Integrating psychosis Recovery by Enabling Adult Carers at Home (psychosis REACH) in an early psychosis clinic
Psychosis typically develops during late adolescence and early adulthood. Due to its early onset, as well as the high likelihood of chronicity, psychosis is associated with diagnoses that are considered to be among the most disabling health conditions worldwide. Yet outcomes are greatly improved by intervening at the earliest possible point. Coordinated Specialty Care (CSC) is an empirically supported international care model for early psychosis that facilitates comprehensive, interdisciplinary care for individuals who are exhibiting early signs and symptoms of a psychotic disorder. CSC has been implemented across the US with promising effects. CSC clients with initial onset of psychosis are provided with a suite of evidence-based interventions to support individuals towards meaningful recovery.
Psychosis is hugely disruptive to the family system especially because the onset of psychosis typically coincides with a time that families are navigating normative developmental changes (i.e., supporting a young person to transition towards independence) leaving an indelible impact on the relationship between young person and family member. In addition, families are often termed ‘frontline providers’ as they frequently become responsible for their loved one’s care coordination and crisis management. Families, especially in the earliest stages of psychosis, may indeed be seen to be providing the most support to their loved ones and yet have had the least access to skills with which to provide this support.
Family interventions are recognized as evidence-based interventions, recommended by national and international clinical guidelines in the treatment of psychosis that serve to improve relations and empower caregivers. The core components of family interventions in psychotic disorders include psychoeducation, problem-solving skills, and communication skills. Unfortunately, although individuals with psychosis are routinely engaged in treatment, a recent national study found that only 1.9% of US families caring for someone with psychosis had received even the bare minimum of psychoeducation. Even within CSC, where family interventions are a recommended component of care, there is little guidance on family interventions that best compliments the care the patient is receiving and that meets the unique needs of the family.
Psychosis REACH (Recovery by Enabling Adult Carers at Home) is a Family Intervention for psychosis that delivers both psychoeducation and evidence-based Cognitive Behavioral Therapy for psychosis (CBTp)-informed skills to family caregivers in the community and can be delivered within a CSC setting. This approach was developed at the University of Washington under the leadership of Dr. Sarah Kopelovich in collaboration with leaders in the field of CBTp including Professor Douglas Turkington and Dr. Kate Hardy.
Dr Kate Hardy, Clinical Professor in the Stanford University Department of Psychiatry and Behavioral Sciences and her colleagues, used an MRI grant to design a system to integrate REACH within INSPIRE which is an existing CSC program at Stanford University.
They aimed to 1) assess the feasibility and acceptability of this intervention delivered within an early psychosis service, 2) explore the effectiveness of the p-REACH intervention on caregiver outcomes (depression and anxiety, expressed emotion, perceptions of caregiver burden, and attitudes toward psychosis), and 3) explore the qualitative experience of families participating in p-REACH training and ongoing group coaching.
In their pilot program family members participated in 3 stages of training and coaching:
1.Self-paced learning followed by 3-hour live demonstration of cognitive- behavioural therapy for psychosis (CBTp) skills, consisting of
a. Recovery-oriented psychosis psychoeducation
b. Cognitive, behavioural, and complimentary techniques to enhance caregiver self-care.
c. CBTp-informed communication, coping, and problem-solving skills
2. Six coaching calls occurring monthly with families co-facilitated by family ambassadors (FAs) and INSPIRE clinic staff
3. FAs met with families 2x 30-minute check-in calls per month for 6 months
Dr. Hardy and her team found that over a 6-month period 100% of the family members reported planning to use the skills immediately following the initial training and at follow-up (3-, 6- and 9-months post- intervention) 100% of family participants reported having utilized the skills as planned. Family participants reported a moderate improvement in their loved one’s symptoms since attending the p-REACH program which was maintained at 6-month follow-up
Overall participants had positive experiences of p-REACH. The majority of participants wished the program could continue for both the community and the opportunity to further learn and consolidate skills. And all participants said they would recommend it to other families considering participating.
This project demonstrated acceptability and feasibility of this model within an early psychosis clinic care setting and changes were consistent with prior research and the aims of the intervention. The qualitative data also supports acceptability and feasibility and provides a framework for further study.
They are now exploring ways to continue this program as part of what the INSPIRE clinic routinely offers to these patients and families. Additionally, Dr. Hardy is involved in the roll out of p-REACH across early psychosis programs in Michigan state as well as exploring culturally adapted p-REACH delivered in Lahore, Pakistan.