Family Support and Intervention

It is essential to attend to the immediate needs of family and friends of young people with a first episode of psychosis. Many young people with early psychosis still live with their parents, and families are the main source of their care during the prodromal and early acute phases. Families require an accessible and flexible service, which acknowledges their role and contribution to care. A crisis intervention model can be used, based on education, to reduce carers' stress and confusion while maximizing their support for the patient [65].

Education

Education about psychosis is essential from the earliest stages of a psychotic disorder. Strategies to deliver effective education should be integrated within the culture of the mental health service, and targeted to families and other carers as well as the patient.

The type and intensity of education must be adapted to the phase of the illness and the capacity of the family and the patient to interpret it. In the earliest stages of a psychotic disorder, at a time of uncertainty, distress and sometimes fear, patients and their carers can be particularly receptive to information about what is occurring, why it is happening and what can be done. ''Normalizing'' the experience - stressing that it is not unique and that it is familiar to health care professionals - is reassuring. Reassurance can also be provided through clear messages that they are in no way to blame for the illness, the health system is ready to assist, that the current distress will be rapidly relieved and that eventual recovery is to be expected. Repeated delivery of educational messages may be needed, particularly in the acute stage. Even when they are acutely psychotic, patients usually understand pragmatic information about their care, and may find it less threatening to be given information than to feel excluded from the information flow [66]. As the patient's acute disturbance starts to settle, then more comprehensive educational strategies can be implemented.

Challenges to education in the first episode of psychosis include the following:

• an uncertain diagnosis and prognosis;

• the normal defensive processes of patients and families in a time of crisis;

• the impact of psychotic symptoms;

• secondary morbidity such as depression;

• cognitive impairment associated with some psychotic illnesses;

• the stigma of mental illness and self-trauma;

• other life stresses and lack of social supports.

Mental health professionals can become desensitized to the impact of an episode of acute psychosis. They need to remain focused on the needs of families, as they face a daunting illness with unfamiliar treatments and systems of care, perhaps after many months or even years of coping alone through a traumatic prodromal period. There is a need to be sensitive to transcultural and language issues.

Families often experience considerable blame and guilt as they search for a reason for the illness. Explaining psychosis using traditional illness models can ease the burden, by describing the roles of neurotransmitter changes and other biological features of psychosis. It is sometimes best to defer any detailed examination of precipitating and perpetuating factors until the acute episode has settled, to avoid perceptions that the family may be to blame.

Table 2.12 Possible fears of families about treatment

• Clinicians will overtly or covertly blame the family for the illness.

• Clinicians will automatically admit the person to hospital without consultation.

• Clinicians will fail to provide adequate follow-up after the assessment process.

• The young person will be turned into a "zombie" by medication.

• The young person will never forgive the family for contacting the service.

Emotional Aspects

Families often move through phases similar to those of the psychotic episode:

• During the prodrome and early stages of a psychotic episode, families might experience some denial and attempt to minimize the problem, until they acknowledge that ''something is not quite right'' and seek help.

• After psychosis has been identified, they can experience a period of grief and distress. A crisis often precipitates first contact with mental health services and the provision of a diagnosis, although the contact with services might initially be ambivalent. Once the patient is in ''the system'', families can be faced with an avalanche of bureaucratic procedures and jargon.

• As the patient moves towards recovery, families develop some sense of coping, confidence and adaptive functioning, while recognizing that professional help will not always be unlimited. There is a realignment of roles and expectations within the family, accompanied by concerns about the possibility of relapse.

Some fears of families about treatment are listed in Table 2.12. Such fears can remain unstated. It is vital to allay them with emotional support and strategic information, which may need to be repeated by different people at different contacts.

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