Counselling the relatives of the long-term adult mentally ill. II. A low-cost supportive model

Expressed emotion in the therapeutic relationship with schizophrenic patients

Patterns of interaction and attitudes in the relationships of 21 young schizophrenic patients, their parents and therapists were explored and compared with each other in this pilot study. The focus was on expressed emotion (EE), which was revealed to have an important impact on the course of the illness. In this study, the EE status of the relatives as well as of the therapists was rated using the five-minute speech sample method. Furthermore, data on the quality of interaction of therapists and parents with the patients were derived from the therapist/relative-patient interaction scale. Results showed that one-third of both the therapists and the parents were rated high on EE. High-EE relatives were rejected and perceived as inscrutable by the patients. The assessment of the therapeutic and familial relationships demonstrated the patients’ need for unequivocal communication. Differences and similarities in the interaction styles, and their implications for research and therapy are discussed.

Burden of care in the home: issues for community management

The number of beds available in the UK for the treatment of mental illness has fallen by over two-thirds since its peak in the mid-1950s. There is a worldwide trend of closure of large mental hospitals and integration of services for the mentally ill in their own local community. Community surveys have shown that an overwhelming majority of mentally ill people are treated in primary care or by specialists, but without being admitted to a hospital. This is now the preferred clinical practice (Shepherd et al, 1981).

Impact on women who care for those with schizophrenia

This study examined the impact of caring on women who were primary care-givers to those with schizophrenia. From the 46 women and 21 men carers assessed for the study, women were considered primary care-givers more often than men (83% v. 57%). Higher levels of burden among women primary carers were associated with living with patients, and more hours in contact with them. Worse perception of patients' social functioning was associated with higher levels of burden. The findings of the study showed that women primary carers have particular needs, and services should consider how to provide support for them in their multiple roles, and over longer periods of time.

Psychological distress, perceived burden and quality of life in caregivers of persons with schizophrenia

BACKGROUND

Caregiving in schizophrenia is a demanding and exhausting activity that challenges the physical and emotional resources of family caregivers. In traditional societies such as India, this is further compounded by illiteracy, ignorance and religious and cultural explanations attributed to mental illness.

AIMS

This study aimed to assess primary caregivers of persons with schizophrenia in terms of their perceived burden, manifestation of psychological distress and quality of life (QOL).

METHODS

The study used a quantitative cross-sectional design and survey methodology to collect data from caregivers in a hospital setting in Thanjavur, India. Standardized instruments were used to collect data from patients and their caregivers.

RESULTS

High perceived burden and lower QOL were seen in the majority of caregivers. They also manifested high levels of anxiety and depression. Patient characteristics such as age, gender, symptoms and duration of illness did not influence the perceived burden of caregivers, while positive and negative symptoms and the duration of illness were correlated with their QOL.

CONCLUSIONS

Findings indicate the need for intervention for family caregivers to enable them cope more effectively with the demands of caregiving. Psychoeducation and participation in peer support groups are advocated as low resource and effective outcome strategies for caregivers in India.

Attitudes and burden in relatives of patients with schizophrenia in a middle income country

Background

Most studies of family attitudes and burden have been conducted in developed countries. Thus it is important to test the generalizability of this research in other contexts where social conditions and extended family involvement may be different. The aim of this study was to assess the relationship between the attitudes of caregivers and the burden they experience in such a context, namely Arica, a town located in the northernmost region of Chile, close to the border with Peru and Bolivia.

Methods

We assessed attitudes towards schizophrenia (including affective, cognitive and behavioural components) and burden (including subjective distress, rejection and competence) in 41 main caregivers of patients with schizophrenia, all of whom were users of Public Mental Health Services in Arica.

Results

Attitude measures differed significantly according to socio-demographic variables, with parents (mainly mothers) exhibiting a more negative attitude towards the environment than the rest of the family (t = 4.04; p = 0.000).This was also the case for caregivers with a low educational level (t = 3.27; p < 0.003), for the oldest caregivers (r = 0.546; p = 0.000) and for those who had spent more time with the patient (r = 0.377; p = 0.015). Although attitudes had significant association with burden, their explanatory power was modest (R² = .104, F = 4,55; p = .039).

Conclusions

Similar to finding developed countries, the current study revealed a positive and significant relationship between the attitudes of caregivers and their burden. These findings emphasize the need to support the families of patients with schizophrenia in this social context.

An emotive subject: insights from social, voluntary and healthcare professionals into the feelings of family carers for people with mental health problems

Caring for people with mental health problems can generate a whole range of positive and negative emotions, including fear, disbelief, guilt and chaos as well as a sense of purpose, pride and achievement. This paper explores the emotions of family carers from the perspectives of social, voluntary and healthcare professionals. Sixty-five participants were interviewed, the sample included directors, managers and senior staff from social, voluntary and healthcare organisations. Participants were encouraged to talk in detail about their understanding of the emotions of family carers. Findings highlight a rich understanding of the broad spectrum of carer emotions and the huge emotional adjustments that are often involved. Diagnosis was seen to be imbued with negative emotions, such as fear, anger and denial. However, feelings of hopelessness and desolation were often counterbalanced by feelings of hope, satisfaction and the emotional rewards of caring for a loved one. Participants noted a clear lack of emotional support for family carers, with accompanying feelings of marginalisation, particularly during transitions and especially involving young carers as well as ethnic minorities. By way of contrast, carer support groups were suggested by professionals to be a holistic, effective and economical way of meeting carers' emotional needs. This paper explores the challenge of family carer emotions from the perspective of managers and practitioners and draws out implications for research, policy and practice.

Family burden during exacerbation of schizophrenia: quantification and determinants of additional costs

BACKGROUND/AIMS

Family members of people with schizophrenia are heavily burdened. Thus, we aimed at quantifying the amount of additional efforts during the two weeks before hospitalisation of acute exacerbating psychosis compared to the time before.

METHODS

By means of the semi-structured 'Interview for Measuring the Burden on the Family' we interviewed relatives of people with schizophrenia. To quantify additional burden we asked how much time a person who would take over the additional burden has to afford. Subscales of different sources of burden and total scales were correlated.

RESULTS

An additional 8.9 hours per day would have to be spent in favour of the patient, which results in additional costs of Euro 3,115-Euro 4,984 (ca. pounds 2,100-3,400) for two weeks. The main sources of additional burden are quantity, quality and nature of contacts to the affected. This includes the frequency of contact to the affected, the whereabouts and symptoms of the affected, as well as the social contacts of the relatives.

CONCLUSIONS

Our results clarify the quantitative aspect of care provided by relatives of people with schizophrenia. Apart from the practical and emotional help to relatives the development of a diversified network of community psychiatry services, e.g. day and night hospitals, as well as crisis accommodations should be established.

People with schizophrenia and their families. Fifteen-year outcome

BACKGROUND

This paper presents 15-year outcome data on place of residence, clinical and social morbidity and carer distress in a cohort of 179 people with schizophrenia who were living with their families in 1981-1982.

METHOD

Data on morbidity and carer distress were derived from replicated patient and informant interviews using standardised research instruments. Details of residence came from patient and informant interviews corroborated by case note information.

RESULTS

Thirty-nine (22%) of the original 179 patients were dead and six (3%) lost to follow-up. Of the remaining 134 patients, 74 (55%) still lived with their families, 31 (23%) lived in institutional accommodation, 26 (19%) lived alone and 3 (2%) were homeless. There was little change in the level of clinical or social morbidity or carer distress.

CONCLUSIONS

These findings suggest that most people with schizophrenia who live with their families remain significantly disabled by their illness, while their carers suffer ongoing distress. Mental health services should seek to support families who want to care for relatives with schizophrenia. Appropriate alternative accommodation must be provided when family care is not possible.

Expressed Emotion in community care staff. A comparison of patient outcome in a nine month follow-up of two hostels

Expressed Emotion was measured in the staff of two similar hostels for the long term mentally ill in an Inner London Borough (Hostel A and Hostel B). Patients in the two hostels showed similar levels of disturbance as measured by the PSE and symptom and behaviour profile scores. Staff from Hostel B displayed higher levels of EE, and were more critical, and these attitudes generalised easily into hostility and rejection. Those from Hostel A showed lower EE with warmth and positive attitudes towards clients. At 9 month follow up, Hostel A and B had similar levels of relapse requiring hospital admission. However Hostel B had a 64% discharge rate compared with 12.5% for Hostel A. These results are discussed with reference to the literature.

The assessment of psychiatric disability in the community. A comparison of clinical, staff, and family interviews

Assessments of some of the symptoms and behaviour problems of long-term psychiatric patients living in the community were obtained independently from clinical interviews with such patients, and from interviews with day staff, residential staff and families caring for them. In general, interviews with residential staff and family members revealed much higher levels of symptoms and behaviour problems than either of the other two interviews. These findings have implications for research and clinical practice including the fact that adequate assessments should include the testimony of family or residential staff.