooked needs of non-family members, and revision of expectations for patients.

The effectiveness and active ingredients of mutual support groups for family caregivers of people with psychotic disorders: a literature review

OBJECTIVES

To explore the literature through a systematic search to assess the effectiveness of mutual support groups for family caregivers of people with schizophrenia and other psychotic disorders.

METHODS

This review of the research literature was based on the procedures suggested by the National Health Service Centre for Reviews and Dissemination (2001) Report Number 4 in the UK [National Health Service Centre for Reviews and Dissemination, 2001. Undertaking Systematic Reviews of Research on Effectiveness: CRD's Guidance for those Carrying out or Commissioning Reviews (CRD Report Number 4). 2nd ed., University of York, York, UK]. A combined free-text and thesaurus approach was used to search relevant research studies within electronic databases, including Medline, Embase, CINAHL, OVID full-text, PsycINFO, the Cochrane Library, the British Nursing Index, the NHS National Research register, and System for Info on Grey literature for the period 1980-2007. Reference lists of all retrieved literature were also searched to identify studies that may have been missed. Twenty-five research studies were selected for inclusion in the analysis on the basis that they were either family led or professional-facilitated support group programmes for family caregivers of people with schizophrenia or other psychotic disorders.

RESULTS

The review identified that most studies on this group programme used qualitative, exploratory cross-sectional surveys and quasi-experimental study designs (n=19); six were experimental studies or randomised controlled trials. There were only a few small-scale, single-centre controlled trials with the findings supporting the significant positive effects of mutual support groups on families' and patients' psychosocial well-being. A number of non-experimental studies conducted in Western countries reported benefits of group participation up to 1 year, such as increased knowledge about the illness, reduced burden and distress, and enhanced coping ability and social support. However, many of these studies lacked rigorous control and did not use standardised and valid instruments as outcome measures or schedule follow-up to examine the long-term effects of support groups on families and/or patients.

CONCLUSIONS

With increasing recognition of benefits from mutual support, this review highlights the dearth of evidence for the effects and active ingredients of mutual support groups. Mutual support may have significant impacts on long-term psychosocial and nursing interventions for both patients with severe mental illness and their families in community mental health care. Further research is recommended to investigate the therapeutic components and effects of mutual support groups for family caregivers of people with schizophrenia and psychotic disorders across cultures.

The relationships among perceived criticism, family contact, and consumer clinical and psychosocial functioning for African-American consumers with schizophrenia

This study examined whether Perceived Criticism (PC) was related to community functioning in a sample of African-American consumers with schizophrenia. The study tested assumptions from the Expressed Emotion literature that were based primarily on samples of white consumers. The study found that PC affected psychiatric symptomatology but not psychosocial functioning. Greater family contact was strongly related to better psychosocial functioning. Findings suggested that the nature and impact of contact between consumer and family for this sample of African-Americans appears different from what has been found in white, middle-class samples.

Evaluation of a peer-led mutual support group for Chinese families of people with schizophrenia

Family interventions in schizophrenia have shown positive effects on patients but little attention has been paid to their effects on family members, particularly those in non-Western countries. This randomized controlled trial evaluated the effectiveness of a bi-weekly, 12-session, family-led mutual support group for Chinese caregivers of schizophrenia sufferers over 6 months compared with standard psychiatric care. It was conducted with 76 families of outpatients with schizophrenia in Hong Kong of whom 38 were assigned randomly to either a mutual support group or standard care. Families' psychosocial health status and patients' symptom severity and length of re-hospitalizations at recruitment, one-week and 12-month post-intervention were compared between groups. Results of repeated-measures mixed model indicated that the mutual support group experienced significantly greater improvements in families' burden, functioning and number of support persons and length of patients' re-hospitalizations at two post-tests. The findings provide evidence that mutual support groups can be an effective family-initiated, community-based intervention for Chinese schizophrenia sufferers.

Effectiveness of psychoeducation and mutual support group program for family caregivers of chinese people with schizophrenia

Schizophrenia is a disruptive and distressing illness, not only for the person affected but also for family members. Family intervention, particularly in a group format using a diverse range of modalities, is thought to effectively satisfy the informational needs of families and enhance their coping abilities when caring for a relative with schizophrenia, and thus reduce a patient's relapse from illness. This study tested the hypothesis that participants in a family psychoeducation and mutual support group would demonstrate significant improvements in levels of patient and family functioning and shorter duration of re-hospitalization than families in routine care. A randomized controlled trial was conducted with a sample of 68 Chinese families of schizophrenia sufferers in Hong Kong, who were randomly assigned to either a family psychoeducation and support group (n = 34), or a routine care group (n = 34). The interventions were delivered at two psychiatric outpatient clinics over a nine-month period. Results of multivariate analyses of variance test indicated that the psychoeducation and support group reported greater improvements on family and patient functioning and shorter lengths of patient hospitalizations at the two post-tests (one month and one year after completion of the intervention), compared with the routine care group. The findings substantiate that within a Chinese context, psychoeducation and mutual support group intervention can effectively help families care for a mentally ill relative.

Revisiting Confucianism as a conceptual framework for Asian family study

Confucianism is the central philosophic background for much of the culture in East Asia (EA), particularly for understanding family and social context. The purpose of this article is to examine more fully Confucianism as a conceptual framework for understanding EA family processes and health practices. Confucianism stresses the traditional boundaries of ethical responsibility and the ideal of good human life as a whole. Embedded within Confucian values are five principal relationships, through which each person defines a sense of identity, duty, and responsibility. Current studies of EA families that consider Confucianism as a theoretical base focus almost exclusively on filial piety and collectivism. Focusing only on these two aspects prevents scholars from exploring more complex interpretations of EA family life. A broader inclusion of multiple concepts from Confucianism can provide guidance in exploring the complex and multidimensional aspects of EA family life and allow for broader articulation of family processes.

Effects of a mutual support group for families of Chinese people with schizophrenia: 18-month follow-up

BACKGROUND

Family intervention in schizophrenia can reduce patient relapse and improve medication adherence, but few studies on this have involved a Chinese population.

AIMS

To examine the effects of a mutual support group for Chinese families of people with schizophrenia, compared with psychoeducation and standard care.

METHOD

Randomised controlled trial in Hong Kong with 96 families of out-patients with schizophrenia, of whom 32 received mutual support, 33 psychoeducation and 31 standard care. The psychoeducation group included patients in all the sessions, the mutual support group did not. Intervention was provided over 6 months, and patient- and family-related psychosocial outcomes were compared over an 18-month follow-up.

RESULTS

Mutual support consistently produced greater improvement in patient and family functioning and caregiver burden over the intervention and follow-up periods, compared with the other two conditions. The number of readmissions did not decrease significantly, but their duration did.

CONCLUSIONS

Mutual support for families of Chinese people with schizophrenia can substantially benefit family and patient functioning and caregiver burden.

Effectiveness of a mutual support group for families of patients with schizophrenia

AIM

This paper reports a study to examine the effectiveness of a 12-session mutual support group for Chinese families caring for a relative with schizophrenia compared with a psycho-educational group and routine family support services in Hong Kong.

BACKGROUND

Schizophrenia is a disruptive and distressing illness for patients and their families. With the current trend of community care for mental illness, there is evidence that family intervention reduces patient relapse and re-hospitalization, satisfies the health needs of families and enhances their coping capabilities.

METHODS

A randomized controlled trial was conducted from May 2002 to June 2003 with 96 Chinese families of a relative with schizophrenia selected from two psychiatric outpatient clinics in Hong Kong. Families were randomly assigned to receive mutual support (n = 32), psycho-education (n = 33) or standard care only (n = 31). The interventions were delivered at outpatient clinics over a 6-month period. Pre- and post- (1 week and 6 months) testing took place and families' functioning, mental health service utilization, patients' level of functioning and duration of re-hospitalization were measured.

RESULTS

At both post-test periods, family caregivers and patients in the mutual support group reported statistically significant improvements on family and patients' level of functioning, when compared with their counterparts in the psycho-education and standard care groups.

CONCLUSIONS

The findings support the use of mutual support groups as an effective modality of family intervention in a Chinese population caring for a family member with schizophrenia to improve both family and patient functioning.

Family psychoeducation as an evidence-based practice

Family psychoeducation programs have emerged as a strongly supported evidence-based practice in the treatment of schizophrenia and bipolar disorder. Over 30 randomized clinical trials demonstrated that psychoeducation programs reduce relapse, improve symptomatic recovery, and enhance psychosocial and family outcomes. Recent work supports family psychoeducation strategies for other disorders, including major depression, obsessive-compulsive disorder, and borderline personality disorder. This review summarizes the research evidence supporting prominent models of family psychoeducation. Professional and peer-led family education programs are also reviewed and differentiated from family psychoeducation. Directions for future research studies to enhance the evidence base and inform treatment recommendations are proposed. Finally, strategies for implementation of family psychoeducation in routine clinical practice are discussed.

Can disability studies and psychology join hands?

Although the field of disabilities studies incorporates psychology within its interdisciplinary purview, it embodies a distinct perspective consonant with the new paradigm of disability. This perspective is contrasted with that of psychology, and the place of disability within psychology is examined. Although psychology has begun to embrace diversity, disability has remained marginalized. Four areas are presented in this article: (a) the foundational ideas of disability studies, (b) training in disability within psychology, (c) the paradigms of disability reflected in research on disability, and (d) future research directions.

Family psychoeducation and schizophrenia: a review of the literature

Family psychoeducation has emerged as a treatment of choice for schizophrenia, bipolar disorder, major depression, and other disorders. More than 30 randomized clinical trials have demonstrated reduced relapse rates, improved recovery of patients, and improved family well-being among participants. Interventions common to effective family psychoeducation programs have been developed, including empathic engagement, education, ongoing support, clinical resources during periods of crisis, social network enhancement, and problem-solving and communication skills. Application of family psychoeducation in routine settings where patients having these disorders are usually treated has been limited, reflecting attitudinal, knowledge, practical, and systemic implementation obstacles. Through consensus among patient and family advocacy organizations, clinician training, and ongoing technical consultation and supervision, this approach has been implemented in routine clinical settings.