Engagement with services in Black African and Caribbean people with psychosis: The role of social networks, illness perceptions, internalized stigma, and perceived discrimination.

OBJECTIVES: Research and policies in the United Kingdom have repeatedly highlighted the need to reduce ethnic disparities and improve engagement with mental health services among Black African and Caribbean people with psychosis. The aim of this study was to examine the role of social network characteristics and psychological factors in engagement with services in Black people with psychosis. METHODS: A cross-sectional study was conducted with 51 Black African and Caribbean adults with non-affective psychosis and currently receiving care from mental health services in England. Measures were completed to examine relationships between social networks, illness perceptions, perceived racial or ethnic discrimination in services, internalized stigma, and current engagement with services from service user and staff perspectives. RESULTS: Social network composition (ethnic homogeneity) moderately correlated with better service user and staff reported engagement. Greater perceived personal control over problems was associated with better staff reported engagement. Lower perceived ethnic or racial discrimination in services, and specific illness perceptions (higher perceived treatment control, greater self-identification with psychosis symptoms, more concern and greater emotional response related to problems) were associated with better service user reported engagement. Internalized stigma was not associated with service engagement. Multivariate regression analyses suggested that a more ethnically homogenous social network was the strongest predictor of better service user and staff reported engagement. CONCLUSIONS: Psychosocial interventions that target social networks, perceived ethnic and racial discrimination in services, and illness perceptions may facilitate better engagement and improve outcomes. Further longitudinal studies are required to examine causal mechanisms.

The role of attachment and dissociation in the relationship between childhood interpersonal trauma and negative symptoms in psychosis.

Negative symptoms have an adverse impact on quality of life and functioning in psychosis. Service users with psychosis have identified negative symptoms as a priority for their recovery. Despite this, there is a lack of effective and targeted psychological interventions for negative symptoms and their underlying mechanisms remain poorly understood. Childhood trauma is a robust risk factor for positive symptoms in psychosis, but the association with negative symptoms is less well established. Our aim was to examine the association between childhood interpersonal trauma and negative symptoms and the psychological mediators of this relationship. Two hundred and forty participants experiencing psychosis completed validated self-report measures of childhood trauma, attachment, dissociation, compartmentalization, and symptoms. Mediation analyses showed that disorganized attachment and dissociative experiences mediated the association between childhood trauma and negative symptoms, when analysed individually and in a combined model. Models adjusted for age and positive and depressive symptoms. Avoidant attachment and compartmentalization were independently associated with negative symptoms but not childhood trauma and thus were not significant mediators. Childhood trauma was not independently associated with negative symptoms. This paper is the first to present empirical data to support a model implicating attachment and dissociation as important psychological processes in the link between childhood trauma and negative symptoms. These exploratory findings suggest that it may be beneficial to consider these relationships in trauma-informed formulations and interventions. Further longitudinal research is required to establish causality and test theoretical models of mechanisms in the pathway to negative symptoms.

Associations between attachment, therapeutic alliance, and engagement in black people with psychosis living in the UK.

BACKGROUND: Compared to other ethnic groups in the UK, Black people have the highest rates of psychosis. This may partly be explained by both assessment bias and structural racism. Mental health services often find it difficult to develop therapeutic relationships with Black people with psychosis. Attachment theory posits that the quality of previous caregiving experiences influence current interpersonal functioning and emotional regulation. In this study, we applied the theory to improve the understanding of therapeutic relationships with people with psychosis. AIMS: This is the first study to examine associations between attachment difficulties, therapeutic alliance, and service engagement in a Black sample with psychosis. METHOD: Fifty-one participants completed self-report measures of attachment and alliance. Staff completed measures of alliance and service engagement. RESULTS: Higher attachment avoidance was related to poorer alliance ratings. These significant findings were not upheld in a regression model controlling for total symptom scores and perceived ethnic/racial discrimination in services. Attachment anxiety was generally not associated with alliance ratings. Neither attachment anxiety nor attachment avoidance was significantly associated with service engagement. CONCLUSIONS: Staff should be supported to better understand the needs of service users with avoidant attachment behaviours and to develop mutually-agreed treatment goals and therapeutic bonds.

Exploring service user and family perspectives of a Culturally adapted Family Intervention (CaFI) for African-Caribbean people with psychosis: A qualitative study.

OBJECTIVES: In the UK, people of African-Caribbean background have the highest rates of psychosis and greatest inequity in mental health services of all ethnicities. National policies have highlighted the lack of evidence-based psychological interventions for this group. The aim of this study was to examine the acceptability of a novel Culturally adapted Family Intervention (CaFI) for African-Caribbean individuals diagnosed with non-affective psychosis and their relatives. DESIGN: A qualitative design. METHODS: Semi-structured interviews conducted with 22 service users and 12 family members following participation in CaFI. The interview topic guide included perceptions of the needs and benefits of CaFI; usefulness, cultural specificity and accessibility of CaFI therapy and supporting materials; content and delivering of CaFI sessions; views and experiences of working with CaFI therapists; and perceived barriers and facilitators to implementation. RESULTS: Deductive framework analysis identified three main themes for service users: perceived benefits, barriers and limitations, and delivery of the therapy. Four themes were identified for family members: perceived benefits, perceptions of therapists, delivery of therapy, and accessibility of therapy content, supporting materials, and cultural appropriateness. CONCLUSIONS: CaFI was found to be an acceptable intervention for African-Caribbean service users with psychosis and their relatives. Family interventions considering the needs of ethnic and cultural groups have the potential to improve the mental health care and experiences of service users and their families. PRACTITIONER POINTS: The Culturally adapted Family Intervention (CaFI) was viewed as acceptable to African-Caribbean service users with psychosis and their families. Through adapting interventions to be more culturally sensitive, it is possible to enhance the care of those who typically have poor engagement with mental health services. In-keeping with their ethos of individualized care delivery, mental health services should place more emphasis on being able to offer appropriate, culturally adapted interventions to their service users.

Examining the Factor Structure and Psychometric Properties of a Guilt Management Scale (GMS).

BACKGROUND: Guilt is commonly associated with distress and psychopathology. However, there is a lack of validated measures that assess how people cope with this aversive emotional and cognitive experience. AIMS: We therefore developed and validated a self-report measure that assesses how people manage their guilt: the Guilt Management Scale (GMS). METHOD: The GMS was administered to a non-clinical (n = 339) and clinical (n = 67) sample, alongside other validated measures of guilt severity, coping, thought control and psychological distress. Results from a principal component analysis (PCA) and assessments of test-retest reliability and internal consistency are presented. RESULTS: The PCA yielded a six subscale solution (Self-Punishment, Reparation, People-Focused, Spirituality, Avoidance and Metacognition), accounting for 56.14% of variance. Test-retest reliability and internal consistency was found to be good-excellent for the majority of subscales. Across samples, Self-Punishment was related to higher levels of guilt and distress whilst Metacognition and Reparation were related to less guilt and distress in the non-clinical sample only. CONCLUSIONS: This paper provides preliminary evidence for the psychometric properties of the GMS in a non-clinical sample. With development and validation in clinical samples, the GMS could be used to inform psychological formulations of guilt and assess therapy outcomes.

Social networks and symptomatic and functional outcomes in schizophrenia: a systematic review and meta-analysis.

PURPOSE: To conduct a systematic review and meta-analysis to examine the strength of associations between social network size and clinical and functional outcomes in schizophrenia. METHOD: Studies were identified from a systematic search of electronic databases (EMBASE, Medline, PsycINFO, and Web of Science) from January 1970 to June 2016. Eligible studies included peer-reviewed English language articles that examined associations between a quantitative measure of network size and symptomatic and/or functional outcome in schizophrenia-spectrum diagnoses. RESULTS: Our search yielded 16 studies with 1,929 participants. Meta-analyses using random effects models to calculate pooled effect sizes (Hedge's g) found that smaller social network size was moderately associated with more severe overall psychiatric symptoms (N = 5, n = 467, g = - 0.53, 95% confidence interval (CI) = - 0.875, - 0.184, p = 0.003) and negative symptoms (N = 8, n = 577, g = - 0.75, 95% CI = - 0.997, - 0.512, p = 0.000). Statistical heterogeneity was observed I2 = 63.04%; I2 = 35.75%,) which could not be explained by low-quality network measures or sample heterogeneity in sensitivity analyses. There was no effect for positive symptoms (N = 7, n = 405, g = - 0.19, 95% CI = 0.494, 0.110, p = 0.213) or social functioning (N = 3, n = 209, g = 0.36, 95% CI = - 0.078, 0.801, p = 0.107). Narrative synthesis suggested that larger network size was associated with improved global functioning, but findings for affective symptoms and quality of life were mixed. CONCLUSION: Psychosocial interventions which support individuals to build and maintain social networks may improve outcomes in schizophrenia. The review findings are cross-sectional and thus causal direction cannot be inferred. Further research is required to examine temporal associations between network characteristics and outcomes in schizophrenia and to test theoretical models relating to explanatory or mediating mechanisms.

Therapeutic alliance in psychological therapy for people with schizophrenia and related psychoses: A systematic review.

Therapeutic alliance is a key predictor of therapy outcomes. Alliance may be particularly pertinent for people with schizophrenia as this group often have a history of interpersonal trauma and relationship difficulties including difficult relationships with mental health staff. This review aimed to determine (a) the quality of therapeutic alliance between people with schizophrenia and their therapists; (b) whether alliance predicts therapeutic outcomes; and (c) variables associated with alliance. Databases were searched from inception up to April 2015. The search yielded 4,586 articles, resulting in 26 eligible studies, involving 18 independent samples. Weighted average client and therapist Working Alliance Inventory-Short Form total scores were 64.51 and 61.26, respectively. There was evidence that alliance predicts overall psychotic symptomatic outcomes and preliminary evidence for alliance predicting rehospitalization, medication use, and self-esteem outcomes. There was evidence for specific client-related factors being linked to different perspectives of alliance. For example, poorer insight and previous sexual abuse were associated with worse client-rated alliance, whereas baseline negative symptoms were associated with worse therapist-rated alliance. Therapist and therapy-related factors, including therapists' genuineness, trustworthiness, and empathy were associated with better client-rated alliance, whereas suitability for therapy, homework compliance, and attendance were associated with better therapist-rated alliance. Key clinical implications include the need to consider alliance from both client and therapist perspectives during therapy and training and supervision to enhance therapist qualities that foster good alliance. Future research requires longitudinal studies with larger samples that include pan-theoretical, well-validated alliance measures to determine causal predictor variables.

The Role of Therapist Attachment in Alliance and Outcome: A Systematic Literature Review.

OBJECTIVES: This review examined the impact of therapist attachment style on therapeutic alliance and outcomes. METHODS: Systematic search procedures yielded 11 studies for inclusion that measured associations between therapist attachment style and alliance and/or outcome. RESULTS: There is some preliminary evidence that therapist attachment style and interactions between therapist and client attachment style contribute to alliance and therapy outcomes. However, methodological weaknesses and heterogeneity across studies highlight the need for more rigorously designed research in this area. CONCLUSIONS: There is sufficient evidence to suggest that therapists need to pay attention to the influence of their own attachment style in therapeutic processes and that there is merit in pursing this area of research further. The review is important in highlighting key design issues to consider in future studies. Copyright © 2014 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Therapist attachment style has the potential to influence therapeutic alliance and client outcome. Improvements in therapeutic practice might be achieved if therapists have greater knowledge of their own attachment styles and how these interact with their clients' attachment styles to influence the psychotherapy relationship and outcomes. From the outset of their careers, therapists should receive training and supervision to enhance the awareness of their individual attachment experiences and how these play out during the therapeutic process.

Social network characteristics of Black African and Caribbean people with psychosis in the UK.

Poorer social networks predict more coercive pathways to care and other adverse outcomes in people with psychosis. People from Black African and Caribbean backgrounds have more negative experiences within UK mental health care systems and family relationships often breakdown. This study aimed to examine the social network characteristics of Black African and Caribbean people experiencing psychosis and associations between network characteristics and severity of psychosis, negative symptoms, and general psychopathology. Fifty-one participants completed social network mapping interviews (a gold standard approach to assessing social network composition) and the Positive and Negative Syndrome Scale. This is the first study to explicitly measure social network size amongst Black people with psychosis living within the UK and results showed that participants' social network size (mean = 12) was comparable to that of other psychosis samples. Networks were of moderate density and comprised disproportionately more relatives than other relationship types. Poor network quality was related to more severe psychosis symptoms suggesting that social network quality may be an important factor in influencing the severity of psychosis. Findings highlight the need for community-based interventions and family therapies to mobilise sources of social support for Black people with psychosis within the UK.

Childhood interpersonal trauma and paranoia in psychosis: The role of disorganised attachment and negative schema.

Paranoia is associated with significant distress and is associated with childhood trauma. Understanding the mechanisms responsible for this association is important for informing psychological interventions. Theoretical proposals suggest that negative schema and insecure attachment may be important mechanisms in the development of paranoia. Disorganised attachment may be particularly relevant. The current study is the first to examine whether the relationship between childhood interpersonal trauma and paranoia is mediated by disorganised attachment, and the impact of disorganised attachment on negative self and negative other schema. A large online sample of 242 people with self-reported psychosis completed measures of childhood trauma, attachment, self and other schema, paranoia and psychosis symptomatology. Path analysis indicated that childhood interpersonal trauma was associated with disorganised attachment, which in turn was associated with negative self-schema, negative other schema, and paranoia. Negative schema about others, but not self, was associated with paranoia. Disorganised attachment and negative other schema fully mediated the relationship between trauma and paranoia. Negative other schema partially mediated the association between disorganised attachment and paranoia. Results were found when controlling for depression, hallucinations and age. Results suggest that interventions that aim to modify disorganised attachment patterns and negative schema about others can potentially alleviate the impact of trauma on paranoia. Findings provide justification for longitudinal studies to confirm the direction of effects, and intervention studies that aim to manipulate disorganised attachment and negative schema about others and observe the impact of this on paranoia.

Modelling Identity Disturbance: A Network Analysis of the Personality Structure Questionnaire (PSQ).

Due to the relevance of identity disturbance to personality disorder this study sought to complete a network analysis of a well validated measure of identity disturbance; the personality structure questionnaire (PSQ). A multi-site and cross-national methodology created an overall sample of N = 1549. The global network structure of the PSQ was analysed and jointly estimated networks were compared across four subsamples (UK versus Italy, adults versus adolescents, clinical versus community and complex versus common presenting problems). Stability analyses assessed the robustness of identified networks. Results indicated that PSQ3 (unstable sense of self) and PSQ5 (mood variability) were the most central items in the global network structure. Network structures significantly differed between the UK and Italy. Centrality of items was largely consistent across subsamples. This study provides evidence of the potential network structure of identity disturbance and so guides clinicians in targeting interventions facilitating personality integration.

The relationship between stigma and subjective quality of life in psychosis: A systematic review and meta-analysis.

People with psychosis are reported to be one of the most stigmatised minority groups in society. Mental health stigma can have a detrimental impact on quality of life (QoL), which is a meaningful outcome for service users experiencing psychosis and using mental health services. This paper provides the first systematic literature review, meta-analysis and quality appraisal of studies examining the association between stigma and subjective QoL in non-affective psychosis. An electronic database search identified 45 articles for inclusion. A random-effects meta-analysis of 37 independent samples (n = 5795) found a statistically significant association between higher stigma and lower subjective QoL of medium strength (r = -0.40, 95% CI: -0.45, -0.35). Separate meta-analyses demonstrated medium-to-large negative pooled effects for self-stigma (k = 25, r = -0.44, 95% CI:-0.49, -0.38), perceived stigma (k = 10, r = -0.32, 95% CI:-0.42, -0.21) and experienced stigma (k = 6, r = -0.30, 95% CI:-0.35, -0.24). A narrative summary of 12 studies suggested psychological mechanisms relating to self-concept and social networks may play an important mediating role in the association between stigma and QoL in psychosis. Psychological interventions should target improvements in these psychological processes to reduce the negative impact of stigma on QoL in psychosis. Further longitudinal research is needed to test theoretical models of causal pathways and explanatory mechanisms.

Paranoia and negative schema about the self and others: A systematic review and meta-analysis.

Negative self and negative other schema have been implicated in the development of paranoia. The current study provides a meta-analysis, narrative review and quality appraisal of quantitative studies investigating the relationship between negative self and negative other schema and paranoia across the paranoia continuum. A systematic search identified 43 eligible studies; 25 were included in the meta-analysis. Meta-analytic findings demonstrated a medium to large relationship between paranoia and negative self-schema (r = 0.46, 95% CI 0.39 to 0.53) and negative other schema (r = 0.48, 95% CI 0.38 to 0.56). The magnitude of associations was similar across people with and without psychosis. Findings demonstrated that associations between negative self-schema and paranoia were not always statistically significant when controlling for confounding variables, particularly depression. The association between negative other schema and paranoia tended to remain significant when controlling for confounding variables. Findings also demonstrated that negative schema may mediate relationships between adverse experiences in childhood and paranoia. Overall, findings support theoretical proposals that both negative self and negative other schema are associated with paranoia. Longitudinal studies are required to confirm the direction of effects. Findings provide support for incorporating and targeting negative self and negative other schema in psychological formulations and therapeutic work.

Development, validation and cultural-adaptation of the knowledge about psychosis questionnaire for African-Caribbean people in the UK.

The absence of assessment tools incorporating different cultural models of mental illness is a major barrier to recruiting ethnic minorities into clinical trials, reducing generalisability of findings and potentially increasing disparities in access to evidence-based care. This study aimed to develop and validate a new Knowledge about Psychosis (KAP) self-report measure and a culturally-adapted version for African-Caribbean people (CaKAP). Content and face validity were achieved through consultations with experts in psychosis and a focus group with service users, carers, and community members. Eighty-seven predominantly White British participants and 79 African-Caribbean participants completed the knowledge questionnaires (KAP and CaKAP) and measures of help-seeking and stigma. Overall, the measures showed good internal consistency and test re-test reliability. Construct validity was evidenced via significant positive associations between knowledge about psychosis and help-seeking and significant negative associations between knowledge and stigma. These measures could improve the delivery of psychosocial interventions and outcome measurement in research trials.

The current status of culturally adapted mental health interventions: a practice-focused review of meta-analyses.

In recent years, there has been a steadily increasing recognition of the need to improve the cultural competence of services and cultural adaptation of interventions so that every individual can benefit from evidence-based care. There have been attempts at culturally adapting evidence-based interventions for mental health problems, and a few meta-analyses have been published in this area. This is, however, a much debated subject. Furthermore, there is a lack of a comprehensive review of meta-analyses and literature reviews that provide guidance to policy makers and clinicians. This review summarizes the current meta-analysis literature on culturally adapted interventions for mental health disorders to provide a succinct account of the current state of knowledge in this area, limitations, and guidance for the future research.

Culturally-adapted Family Intervention (CaFI) for African-Caribbeans diagnosed with schizophrenia and their families: a feasibility study protocol of implementation and acceptability.

BACKGROUND: African-Caribbeans in the UK have the highest schizophrenia incidence and greatest inequity in access to mental health services of all ethnic groups. The National Institute for Health and Care Excellence (NICE) highlights this crisis in care and urgent need to improve evidence-based mental healthcare, experiences of services and outcomes for this group. Family intervention (FI) is clinically and cost-effective for the management of schizophrenia but it is rarely offered. Evidence for FI with minority ethnic groups generally, and African-Caribbeans in particular, is lacking. This study aims to test the feasibility and acceptability of delivering Culturally-adapted Family Intervention (CaFI) to African-Caribbean service users diagnosed with schizophrenia. METHODS/DESIGN: This is a feasibility cohort design study. Over a 12-month intervention period, 30 service users and their families, recruited from hospital and community settings, will receive ten one-hourly sessions of CaFI. Where biological families are absent, access to the intervention will be optimised through 'family support members'; trusted individuals nominated by service users or study volunteers. We shall collect data on eligibility, uptake, retention and attrition and assess the utility and feasibility of collecting various outcome measures including readmission, service engagement, working alliance, clinical symptoms and functioning, perceived criticism, psychosis knowledge, familial stress and economic costs. Measures will be collected at baseline, post-intervention and at 3-month follow-up using validated questionnaires and standardised interviews. Admission rates and change in care management will be rated by independent case note examination. Variability in the measures will inform sample size estimates for a future trial. Independent raters will assess fidelity to the intervention in 10 % of sessions. Feedback at the end of each session along with thematically-analysed qualitative interviews will examine CaFI's acceptability to service users, families and healthcare professionals. DISCUSSION: This innovative response to inequalities in mental healthcare experienced by African-Caribbeans diagnosed with schizophrenia might improve engagement in services, access to evidence-based interventions and clinical outcomes. Successful implementation of CaFI in this group could pave the way for better engagement and provision across marginalised groups and therefore has potentially important implications for commissioning and service delivery in ethnically diverse populations. This study will demonstrate whether the approach is feasible and acceptable and can be implemented with fidelity in different settings.