Psychosis REACH: Effects of a Brief CBT-Informed Training for Family and Caregivers of Individuals With Psychosis

Psychosis REACH consists of a tripartite training model: recovery-oriented psychosis psychoeducation, caregiver self-care, and a set of skills informed by cognitive-behavioral therapy for psychosis (CBTp): communication, coping, and problem-solving skills, collectively known as the FIRST skills. The training modules were developed from previous iterations of the workshops and informed by feedback from past family trainees. We collaborated with a Family and Caregiver Advisory Board on training planning and additional customization of the original model. The board consists of 10 community members who each have a loved one with psychosis and a patient and family advocate of a large health care system.

All trainees received the 1-day core training, which introduced them to recovery-oriented psychoeducation and the FIRST skills by using didactics, demonstrations, and large-group discussion. The additional 3 days of intensive training provided more in-depth training in the FIRST skills, including role play and discussion of application of these skills. Both courses were led by two of the authors (K.H., D.T.), who have extensive experience providing CBTp training for clinicians and have previously trained family members in CBTp skills.

The training was cosponsored by a private foundation and state funding and could therefore be provided free of charge. Promotional materials were disseminated to mental health advocacy organizations in Washington State and to outpatient and inpatient settings statewide and through word of mouth by our advisory board. Therefore, the recruitment strategy relied heavily on snowball sampling. To ensure equity in accessibility to the event, we provided assistance with lodging and travel by request. Eligibility for the training included self-identification as a family member or caregiver of an individual with a psychotic spectrum disorder and English fluency. The sample was nonrandom, because participants self-selected into the core 1-day training or the additional 3 days of training (4-day, “enhanced”) condition. Those who self-selected into the enhanced condition had expressed willingness to work with families in the future as a Psychosis REACH “family ambassador” by cofacilitating subsequent trainings. The aim of training family ambassadors is to provide future training that is grounded in the lived experience of natural supports and to support long-term sustainability by ensuring local support to coach REACH-trained families in skill application.

Trainees were asked to complete a REDCap-administered survey at three timepoints: 1 month prior to the training (pretraining), immediately following the training (posttraining), and 4 months after the training (follow-up). They received no financial compensation for pre- or posttraining surveys and received a $20 gift card by e-mail for completing the follow-up survey. The pretraining survey consisted of a questionnaire to establish demographic characteristics, psychiatric characteristics of their loved one (e.g., diagnosis, lifetime hospitalizations), relationship to the individual with psychosis, and their participation in their loved one’s care to date. The measures described below were included across all three timepoints.

The Experience of Caregiving Inventory (ECI) is a 66-item self-report measure that assesses the subjective positive and negative experiences of caregivers of individuals with a psychotic spectrum disorder (17). Items are rated on a 0–4 scale. Higher ratings reflect either greater difficulty in caregiving (negative subscale) or greater positive caregiving experiences (positive subscale). Scores are aggregated into total negative and total positive scores. Because of the length of the measure, the ECI was administered at pretraining and follow-up only. The Psychosis Attitude Scale (PAS) is a 19-item measure used to assess attitudes toward individuals with a psychotic disorder (e.g., “People with psychosis need others to take care of most things for them”) (18). Items are rated on a 7-point Likert scale with reverse coding on eight of the 19 items. Higher total scores represent more prosocial views of psychosis. The PAS, originally developed for evaluating attitudinal change among mental health professionals undergoing CBTp training, was adapted for family and caregivers in the Psychosis REACH program in an effort to ascertain whether the training affects family members’ conceptions about psychosis and its amenability to interventions. The Hospital Anxiety and Depression Scale (HADS) is a 14-item scale measuring anxiety and depressive symptoms in both clinical and nonclinical samples (19). The Family Attitude Scale (FAS) is a 30-item measure assessing the frequency of hostility or emotional overinvolvement by caregivers (20). The FAS has good convergent validity with lengthier measures of expressed emotion (20). Responses are rated on a 5-point Likert scale, with higher scores indicating higher levels of burden or criticism in the home. Finally, in order to ascertain trainees’ perceived sense of mastery of CBTp-informed skills, we codeveloped a 12-item self-report inventory of the FIRST skills on a Likert comprehension scale, from 1, minimal, to 5, advanced. Brief definitions of each skill component (e.g., befriending) were provided to reduce the likelihood of a terminology confound.

All analyses were completed with SPSS, version 26. A chi-square test of independence was used to evaluate whether persons who participated only in the 1-day training differed in gender from those who participated in the enhanced training. Because of small samples, a series of Fisher’s exact tests were used to subsequently investigate differences between training conditions on categories of race, education, and marital status. Longitudinal changes across the full sample were evaluated by using either a paired-sample t test when only two repeated measures were present (e.g., ECI) or a one-way repeated-measures analysis of variance (ANOVA) for measures present across all three timepoints (PAS, HADS, FAS, and CBTp skills). Statistically significant omnibus F tests indicated that a measure changed over time within the full sample, which was further examined with post hoc Bonferroni-adjusted comparisons to evaluate the relationship of survey responses between timepoints.

We also evaluated whether a significant degree of change occurred over time between trainees who received the 1-day core training versus the enhanced training. Two-way mixed ANOVAs were conducted with training condition, time (0, pretraining; 1, posttraining; and 2, 4-month follow-up), and the training condition × time interactions entered into the model. Significant training condition × time interactions were the primary test of interest in these models, because they would indicate that the two training groups differed in the amount of change over time. For all analyses, the alpha level was set at p<0.05. Effect sizes were calculated by using partial eta squared. Because there is no consensus on how effect sizes should be interpreted in a sample of caregivers trained in CBTp-informed skills, we adopted Cohen’s heuristic of 0.01, 0.06, and 0.14 partial eta squared values corresponding to small, medium, and large magnitudes, respectively (21).

A total of 276 individuals registered for the training. Throughout the registration period, 93 individuals were excluded from further analysis because of cancelled registration (N=39), not meeting eligibility criteria (N=19), or registering but not attending the training (N=35). In total, 183 family members and other caregivers (referred to below as caregivers) attended the 1-day core REACH training, of whom 92% (N=168) consented to survey participation. Twenty-nine caregivers participated in the enhanced training, all of whom consented to participation.

Trainees’ characteristics are presented in Table 1. Trainees ranged in age from 15 to 86 (mean age=56.2), and most were female (74%), married (62%), and White (90%) and had more than 12 years of education (79%). No differences were found between conditions across any of the demographic variables. Trainees were mostly a parent of an individual with psychosis (76%), and most reported that their loved one’s principal diagnosis was a schizophrenia spectrum disorder (69%), followed by mood disorders with psychotic features (22%) (Table 2). Caregivers reported that their loved one had experienced a median of three lifetime hospitalizations. The average duration of illness for loved ones was 7.95 years but varied considerably (range=0–55, SD=8.45).

Descriptive statistics of outcome measures across all times points and each training group are presented in Table 3. Mixed ANOVAs evaluating group differences in these scores across time are presented in Table 4.