Forty-two papers were published between and and one in Typically these followed a similar structure and were broadly modelled on the Behavioural Family Therapy approach 61 see online supplementary file 3 for full study characteristics. The vast majority were cross-sectional studies and 13 were naturalistic evaluations, descriptions or case studies of a service.
The themes closely relate to temporal sequencing in the process of delivering an intervention: The figure provides a visual representation of the matches and gaps between barriers and facilitating factors related to involving families. This is for the most part conceptual, as barriers and their direct facilitating factors may not have been discussed in the same study. The themes and subthemes are explored in greater detail in the synthesis below, which includes details of problems associated with delivering approaches that involve families as well as barriers and facilitating factors of this work.
Barriers, problems and facilitating factors related to family work. This theme reflects the majority of the findings, mostly from staff perspectives. Their experience of implementing family work could be characterised as working in relative isolation in a system where colleagues and managers did not value and prioritise family involvement or were openly hostile to it. With multidisciplinary cooperation and working systems not in place, practical burdens associated with family work were sometimes insurmountable.
Mirroring this, factors that enabled family involvement to take place were related to top-down management support, prioritisation and changing the culture of family work.
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This subtheme covered general attitudes, such as family involvement not being valued at organisational and team level but also highlighted possible entrenched reasons for this. For example, individualistic, biological paradigms made family work seem secondary or optional 62—64 and staff found it difficult to adopt a collaborative stance, relinquishing the role of didactic problem solver. Overwhelmingly, staff reported on the practical burdens of family work: Commonly, staff reported on the unsupportive attitudes of managers and colleagues as limiting the implementation of family involvement.
Staff also reported on lacking access to adequate supervision and training 62 , 63 , 65 , 66 , 83 , 86 , 87 , 92 as barriers to implementation. This may link with reports of staff lacking skills or confidence to do the work. Difficulties arose when only a minority of team members had been trained in an intervention. The next theme related to the process of engagement, informed more broadly by both staff and family responses. A picture emerged of families sometimes being reluctant to engage, and of valid concerns. Yet the successful establishment of trusting relationships indicates these concerns may be surmountable in many cases.
Similar issues around the nature of involving families emerged as a barrier to families becoming involved and as problems during treatment. Some concerns seemed linked to fears around power and control: Both families and staff expressed fears of making the current situation worse, such as by burdening the family and worsening the patient's symptoms.
These were often unspecified as scepticism, lack of motivation or refusal from the families, occurring prior to engagement or during treatment. The final theme related to factors that affected how staff members delivered FIs and how families experienced them. As a whole, both family and staff responses highlight the importance of respectful, equal partnership, enhanced by professional skills and experience. Collaboration between families and professionals on an equal footing appeared valued by both families and professionals.
Lack of collaboration was cited as a problem during delivery, resulting in families feeling patronised or not understood. How families experienced an approach closely linked with their experience of the professional. Some families reported experiencing an approach as negative or critical, both through the model itself for example, its characterisation of illness, or experiences of the professional, perhaps as criticising parenting. A lack of continuity was cited as a problem, 99 while a facilitator was having the same team involved from the beginning and staying with the family throughout the treatment process.
Approaches were sometimes described as culturally insensitive: Professionals highlighted the complexities of working both with families and with patients with psychosis. Developing a clear structure for the intervention may be beneficial for the delivery of family involvement, provided that flexibility to accommodate individual needs is ensured. Concerns emerged regarding privacy, power relations, fear of negative outcomes and the need for an exclusive patient—professional relationship.
Exploring and acknowledging such concerns through open, yet non-judgemental communication could facilitate the establishment of a therapeutic alliance between staff, families and patients. These findings may help to explain why family interventions—despite their overwhelming evidence base and their inclusion in practically all policies and guidelines—are so poorly implemented in routine practice.
The requirements identified may be challenging given that family-oriented practice may need to be embraced by a whole organisation and included in work routines in order to be implemented. To our knowledge, this is the first systematic review that specifically focused on barriers, problems and facilitating factors for the implementation of family involvement in the treatment of patients with psychosis. This is of high importance given the current climate of government policies and psychiatric guidelines stipulating that families should be supported and actively involved in psychiatric treatment, 6—11 and the disappointments in achieving this in practice so far.
The search strategy allowed for the capture of a large number of studies, different researchers independently extracted and reviewed the data and when necessary authors were contacted to clarify ambiguous information. While interpretative, this process has been carried out in accordance with RATS guidelines 61 and presented transparently. Though some themes were not highly recurrent—for example, criticisms of manualisation emerged only in structured approaches such as Behavioural Family Therapy—in all, findings were complimentary, not contradictory. The fact that common themes emerged in spite of variations in approach, across 16 countries, speaks for the robustness of the findings as representing shared issues with family involvement.
However, a number of limitations must be considered when interpreting the results of this study. Methodologically, conducting subgroup analysis, that is, for different intervention models, was not considered viable due to the strong association between type of approach and methodology used for example, Open Dialogue with case studies and Behavioural Family Therapy with the Family Intervention Schedule FIS questionnaire.
Carrying out a subgroup analysis may have therefore had the risk of mischaracterising certain approaches due to variation in the richness of data. While there are well-established methods for assessing the quality of intervention studies, this is not the case for studies of implementation processes, qualitative or mixed methods research 56 and the use of appraisal tools in qualitative research remains contentious.
Despite efforts to find grey literature, the search strategy may still have been limited in its bias towards published research, yet the nature of this review topic means that service level audits and evaluations are likely to be of relevance. Conceptually, the dominance of staff and academic perspectives may have led to barriers within the organisation being explored most thoroughly, however does not lead to the conclusion that there are no inherent problems with involving families in clinical settings.
Our findings reflect important key features for implementation of evidence-based practices, already identified in previous research in implementation science, such as top-down input and leadership and the need for continuing consultation and training. The fundamental role of the organisational context is emphasised in the literature with both culture the normative beliefs and shared expectations of the organisation and organisational climate the psychological impact of the work environment on the professional strongly moderating the uptake of EBP. Clinicians may uphold the patient—professional alliance by addressing concerns regarding privacy and by being mindful that patients do not perceive a loss of power due to having family involvement in their care.
So far the findings largely reflect what can go wrong rather than provide evidence of successful implementation. For example, sustainability has not been addressed in the review as this stage has hardly been reached. More research will be needed to see which organisational steps can actually change the culture in a service so that family involvement happens, not only in a research study or with particular patients, but with all families, every day and over longer periods of time. This may also enable insight into the potentially varied experiences of minority groups.
These views may be best obtained outside of group interviews, in which a power imbalance may be present. There would also be value in exploring the views of professionals who have not already demonstrated commitment to family work. This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author s and has not been edited for content. AD and EE extracted data and carried out the thematic synthesis.
All authors contributed to and approved the final submitted version. Provenance and peer review Not commissioned; externally peer reviewed. You will be able to get a quick price and instant permission to reuse the content in many different ways. Skip to main content.
Log in via OpenAthens. Log in using your username and password For personal accounts OR managers of institutional accounts. Forgot your log in details? Register a new account? Forgot your user name or password? Search for this keyword. Latest Content Archive Authors About. Log in via Institution. Implementing family involvement in the treatment of patients with psychosis: Abstract Objective To synthesise the evidence on implementing family involvement in the treatment of patients with psychosis with a focus on barriers, problems and facilitating factors.
Strengths and limitations of this study Can inform policies and guidelines on family involvement so that they impact on routine practice. Synthesises rich qualitative data from professionals, patients and families. Background The process of deinstitutionalisation of mental healthcare in the western world has led to families and others in the community shouldering the psychosocial burden of care and informally adopting the role previously provided by professionals in healthcare services.
Methods The full protocol for this systematic review is reported in the online supplementary file 1. Identifying relevant studies Computerised databases were searched for eligible studies: Inclusion procedure A study was eligible for inclusion if: Data extraction and synthesis Theoretical Thematic Analysis 60 using inductive themes to identify the barriers, problems and facilitating factors of family involvement was used as a framework to explore further themes.
Overview of papers Forty-two papers were published between and and one in Organisational attitudes and paradigms This subtheme covered general attitudes, such as family involvement not being valued at organisational and team level but also highlighted possible entrenched reasons for this. Practical needs associated with family work Overwhelmingly, staff reported on the practical burdens of family work: Management culture Commonly, staff reported on the unsupportive attitudes of managers and colleagues as limiting the implementation of family involvement.
Training needs Staff also reported on lacking access to adequate supervision and training 62 , 63 , 65 , 66 , 83 , 86 , 87 , 92 as barriers to implementation. Team attitudes, commitment and multidisciplinary cooperation Difficulties arose when only a minority of team members had been trained in an intervention. Reservations about involving families Similar issues around the nature of involving families emerged as a barrier to families becoming involved and as problems during treatment.
Problems engaging families These were often unspecified as scepticism, lack of motivation or refusal from the families, occurring prior to engagement or during treatment. Working relationships between families and professionals Collaboration between families and professionals on an equal footing appeared valued by both families and professionals.
Individualisation within the approach Approaches were sometimes described as culturally insensitive: Working with complex needs Professionals highlighted the complexities of working both with families and with patients with psychosis. Strengths and limitations To our knowledge, this is the first systematic review that specifically focused on barriers, problems and facilitating factors for the implementation of family involvement in the treatment of patients with psychosis.
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Comparison with available literature and implications for practice Our findings reflect important key features for implementation of evidence-based practices, already identified in previous research in implementation science, such as top-down input and leadership and the need for continuing consultation and training. Future directions for research So far the findings largely reflect what can go wrong rather than provide evidence of successful implementation. J Psychiatr Ment Health Nurs ; Parker G , Clarke H. Making the ends meet: Policy Politics ; OpenUrl Web of Science.
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