SEMINAR ON

FAMILY INTERVENTION /
EDUCATION OF PATIENT WITH
SCHIZOPHRENIA

Date of submission: 16.12.2022

SUBMITTED TO: SUBMITTED BY:

Dr. Bhuvaneswari R Dipa Mani Rabha

Lecturer M.Sc 2nd year

CON, JIPMER CON, JIPMER

 Family intervention/ education of patient with schizophrenia

INTRODUCTION

Schizophrenia is a serious mental disorder that has a significant impact not only on patients suffering from
the disorder but also on their families. The end of traditional institutional care within psychiatric hospitals
has led to an emphasis on the importance of emotions and affections within the family and the recognition
of the high level of burden on relatives. The social and emotional implications for families and patients with
schizophrenia are harmful, resulting in impairment of social and occupational functioning. From the onset
of the disorder, caregivers spend a lot of time worrying about their relatives’ well-being and future care,
neglecting their own care. The uncertainty about diagnosis, prognosis, and adequate treatment can trigger
high levels of anxiety and stress within the family and all this contributes to caregivers burden. In addition,
families must adjust very quickly to this new role of “informal care”, for which they often feel unprepared.

It is estimated that in Western countries, between 50% and 80% of patients with schizophrenia are in close
contact with their relatives and friends. When the patients return to the community after an admission or
first contact with the mental health services, their relatives are the main support system, even more than
the medical staff. Muela and Godoy indicated that there is “something in the family interaction that seems
to cause a relapse of the patient and seems to influence the course of the disease, instead of being the
origin of the same”. Following this, it seems reasonable to dedicate research and clinical resources to
determine to a greater extent the needs of caregivers in order to improve the family environment and,
consequently, the patient’s recovery.

DEFINITION:

A group of disorders manifested by fundamental disturbances or distortions in thinking, mood and

behaviour, last for at least a month of active phase symptoms like delusions, hallucinations, disorganised
speech, grossly disorganised or catatonic behaviour, negative symptoms such as shallow or flat affect,
alogia or avolition and incongruous mood. - ICD10.

Disturbance in thinking is marked by alteration of concept formation, which may lead to misinterpretation
of reality, hallucinations and delusions. Mood changes include ambivalent, constricted, inappropriate
emotional responsiveness, or blunted effect. Lack of empathy with others, disturbance in behaviour may
be withdrawn, regressive and bizarre. – American Psychiatric Association.

Family interventions

Although there is not a unique approach for family interventions, evidence-based family therapies usually
include psychoeducation, stress reduction, emotional processing, cognitive reappraisal, and structured
problem solving. Intervention consists of a combination of psychotherapeutic strategies for working with
the relatives of people who suffer from psychosis, and it aims to develop a collaborative relationship
between the family and the treatment team in order to help patients make progress toward recovery.
Interventions are always delivered by mental health professionals but can differ in theoretical orientation,
modality, or length.
PORT Recommendation. Persons with schizophrenia who have on-going contact with their families,
including relatives and significant others, should be offered a family intervention that lasts at least 6–9
months.

• ‘Family’ includes people who have a significant emotional connection to the service user, such as
parents, siblings and partners.

• The goals of family-based services are

-To increase understanding of the disorder,

-Reduce levels of expressed emotion,

-Reduce feelings of isolation, stress, and burden of family members,

-Foster development of coping skills, and

-Develop an ongoing collaborative relationship between family and clinicians.

Objective:

To facilitate the family in managing the affected member better by improving their interactions in the
home setting. The aim is to avoid further episodes and hospitalization.

Aims of family interventions:

 To help families cope with their relatives’ problems more effectively.

 Collaboration with relatives who care for the person with schizophrenia.

 Reducing the emotional stress and burden on relatives and within the family unit.

 Enhancement of relatives' ability to anticipate and solve problems.

 Reducing expressions of anger and guilt by the family.

 Maintenance of reasonable expectations for patient performance

 Attainment of desirable change in relatives' behavior and belief system

BASIC INTERVENTIONS WITH THE FAMILY

Objective: To facilitate the family in managing the affected member better by improving their
interactions in the home setting. The aim is to avoid further episodes and hospitalization.

Sessions: Suggest to them the appropriate ways of responding to the affected member. Help them to
identify the inappropriate responses that they may be performing, so they may be able to recognize and
modify them. You will need two to three sessions to achieve this, as family members may want to
discuss each suggestion in detail.
Who to include: It would be preferable if all the family members are present for this session. If this is
not possible, then the primary caregivers or the leader of the family should attend. The affected member
may also be included in these sessions.

Mode: You can present this:

a) In the form of a lecture format for an individual family

b) For a group of different families

c) Use overhead projectors.

Suggestions to be given to the family

1. Comply with medication:

Prepare the family for the possibility of the affected member discontinuing the medication when they
feel better/ to stop the side effects. Explain that the negative side effects of medicines reduce quickly
after stopping medication. The positive effects takes longer to reduce after the medicines have been
stopped. Thus, it may falsely appear that the affected member is doing well and that medication is not
required.

Remind them that the support of the family members is required when the affected member is resistant
or forgets to take the medication.

2. Normalize the family routine:

Discuss with the family the disadvantages of making the affected member the center of their lives. Tell
them that since schizophrenia is a long-term illness, they may become too stressed to be able to look
after the affected member. They may also develop problems of their own. This could result in the
affected member feeling guilty and responsible. The affected member could then perceive himself as a
burden to his family. He would not see his family as a place to seek support.

Encourage them to as far as possible, resume the daily routines that were present before the illness. If
there were no routines or they appear disruptive, help them to make a daily routine. This routine should
also include time for leisure, celebration of festivals, birthdays, etc.

Advise them to attend to the needs of other family members. They should not always support the
affected member when he is unreasonable and then be stricter with other members of the family.

3. Revise expectations:

The affected member is often expected to revert to their former roles and behaviours after
hospitalization. The family feels disappointed when the affected member is unable to do so. Discuss and
encourage them to have realistic expectations of what the affected member can do. The family should
be encouraged to view the affected member as having a serious physical illness, which requires a long
time for resting. The family will otherwise tend to view a brief hospitalization to mean the affected
member does not have a serious illness.
Once the affected member’s symptoms are stable, some affected members can be inactive, sleep more
and appear not motivated. They may also be restless and be unable to perform small tasks. Reassure
the families that these are a normal part of the course. Discourage them from viewing the affected
member as “lazy.”

4. Set limits: Inform them that just because the affected member is ill, the family does not need to/
should do whatever the affected member asks. Instead they should set limits on the undesirable
behaviours by:

Help them to identify what behaviours they will and will not tolerate. Help them to decide which
behaviours are intolerable (violent and bizarre) and which are irritating (based on a consensus). When
the behaviour occurs, they must immediately set limits so as not to form a pattern of behaviours. For
example, if the affected member hits a family member, they should try to stop them from doing so each
time. Instruct them not to tolerate the behaviour for some time and then later try to stop the affected
member.

Advise them to avoid discussing with the affected member the reasons for setting the limit or how they
feel about it. Train them to only state that the behaviour is unacceptable, without explaining why.

Advise the family to be specific in their requests and to use specific reminders when they want the
affected member to do a task. Advise them against, for example, expecting the affected member to do
household chores unless they have been specifically told what to do and how often to do it. The affected
member may forget and need reminders.

Help the family to identify which reinforcers are most effective. They can identify material reinforcers
(such as money, food, etc) and activity reinforcers (for example, if the affected member does the chores
then they can watch TV or be taken for an outing).

Assist them in identifying a variety of reinforcers so that the affected member is not bored. Initially
material or activity reinforcers should be used with social reinforcers (smiling, praise, patting them). Later
the material reinforcers should be reduced but the social ones continued.

5. Selectively ignore

Discuss with them the improbability of solving all their problems at once.

Advise them to select one or two issues, which they wish to focus on. They should ignore the others
until they are successful in solving the selected ones.

Instruct the family that they must, however, not ignore behaviours such as suicidal threats, violence or
other psychotic behaviours. The approach to be adopted for these problems are addressed in the
chapter “Addressing and Handling Difficult Problems”

6. Reduce stress: Remind them that the affected member has a lower tolerance for stress.

Instruct the family to reduce fights, conflicts, rejection and nagging behaviours.
Discuss with them how being over enthusiastic, showing extreme concern and encouragement can be
upsetting for the affected member, and discourage them from doing so.

Advise them that should the affected member wish to withdraw and be alone, the family should allow it.

To avoid the affected member withdrawing completely, discuss with them opportunities or activities to
offer the affected member to engage in, such as going out. Prepare them to accept the possibility that
the affected member will refuse.

7. Simplify communication:

Affected members often do not respond immediately when spoken to. There may be a pause or delay
before they communicate. Advise the family members to avoid speaking on the affected member’s
behalf when this occurs. Advise them to wait for the affected member to respond. Remind them that the
affected member can contribute to the conversation.

Advise them to avoid the tendency to assume what other members are thinking about, want or need,
even before they say so. Encourage them to speak only for themselves. Advise them to accept what
other members say even if they do not agree with it.

Advise family members against talking about complex and emotional topics in the presence of the
affected members. Especially during times of crisis. They should also avoid detailed conversations,
which the affected member will find confusing.

8. Identify warning signs:

Review with the family the significance and meaning of possible warning signals.

Signals differ from patient to patient. Inform the family that there are numerous warning signs.

These help in avoiding another episode or hospitalization.

Advise the family to observe whether these warning signs are fleeting or are present continuously for at
least a week and/ or appear to be increasing. If the latter, the family should consult the treating team.

Some warning signals for the family to look out for are: alterations in routine habits (like sleeping and
eating), becoming easily irritable, muttering to self, changes in personality or bizarre behaviour.

9. Enhancing social networks:

Family members at times adopt the attitude that they should not trouble others with their problems.
They may also worry about the reactions of others. Discuss with the family the benefits of discussing
their problems with others like relatives, friends, neighbours, religious or social organizations as it will
help in reducing their distress. It also helps them to generate new and better solutions to their problems
and prevents them from using the same unsuccessful tactics in solving their problems.

Use the reasons stated in the introduction chapter (Why involve the Family? Point # 13) when discussing
with them about the need for improving their social contacts. Point out to them that they will not be able
to care for the affected member for a long time unless they look after themselves as well.
Identifying Inappropriate Responses of the Family

a) Adapting and normalizing the situation: Family members usually adapt their routine to include the
affected member’s behaviours. This is usually a slow and gradual process of adaptation that helps the
affected member to maintain a role in the family, but as the affected member becomes unable to do so
due to the illness, the family members find it difficult to adjust. You should be able to get this information
from the “coping” part of the assessment.

b) Coaxing and rational persuasion: Family members tend to convince the affected member that their
unusual ideas and beliefs are untrue and to persuade them to behave in more acceptable manner.
Family members think that it is possible for the affected member to control their symptoms. You should
be able to get this information by asking the family what they say to the affected member when he is
symptomatic. If not, ask the family members if they have ever made such statements.

c) Making sense out of nonsensical communication: Even though it becomes apparent that the affected
member does not make sense, some family members may still try to understand the meaning of the
affected member’s often bizarre and nonsensical statements. They may try to determine the essence of
the message or to look for something realistic in what the affected member says.

d) Ignoring: Family members sometimes hope that the affected member will gradually stop, behaving the
way they do-hoping that it will go away. At times, they ignore the illness symptoms or deny the
significance of it, or try not to think about it. This is ineffective when the symptoms are extreme.

e) Providing constant supervision: Family members are unable to predict the affected member’s
behaviours. So, they tend to constantly supervise the affected member’s behaviour. This gives them
some kind of control over the situation. They feel it protects the affected member. However, it is difficult
for the family to maintain this constant supervision for a long time.

f) Reducing their own activities: The family members gradually begin to plan their routines and activities
to care for the affected member. This may involve actually looking after the affected member and
supervising him so that he does not harm himself or others. Family members become exhausted and
eventually use even their spare or free time to do the minimum necessary house work.

g) Ignoring the needs of other family members: Caring for the affected member becomes a full time job.
The emotional needs of the other members become secondary or the caregivers may not have enough
time and energy to look after the others. This results in others feeling uncared for or neglected, and
family relationships deteriorate.

The role of family therapy in the management of schizophrenia: challenges and solutions

Family interventions for schizophrenia have been amply demonstrated to be effective and are
recommended by most of the international clinical guidelines. However, their implementation in the
clinical setting as well as in treatment protocols of patients with psychosis has not been fully achieved
yet. With the increasing deinstitutionalization of patients, family has begun to assume the role of care
performed by psychiatric hospitals, with a high emotional cost for caregivers as well as the recognition of
burden experiences. Families have been the substitute in the face of the scarcity of therapeutic,
occupational, and residential resources. For this reason, the viability of patients’ care by their families
has become a challenge. This article aims to discuss the most important aspects of family interventions,
their impact on families, and the most important challenges that need to be overcome in order to achieve
well-being and recovery in both patients and caregivers.

Family interventions

This can be started either during the acute phase or later, including in inpatient settings. Family
intervention should:

• Include the person with schizophrenia if practical.

• Be carried out for between 3 months and 1 year

• Include at least ten planned sessions

• Take account of the whole family’s preference for either single-family intervention or multi-family group
intervention

• Take account of the relationship between the main carer and the person with schizophrenia

• Have a specific supportive, educational or treatment function and include negotiated problem solving or
crisis management work.

• For whom a longer intervention is not feasible or acceptable a shorter intervention that is at least 4
sessions in length should be offered to persons with schizophrenia.

• Characteristics of the briefer interventions include education, training, and support.

• Proposed as adjuncts rather than alternatives to drug treatments

• The selection of a family intervention should be guided by collaborative decision making among the
patient, family, and clinician.

Family interventions have been found to significantly reduce rates of relapse and re-hospitalization.
Possible benefits for patients include:

• Reduced psychiatric symptoms,

• Improved treatment adherence,

• Improved functional and vocational status, and

• Greater satisfaction with treatment.

Positive family outcomes include:

• Reduced family burden and

• Increased satisfaction with family relationships.

Psychoeducation

Implies provision of information and education to a service user with a severe and enduring mental
illness, including schizophrenia, about the diagnosis, its treatment, appropriate resources, prognosis,
common coping strategies and rights.

Psychoeducation involves quite lengthy treatment and runs into management strategies, coping
techniques and role-playing skills. It is commonly offered in a group format.

What is psychoeducation?
Psychoeducation is a process by which you impart knowledge of the illness to the family, and with your
continual assistance, modify their attitudes. You also formulate and implement better coping skills and
other preferred interactions with the affected member.
Objective:
To educate the family about all the relevant aspects of schizophrenia. The information that you will
provide is given in the Psychoeducation Booklet in Appendix I. These sessions should enable them to
understand the illness and care more effectively for their affected family member. It will also allow you to
determine the family’s perception of the illness, how their beliefs influence their behaviour and how
amenable they are to seeing the illness from a different perspective.
Sessions:
You may be unable to complete the psychoeducation in one session and may need to take more
sessions to do so. The sessions should be tailored to the individual affected member’s symptoms and
circumstances. It covers the causes, symptoms and prognosis of schizophrenia, the treatment and
management.
Who to include:
If there are many relatives, you should assess each relative’s knowledge in individual sessions and then
present the information to the family collectively. You may decide whether to include the affected
member in the family sessions. Otherwise, the affected member can have a separate information-giving
session.
Seeing the family in the absence of the affected member may be preferable as the relatives, may want
to ask questions about the affected member, which they may feel uncomfortable asking in his presence.
The affected member may also disrupt the session by being unable to concentrate, showing
inappropriate emotions or their speech may be disturbed, etc, if the affected member is actively
symptomatic.
When you have more than two families to educate, you can have all the family members of both the
families present and do the session for the group.
Mode: You can provide the psychoeducation:
a) In a lecture format-in that you will do most of the speaking to a family.
b) With more than one family at a time-in a group setting.
c) Provide them with reading material on schizophrenia to go through first and then later clarify their
doubts
d) Present it in the form of video footage for the family.

Guidelines on providing psychoeducation:

1. Remember that even if the family members do accept most of the information, they rarely change
their beliefs about causation
2. The family’s view of the affected member’s condition may not change immediately in response to the
psychoeducation, but will gradually change later.
3. Allow them time to ask questions and pause after each theme to allow them to respond.
4. You may need to encourage some families to ask questions or voice their disagreements with the
information provided.
5. Due to the above, be prepared to discuss and clarify the information with the family.
6. Avoid over-loading the family with too much information or medical jargon.
7. Use analogies to explain concepts that are difficult to understand. Use examples from the history of
the affected member.
8. Listen and understand the family’s view of the illness.
9. Be sensitive to the distress experienced by the family members, such as when the affected member is
violent, suspicious or has delusions that the spouse is unfaithful, etc. Be alert to this and address it in
future sessions.
10. If you do not know the answers to their questions, admit uncertainty. Assure them that you will
provide the information in the next session and do so.
11. They may ask the same questions repeatedly over a number of sessions. You need to be patient in
answering them and when negotiating differences that they perceive in the affected member’s condition
and your scientific explanation of the illness.
Educating the family
The diagnosis
Some families may feel afraid or distressed when they hear that the affected member has
‘schizophrenia’. It is important that they are aware of the diagnosis. If not, they may assume other
causes to be responsible for the affected member’s behaviour and treat the affected member the way
they think is more suitable.
Another drawback of not knowing the diagnosis is that the family may think the affected member has
more control over his or her symptoms than he or she actually has. They may then conclude that
medication is unnecessary and at times, even harmful. They may also doubt whether the affected
member is pretending to have an illness.
Terms like schizophrenia and psychosis may be confusing for them. Clarify their doubts. They may feel
uncomfortable using the term ‘schizophrenia’ with their friends or relatives, as they may feel stigmatized.
They can use terms (such as ‘breakdown’) which they are comfortable with to describe the illness to
others.Some families associate schizophrenia with violence. When the affected member is not violent,
they may not then accept the diagnosis. They may be afraid that the affected member may become
violent later. You will need to clarify such fears and doubts by stating that not all schizophrenic-affected
persons become violent. Most are shy and fearful.
The symptoms
Use examples from the affected member’s behaviour to educate the family about their symptoms. You
may notice that families often find it difficult to focus on the symptoms of schizophrenia.
They usually tend to talk about specific experiences of the illness. This is normal.
Inform the family that each affected member has a different symptom pattern. The affected member can
have different symptoms at different phases of the illness. This is important, as family members may not
pay attention to you when you speak of symptoms that the affected member does not have.
Emphasize that the affected member’s positive symptoms cannot be easily understood. They are
thoughts, ideas, and voices that go in inside the affected member’s head. The family can see their
indirect effects through the affected member’s behaviour.
Emphasize that the symptoms are real to the affected member. Thus, the affected member cannot
control them. They will neither be able to resist answering the voices they hear nor can they be
dissuaded from their fears. They are not doing it on purpose.
Emphasize that negative symptoms (like lethargy, absence of emotion, amotivation) cannot be easily
over come by the affected member.
Ensure that the family does not form the impression that all the problems are outside the affected
member’s control. They will otherwise be over protective of the affected member and feel guilty if the
affected member makes demands on them.
Causes of schizophrenia
Families usually have their own theories as to why the illness may have occurred. These are
problematic only when the family acts upon such beliefs as the sole cause of the illness. For example, if
they think the affected member is too sensitive or imaginative, they may then try to talk the affected
member out of delusional ideas or protect them from stress.
Family members may think they caused or could have prevented the illness in some way, especially if
an incident precipitated the illness. Such theories make the relatives guilty and depressed. They may
blame it on a failure in the affected member’s exams or a love affair, bad parenting, superstitious beliefs.
You may need to answer doubts such as whether the affected member will be able to have children,
and will they inherit the illness. You can answer such questions by telling the families that the children
will not inherit the illness. They may or may not however, inherit the tendency to develop the illness. If
they do, then some develop the illness with exposure to little stress; whereas others with massive stress.
Medication
Discuss with the family and emphasize the need for regular treatment as prescribed and not an erratic
treatment by the family.
Emphasize that medication will need to be taken for a long period of one to two years or, even
indefinitely. The duration of the treatment depends on the recovery and not the duration of illness before
the treatment.
Some families may feel that the medications are like “sleeping tablets” and are addictive if used for a
long time. They may then decide that the affected member should learn to cope without the medication.
Clarify that this is not so and that the medications reduce the positive symptoms.
Discuss with the family and emphasize the need for continuing the medication even when the affected
member appears better. The medications control the symptoms. Inform them that the underlying
problem will still be present. By continuing the medication, they can prevent symptoms from recurring.
Should the family ask, you should be able to explain how the medications work. Explain that
schizophrenia develops from a malfunctioning of chemicals in the brain. The medication works by
compensating for this malfunction. This usually involves restoring a chemical imbalance.
The result of which will be fewer hallucinations and delusions.
Discuss and explain the common, unwanted side effects of medication. Reassure them that by
changing/ reducing medication or by adding other medications it can be eliminated.
If family members enquire, state that Electroconvulsive therapy (ECT) may be indicated for catatonic
patients and for patients who for some reason cannot take anti-psychotics. Patients who have been ill for
less that one year are the ones most likely to respond.
Course and prognosis
Most families expect the affected member to be cured-that is, to not have any more episodes.
They may assume that the affected member does not require further treatment and that the illness will
not recur. Discuss remissions and relapses in schizophrenia and the need for longer treatment duration.
Inform them that there are good chances that the affected member can recover from an episode and
have a near normal life. Reassure them that they may recover up to 60-70% with medicines and other
treatments. This statement should be made depending on the severity and chronicity of the illness. It
would be inappropriate for affected members who have a long history of symptoms and poor social
functioning.
For chronic affected members, your discussions should focus on reduction of symptoms and
improvement of the affected member’s ability to live independently. Discuss rehabilitation programs and
family support to help the affected member return to living a normal life.
Inform the family that there are possibilities of the affected member having future episodes of
schizophrenia. This statement helps the family to continue the medication for long periods and prevents
them from being disappointed when the affected member has a relapse.
ASSESSMENT

SESSION I

Objective: To determine the family’s knowledge of the affected member’s illness, as well as the effect of
the illness on the family’s functioning.

Guidelines:

1. Knowledge of the affected member’s past and present symptoms (content of their delusions, nature of
hallucinations, behaviours related to these symptoms as well as negative symptoms) in detail is
necessary.

2. Prior understanding of the family’s attitudes and beliefs about the illness in general and the symptoms
of the affected member, in particular will help to foster an interactive mode of information presentation
for the psychoeducation sessions.
3. You should speak to the whole family together, preferably in the absence of the affected member. You
should address the question to the family as a whole and then ask each of the family members for their
individual opinion.

4. Although your primary objective is to assess the family, be prepared to answer the family’s questions.
It is unlikely that you will be able to gather all the details of your assessment without the family
questioning you about the illness. Judge whether it is appropriate to answer every question now or some
of them later, as planned.

1. Knowledge about illness:

To begin with, ask the family as to whether they think something is wrong with the affected family
member or not. Almost all the family members should agree that something is wrong.

If so, ask them what do they think is wrong with him/her? The responses to this could vary depending
on whether this is the first episode of the affected member or whether the affected member has had
numerous episodes in the past. If it is the first episode, the family may or may not report any of the
psychiatric symptoms, i.e., they may be unable to say that the affected member has “hallucinations” or
“delusions”. They will instead report the “effect or influence” of hallucinations or delusions on the affected
member’s behaviour. Thus, they may reply that the affected member has odd behaviours such as
laughing and talking to himself, saying odd things that do not make sense, not doing well in work or
school, withdrawing from social contacts with others, etc.

Ask the family what illness the affected member has. The family members may not have been told the
diagnosis or if they have been, may not understand it. If they do not know the diagnosis, you must tell
them. This leads to the family wanting to know more details about it. Judge how much to tell them at this
point. You could give them some information on the course, causes and prognosis of the illness.

If the family member’s do know what the diagnosis is, then ask each family member to tell you what he
or she thinks schizophrenia means. This will allow you to assess what the family knows or thinks they
know about schizophrenia. It will also reveal some of their fears and misconceptions about the illness.
They may think it is similar to “multiple personality” or “split personality”.

2. Burden

These questions are more relevant for families who are living with an affected member for a number of
years than those living with a first episode affected member. Assess the objective burden of the family
by asking the family members to describe the consequences of living with a schizophrenic member. Ask
them to describe the differences that they now observe in their family life, how it has affected them
financially, in terms of their physical wellbeing, leisure time, social supports from others, etc.

To ascertain the subjective burden, ask the family members to each describe how they feel emotionally
about having a schizophrenic relative, how they feel when they are around the relative, and their
expectations of the relative. Some of the possible emotional responses that the family may have are
listed in the section entitled Family Responses. Other responses of the family are: frustration (since the
affected member is unable to communicate clearly with them or for being “lazy”), anger (at the affected
member for having the illness or the restrictions that it has imposed on them), and sadness (as the
affected member may be unable to fulfil expectations of a bright career), hopelessness and pessimism.

3. Needs

You may have already formed an impression of what the family wants from you while engaging the
family and while enquiring about the burdens they perceive. If not, ask the family members what they
expect to receive from you. Ask them what the problems they would like to solve are in the care of the
affected member.

The families may also come to you with their own needs. Some families may expect you to provide
information about the illness. They will want to know about the treatment, the cause of the illness, the
prognosis and chances of recovery. They may also want to know about the effectiveness of different
treatments like homeopathy, ayurvedic, etc.

4. Social supports

Most families over time gradually become isolated from their families and friends. Ask the family
members what they each do to distract themselves from the problems of living with the affected
member. Do they have contacts outside of the family whom they can spend time with aside of working
hours? Does the family approach anyone outside the immediate family at crisis times?

If not, what are the difficulties experienced by the family in doing so? Are these contacts able to provide
support? What kind of support do they provide? Do they offer to supervise the affected member while
the family goes out? Do they offer financial support? Do they advise the family as to what they should
do? Do they listen to the problems of the family and help them emotionally to cope?

Does the affected member have any contacts outside of the family as well? Do these contacts visit the
affected member during or after episodes of the illness? How do they help the affected member?

5. Family responses: Ask the family members how they feel about their relative having schizophrenia.

They may deny or have difficulties accepting that the relative has schizophrenia. This is a response
commonly seen when the family first receives the diagnosis of schizophrenia. They may not fully accept
it later either.

They may get angry that the affected member has the illness. They may feel envious of others. They
may think “why did this happen to me”. They make promises to cure the illness. Such as“I promise to
pray every day if he is cured of this illness.”They may feel depressed when they are unable to cope. The
financial burdens, the affected member’s inability to work, stigma, etc increase this feeling.

They continue to hope for a cure, the discovery of new medication that will improve the symptoms. This
helps them to cope during their suffering.

DETAILED ASSESSMENT OF THE FAMILY

When you initially met the family, the family would have perceived you as someone who will provide
information on how to resolve the affected member’s illness. One of the disadvantages of only providing
information to the family is that they do not perceive the illness as something that the family as a whole
unit can work together to resolve. It also results in only one or two members of the family sharing the
responsibility of caring for the affected member. Their greater stress load will interfere with their own
daily responsibilities as well as their interactions with the affected member and the remaining family
members. Gradually, with your guidance the family will be able to view the problem from this
perspective.

In order to get a better understanding of the patterns of behaviour in the family; the following should be
kept in mind through sessions with the family.

How to assess the family in more detail?

1. What are the roles of each family member?

In every family, each member contributes to the functioning of the family in the roles that they play.
There are expectations of certain members to fulfill these roles and they may be held accountable. To
determine the family member’s roles, ask them questions like: which all members help in the household
chores? Or who are the breadwinners of the family? When the family members are upset, which
member do they approach to discuss their problems with? Which family member is responsible for
maintaining the family rules? When they fulfill these roles, are they meeting the expectations of other
family members? You may get responses that indicate the father, mother, (or both) contribute to the
financial status of the family. The mother may manage the household routine and be the one to whom
family members turn to for emotional support. The father may enforce discipline amongst the children.

2. How do the family members communicate?

Observe the way the family members communicate with each other and with the affected member
during your sessions. It may take a number of sessions before you are able to accurately understand
their communication patterns. Ideally, a family should be able to communicate clearly, directly, using
verbal and non-verbal communication, and with the feelings of other members taken into consideration.

In some families, there may be unequal communication between all members. Some family members
may talk much more than others, excluding others from participating, especially the affected member.
Some family members may not listen or pay attention to what other members are saying, especially the
affected member.

Family members may not speak clearly and directly to one another. For example, if the father is strict,
then the children may not speak to him directly about their needs but may instead ask the mother to
speak on their behalf.

Family members may talk about the affected member or other family members as though they were not
present. For example, it is easier for the family member to say, “He’s a lazy person” than telling the
affected member, ‘You are a lazy person”.
3. Is the family cohesive?

Based on your observations of the family’s communication styles and emotional behaviours, assess
whether the family perceives a sense of unity, a “we” feeling. Family members may be attached or
detached to each other in healthy as well as unhealthy ways.

The members could be emotionally over involved in the lives of the other members or they may be
disinterested and not involved at all. These are disruptive to the family functioning.

Rituals, such as eating meals together and other joint activities, strengthen the parent-children bonds as
well as the marital bond within the family.

4. How does the family cope?

Ask them how they have handled crises in the past? Preferably, ask this in the context of a specific
situation that may have occurred to the family. For example, what did the family do when the affected
member had previous relapses or how did they respond when they first observed the affected member’s
deterioration in normal functioning?

What was each individual’s contribution? Who took the initiative to solve the problem? How did they
solve the problem? Were they able to effectively solve the problem or did it recur? Was the family
confused and unable to solve the problem? Were they able to cope?

The answers to the above indicate their ability to solve problems and how they will cope with the
affected member. Family’s members may unite on such occasions and be supportive; or they may turn
to other relatives to help them. They may alternatively be unable to cope and have to visit a professional
for support.

ASSESSING AND HANDLING DIFFICULT PROBLEMS

A. Assessment:

In your first session, as well as in other sessions, you would have obtained information on the family’s
approach to problems, the coping ability of the affected member and the family, their successfulness or
unsuccessfulness in solving problems. These will mostly be unsuccessful or successful for a short
period.

With the help of specific examples and this information, point out to the family, the approach they
adopted and their success in the short term as well as the long term.

Inform the family of the strengths you have identified in them. These can be abilities, interests and
resources available to the affected member as well as the family members. Family members can include
other strengths that you may not know about. Relate how these can be used to help obtain the desired
outcomes or goals.

Family members often compare the affected member’s previous functioning with their current level.
They may not consider skills and abilities that the affected member previously had to be present still.
They may feel some skills (like driving a car, etc) are not worth mentioning.
If the affected member is unable to suggest any interests, ask the affected member to describe what
they used to enjoy doing. This can be added to the strength list.

B. Teaching Problem solving skills

Objective: To assess the problem solving skills of the family and help the families to understand the
need for it. Teach them an effective and uniform method of problem- solving through discussion, and by
solving problems as a family and not individually.

Sessions: You will need 1-2 sessions. Initially assess the problem solving skills of the family. Then
teach the family the steps involved and help them to practice these skills.

Who to include: The family members as well as the affected member should attend the sessions.

Mode: To train the family to learn the steps, you can:

a) Have a discussion with the family

b) Give them homework assignments and feedback on their performance

c) Within a session, give them assignments

d) Do a role-play using actual problems reported by the family.

Guidelines for teaching problem solving skills:

1. It will not be easy to get the family and the affected member to agree on what the problems are. For,
example, one family member may be preoccupied with the untidiness of the affected member, whereas
the others may not think it important.

2. Discuss with the family the reasons for not giving the affected member very difficult tasks, as they
may be unable to do it. It may require too much concentration, decision-making, planning, physical
activity etc. The affected member may not be ready or able to fulfill the requirements necessary.

3. Be prepared for the affected member and the family members to not carry out the agreed upon plans.
This may be because they feel the benefit is not worth the effort to achieve it or/ and may doubt their
usefulness.

4. Due to the unpredictability of the illness, the intervention should be flexible to accommodate new or
urgent problems. However, you should not be handling crisis problems every session.

Ask the family if they have had any new problems since the last session. Consider these in conjunction
with the continuing problems that remain unsolved.

5. Family members may divert your focus on a single problem by raising other equally important
problems. Resist this politely but firmly by explaining that they can progress by dealing with one problem
at a time. This is an opportunity for you to ‘role-model’ to the family on how to solve problems.
6. Ensure that the first problem chosen to solve is easy for them to achieve or to solve in a short time
period, like one to two weeks. This will give them immediate feedback and reinforcement of their efforts.

7. Some problems associated with a severe and chronic course of illness may continue indefinitely. For
example, the affected member may be unable to resume his previous occupational level, to live without
some support, to maintain many friendships and social activities, etc.

ACTIVITY SCHEDULE

Most affected members do not use their time productively. They may spend the day doing nothing in
particular. Families as a result often complain that the affected member is ‘lazy’. This can be overcome
by constructing a schedule of activities for the affected member to do. It is important for the affected
member to follow an activity schedule for the following reasons:

1. It will keep the affected member engaged in useful tasks

2. The affected member will be able to learn punctuality and improve his knowledge of time

3. It will improve his memory, attention, concentration and judgmental abilities

4. It will distract the affected member from becoming engrossed in the hallucinations and delusions.

5. It will help him to develop problem-solving abilities

6. It will improve his initiation and independence

7. It will improve his self-confidence

An activity is specific goal oriented behaviour. Activities like doing puzzles, telling stories, playing games,
singing, dancing, creative writing are non-productive. Productive activities could be tasks like making a
collage, stitching, making baskets, etc. When selecting an activity, it should meet the following criteria

a) Be goal directed

b) Have meaning to the affected member-meet his individual needs

c) Involve mental and physical participation

d) Be related to his interests and leisure activities

e) Be adaptable, gradable and age-appropriate

An activity schedule involves the affected member ‘doing’ something i.e. being participative, involved
and productive. It should be a combination of work, rest, leisure, self-care and sleep. Tasks should be
gradable i.e., the affected member should begin from a lower level of difficulty and then move to higher
levels.
PERSONAL HYGIENE:

a) Brushing teeth: The affected member may or may not be brushing their teeth daily. Even when they
do brush daily, they may not do so adequately. This leads to poor dental and oral hygiene. You will need
to teach them the right way to do so.

Insist that the affected member brush his teeth daily. The family members should be asked to ensure
that this occurs.

b) Bathing: The affected member may not be bathing or may be doing so with assistance from family
members. You will need to tell them how to do so. First, establish the frequency with which the family
wants the affected member to bathe- daily or alternate days.

c) Grooming:

Nails: The affected member should have short and clean nails on his fingers and toes. You can
demonstrate how the affected member is to use a nail cutter. The family can supervise the first few
attempts of the affected member to ensure that he cuts it safely and neatly.

Shaving: You will need to demonstrate to the affected member how to shave his face. This will require
showing him the steps involved such as: applying the shaving cream to the brush and applying it on the
lower jaw. The right angle at which to hold the shaver and how to shave. To wash and towel dry the face
afterwards.

Hair: Show the affected member how to brush their hair. They must do so daily. In the case of women
affected members, you may also need to show them how to braid their hair and tie it in the style they are
comfortable with. They should try to maintain a neat appearance over the day.

d) Basic Hygiene: This is a sensitive issue and you must be careful when you discuss this topic so as
not to offend the affected member or the family. The affected member should be encouraged to have
clean and regular toilet habits.

e) Keeping personal clothes clean and in order: The affected member may or may not have washed
clothes before their illness. Those who have washed clothes and continue to do so may need to improve
their skills. In some families, the family members may not be in the habit of washing their own clothes.
They may have a maidservant to wash them or may use a washing machine. You can emphasize that
paid help, washing machines may be unreliable, and therefore it is better to be self-reliant. It would be
ineffective to insist on the affected member washing his own clothes when the family members do not
perceive this as a need. The affected member can however be taught how to fold their clothes and stack
them neatly in the wardrobes.

f) Dressing: The family members must ensure that the affected member has clean clothes and under
clothes to wear everyday. The clothes must be chosen with regard to the weather or the occasion.
Affected members are to maintain a neat appearance through the day.
g) Eating habits: The affected member should be provided regular meals at regular times.The affected
member should be told to wash his hands (with soap preferably) before eating the food.The affected
member is to take a plate and glass of water and place it at the table where he is going to eat.

3. HOUSEHOLD TASKS

The family should encourage the affected member to tidy his bed upon awakening. They should
demonstrate how to fold the blanket, straighten the bed sheets and pillows.The family should encourage
the affected member to change and wash the bedclothes as often as they usually do.

The family should encourage the affected member to keep his room neat and clean. He should be
encouraged to pick up fallen items and replace them. He should clean the floor if something has been
spilt. Family members should demonstrate how this should be done.

4. MANAGING MONEY

The family may need to teach the affected member to recognize the various denominations for both
coins and notes.

The family members should encourage the affected member to purchase things required for the family
and him. Family members can initially give the affected member the exact amount to be spent. Later, the
affected member should be encouraged to pay the appropriate amount, collect the correct balance and
return home with the items.

5. PUBLIC TRANSPORT

The affected member should learn to travel independently whether by bus or train. The family should
teach him traffic rules-traffic signals, road crossing.

The family should help the affected member familiarize the route to the bus stop. He should be informed
of the bus route and number to take.

If he is unsure, instruct him to ask his co-passengers or bystanders at the bus stop.

The affected member is to ensure that he enters the correct bus before buying the ticket.

If he is in doubt, he is to clarify with the bus conductor before boarding.

The affected member should be told to carry sufficient money for travelling to and from.

The affected member is to state destination clearly to the conductor while paying for the ticket.

The affected member is to retain the ticket until he alights.

If the affected member is unsure of the route, he is to be instructed to check with the conductor as to
which stop he should alight.

The affected member is to behave well with the co-passengers.

6. CONVERSATIONAL SKILLS:

The affected member should learn to have meaningful, clear and socially appropriate conversation.

He should be able to understand and express messages adequately.

You can ask the affected member to repeat simple words and then later more complex words and
sentences. These should be related to what the affected member should have to use in his daily life. The
affected member has to pronounce the words correctly.

Teach the affected member common greetings with its appropriate expression. Encourage the affected
member to use them with the family within and outside the sessions. This will help the affected member
to learn how to initiate conversations.

Have conversations with the affected member. It should be on simple themes. For example, requesting
family members to give something, buying something at a shop, meeting a new affected member,
traveling in a bus, etc. These themes should be prepared before the session and should be related to
the affected member’s needs. You can also give homework in the form of topics (of interest) to learn
about which are then to be described and talked about in the next session.

The affected member should be given the feedback in the form of suggestions afterwards. Encourage
the affected member to be clear, loud, maintain eye to eye contact while talking. Encourage them to talk
spontaneously, to initiate and maintain a conversation, to give elaborate answers etc. Encourage them
to clarify doubts when necessary and to express appropriate feelings.

7. EMPLOYMENT/ EDUCATION:

Some families may be impatient for the affected member to go back to work or school. Others may be
hesitant because of past experiences when the affected member was unable to tolerate the stress and
had a relapse. It should be attempted only if the affected member has been stable for several months.
All the family members should agree to it, so that they can be supportive and help in the problem
solving. Educate the family that the skills necessary to be in employment or education are complex.
These include:

a) Ability to keep time

b) Tolerance of a routine

c) Independence

d) Some motivation to do well

e) Ability to pay attention to details

f) Ability to understand and incorporate advice from supervisors or teachers

g) Ability to communicate and mix with fellow workers or students

h) Be able to recognize early signs of the illness and deal with them
8. Coping with stigma

The affected member may have had many years of isolation due to which they may lack confidence, get
embarrassed or feel threatened easily. They may fear rejection because they have had a mental illness.
They may also be afraid because of their experiences of the responses and reactions of others to their
psychotic symptoms.Thus you should be empathic but encourage the affected member to have realistic
expectations. Help the affected member to weigh the advantages and disadvantages of continuing to
isolate oneself from the society.

Persuade the affected members that having the occasional symptom should not block their ability to
socialize. Graded tasks and task assignments should be used to persuade affected members to go out
and mix more easily. The family members can accompany the affected member the first few times.

9. Managing symptoms

a) Cognitive strategies: These strategies attempt to control the symptoms by a change in the cognitive
or thought processes.

Attention-switching The affected member switches their attention from one subject to another by
focussing attention on distracting thoughts. For example, teaching the affected member to concentrate
on a positive and reinforcing image such as a pleasant holiday or a scenery when they experience a
delusional thought or an hallucination.

Attention narrowing This method can be adopted for a short time only. Examples are thought stopping,
or when the affected member clears their mind or blanks out their thoughts.

Self-instruction The affected member instructs themselves or engages in a covert dialogue either to
assess a situation or to cue behaviour. They can relabel illness-related experiences and it prompts
positive coping strategies. Examples are “The voices are not real, they cannot hurt me and are just a
part of my illness” or “I must concentrate on relaxing and slowing my breathing”.

Rational restructuring This method works well with some affected members only. It is difficult to apply
when the affected member has either no insight or is completely convinced by the symptoms. The
affected member can test the experience of psychotic symptoms in reality. This involves generating
alternative hypotheses to prove the symptom to be real or illness related. Evidence to support or refute
these hypotheses are then collected and evaluated.

b) Behavioural strategies: These attempt to control the symptoms by a change in action.

Engaging in solitary activities

This involves some element of distraction and is used to decrease the affected member’s level of
arousal. The affected member engages in an activity in response to their symptom that does not involve
others. For example, the affected member could go for a walk alone, read, exercise, make something
etc.
Social withdrawal

This involves actively disengaging from social contact. It is an escape or avoidance response and can
have severe long term consequences in terms of isolation. It should be used carefully. It should be used
as a means of gradually building up tolerance to social situations and as a temporary stress reduction
technique. Goals should be set for gradually increasing their length of tolerance of social situations
before the affected member disengages. It should be used as a rest period and then the affected
member should re-enter the social interaction. For example, the affected member can withdraw from the
conversation and not leave the room.

Engaging in social interaction

This helps the affected member to cope as well as to normalize their level functioning. Conversations
may help to interrupt and inhibit the internal events like psychotic symptoms.

c) Physiological strategies: These attempt to control the symptom by producing a change in the
affected member’s physiological state.

Relaxation and/ or breathing exercises The various methods of relaxation such as progressive muscle
relaxation or breathing exercises can help in distracting and reducing the arousal of the affected
member.

D. Management of problems faced by the family

a.) What to do in a crisis? Or how to manage the affected member when acutely symptomatic?

The family will be unable to reason with acute psychosis. Advise the family members to:

Not express irritation or anger. They should attempt to keep their emotions under control.

They should decrease other distractions (TV, radio) immediately.

Advise the family to calmly ask anyone (friends, guests) who are present to leave.

They should speak quietly, firmly and with simplicity to the affected member.

They should express understanding for what the affected member is experiencing.

b.) What to do when the affected member is violent?

The family can first identify the precipitating behaviours and events. Encourage the family to use
problem solving steps. Encourage them to suggest methods of dealing with a potential violent behaviour.
Some possible solutions are:

Asking the affected member to go to another room or asking the involved family member to go to
another part of the house or to leave the house.

The family can also contact the police and explain what they are experiencing. They can seek their help
to obtain treatment, to control the violent behaviour or admission.
c.) What to do if the affected member refuses to take medication?

Some affected members do not believe they are ill. They may accept as fact their hallucination,
delusions or perceptions of reality, however unreasonable they may be. These affected members are
difficult to maintain on medication. If the family or you attack these beliefs, you can lose both the affected
member’s trust and your own credibility. Certain specific techniques can be used, such as:

Through negotiation, encourage the affected member to give the treatment and medication a fair trial to
see if it can help. Help the affected member to appreciate that the medication may ‘decrease anxiety’ or
make them more comfortable.

The family can introduce benefits or privileges, which the affected member can obtain if they agree to
medication.

If affected member terrorizes family members or behaves in dangerous way to others or home, the
family can use an ultimatum. They could say that the affected member must take medication and
maintain a minimum level of appropriate behaviour or they cannot live at home.

d.) How to cope with stigma?

Families often cope better if there is a larger network from which they can ask for help pr find relief. The
usual excuses that the family gives for not going out are: “ I am too tired”, “ I do not have the time”, and
“my son (affected member) needs me or cannot be left alone. Although there may be some truth to this,
it is important that they be pushed so break out of their isolation. You can frame it as “You need to look
after yourself to help the affected member” or “the affected member needs to be on their own to
encourage independence” or “everyone in the family needs to look after themselves in order to cope”.

f.) How to cope with the affected member drinking alcohol/ smoking cigarettes/ drinking numerous cups
of coffee or tea?

This is an emotional issue. Some families have the misconception that the affected member’s illness
started because they mixed in bad company and used alcohol or drugs. They misattribute the cause of
the illness entirely to this. Make clear to the family that although they have the effect of enhancing
vulnerability to the onset of the illness or relapses, they on their own do not cause the illness. The family
may otherwise blame the affected member for causing their illness.
 Conclusion

Medication is an initial must for every individual afflicted with schizophrenia, but it is by no means a cure.
“Rehabilitation is the tertiary prevention process of helping the person who has a serious mental illness
return to the highest possible level of functioning”. In order to reach the optimum results with
rehabilitation, all aspects of a schizophrenic’s life must be considered. It is ideal to keep expectations
open and flexible, in order to accept the schizophrenic at his or her level of functioning. The best
rehabilitation plan is individualized and is formulated with the aid of the schizophrenic, the family and all
health care providers associated with the schizophrenia sufferer. It is necessary to provide the
schizophrenic with courtesy, consideration and most of all respect. This will help achieve self-assurance
and autonomy, and to help achieve the single most important aspect of rehabilitation: improving the
quality of the schizophrenic’s life.

Theory application

The theory to be applied in the context is Orem’s self care deficit theory.

 It specifies when nursing is needed.

 The client with schizophrenia may belong to wholly compensatory or partly compensatory system in their
acute stage.

 The nurse should assess the health status and needs of the patient.

 She should support and protect the patient, should accomplish the patient’s therapeutic self care and
compensate for family’s ability to engage in self care.

Journal reference

Title: Family intervention for schizophrenia

Author: Fiona Pharoah, Jair Mari, John Rathbone, and Winson Wong

Abstract:

Background

People with schizophrenia from families that express high levels of criticism, hostility, or over
involvement, have more frequent relapses than people with similar problems from families that tend to
be less expressive of emotions. Forms of psychosocial intervention, designed to reduce these levels of
expressed emotions within families, are now widely used.
Objectives

To estimate the effects of family psychosocial interventions in community settings for people with
schizophrenia or schizophrenia-like conditions compared with standard care.

Search strategy

We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register
(September 2008).

Selection criteria

We selected randomised or quasi-randomised studies focusing primarily on families of people with

schizophrenia or schizoaffective disorder that compared community-orientated family-based
psychosocial intervention with standard care.

Data collection and analysis

We independently extracted data and calculated fixed-effect relative risk (RR), the 95% confidence
intervals (CI) for binary data, and, where appropriate, the number needed to treat (NNT) on an intention-
to-treat basis. For continuous data, we calculated mean differences (MD).

Main results

This 2009-10 update adds 21 additional studies, with a total of 53 randomised controlled trials included.
Family intervention may decrease the frequency of relapse (n = 2981, 32 RCTs, RR 0.55 CI 0.5 to 0.6,
NNT 7 CI 6 to 8), although some small but negative studies might not have been identified by the
search. Family intervention may also reduce hospital admission (n = 481, 8 RCTs, RR 0.78 CI 0.6 to 1.0,
NNT 8 CI 6 to 13) and encourage compliance with medication (n = 695, 10 RCTs, RR 0.60 CI 0.5 to 0.7,
NNT 6 CI 5 to 9) but it does not obviously affect the tendency of individuals/families to leave care (n =
733, 10 RCTs, RR 0.74 CI 0.5 to 1.0). Family intervention also seems to improve general social
impairment and the levels of expressed emotion within the family. We did not find data to suggest that
family intervention either prevents or promotes suicide.

Conclusions

Family intervention may reduce the number of relapse events and hospitalisations and would therefore
be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects
of these trials may be overestimated due to the poor methodological quality. Further data from trials that
describe the methods of randomisation, test the blindness of the study evaluators, and implement the
CONSORT guidelines would enable greater confidence in these findings.
 BIBLIOGRAPHY:

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3. Mueser KT, Deavers F, Penn DL, Cassisi J. Psychosocial treatments for schizophrenia. Annu Rev
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4. Pharaoh F, Rathbone J, Mari JJ. Family intervention for schizophrenia. Cochrane Database Syst
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