Roberto Zarate

Evaluation of expressed emotion in schizophrenia: A comparison of Caucasians and Mexican-Americans

Social desirability, while a recognized source of respondent bias among Mexican-Americans, has not been evaluated as an explanation for the lower rate of high expressed emotion (EE) found in the family members of Mexican-Americans versus Caucasians with schizophrenia. In this study, we tested the hypothesis that the lower rate of high EE (hostility and criticism) among Mexican-Americans was the result of cultural factors impacting on how information was reported by the Mexican-American relative of a patient with schizophrenia. We compared the ratings of EE between Caucasian (N = 17) and Mexican-American (N = 44) patients with schizophrenia or schizoaffective disorder and their key relatives using the level of expressed emotion (LEE) scale (paper and pencil instrument rated by the patient and relative separately) and the Five Minute Speech Sample (observational experimenter rated). The ability of the various measures to predict relapse over two years was also examined. Contrary to our hypothesis, there were no differences between patient and family measures within ethnic group. Mexican-American patients and relatives reported lower rates of high EE than Caucasians across all measures. High EE predicted relapse across measures for Caucasian participants, but did not predict relapse for Mexican-Americans on any of the measurement instruments. We discuss the implications of these findings on cross-cultural research and family interventions for individuals with psychotic disorders.

A Randomized Controlled Trial of Family Intervention for Co-occurring Substance Use and Severe Psychiatric Disorders

Substance use disorders have a profound impact on the course of severe mental illnesses and on the family, but little research has evaluated the impact of family intervention for this population. To address this question, a randomized controlled trial was conducted comparing a brief (2-3 mo) Family Education (ED) program with a longer-term (9-18 mo) program that combined education with teaching communication and problem-solving skills, Family Intervention for Dual Disorders (FIDD). A total of 108 clients (77% schizophrenia-spectrum) and a key relative were randomized to either ED or FIDD and assessed at baseline and every 6 months for 3 years. Rates of retention of families in both programs were moderate. Intent-to-treat analyses indicated that clients in both programs improved in psychiatric, substance abuse, and functional outcomes, as did key relatives in knowledge of co-occurring disorders, burden, and mental health functioning. Clients in FIDD had significantly less severe overall psychiatric symptoms and psychotic symptoms and tended to improve more in functioning. Relatives in FIDD improved more in mental health functioning and knowledge of co-occurring disorders. There were no consistent differences between the programs in substance abuse severity or family burden. The findings support the utility of family intervention for co-occurring disorders, and the added benefits of communication and problem-solving training, but also suggest the need to modify these programs to retain more families in treatment in order to provide them with the information and skills they need to overcome the effects of these disorders.

Family intervention for co-occurring substance use and severe psychiatric disorders: participant characteristics and correlates of initial engagement and more extended exposure in a randomized controlled trial.

Clients with severe mental illness and substance use disorder (i.e., dual disorders) frequently have contact with family members, who may provide valuable emotional and material support, but have limited skills and knowledge to promote recovery. Furthermore, high levels of family conflict and stress are related to higher rates of relapse. The present study was a two-site randomized controlled trial comparing a comprehensive, behaviorally-based family intervention for dual disorders program (FIDD) to a shorter-term family psychoeducational program (FPE). The modal family was a single male son in his early 30s diagnosed with both alcohol and drug problems and a schizophrenia-spectrum disorder participating with his middle-aged mother, with whom he lived. Initial engagement rates following consent to participate in the study and the family intervention programs were moderately high for both programs (88% and 84%, respectively), but rates of longer term retention and exposure to the core elements of each treatment model were lower (61% and 55%, respectively). Characteristics of the relatives were the strongest predictors of successful initial engagement in the family programs with the most important predictor being relatives who reported higher levels of benefit related to the relationship with the client. Subsequent successful exposure to the family treatment models was more strongly associated with client factors, including less severity of drug abuse and male client gender. The results suggest that attention to issues of motivating relatives to participate in family intervention, and more focused efforts to address the disruptive effects of drug abuse on the family could improve rates of engagement and retention in family programs for dual disorders.

Emotional over-involvement can be deleterious for caregivers' health: Mexican Americans caring for a relative with schizophrenia.

The study of emotional over-involvement (EOI) has focused primarily on its relationship with patients’ course of illness. We know little about the predictors and possible consequences of EOI for caregivers. Based on past research, we tested the hypotheses that EOI is associated with worse physical and psychological health among caregivers and examined whether caregiver burden and social support may mediate this relationship. Method In a sample of 37 Mexican American caregivers and their ill relatives recruited from two outpatient clinics, we examined the relationships between EOI, caregiver burden, caregivers’ level of social support, and caregivers’ health. Additionally, we examined whether caregiver burden and social support may mediate the relationship between EOI and caregivers’ health. Cross-sectional analysis indicates that at baseline EOI was not associated with caregiver burden or social support, but was related to worse current health. Longitudinal analysis, however, indicates that EOI at baseline was associated with greater burden, less instrumental support, and worse health among caregivers at follow-up. Moreover, objective burden and instrumental support mediated the relationship between EOI and several health outcomes. Consequently, EOI may be a marker of poor current health status and predicts worse future health among Mexican–American caregiving relatives of individuals with schizophrenia. Moreover, changes in burden and social support associated with EOI appear to mediate the relationship between EOI and several health outcomes among caregivers. These findings suggest that it might be important for family interventions to not only address the functioning of individuals with schizophrenia but also their caregiving relatives.

Expressed emotion and family interactions in Mexican Americans with schizophrenia.

Patients with schizophrenia who are exposed to family environments high in expressed emotion (EE) are at increased risk of relapse. EE is usually measured by an interview with one family member and does not include a direct assessment of family interaction. To understand better the key processes that underlie the relationship between EE and course of illness, we applied a well-validated measure of family interaction, the Structural Family Systems Ratings (SFSR), to 28 Mexican-Americans with schizophrenia and their families. The relationships among EE indices, SFSR components, and relapse were examined. Although measures of EE and family interactions were not related, both EE and one component of the SFSR, family resonance, were associated with a psychotic relapse within 1 year of the assessment. The results suggest that Mexican Americans with schizophrenia benefit from living with families that are able to adapt to the ever-changing circumstances and needs of their ill relatives.

Antisocial personality disorder in people with co-occurring severe mental illness and substance use disorders: clinical, functional, and family relationship correlates

Antisocial personality disorder (ASPD) is an important correlate of substance abuse severity in the addiction population and in people with co-occurring serious mental illness and addiction. Because family members often provide vital supports to relatives with co-occurring disorders, this study explored the correlates of ASPD in 103 people with co-occurring disorders (79% schizophrenia-schizoaffective, 21% bipolar disorder) in high contact with relatives participating in a family intervention study. Clients with ASPD were more likely to have bipolar disorder and to have been married, but less likely to have graduated from high school. ASPD was associated with more severe drug abuse and depression, worse functioning, and less planning-based social problem solving. The relatives of clients with ASPD also reported less planning-based problem solving, worse attitudes towards the client, and worse mental health functioning. Client ASPD was associated with less long-term exposure to family intervention. The findings suggest that clients with ASPD in addition to co-occurring disorders are a particularly disadvantaged group with greater illness severity, more impaired functioning, and more strained family relationships. These difficulties may pose special challenges to delivering family intervention for this group.

FAMILY PSYCHOEDUCATION WITH PATIENTS WHO HAVE CO-OCCURRING SUBSTANCE USE DISORDERS AND SEVERE MENTAL ILLNESS

been empirically demonstrated through the provision of regulated and quality training followed by their supervised application to clinical practice, and ascertaining limits, establishing indicators, evaluating the quality of their application and their effects, thereby obtaining essential information for their future dissemination in clinical practice. Results: the preliminary results from the mental health services of the Murcia Region are presented. The low application in clinical practice is confirmed, particularly in mental health centres, with therapy/family per year ratios ranging between 0-8. The benefits obtained where strategies have been applied are similar to experimental studies. The greatest shortcomings identified were connecting with the family and the absence of re-call sessions. The current organisation of services and overburdened staff and the need for changes on the part of professionals towards a therapy model that takes setting into account, are underlined as the greatest obstacles for their implementation. Conclusions: Additional measures are necessary, such as specific funding and professional incentives.

Improving Work Outcome in Supported Employment for Serious Mental Illness: Results From 2 Independent Studies of Errorless Learning

Background Heterogeneity in work outcomes is common among individuals with serious mental illness (SMI). Objective In 2 studies, we sought to examine the efficacy of adding errorless learning, a behavioral training intervention, to evidence-based supported employment to improve SMI work outcomes. Work behavior problems were targeted for intervention. We also explored associations between early work behavior and job tenure. Methods For both studies (VA: n = 71; community mental health center: n = 91), randomization occurred at the time of job obtainment with participants randomized (1:1) to either errorless learning plus ongoing supported employment or ongoing supported employment alone and then followed for 12 months. Dependent variables included job tenure, work behavior, and hours worked and wages earned per week. For the primary intent-to-treat analyses, data were combined across studies. Results Findings revealed that participants in the errorless learning plus supported employment group stayed on their jobs significantly longer than those in the supported employment alone group (32.8 vs 25.6 wk). In addition, differential treatment effects favoring errorless learning were found on targeted work behavior problems (50.5% vs 27.4% improvement from baseline to follow-up assessment). There were no other differential treatment effects. For the prediction analyses involving work behavior, social skills explained an additional 18.3% of the variance in job tenure beyond levels of cognition, symptom severity, and past work history. Conclusions These data support errorless learning as an adjunctive intervention to enhance supported employment outcomes and implicate the relevance of workplace social difficulties as a key impediment to prolonged job tenure.

The Role of Robert Liberman in the Development of Family Psychoeducation

Over the past 50 years, mental health professionals have come to recognize the enormous benefits that can be derived from involving the families of people with serious mental illness in the treatment enterprise. One of the earliest advocates for this perspective, Robert Liberman, has played a pivotal role in the development of evidence-based practices targeted to improving the outcomes for this population. From his early work starting in the 1970 s with Ian Falloon on behavioral family therapy for schizophrenia, through his influence as director of the UCLA Clinical Research Center in the 1980 s and ‘90 s on colleagues who applied family psychoeducation principles to the treatment of other mental disorders, to his most recent efforts designed to adapt these approaches to people of diverse cultural backgrounds, Liberman has steadfastly championed the value of teaching families the skills required to meet their needs and to enhance the social adjustment and quality of life of individuals with serious mental disorders.