CLINICAL HANDBOOK OF SCHIZOPHRENIA

374 VI. SPECIAL POPULATIONS AND PROBLEMSgrief, stress, and burden. Family members must be collaborators in this process. The issuesfor families of patients with a first episode of psychosis differ from those in familiesof patients with multiepisode psychosis (see Table 36.3). Diagnostic ambiguity and uncertaintyare major issues, which means that education must be less specific than that for individualswith a more clearly established course. Furthermore, families that may have noprior experience in dealing with someone with a psychosis may be less willing to seekoutside support.One model for working with families, called the recovery stage model, is based onthe course of recovery for a person experiencing their first psychotic episode. The modelhas four stages: (1) managing the crisis, (2) initial stabilization and facilitating recovery,(3) consolidating the gains, and (4) prolonged recovery. Each stage has specific interventionsand clearly defined goals. Briefly, the primary goal in the first stage of treatment iscrisis management, which involves engaging the family and developing a good workingrelationship. Individual families are provided support and education about psychosis.The second stage focuses on stabilizing the patient and family, and facilitating recovery.Families are offered both individual and group treatment at this stage. In the third stage,the family worker helps family members integrate the information and skills they learnedin the previous stages into their daily lives. In the final stage of treatment, families areprepared to transition into appropriate, long-term treatment programs. Note that in eachphase of treatment, families identified as high-risk for difficulties are offered additionalinterventions and support. Lengths of the stages vary depending on the needs of the familyand the patient’s rate of recovery. Typically, the crisis stage may last a few months, followedby a 3- to 12-month recovery stage and a 12-month consolidation stage.A 3-year follow-up of a large Canadian sample of families of individuals with firstepisodepsychosis describes several clinically relevant issues, including the undoubtedlyhigh levels of family distress. This distress has been demonstrated to improve significantlyfor many families after 1 year. However, families with more severe distress often took 2years to recover. In considering the psychological well-being of the families, it was actuallyfamily members’ appraisals of the impact and consequences of the illness that weremost associated with their psychological well-being, not the severity of the illness. Furthermore,in this study, more than 80% of available families participated. These resultsindicate that family interventions are beneficial and can be effective in real clinical situations,and that engaging the family during the patient’s first psychotic episode is advantageous.Family interventions can be provided in two ways: to individual families or togroups. The interventions can be provided by either a special family worker or by casemanagers as part of a range of services for the individual patient. There is little researchevidence to guide the choice of interventions. There is some evidence that family groupscan become long-term self-supporting organizations, but it is not clear what proportionof the population of families can be engaged in groups. Providing each family with a specificfamily worker who makes outreach visits to family homes has been shown to engagethe families of 70–80% of patients. Both family education and support provided by an in-TABLE 36.3. Issues for Families of Early-Psychosis PatientsIssues for familiesDiagnostic ambiguityInexperienceLack of external supportTreatment implicationFocus on individual family unitFocus on issuesEducation accepts ambiguity