Journal of Psychiatric and Mental Health Nursing, 2007, 14, 356365

Family work in first-onset psychosis:

a literature review
R. ASKEY1 bsc(hons) pgdip rn, C. GAMBLE2 ba(hons) rgn rmn rnt &
R . G R AY 3 b s c ( h o n s ) m s c p h d r n
1

Psychosocial Therapies Practitioner, South London and Maudsley NHS Trust, Southwark Team for Early
Psychosis (STEP), 2Consultant Nurse, South West London and St Georges Mental Health Care Trust, Main
Building, Springfield University Hospital, and 3Senior Lecturer and Head of Section, Kings College London,
Institute of Psychiatry, De Crespigny Park, London, UK

Correspondence:
R. Askey
South London and Maudsley

ASKEY R., GAMBLE C. & GRAY R. (2007) Journal of Psychiatric and Mental Health
Nursing 14, 356365
Family work in first-onset psychosis: a literature review

NHS Trust
Southwark Team for Early
Psychosis (STEP)
106 Weston Street
London SE1 3QB
UK
E-mail: ryan.askey@slam.nhs.uk

Family intervention may be helpful for people with psychosis. We reviewed the literature for
family intervention for people with a first-onset psychosis. There is limited and conflicting
evidence of the efficacy of family intervention for this population. Definitive randomized
controlled trials are required to establish the efficacy. At this time, evidence suggests that in
High Expressed Emotion (EE) families, family intervention is a possible effective intervention. We suggest caution in families with Low EE as one study suggests that in Low EE
families, family intervention can increase the levels of EE.
Keywords: early intervention, family work, service development
Accepted for publication: 6 February 2007

Introduction
Psychosis can affect all aspects of life and without support
and adequate care, it can place a heavy burden on significant others and society at large (McGorry 2000). The
vast majority of first episodes occur between the ages of
1435 years and the onset is often during a critical period
in the persons development. One in 10 people with psychosis will commit suicide and two-thirds of these will
occur within the first 5 years of illness (Department of
Health 2001). Generally, this is because it can take up to
2 years after the first signs of illness before professional
help is either sought or provided. Lack of awareness,
ambiguous early symptoms and stigma all contribute to the
delay in treatment (Sainsbury Centre for Mental Health
2003). Indeed, the early stages of psychosis or first-onset
frequently present as terrifying and bewildering for the
majority of first-onset service users who live at home
(6070%) with their families (Addington et al. 2001). The
356

unusual behaviours displayed generate emotions such as

fear, sadness, guilt and anger. Such feelings are fairly predictable, as families generally do not have any knowledge
or previous experiences to guide them. Because of these
emotions, informal carers often feel hopeless and overwhelmed (Shore 2006). This sense of powerlessness can
additionally reduce coping strategies; increase social isolation and a third of relatives either demonstrate clear or
report mild depression (Kuipers & Raune 2000). A high
risk of personal distress as opposed to a feeling of burden
has also been noted (Szmukler et al. 1996). Moreover, the
issues families face at this early stage are recognized to be
different from those caring for relatives with an established
illness (Addington & Burnett 2004). There is often diagnostic uncertainty, limited understanding of the course of
psychosis and poor early intervention treatment. This can
result in:
poorer outcomes and prognosis;
slower and less complete recovery;
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

Family work in first-onset psychosis

increased vulnerability to further relapse;

increased risk of depression and anxiety;
interference with psychological and social
development;
strained relationships, loss of family and social
supports (McGorry 2000).

Early intervention paradigm

Until recently, there have generally been two paradigms
on the course of psychosis. The first sees this as an
episodic disorder, where treatment is provided through
both acute care and prophylaxis. The second proposes
that if the illness develops a chronic course, rehabilitation is required to ameliorate service users disabilities
(Birchwood 2000).
However, Birchwood (2000) now recognizes a third
paradigm that promotes a more promising outlook as it
recognizes the importance of early detection. This involves
a combination of medical and psychosocial interventions
aimed at preventing or reducing social, psychological and
mental deterioration of especially young, vulnerable service
users. McGorry (2000) argues that the main aim of such
intervention is to reduce secondary illness, caused by frightening, undignified and stigmatizing treatment systems.
Crudely using harsh drug therapies and neglecting psychotherapeutic and psychosocial aspects of treatment. Much
of this iatrogenesis can be avoided or repaired if social
support systems, cultural, psychological and biological
models of health care are understood, appreciated and
utilized (McGorry 2000).
The best recommended mix of specialist pharmacological, psychological, social, occupational, and educational
interventions at the earliest opportunity is therefore
required (National Institute for Clinical Excellence 2002).
The Department of Health (2001) recommends that early
intervention services should increase the stability of people
with psychosis and their significant others. Services should
facilitate opportunities for personal fulfilment, by promoting recovery and providing evidence-based interventions
during the early phase of illness.
If the aforementioned aims are to be achieved and family
morbidity such as depression, anxiety and complicated
grief reactions is to be reduced or prevented (Gleeson et al.
1999), then professionals need to work constructively and
collaboratively with service users significant others. This is
vital as the family can play a major supportive role, provide
social contact and help reduce service users risk of relapse
(Pilling et al. 2002). The family is an essential ingredient
in the positive management of early psychosis recovery
(Addington & Burnett 2004).
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

Family intervention with schizophrenia: firstand second-generation studies

During the late 1960s and early 1970s, investigations were
made as to whether family atmospheres could influence the
course of illness in schizophrenia. It was found that service
users living with relatives who displayed high levels of
criticism, hostility or over-involvement relapsed more than
service users whose families were less expressive of their
emotions. They named these behaviours High Expressed
Emotion (High EE) (Brown et al. 1972). Expressed
Emotion does not tell us much about the causes of schizophrenia, but it can be a predictor of its course when
someone with the illness lives with relatives. Low EE
relatives tend to display higher levels of warmth and higher
level positive coping strategies (Kuipers et al. 2002).
These early generation findings led to the development
of family work approaches to reduce relapses. They aimed
to increase service users social functioning, to reduce
family burden and to improve quality of life of service users
and their relatives. Family work is based on a broad
psychoeducational and cognitive behavioural therapy
approach (Midence 2006). It is known that educating families about the illness alone does not reduce levels of EE in
families with High EE (Kuipers et al. 2002). However,
working with them to tackle practical problems such as
improving communication, effectively developing coping
skills and helping families to attribute the symptoms to
illness can decrease their critical or over-involved behaviours. These interventions can reduce relapses for this
population (Kuipers et al. 2002). As awareness and knowledge increases, tension and stress throughout the family
decreases, improving the quality of life for all concerned
(Barrowclough & Tarrier 1997). The reduction in families
ambient and chronic stress levels can enable the service user
to cope better with unavoidable stressors and reduces their
risk of relapse (Falloon et al. 1984).
The basic assumption and philosophy of the treatment
model is that schizophrenia can be viewed under the stressvulnerability concept (Kuipers et al. 2002). Fowler et al.
(1999) describes this as the biopsychosocial approach,
which identifies that at times of extreme stress, for example,
solitary confinement, sleep deprivation and physical illness,
transient psychotic symptoms can be manifested in any
person. The stress-vulnerability model attempts to normalize these extreme stress reactions. Kuipers et al. (2002)
suggest that instead of families being blamed for the illness,
they are encouraged to be therapeutic agents in order to help
their relative. Families are seen as having needs and
strengths, and the burden of caring for someone with psychosis is taken very seriously. The family work package is
offered as an adjunct to medication and case management.
357

R. Askey et al.

The published results of early family work studies are

unequivocal in demonstrating superiority over medication
alone in preventing relapses (Goldstein et al. 1978, Falloon
et al. 1982, Leff et al. 1982, Hogarty et al. 1986). The
studies demonstrate that relapse rates can be reduced by
20% if families receive family intervention (Addington &
Burnett 2004).
Second-generation family work studies focused on
training staff within the clinical setting. These also consistently showed effectiveness over medication and routine
follow-up (Mari & Streiner 1994, Dixon & Lehman 1995,
Goldstein & Miklowitz 1995). A meta-analysis by Mari &
Streiner (1994) observed that these interventions were
effective in decreasing hospital admissions and improving
medication adherence. They also elucidated that family
intervention reduced the frequency of relapse over a period
of 6 months to 2 years. Tarrier et al. (1994) demonstrated
in their 5- and 8-year follow-up studies the reduction of
relapse was durable.
Fadden (2001) argues that there can be no doubt that
offering family interventions to people with psychosis can
reduce relapse, distress and improve functioning. The difficult question is what are the effective components of
family intervention. Various formats have been successfully
used, ranging from the individual family unit (Goldstein
et al. 1978, Falloon et al. 1982, Hogarty et al. 1986,
Tarrier et al. 1988, Randolph et al. 1994), individual
family plus a carers group (Leff et al. 1982), carers group
only (Leff et al. 1989), multi-family groups (McFarlane
et al. 1995), parallel service user and carers group
(Kissling 1994) and brief educational intervention for Low
EE families (Leff et al. 1982, Tarrier et al. 1988, Linszen
et al. 1996). Fadden (2001) also highlights that there
are varying degrees of success that are in relation to
whether families are engaged and/or whether the illness
was episodic.

Family intervention and first-onset work

Gleeson et al. (1999) observed that the existing models
of family intervention with first-onset psychosis were
designed for use with more long-standing service users,
which they argue could lead to clinicians imposing a pessimistic attitude towards the course and outcome of the
illness. This standpoint is incongruent with the hope and
recovery early intervention paradigm in which Birchwood
(2000) advocates. This concern is supported by Collins
(2002) who highlights that it is common for first-onset
families to be given information on chronic schizophrenia
and to be encouraged to attend groups that typically focus
on coping with very debilitating and persistent forms of the
illness.
358

To date, there have only been a limited number of

studies that have examined the use of family work with
first-onset psychosis (see Table 1). Indeed, they have mainly
focused upon EE and service user outcome and have made
little attempt to isolate which interventions are more or less
efficacious (Gleeson et al. 1999).

Search strategy used for the literature review

Embase 1980 to week 38, 2006
CINAHL 1982 to September week 1, 2006
PsycINFO 1967 to September week 1, 2006
Ovid MEDLINE 1966 to September week 1, 2006
Cochrane Database third quarter 2006
British Nursing Index 1985 to September 2006
Search terms used Family work, family intervention,
behavioural family intervention, psychoeducation, psychosis, schizophrenia, severe mental illness, early-onset psychosis, first-onset psychosis, recent-onset psychosis.
Leavey et al. (2004) completed a randomized controlled
trial on a brief intervention for families of service users
with a first-onset psychosis. The intervention consisted of
psychoeducation, early warning signs monitoring, coping
strategy enhancement, problem-solving and communication enhancement. There were no significant findings
regarding carer satisfaction with services and service user
outcomes. However, they did note their power calculations
were compromised because of poor retention and recruitment of participants. They also highlighted that their sessions were not as long as recommended by researchers.
What is also unclear is why they did not measure EE or use
standardized measure to assess service user outcomes.
Within the Linszen et al. (1996) study, service users were
assigned randomly to either service user-orientated psychosocial intervention alone, or psychosocial intervention in
combination with their family members receiving behavioural family intervention. It was unclear why the service
users were excluded from this intervention and evidence
suggests that this is less effective (Falloon et al. 1982).
The psychosocial intervention included psychoeducation,
medication management, insight work, coping strategy
enhancement and assistance with employment. Overall,
adding behavioural family intervention did not reduce the
relapse rate of service users with a first-onset psychosis
with High EE families. Also families with Low EE became worse with family intervention, revealing a trend of
P = 0.10 (Linszen et al. 1996). The family therapists were
blinded to the EE status that resulted in Low EE families
being offered communication and problem-solving skills.
The consequence of this was that families interpreted the
focus of improving communication as defects in their relationships with family members. This also raised their stress
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

Rationale

Carer satisfaction with

mental health services
related to
psychoeducation is
generally poor. Authors
aimed at assessing the
impact of a brief
educational and advice
support service on carers
of service users with a
first-onset psychosis.

Main hypothesis was that

the addition of
behavioural family
intervention to the
psychosocial intervention
programme would be
beneficial for service
users with High EE
families.

Study

Leavey et al. (2004)

Linszen et al. (1996)

Comments
Blindness: unclear if
double- or single-blind.
No measure was used to
assess EE or to measure
client symptoms. The
internal validity of the
trial was threatened
because of a significant
number of families either
dropped out or did not
participate. This raised
the possibility of type II
error. Length of
intervention is shorter
than recommended.

No rationale why service

users were excluded from
the family intervention
arm of treatment. Family
therapists were blind to
the EE status of families.
Low EE families were
taught communication
skills where there were
no deficits. Included
within the Cochrane
review. Outcome measure
validated and reliable.

Outcomes
Family intervention had
no effect on relatives
satisfaction or service
user outcomes.

Behavioural family
intervention did not
reduce relapse rates for
families with High EE.
Low EE families became
worse with the
intervention.

Data analysis
Cross-sectional group
comparisons were carried
out using Students t-test
for parametric data and
x2/Fishers exact tests for
proportions as
appropriate.

BPRS and relapse data

were analysed using
survival analysis. The
effect of covariates was
analysed using
proportional hazard
analysis Cox regression.

Intervention
Seven sessions in the
family home.
Psychoeducation, early
warning signs
monitoring, coping
strategy enhancement,
problem-solving and
communication
enhancement.

18 sessions of behavioural
family intervention over 1
years treatment with
1-year follow-up.

Method
Randomized Controlled
Trial (RCT) Experimental
group received a brief
intervention comprising
education and advice.
Control group received
care as usual. Outcomes
were measured using the
Verona Service
Satisfaction
Questionnaire (VSSS-32),
The Caregiver Strain
Index. A non-validated
Likert scale used to
measure carers perceived
severity of illness. Patient
outcomes were measured
by admission rates and
length of stay.
RCT, single-blind
Experimental group
received behavioural
family intervention,
including individualorientated psychosocial
intervention, 18 sessions
Control group received
individual-orientated
psychosocial intervention.
Service user outcomes
were measured using
Brief Psychiatric Rating
Scale (BPRS) and scrutiny
of notes. Expressed
emotion was assessed
using the Camberwell
Family Interview (CFI).

Participants
Recruitment from two
large services in North
London between 1998
and 2000 over a
24-month period. Service
user diagnosis of a new
psychotic illness (ICD -9).
Exclusions: service users
with an organic disorder
or learning difficulty
n = 106 Experimental
n = 57 Control n = 49.

Diagnosis of first-episode
schizophrenia or related
disorders (DSM-III-R).
Exclusions: primary
substance dependence,
drug-related psychosis
n = 76 Experimental
n = 37 Control n = 39.

Table 1
A summary of studies that have examined the use of family work with first-onset psychosis

Family work in first-onset psychosis

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

359

360

Rationale

Follow-up assessment of
social functioning in
early-onset schizophrenia
service users during a
5-year period of
intervention.

To determine the effect

of integrated treatment
vs. standard treatment
on subjective burden, EE,
knowledge of illness and
satisfaction with
treatment.

Study

Lenior et al. (2001)

Jeppesen et al.
(2005)

Table 1
CONTINUED

Outcome measures not

reliable, validated or
generalized for this area.
This was acknowledged
by the authors. Lack of
inter-rater reliability
assessments. Possible bias
because of high and
skewed attrition of
relatives at entry and at
follow-up. Family
intervention not
described in detail. Lack
of masking of
investigators. Number of
carers within the study
not identified.
There was a significant
beneficial effect on
reducing burden
P = 0.031. A significant
beneficial effect upon
distress P = 0.047. No
difference between the
two groups for distress
related to service user
disturbed behaviour.
63.2% of relatives in
the Experimental group
changed from High EE
to Low EE compared
with 59.1% within the
Control group. 18.7%
of relatives within the
Experimental group
changed from Low EE
to High EE compared
with 12.5% within the
Control group. No
significant difference in
reducing High EE.
Distress, knowledge and
satisfaction mean scores
were analysed by
analysis of covariance
using Students t-test.
Categorical response
data were analysed with
Pearson x2 test.
Continuous, nonnormally distributed
data was analysed using
MannWhitney U-tests.

Treatment over
18 months every 2 weeks.
Assertive community
treatment, medication
management, social skills
training and
psychoeducational
multi-family group.
Focused on problemsolving and coping
strategy enhancement.

RCT, not blinded.

Experimental group
received assertive
community treatment,
medication management,
social skills training and
psychoeducational
multi-family group.
Focused on
problem-solving and
coping strategy
enhancement. Treatment
over 18 months every
2 weeks. Control group
were assigned to
treatment as normal.
Burden was measured
using the Social
Behaviour Assessment
Schedule. Knowledge of
schizophrenia was
measured using a
multiple- choice
questionnaire. Carers
satisfaction was
measured using the
Client Satisfaction
Questionnaire. EE
measure using the
Five-Minute Speech
Sample.

Service users with a firstepisode psychosis,

diagnosis included:
schizophrenia,
schizotypal disorder,
persistent delusional
disorder, acute and
transient psychotic
disorder, schizoaffective
disorder, induced
delusional disorder, or
unspecified non-organic
psychosis according to
the ICD-10 aged
1845 years. Exclusions:
no exposure to
antipsychotic medication
exceeding 12 weeks.
Mental retardation and
organic mental disorder;
no psychotic condition
solely because of acute
intoxication or
withdrawal state.
Relatives who were
given permission via the
service user. n = 547
service users
Experimental n = 159
Control n = 272 Number
of carers?

Excluded from Cochrane

review. Their results did
not confirm the effect of
family intervention
completely because the
intervention did not
affect the relapse rate.

Service users with

schizophrenia or
related illnesses have
considerable social
limitations. Service
users who received
family intervention
spent fewer months in
hospital than service
users who had the
standard intervention.

MannWhitney U-tests
were used to compare
three areas of social
functioning. Testing
associations between
three areas of social
functioning and the
total duration of
psychotic episodes were
performed by
Spearmans rank
correlations.

Intervention (see Linszen

et al. 1996).

Follow-up study.
Intervention (see Linszen
et al. 1996). Outcomes
were measured using the
Life Chart Schedule.

Diagnosis of
schizophrenia,
schizoaffective disorder,
schizophreniform
disorder and other
psychotic disorders
(DSM-III-R). Exclusions:
primary substance
dependence,
drug-related psychosis
n = 73 Experimental
n = 33 Control n = 31.
Three families ceased
the treatment, three
families refused the
expressed emotion
assessment, three
families refused
randomization.

Comments

Outcomes

Data analysis

Intervention

Method

Participants

R. Askey et al.

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

To confirm the efficacy

of family intervention of
first-onset psychosis
service users in China.

To clarify which of the

two variables, namely EE
and communication
deviance (CD), are
closely associated with
the course of
schizophrenia.

Zhang et al. (1994)

Rund et al. (1995)

No details of the
number of carers
included within the
study. No assessment
or measure of EE.
Included within the
Cochrane review.

No measure of EE
assessment or status.
Unclear if raters were
single- or double-blind.
Unclear why only male
clients were included
within the study.
Included within the
Cochrane review.

Families not randomly

assigned possibly
leading to bias.
Non-significant
number of
participants. Minimal
details of the type of
intervention used. No
definition for the CCS
outcome measure.

Relapse rates for

6-months follow-up
were 0% for the group
that received family
work and high-dose
medication and 48%
relapse rates in the
group with low-dose
medication and no
family work.

Significantly lower rate

of hospital readmissions
for the family
intervention group
15.4% vs. standard carer
53.8% at 18-month
follow-up.

CD proved to be a
better predictor for
people with
schizophrenia than EE.
Service users use GAS
scored improved their
relatives changed from
High EE to Low EE
(58%). CD proved to be
more resistant to
psychosocial
interventions. 17% of
relatives reduced their
CD.

BPRS data were analysed

by using analysis of
covariance.

BPRS, GAS and

readmission rates were
measured using the
Turkey
multiple-comparison
test.

Spearman rank
correlation was used to
analyse the EE, CD,
relapse rates and GAS
outcomes.

Six sessions over 6 weeks

of crisis-orientated
therapy. Objectives
included families
accepting the service
user has psychosis,
identifying precipitating
factors and stressors
prior to illness, and
relapse prevention.

Sessions over an
18-month period. Initial
session prior to
discharge focusing on
education. Then
multi-family groups
every 3 months. These
consisted of coping
strategy enhancement,
relapse prevention,
reappraisal of illness
behaviours.
Psychoeducational
programme lasted
2 years consisted of
three phases: (1) a
hospital period; (2)
rehabilitation; and (3)
follow-up period.

RCT, single-blind. Six

sessions over 6 weeks.
Plus 6-month follow-up.
Experimental group
were assigned to Crisisorientated family
therapy, standard care
and either high- or
low-dose fluphenazine.
Control group assigned
to standard care and
either low- or high-dose
fluphenazine. Service
user outcomes were
measured using BPRS
and relapse rates.
RCT, randomly assigned.
Sessions every
13 months over an
18-month period,
18-month follow-up.
Education and family
group sessions,
additional follow-up.
Outcomes were
measured using BPRS,
the Global Assessment
Scale (GAS) and relapse
rates.
Cohort compared with
families receiving
standard care.
Psychoeducational
treatment programme
lasted over a 2-year
period. Outcomes were
measured using GAS and
relapse rates for service
users. The CFI for
relatives EE status and
the CCS for relatives
level of CD.

Diagnosis of
schizophrenia using the
Chinese Medical
Associations Criteria. No
previous admissions,
mean duration of illness
2.8 years. Exclusions:
concurrent medical
illness. Mean age
23.8 years. Male n = 78
Experimental n = 39
Control n = 39
Diagnosis of
schizophrenia using the
DSM-III-R criteria.
First-onset psychosis.
Exclusions: organic
psychosis and substance
misuse. Mean age
16.0 years. Male = 8
Female = 4. n = 16

Diagnosis of
schizophrenia according
to the New Haven
Schizophrenia Index. 1st
or 2nd admission to
hospital. Mean age
23.36 years. n = 104
Experimental n = 52
Control n = 52 Eight
service users left the
study.

CCS, Carer Communication Scale; EE, Expressed Emotion.

Main hypothesis was

that in early psychosis if
antipsychotics were
given in high doses and
social treatments were
added, the outcomes
were improved.

Goldstein et al. (1978)

Family work in first-onset psychosis

361

R. Askey et al.

levels within the sessions. This study concluded that behavioural family intervention should be linked to the stage of
illness and more attention should be paid to facilitating the
process of grief and mourning. It was reported that the use
of behavioural communication tasks interfered with the
families need to deal with emotions regarding the recent
episode of their relatives illness. Overall, the relapse rates
were low at 16% at 1 year. Adding family intervention did
not affect the relapse rate (Linszen et al. 1996). Average
relapse rates of psychosis are around 3040% within the
first 12 years despite adherence of prescribed medication
(Leff & Wing 1971, Johnson 1976, Hogarty 1984).
A 5-year follow-up study by Lenior et al. (2001) evaluated whether family intervention within first-onset psychosis was superior over standard care (see Linszen et al. 1996
for intervention). They found that in families who received
family intervention, service users spend fewer months in
hospital compared with service users assigned standard
care. Confusingly this was the follow-up study of Linszen
et al. (1996) who did not find any significant difference
when adding family intervention.
Jeppesen et al. (2005) attempted to determine the effects
of integrated treatment on family burden and EE with
families of first-onset psychosis service users. Families were
assigned to either standard care or integrated treatment.
The latter consisted of assertive community treatment, psychoeducational multi-family groups and social skills training. No in-depth details were given regarding the nature of
the family intervention. Their results indicated that families
in the integrated treatment programme felt less burdened
and were significantly more satisfied with care than families
who were assigned to standard care. They did not find
any significant differences between the experimental and
control group in reducing EE. The authors acknowledged
several flaws within the study. These included not using
validated outcome measures and not masking the investigators possibly leading to bias.
Goldstein et al. (1978) used a randomized controlled
trial comprising of high and low doses of antipsychotic
medication with crisis-orientated family intervention. The
family intervention consisted of six sessions over a 6-week
period with a follow-up session after 6 months. Limited
details of the intervention were described and were highlighted as objectives: families accepting the service user had
psychosis. Identifying precipitating factors and stressors
prior to the illness. The study concluded that families that
received high doses of medication and family intervention
service users relapsed less than those who received lowdose medication and family intervention. Families that
received family intervention showed there was a significant
reduction in psychotic symptoms in service users at
6 weeks, but was only sustained for service users with high
362

doses of medication. Expressed Emotion status was not

reported or measured, despite evidence to support its
importance around the time of the study (Brown et al.
1972).
Zhang et al. (1994) conducted a randomized controlled
trial of behavioural family intervention in 78 first-onset
male service users with schizophrenia in China. The intervention included psychoeducation, improving communication, problem-solving and relapse prevention. The
experimental group attained a significantly better outcome
on service user relapse rates and social functioning (15.4%
vs. 53.8%). Despite these positive outcomes with the intervention there was no mention of EE status.
Rund et al. (1995) administered a 2-year psychoeducational treatment programme for 12 first-onset psychosis
service users, which included educational sessions for families. The results showed that 58% of families changed from
High to Low EE status over the 2-year period. However,
there were no details of the type of intervention used and
the results need confirmation within a larger study as the
number of participants yield non-significant results.
A later study concluded that the need for intensive
family work in an early psychosis service was not overwhelming (Slade et al. 2003). Most first-onset families only
received information, a clear plan of who to contact and
the offer of ongoing family support. The study indicated
that most families tended to turn down the intensive
support, but were grateful for basic psychoeducation (Slade
et al. 2003).
Kuipers & Raune (2000) and Raune et al. (2004)
acknowledge the limited research in relation to family
intervention in first-onset psychosis. However, they argue
that there is accumulating evidence that during the firstonset of psychosis families may react in similar ways as
families who care for someone with a more chronic illness
such as schizophrenia. Within their two studies after comparing High and Low EE families of people with a firstonset psychosis, they found that consecutively 40% and
43% of families showed high levels of EE and burden. Both
studies suggest that the key issue is the appraisal and attribution of problems faced by families and their tendency to
use avoidant coping strategies when faced with stress that
exceeds their capacity to deal with situations. They indicate
that families frequent appraisals of care can lead to perceived burden and High EE. Avoidant coping in families
was the strongest predictor of EE. This counters the argument made by many researchers that the development of
High EE and burden is the result of a more insidious
interactive process (Kuipers & Raune 2000, Raune et al.
2004). What Raune et al. (2004) did not find was
any association between EE and illness-related factors
(symptom type and severity, age of onset, illness length and
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

Family work in first-onset psychosis

diagnosis) or family distress or depression. The key interventions suggested by Kuipers & Raune (2000) for firstonset families should be the facilitation of problem solving,
psychoeducation, and the understanding of the emotional
grief and isolation that relatives are likely to face when they
become carers for the first time. If these interventions are
made available, then they may help to reduce both the
emotional and financial costs for service users and their
families (Kuipers & Raune 2000). Raune et al. (2004)
suggest that the main implication from their study is the
importance of targeting families appraisal, particularly at
the first onset. They believe that their study confirms the
importance of lowering burden, reducing avoidant coping
and improving families understanding of service users
social behaviour. They conclude that offering families
appropriate support would probably reduce both family
and service user morbidity in the long term. Collins (2002)
disagrees and suggests that interventions with families
during a first-onset psychosis should move beyond the limitations of the previous era. The interventions should allow
clinicians to begin to ask questions about what underlies
successful family adaptation after the onset of psychosis.
This, in turn, could help to identify and promote the
key processes that enable families to successfully navigate
through the course of illness. The right mix of family
intervention adapted for first-onset families could be compelling as it could offer significant opportunities for secondary prevention (Collins 2002). In summary, Gleeson
et al. (1999) suggest future first-onset psychosis family
research work should review whether all the components
reflect the experience of the majority of families. It should
examine what impact early psychoeducation sessions have
upon the course of illness and acknowledge that if early
stages appear in a predictive sequence, then a staged
approach to family work should be investigated (Gleeson
et al. 1999).

Clinical implications for mental

health nursing
Evidence thus far suggests that practitioners in early intervention services should:
Acknowledge that relatives judgment of their role is
likely to affect future difficulties experienced, so supportive interventions to deal directly with such
appraisals should be employed (Raune et al. 2004).
Provide non-jargon psychoeducation (Addington &
Burnett 2004) that is progressively designed and
attractive to young people.
Avoid a poor prognosis message as families can
find this painful. Optimistic approaches, coupled
with realism, enhance the chances of improvement
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

as initial psychotic episode constitutes a critical

opportunity for the family to receive support, and to
support the service user (Gleeson et al. 1999).
Recognize the emotional grief and isolation that relatives are likely to face and offer supportive problemsolving, psychoeducation sessions at a time when it
requested.
Appraise problems faced by families and their tendency to use avoidant coping strategies, through the
use of systematic assessment, as this could provide
full and frank exchanges of ideas and expertise
(Repper et al. 2005).
Train the multidisciplinary team to be familyinclusive, so families and their significant others are
proactively engaged and included from the start.
Gain access to specialist supervision, so they can
practise family work (Slade et al. 2003).

Conclusions
The message to families should be one of hope and recovery
that is balanced with appropriate realism with the risks of
relapse especially within the first 25 years of illness if
intensive and supportive interventions are not carried out
(McGorry 2000). The Department of Health now recognizes the need for early intervention services, and some
researchers within the early intervention family work movement appear to give an optimistic outlook for early intervention (Linszen et al. 1996, Collins 2002). It is hoped that
such pioneering projects will become more commonplace
within the next few years. The National Health Service
(NHS) Plan (Department of Health 2000) stated that 50
early intervention teams would be set up by the end of 2005.
However, National Service Framework for Mental Health
Five Years On highlighted that the NHS Plan has only
achieved 41 teams; they are smaller than envisaged and are
only meeting 3% of their service users needs (Department of
Health 2004). McGorry (2005) concludes with caution that
mental health reforms frequently do not take account of
evidence-based work and that supporters of early intervention should fight to keep family work on the agenda. He
argues that it is critical to avoid the risk of this vital reform
not to be seen as fashion, highlighting that so much good has
come from the early intervention movement.
Clearly, family intervention models for psychosis were
designed for the 20th century adult population. What is
also apparent is that there is conflicting evidence in the use
of family intervention in first-onset psychosis and limited
research within this arena. The early intervention literature
has not yet directly asked whether family intervention is
being carried out, or by whom. It also has not identified
what sort of attributes or experience staff in early interven363

R. Askey et al.

tion services require to positively include and engage

families. These questions need to be answered if family
intervention is to be integrated successfully and kept on the
agenda for professionals working with this population.
Otherwise, as follow-up studies of trained staff highlight
(Kavanagh et al. 1993, Fadden 1997, Mairs & Bradshaw
2005), there is a high risk that family intervention will be
only offered in specific complex cases and not used as an
integral part of early intervention services.
Definitive randomized controlled trials are required to
establish the efficacy of family intervention in the use of
first-onset psychosis.

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