Integrating CBT/psychoeducational and systemic approaches to psychosis

Transcription

1 Integrating CBT/psychoeducational and systemic approaches to psychosis Frank Burbach Consultant Clinical Psychologist AFT Conference Bristol

2 Overview Historical context- family blaming, EE, psychoeducation, coping/ adaptation, NICE Somerset approach Cognitive-Interactional cycles Recasting EE research in interactional terms BABCP Couples SIG Burbach 2012

3 Family Blaming Early FTs developed interactional models to explain psychosis Psychiatric services message to families: the patient s illness (is your) fault and (you) should go away, shrouded in guilt, and leave the professionals to undo the damage (Goldstein,1981, in Lefley, 1992) Backlash by carers organisations Burbach 2012

4 A new approach- Family Management Psychosis is an illness Stress- vulnerability model Family dysfunction is caused by the stress of caring Relatives need to decrease stimulation to prevent relapse Burbach 2012

5 COPING AND ADAPTATION A new theoretical framework to replace views of families as pathogenic (Marcus, 1979) 1. Focus on developing competencies and coping skills 2. Pragmatic approach addressing tangible problems in a realistic way 3. Strategies are adapted to the families ways of coping 4. Removes attitudinal barriers between families & professionals: - judgmentalism towards families values & customs - failure to recognise ineffective management as the result of responding to unusual situations - failure to respect families as experts on their own members Burbach 2012

6 Medical and Psychotherapeutic approaches Healing or curing symptoms Solving the presenting problem (?carry over to other situations) Therapists do not make explicit their values or techniques Case oriented individuals, single families Assessment leads to diagnosis Stigma higher pathology, diagnosis, therapy Educational approaches Teaching skills Emphasis on developing skills which can apply in a range of current and future problems Educators are upfront about what they are doing Programmes developed for the widest range of students Cause of deficits is not important, instructor has the knowledge and skill to overcome the deficit Greater public acceptance, little embarrassment, less resistance Burbach 2012 Outcome measurement is difficult; subjective clinical criteria often used Hatfield, 1983 Knowledge is the goal easier to measure

7 Burbach 2012 TOPICS ADDRESSED IN FAMILY PSYCHOEDUCATION Optimum medication management Stress management strategies Psychotic disorders education Symptom management strategies Development & maintenance of effective social support Crisis resolution strategies Social living skills training for achieving personal goals Coping strategies Problem-solving education Communication skills Relapse prevention (early warning signs/action plan) ( based on Dale Johnson, 2007)

8 RESEARCH EVIDENCE Parental criticism, hostility & emotional over-involvement is associated with relapse 52% v. 20% -Bebbington & Kuipers, 1994 N=1346 Contact with high EE families associated with relapse (69% v. 28% - Leff & Vaughn,1976 N=128) Interventions that EE improve (halve) relapse Burbach 2011 Extensive evidence base (Cochrane reviews) has led to FI being recommended for everyone with a diagnosis of Schizophrenia (NICE)

9 Burbach 2012 So how have we presented our approach?

10 Principles, Concepts & Content of Family Work (Meriden Conference, 2007) Family work core principles (Fadden 2006: 162-4) - A genuinely positive attitude towards families - Acknowledgement of the family s skill & expertise - Understanding the intention behind the action - Every family has its own culture We would add the following- - An understanding of family systems & how they evolve over time - An ability to explore unhelpful patterns of interaction in which all family members have been caught up, despite their best intentions - An ability to enable conversations in which every family member feels understood, families recognise their strengths, and feel empowered to make beneficial changes Burbach 2007

11 CLINICAL APPROACH (1996 & 2006) Systemic Cognitive behavioural Collaborative Stance Informative Competency based Family needs-led Burbach 2011

12 ESCALATION OF INTERACTIONS OVER TIME PARENT Burbach 2011

13 STRESS-VULNERABILITY MODEL ENVIRONMENTAL STRESS SYMPTOMATIC WELL Threshold Low Biological Vulnerability High Burbach 2011

14 COGNITIVE INTERACTIONAL ANALYSIS inactive withdraws psychotic symptoms he/she is unreasonable and doesn t understand Emotions: -Frustration -Anger -Sadness -Grief 's/he is lazy' criticizes questions requests shouts Burbach 2012

15 COGNITIVE OR BEHAVIOURAL INTERVENTIONS Person with psychosis Behavioural Interventions GOAL SETTING POSITIVE REINFORCEMENT Empathic reappraisals He/she is is concerned/ cares cares about about me me and and is is trying trying to to help help Partner Empathic reappraisals He/she is is ill / ill / struggling with with a serious mental mental health health problem Behavioural Interventions Communication Training (BFT) It really makes me feel cross when you Please do Burbach 2011

16 VIRTUOUS COGNITIVE INTERACTIONAL CYCLE Talk about experiences (Symptoms may decrease) Going through a difficult time; convalescence They care care about me me and and are are trying to to help Sympathy; talk; be available; help Burbach 2011

17 A COLLABORATIVE, FLEXIBLE APPROACH Constructing a safe, secure base for families to deal with strong feelings (eg anger, guilt), reflect & experiment, explore options, reach a shared understanding Reducing negative arousal & distressing affect Enable therapeutic conversations / develop new perspectives / encourage a sense of personal agency - explore interactional cycles - discuss stress-vulnerability - develop coping strategies - discuss medication & side effects - behavioural techniques (goal setting; probl. solving; comm. skills) - cognitive techniques (explore & re-evaluate beliefs; reality testing) - 'individual CBT' in a family session - identify early warning signs/ relapse prevention - liaison/advocacy Burbach 2012

18 DEVELOPING ALTERNATIVE PERSPECTIVES (Motivational Int.; Solution Focused T; CBT; Narrative T) Exploring pros and cons eg: What are the drawbacks and benefits of taking the medication? Looking for exceptions to the problems eg: When was the last time you didn t obey the voices? Considering alternative perspectives eg: If you described this to your friends what would they say? Developing possibilities for the future eg: Its good to hear that you have had some success in managing your voices at the family wedding. What does this tell you about your coping abilities and what may be possible in the future? Burbach 2011

19 COLLABORATIVE STANCE Family needs are central to the therapeutic process. We focus on user/carer strengths, empowerment and Recovery. We work collaboratively rather than providing an expert solution. Ideas and techniques are offered rather than prescribed. We value and work with multiple perspectives. Burbach & Stanbridge 2009

20 Subsequent EE research UCLA studies- researched high EE interactions and development of EE over time eg. Withdrawal : warmth, EOI Crit. Miklowitz et al (1989) found that High-EE-critical families became locked either into symmetrical critical interactions or complementary interactions in which the person with schizophrenia is self-denigrating and appears to have internalised the criticism. Research emphasising the primacy of appraisal of family members behaviour (eg. Lobban & Barrowclough) Burbach 2012

21 EE Interactional cycle: complementary transactional pattern (Burbach, 2013) Partner Person with psychosis Behaviour: You drink too much, are lazy and you smell (Critical comments) Closely monitoring personal hygiene (EOI) Appraisal / Beliefs: You are always on my case. You don t understand. I always get it wrong, I am useless. Affect: Frustration; anger Appraisal / Beliefs: S/he is lazy and just needs to try harder Affect: Behaviour: Feels hopeless, helpless and guilty; Emotionally overwhelmed Social withdrawal; lack of motivation; poor personal hygiene Burbach 2012

22 EE Interactional cycle: symmetrical counter criticism (Burbach, 2013) Behaviour: This house is not a hotel. (crit) I work so hard for you and you just sit on your backside and do nothing. You have always been a lazy sod. (hostility) Appraisal / Beliefs: I can t help being like this. You are unreasonable to expect me to do it all. You don t care even though I am struggling Affect: Frustration; anger Affect: Anger, Fear of withdrawal of love Appraisal / Beliefs: S/he is lazy and just needs to try harder Behaviour: You re expecting too much, I need you to give me more support/ cut me some slack. (crit) Shut up, you bloody b*****. (hostility) Does not help around the house; social withdrawal Burbach 2012

23 Pavlo Kanellakis, KCA Frank Burbach, Somerset Partnership NHS FT Lee Grant, Efficacy Dan Kolubinski, Efficacy BABCP Conference, Leeds, June 2012

24 Earlier Experience Beliefs Assumptions Rules for living Activating Event Assumptions Activated Here and now principle Earlier Experience Beliefs Assumptions Rules for living Activating Event Assumptions Activated Negative Automatic Thoughts Negative Automatic Thoughts Emotions Behaviours Behaviours Emotions Physical Reactions Physical Reactions Lee Grant, 2012

25 Acknowledgements I d like to thank Roger Stanbridge and other colleagues in the Somerset Family Interventions Service who have contributed to the development of these ideas since 1996 Burbach 2012

26 PUBLICATIONS : Family Interventions in psychosis Burbach, F.R. (1995) Services for families which include a 'psychotic' person. Context, 24: Burbach, F.R. (1996) Family based interventions in psychosis - An overview of, and comparison between, family therapy and family management approaches. Journal of Mental Health, 5: Burbach, F.R. and Stanbridge, R.I. (1998) A family intervention in psychosis service integrating the systemic and family management approaches. Journal of Family Therapy, 20: Burbach, F.R., Donnelly, M. and Stanbridge, R.I. (2002) Service Development Through Multi-Disciplinary and Multi-Agency Partnerships. The Mental Health Review, Vol. 7 (3): Bailey, R., Burbach, F.R. and Lea, S. (2003) The Ability of Staff Trained in Family Interventions to Implement the Approach in Routine Clinical Practice. Journal of Mental Health, 12: Burbach 2012

27 PUBLICATIONS : Family Interventions in psychosis Stanbridge R.I., Burbach, F.R., Lucas, A.S. & Carter, K. (2003) A study of families satisfaction with a family interventions in psychosis service in Somerset. Journal of Family Therapy, 25: Burbach, F.R. and Stanbridge, R.I. (2006) Somerset's Family Interventions In Psychosis Service: An Update. Journal of Family Therapy, 20: Burbach, F.R., Carter,J., Carter,J. and Carter,M. (2007) Assertive Outreach and Family Work. In Velleman,R., Davis,E., Smith,G. and Drage,M. (eds.) Changing Outcomes in Psychosis: Collaborative cases from practitioners, users and carers. Oxford: Blackwell. Pearson, D., Burbach, F. and Stanbridge, R. (2007) Meeting the needs of families living with psychosis: implications for services. Context, :9-12. Stanbridge, R.I. and Burbach, F.R. (2007b) Involving Carers (Part 1) Chapter 5 in Froggatt, D., Fadden, G., Johnson, D.L., Leggatt, M. and Shankar, R. (Eds). Families as Partners in Mental Health Care: A guidebook for implementing family work. Toronto: World Fellowship for Schizophrenia and Allied Disorders Burbach 2012

28 PUBLICATIONS : Family Interventions in psychosis Burbach, F.R. and Stanbridge, R.I. (2008) Training to develop family inclusive routine practice and specialist family interventions in Somerset. Journal of Mental Health Training, Education and Practice, 3: Burbach, F.R. and Stanbridge, R.I. (2009) Setting up a family interventions service. Chapter in Lobban, F. and Barrowclough, C. (Eds), A casebook of family interventions for psychosis. Chichester: Wiley-Blackwell Burbach, F.R., Fadden, G. and Smith, J. (2010) Family Interventions for first episode psychosis. Chapter in French, P., Read, M., Smith, J., Rayne, M. and Shiers, D. (Eds) Promoting Recovery in Early Psychosis. Chichester: Wiley- Blackwell Burbach, F.R. (2013) Towards a systemic understanding of family emotional atmosphere and outcome after psychosis. Chapter 9 in Gumley, A., Gillham, A., Taylor, K. & Schwannauer, M. (Eds), Psychosis and Emotion: the role of emotions in understanding psychosis, therapy and recovery. Routledge: Burbach 2012