Summary of the impact

Psychosis is a serious mental illness for which treatment can be aided by psychological therapies. Researchers at King's College London (KCL) demonstrated that family environment is key to recovery and developed and validated a family intervention for psychosis. Family intervention for psychosis is a recommended treatment in NICE guidelines (2009), as well as by the Patient Outcomes Research Team in the USA. The NICE guideline committee was chaired and advised by KCL researchers. Family intervention for psychosis is part of training programs for clinical staff and has changed NHS practice. The KCL-led website mentalhealthcare.org.uk disseminates this research to families of those with psychosis.

Underpinning research

Psychosis, a serious mental illness, affects around 2% of the population. Family intervention for psychosis (FIp) is a cognitive behavioural psychological intervention involving specific supportive educational and problem solving/crisis management sessions with the service user and their family. At least 10 sessions are recommended over 3-12 months. FIp pioneers the approach of the service user as expert in their own problems and works by assuming that family carers are not to blame but are trying to do their best to cope in what can be difficult and unsupported settings. FIp was the first psychological intervention for psychosis that showed good evidence of changing outcomes, including reduced relapse rates in patients, improved family relationships and lessening the burden of care.

The development of and research into FIp at Institute of Psychiatry, King's College London (KCL) has been carried out by Prof Elizabeth Kuipers (1977-present, Professor in Clinical Psychology), Prof Philippa Garety (1997-present, Professor of Clinical Psychology), Prof Paul Bebbington (1977-96, Professor of Clinical Psychology), Prof Julian Leff (1966-2003, Professor of Social and Community Psychiatry) and Dr Dominic Lam (1988-2005, Reader). Research focused on understanding the mechanisms that might contribute to change in carers and improving outcomes for service users. This approach was in distinct contrast to the view prevalent in the 1980's that psychosis was a biologically based condition that would not be amenable to changes in the quality of relationships. A 1994 aggregate analysis by KCL researchers confirmed that the family setting can impede recovery in psychosis. It showed that relapse could be predicted by the level of negative expressed emotion (EE) within a family (50.1% in families with high EE ratings compared with 21.1% in those with a low EE rating) (1). This led to the further development of FIp, the efficacy of which was established by a widely cited meta-analysis in collaboration with University College London and the University of Oxford in 2002. The study found a significant benefit in terms of relapse rates, medication compliance and hospitalisation where family interventions had occurred, when compared to standard care without an active intervention, with some evidence of reduced burden experienced by families (2).

KCL research into FIp was compiled into a manual, originally published in 1992 with a second edition in 2002. This emphasises a number of points, including: offering discussion of up-to-date information about psychosis; conflict and problem-solving; the emotional processing of grief, loss and anger; improving communication and reducing criticism. FIp is aimed at all willing and available family members. With a focus on relapse prevention, it allows families to define their own particular problems and work at ways to understand and improve them (3). This manual was later used to provide FIp to families after a recent relapse (4).

To help refine the intervention, in 2003 KCL researchers completed further randomised control trials of offering help to long term carers (5) and those in early interventions services for psychosis (6). This work, together with implications for evidence based interventions, has been developed into a cognitive model of informal carer relationships in psychosis, published in 2010 (7).

References to the research

Grants

• P Garety, E Kuipers (joint PIs), Profs D Fowler, G Dunn, P Bebbington. Cognitive and Social Processes in Psychosis: developing more effective treatment approaches. Wellcome Trust Programme Grant. 2001-2007. £1,632,207.

• E Kuipers (PI), G Thornicroft, S Gentleman. Involving mental health carers in research. Wellcome Trust public engagement activity award. 2008-2010. £59,905.

• E Kuipers. To make new films for the website mentalhealthcare.org.uk. British Psychological Society Public Engagement Grant. 2010-2011 (6 months). £7,500.

• E Kuipers. Help to maintain and develop the website mentalhealthcare.org.uk. The Maudsley Charity. 2011-2013 (24 months). £50,760.

Details of the impact

In England, care for people with schizophrenia and psychosis costs around £11.8 billion a year. To help people experiencing psychosis, researchers at King's College London (KCL) developed and tested the cognitive behavioural psychological therapy family intervention for psychosis (FIp), which involves both the service user and their family.

FIp in Guidelines
A major impact stemming from KCL research on FIp is that this therapy is now a recommended treatment for service users with psychosis in contact with carers in current National Institute for Health and Care Excellence (NICE) guidelines on interventions for schizophrenia (2010). This recommendation means there is a requirement for services to consider how to deliver this. This guideline cites both a meta-analysis from KCL as background information (Bebbington et al. 1994) and uses more recent work as a basis for their recommendation (Garety et al. 2008). The Guideline Development Group for this NICE publication was chaired by Prof Kuipers (1a). A recent NICE scoping review confirmed that there is no new evidence that will contraindicate the efficacy of FIp and thus the recommendation that it should be offered to those with schizophrenia who are in contact with carers will continue for the next update, due out in 2014 and also chaired by Prof Kuipers. These conclusions are supported by an influential Cochrane review (1b) and by updated Patient Outcomes Research Team recommendations in the USA that include reference to Pilling et al. 2002; Garety et al. 2008 and Szmukler et al. 2003 (1c).

FIp in Practice
As a result of the work of KCL researchers, FIp is now part of early intervention services for psychosis in the UK and it is standard practice to offer families help and support from first onset. To implement their research on FIp, Prof Kuipers was the Founding Director of the Psychological Intervention Clinic for Outpatients with Psychosis (PICuP) at the Maudsley Hospital, part of South London and Maudsley NHS Foundation Trust (SLaM) (2a,b).

In 2011, the Department of Health (DH) produced the document `No health without mental health,' which included objectives such as that "more people who develop mental health problems will recover." One of the ways they proposed to aid this was to champion "work with the whole family, using whole-family assessment and support plans where appropriate." They pledged that "from April 2011 local agencies ... will be able to create a Community Budget freeing up money to be spent on innovative types of family intervention services that address the needs of the whole family" (3c).

To advise on best ways to implement such priorities, in 2011 the DH expanded the Increasing Access to Psychological Therapies — Severe Mental Illness (IAPT-SMI) initiative (first set up in 2006), which has the aim to "increase public access to a range of NICE approved psychological therapies for psychosis, bipolar disorder and personality disorders." In 2012, SLaM was one of only two places chosen to be IAPT-SMI demonstration sites for psychosis (3d). In order to ensure that therapy is delivered to a uniformly high standard, the IAPT-SMI programme has developed a competencies framework that included input from Prof Kuipers. Here, one of the competencies is to have "an ability to draw on knowledge of the theory and principles underpinning therapeutic models commonly applied for people with psychosis and bipolar disorder ... e.g.: family interventions" (3e,f).

Wider Use of Flp
FIp is endorsed by the Schizophrenia Commission, an independent body of 14 experts set up by Rethink Mental Illness to which Prof Kuipers was asked to provide evidence. In their 2012 report, they noted that FIp is one of "eight treatment areas where the evidence base suggests that increased investment will generate cost savings through reducing the probability that an individual will need to be admitted to hospital" (3a). Internationally, the Flp manual is currently forming the basis of new early intervention services in Northern Italy in the GET UP PIANO Trial (3b).

Training Programmes in FIp
As a result of the development of FIp, training courses have been set up such as the NHS's Meriden Family Work Programme, hosted within Birmingham and Solihull Mental Health Foundation NHS Trust (Director Dr Grainne Fadden, formerly a DClin Psy and PhD student at KCL). This programme trains and supports clinical staff in the skills needed to work with families. Their work is based on a number of studies into FIp, including Kuipers et al's 2002 guide on family work and Pilling et al. 2002 (4a). FIp is also offered to healthcare professionals by the Florence Nightingale School of Nursing & Midwifery at KCL as part of their continuing professional development (4b) and as a postgraduate Diploma or Certificate at the Institute of Psychiatry (4c). Family intervention, including FIp, has become part of the Doctorate in Clinical Psychology course at KCL's Institute of Psychiatry, leading to a professional qualification to practice (4d).

Help for Service Users and Families
Research at KCL has shown that carers of people with psychosis have an unmet need for accurate, research-based information about psychosis and answers to their questions. This led Prof Kuipers to develop the website mentalhealthcare.org.uk, which includes information on psychosis for both service users and carers. It also has a series of short films and an `Ask the Expert' section that features a Psychiatrist, Psychologist (Prof Kuipers and a colleague), Pharmacist and Social worker (all from KCL and/or SLAM) replying to questions on psychosis and therapy posed through the website. Part of the website is dedicated to family therapy and includes details of FIp. It has had very positive feedback from carers, service users and staff both in the UK and internationally. It had been accredited by a DH Quality Standard and received funding from the Wellcome Trust, the British Psychological Society and the Maudsley Charity. The site had 26,000 hits in May 2013 (5a,b).

Sources to corroborate the impact

1) FIp in Guidelines

a. NICE guideline update 2010: Schizophrenia — The NICE Guideline on core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. Updated Edition 2010. Prof E Kuipers, Chair, Guideline Development Group: http://www.nice.org.uk/nicemedia/live/11786/43607/43607.pdf

b. Pharoah F, Mari J, Rathbone J, et al. Family intervention for schizophrenia. Cochrane Database of Systematic Reviews 2010;12:CD000088. Doi: 10.1002/14651858.CD000088.pub3

c. Dixon LB, Dickerson FB, Bellack AS, et al. The 2009 schizophrenia PORT Psychosocial treatment recommendations and summary statements. Schizophr Bull 2010;36(1):48-70. Doi: 10.1093/schbul/sbp115

2) FIp in Practice

a. PICuP: http://www.national.slam.nhs.uk/services/adult-services/picup/

b. PICuP Booklet including FIp (page 9): https://www.national.slam.nhs.uk/wp- content/uploads/2011/08/PICuP-Service-Booklets.pdf

c. Department of Health. No Health Without Mental Health (pgs 21, 40): https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf

d. Improving Access to Psychological Therapies — Severe Mental Illness Website: http://www.iapt.nhs.uk/smi-/

e. Roth and Pilling (2013). A Competence framework for psychological interventions for people with psychosis and bipolar disorder (pgs 17, 24: http://www.ucl.ac.uk/clinical-psychology/CORE/Docs/Working%20with%20Psychosis%20and%20Bipolar%20Disorder%20background%20document%20web%20version.pdf

f. Generic Therapeutic Competencies (p1): http://www.ucl.ac.uk/clinical-psychology/CORE/Docs/All%20generic%20competences%20web%20version.pdf

3) Wider Use of FIp

a. The Abandoned Illness. A report by the Schizophrenia Commission Report. Nov 2012: http://www.rethink.org/media/514093/TSC_main_report_14_nov.pdf

a. Ruggeri M, Bonetto C, Lasalvia A, et al. A multi-element psychosocial intervention for early psychosis (GET UP PIANO TRIAL) conducted in a catchment area of 10 million inhabitants: study protocol for a pragmatic cluster randomized controlled trial. Trials 2012;13:73. Doi:10.1186/1745-6215-13-73

4) Training Programmes in FIp

a. The Meriden Family Programme. Family intervention references:
http://www.meridenfamilyprogramme.com/docs/Family%20Intervention%20References%20-%20Jan10.pdf

b. Florence Nightingale School of Nursing & Midwifery course in Family Interventions for Psychosis:
http://www.kcl.ac.uk/teares/nmvc/external/prospectus/course_info.php?code=6KNIH314

c. Family Interventions in Psychosis PG Diploma or Certificate at KCL:
http://www.kcl.ac.uk/aboutkings/quality/academic/prog/specs/1213pdfs/PGDipPGCertFamilyInt erventionsinPsychosis.pdf

d. Doctorate in Clinical Psychology: http://www.kcl.ac.uk/prospectus/graduate/doctorate-in-clinical-psychology/structure

5) Help for Service Users and Families

a. www.mentalhealthcare.org.uk

b. FIp: http://www.mentalhealthcare.org.uk/family_therapy