Family Systems

CFI "High EE" indicated by:

(a) Six or more critical and/or hostile comments (b) Rating of 4 or more for emotional over-involvement *High EE need only be present in ONE caretaker for the family to be classified as EE*

Deviant roles and communication styles in the family environment

--->Deviant modes of perceiving, feeling and thinking about oneself and ones relationship to the extra-familial social world

Cognitive Coping (Adapting to, Selecting and Shaping)

-Appraisal -Cognitive Control -Self Efficacy

Camberwell Family Interview (CFI)

-Brown et al. British studies (1958 -1972) -Vaughn et al (1984)

Things we know about SPD

-Can and does occur in larger numbers than two -May be the key motivating factor in some suicide pacts and homicides -Most common diagnosis of the inducer is Schizophrenia -Higher incidence of Schizophrenia in the FIRST DEGREE RELATIVES of the submissive individual -Usually highly resistant to change

Singer's work

-Communication deviance in families correlates with severity of clinical disorder in sz offspring -Severity of clinical disorder and communication deviance in the family of szs both independently predict severity of clinical disorder in sz offspring -Parents often have more severe communication deviances than the sz offspring. -The form and style of the communication deviances in the family could be matched with communication deviances in the Sz offspring -Using communication deviance information szs could be matched in a blind test with the family of origin.

Shared Psychotic Disorder

-Delusion develops in an individual in the context of a close relationship with another individual of group of individuals who already have the established delusion -The delusion is similar in content to that of the person who already has the established delusion -Not better accounted for by another disorder -Note: No duration requirements

The Family mechanisms for denying role divergence engender three types of pathological thinking:

-Fragmentation or absence of relation and continuity -Denial of meaning (meaning limited to the literal and concrete (under-inclusive)) -Paranoid thinking (defense against fragmentation (everything is relevant - over-inclusive thinking)). Hence meaning is again denied.

Behavioral Coping (Selecting and shaping Environments)

-Generating Alternatives -Implementing Alternatives

Jackson (and Palo Alto group)

-Homeostasis -Double Blind

CFI "How"

-Interviews are conducted with each caretaker (individually) -Interviews are audiotaped and transcribed. -Each interview takes about 1.5hrs per caretaker -Interviews focus on most recent episode and perceived impact on family. -Restricted to the 3 months immediately preceding the pt admission Transcripts are coded for the presence of: -(a) Critical comments by caretaker (number of instances of) -(b) Hostility by caretaker (number of instances of) -(c.) Emotional Over-involvement (rated on a scale of 0 [absent] to 5 [high]

Social Support Recruitment (Shaping Environment)

-Network Size -Number of Clusters -Boundary Density -Multiplexity

Laing

-Nexus of Mystification -Existential rebirth -Villa 21 and Kingsley Hall

Lidz's Assumptions

-Per Talcott Parson's thesis that the family is a special type of group with biologically prescribed roles: -Wife = expressive-affectionate, nurturing role. Primary conduit for cultural expectations for the child; -Husband = instrumental, adaptive leadership characteristics -Human beings are not naturally endowed with an inherent logic of causal relationships. Perceiving, thinking and communicating are skills that are influenced by the early family environment

Characteristics of a family dominated by pseudomutual relationships:

-Persistent sameness in the family structure Intense concern about possible divergence from the family role structure -Absence of spontaneity

SPD Prevelence

-Rare in clinical settings but probably quite prevalent in community samples. -Research hindered by the difficulty of differentiating between subcultural, religious and delusional beliefs -The inducing individual is usually the dominant individual in the relationship -The relationship is based on common needs and marked by strong emotional rapport. -Often related by blood or marriage and have lived together for a long time -95% involve members of the same family -1/3 involve sisters -1/3 involve husband/wife or mother/child -1/3 involve other combinations -The dominant individual is usually older, more intelligent, better educated and has stronger personality traits

Communication Disturbance in Relatives of Szs Beyond the age risk for Sz (key findings from Docherty, N)

-Relatives of Szs had more Communication Disturbances than control (CDs= use of words with ambiguous meanings; use of vague over-inclusive words; language structural breakdown; vague references; missing information) Note: relevant to older concepts of: Communication deviance; double bind; Nexus of mystification; double bind; transmitted irrationality Communication Disturbance severity positively correlated with severity of Illness in offspring Conclusion: Communication disturbance in family members may be a manifestation of a stable genetic vulnerability

Wynne & Singer

-Rubber Fence -Complementarity -Family Thought Disorder -Communication Deviance

B. Affective Style (AS)

-Schizophrenia -Mood Disorders

C. Life Events

-Schizophrenia -Mood Disorders

A. Expressed Emotion (EE)

-Schizophrenia -Mood Disorders -Other

E. Coping

-Schizophrenia -Mood Disorders -Anxiety Disorders

Who is at risk for SPD?

-Submissive persons often affected with physical disabilities, thus increasing their dependence -Live in relative isolation -Those living in poverty or economic distress -All cultural and ethnic groups -Probably more common in women* -Apart from delusion, behavior of submissive is usually NOT odd -The shared delusion CAN BE (but not usually) bizarre. Usually kept in the realm of possibility and may be based on past events or certain common expectations

Lidz

-Transmitted Irrationality -Imperviousness and Masking -Marital Skew -Marital Schism

Double Blind conditions

-Two more persons -A repeated, habitual experience -Primary negative injunction -Secondary, more abstract conflicting injunction -A third injunction preventing escape or comment

EE, AS and the Course of Bipolar Disorder (key Findings from Miklowitz et al)

-Unlike SZ families, AS and EE were found to be unrelated in families of Bipolar Disordered patients -Found an interaction between Family EE and AS profiles -EE did not predict social attainment scores but AS did. -Pts who married other disturbed individuals were less likely to function well on follow-up than those individuals who married well spouses. -EE and AS were both unrelated to medication compliance

Network Size

-bigger is better -high ratio of non-family to family better

Active/Acute phase

-characterized by hallucinations, paranoid delusions, and extremely disorganized speech and behaviors. -pt appears obviously psychotic. -if left untreated, active psychotic symptoms can continue for weeks or months -symptoms may progress to the point where the patient must enter the hospital for treatment

Expressed Emotion and Affective Style: Other Facts, Theories and Findings

-for Sz, Median relapse rates across studies over 9-12 mts after discharge: -47% HEE vs. 21% Low EE -EE also predicts outcomes Depression, Bipolar Disorder, Wt reduction and skill retention in Mildly MR subjects -not unique to family members. -also found among non-family caregivers -High EE more common in Western countries -Criticism positively correlated with Hostility in Western countries but less-so in non-western countries -not all studies support the Brown et al findings. e.g. Mc Millian et al . (Nortwick Park study)

EE Findings

-most studies find no differences in terms of relapse between high and low EE Families after 9mts. -no evidence of strong gender differences in EE susceptibility -poor premorbid functioning may be correlated with high EOI. However not associated with Criticism or Hostility Paradox: -6-12 mts after discharge, 50% of HEE families register as LEEs on the CFI. -If EE were evident only during relapse it should NOT affect future outcomes for the pt -Miklowitz et al (1989) found that the interactions in HEE families changed within 8 weeks post discharge.

AS "How"

-pt and the caretakers are interviewed in separate 10 min sessions. -2 issues are selected: 1 from the caretakers and 1 from pt. -pt and caretakers are asked to resolve the 2 issues in 2 separate 10 min sessions. follow-up sessions (1 issue per session). -all sessions are audiotaped with clinicians outside of the room The audiotapes are transcribed and coded into the following categories: (1) Supportive Statements (2) Critical Comments (a) Benign, situational type (b) Harsh, personal, trait-attribution type (3) Guilt-inducing statements (4) Neutral-intrusive statements

Prodromal Phase

-refers to the period of time from when the first change in a person occurs until he or she develops full-blown psychosis -the time span leading up to the first obvious psychotic episode

Family System Models of SZ

1. Bowen [Emotional Divorce, Interdependent Triad, 3 Generation Assumption] 2. Wynne [Pseudomutuality, Rubber Fence, Communication Deviance] 3. Jackson [Double Blind, Homeostasis] 4. Lidz [Marital Skew, Marital Schism, Communicated or Transmitted Irrationality] 5. Laing [False Self, Nexus of Mystification]

The concept (and the reality) of Shared Psychotic Disorder important for a number or reasons:

1. Speaks to the possibility of social communication/transmission of at least some of the key elements of psychosis (i.e., aberrant beliefs). Hence it offers partial validation to the broad assumption held by: (a) Early Psychodynamic theorists and (b) Early Family systems theorists, that psychotic illness are to some extent a product of of early social/familial relationships. 2. Speaks to the MAINTENANCE AND REGULATION of aberrant thought and beliefs through ongoing social relationships. Hence, consistent to a degree with: (a) Self Psychology theories; (b) Modern theories about the role of the emotional climate in the family (e.g., Expressed Emotion) and the role of social networks.

With respects to the EE findings however..

1. Tarrier et al. (1979) found that even after 2 years the GSRs of SZs from HEE families adapted less rapidly to the presence of A HEE relative in the room 2. Affective Style (the behavior analog of the EE) is measured at discharge not admissionEvidence of reciprocal family interactions = Pts from HEE families more critical of their families When EE is low, pts and relatives tailor their responses to the behavior, needs and expectations of each other (mutuality?) When EE is high = a. Less flexible/accommodating (rubber fence?) b. More coercive (projective identification?) c. Associated with more vigilance (projection?) d. More ambiguous (double bind, nexus of mystification, pseudo-mutuality?) e. More inconsistent over time (variable schedule of reinforcement?)

Affective Style (AS)

A Behavioral Analog to Expressed Emotion (Doane et al)

How do External Intelligence models explain individual differences? Two complementary conjectures:

A. Everyone is a member of numerous non-shared subcultures (including family of origin) that pull for specific problem solving skills and strategies, some of which will not be shared or preferred by the dominant culture B. Cultures and subcultures vary in the effectiveness of their preferred strategies for solving common, trans-cultural problems.

Family mechanisms that prevent deviations or at least the recognition of deviations from the rigid family structure:

All of the strategies are designed to manipulate the focus of selective attention and set attentional priorities: -Creation of family myths and ideology that stress catastrophic consequences of openly recognized divergence -Indiscriminate approval of activities and interests -Secrecy -Use of intermediaries to communicate expectations

AS "What"

An assessment of the interactional style/patterns of the caretakers and the patient

CFI "When"

At time of admission to hospital

The three types of pathological thinking result in an abnormal mode of interpersonal communication, which is referred to as:

Communication Deviance [Note: It is assumed that there are expressive and receptive components to the construct of Communication Deviance]

Expressed emotion studies (CFI)

Have found that: a. Patients from High EE families were 3-8 times more likely to relapse than those from low EE within 9mts from discharge b. Association between EE and relapse was independent of pre-admission illness severity or work impairment Major difference: -British study: Medication and face to face contact ADDITIVE -US study: Medication and face to face contact INTERACTIVE

Model 1: EE causes Relapse

High EE behavior---> Symptoms of SZ

Self Psychology and Interpersonal Models

How others relate to us determines how we relate to ourselves: A selection pressure that determines the skills and attributes we value and practice and the ones we don't.

Wynne

Most reliable and robust work in family systems (later worked with margaret singer) -Made the case that people were made by two important but basic assumptions: -human beings are object related (interpersonal functioning) -everyone strives for a personal identity (self functioning) Complementarity (the quality of relatedness). Three types: -Pseudomutualitity, -Non-mutuality -Mutuality

Bowen's Theory

Noticed that between mother and father an "emotional climate" which he called emotional divorce. All disagreements would sort of "hush" down based on an inability to make decisions. He argued that this represented a shared immaturity of the parental figures in the family. Great deal of unpredictability, the way they produced predictability they produce a sick child, mother becomes "over adequate" and over protected. Father would remove self and become a distant observer, dismissing things to mother. Mother would convince child they were sick. "without us you will die"— somatization was common observation in the offspring. Argued it created stability but ridged role structure. Child NEEDS parents.

Residual Phase

Obvious psychosis has subsided, but the pt may exhibit negative symptoms of SZ, such as social withdrawal, a lack of emotion, and uncharacteristically low energy levels. And, although frank psychotic behaviors and vocalizations have disappeared, the patient may continue to hold strange beliefs. For instance, when you're in the residual phase of schizophrenia, you may still believe you have supernatural intelligence, but no longer think you can read people's minds word-for-word.

Model 2: EE as an Epiphenomenon

Prodromal SZ symptoms--->Active Sz Symptoms OR High EE Behavior

Model 3: A vulnerability Stress Model

Prodromal Symptoms, High EE behavior and Active Symptoms all promote one another (loop)

Ego in Ego Psychological Theory

Psychotic Symptoms are a compromise formation (family needs v. self-needs)--->Adaptational pressures in the Family--->Selection of Ego functions/Cognitive--->skills--->Selection of Family Roles--->Identity Formation

First break (three generations assumption)

Rapid growth in adolescence disrupts the family equilibrium, often resulting in the first break as the child is forced to cope with the demands of the extra-familial environment without the requisite cognitive/emotional skills

Three generations assumption

Says the mother conveys to the child two contradictory demands: - To remain helpless -Become mature and succeed outside the family

CFI "What"

Semi-structured Interview to assess caretakers' attitudes toward the patient

AS "When"

Takes place about 2 weeks after discharge from the hospital

Like Shared Psychotic Disorder...

The aberrant family structures and processes leads to vicious cycle that Progressively isolates the family and the identified individual from potentially corrective extra-familial experiences.

Number of Clusters

The more the better

All of the family models include a "Double Blind"

This environment forecloses the use of "shaping" and "selection" in devising a solution, thus forcing the individual to "adapt" to the "double bind" environment.

CFI "Purpose"

To identify families with High Expressed Emotion

Sternberg's External Affairs Component of Self Governance

Unlike most External Intelligence Models the External Affairs component is assumed to have a Bi-directional relationship with the Internal Affairs component.

Family Studies Predicting Onset of Illness (Goldstein and Rodnick key findings)

Use of CD and AS to predict onset of Sz specturm disorders Conclusions: 1. CD and Affective styles exist in families before onset of sz spectrum Disorder symptoms 2. CD may trigger SZ or SZ spectrum disorder by being either a: i. Genetically transmitted thought disorder ii. A Stressor iii. A reaction to having to raise a SZ child (CD also found in MR parents) Iv. A modeling influence

Bowen

Was the first person to put a "family" in a study. -Emotional Divorce -Interdependent Triad -Three Generation Assumption

Rubber fence

continuous elastic boundary created by a family atmosphere of pseudomutuality

Interdependent Triad

coping strategy for dealing with immaturity, anxiety and feelings of helplessness - enhances predictability.

Boundary Density

degree of separation between clusters - moderate to high levels of separation -[low density] good)

Multiplexity

degree to which individual network members fulfill multiple roles in the patient's life -the more the better

Emotional Divorce

due to shared immaturity/incompetence marked by a façade of rigid complementary roles of over-adequacy and inadequacy

Mothering of Helplessness

poor discrimination between psychological distress and medical symptoms --- medical symptoms are potentially controllable and confirmation of presumed helplessness.

Density

ratio actual to potential links within clusters -degree of interconnectedness - moderate to high levels good

Self representation/Identity

remains merged with the role structure of the family

Deviant family systems

retard the evolution the self-government system

First psychotic break occurs when

the individual is forced to solve extra-familial social problems on their own using the self-government system molded by the deviant family system.

AS "Purpose"

to identify issues of conflict in the current family environment

AS "Negtive Affective Style families are families that evidence":

(1) One or more Harshly Critical or Guilt-Inducing statements in one or more of the 10 min. interactive sessions; OR (2) Six or more Neutral-intrusive statements in a SINGLE 10 min session.