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Cognitive model of caregiving in psychosis

  • Elizabeth Kuipers (a1), Juliana Onwumere (a1) and Paul Bebbington (a2)

There is a long history of research into the attributes of carers of people with psychosis, but few interventions target their distress or their difficulties.


To describe an empirically based model of the relationships of those caring for people with psychosis to inform clinical and theoretical advances.


We developed a model of informal carer relationships in psychosis, based on an integration of the literature elaborating the concept of expressed emotion. The model accounts for divergent outcomes of three relationship types: positive, overinvolved and critical/hostile relationships.


Good evidence supports a number of hypotheses concerning the origin and maintenance of these relationship outcomes, which relate to specific differences in carer attributions, illness perceptions, coping behaviour, social support, distress, depression and low self-esteem predicted by our model. We propose that interventions aimed at modifying the specific maintenance factors involved in the different styles of relationships will optimise therapeutic change both for service users with psychosis and for their carers.


Family work in psychosis, which improves relationships through problem-solving, reduces service user relapse. It is now time to consider theory-based interventions focused on improving carer outcomes.

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Corresponding author
Correspondence: Professor Elizabeth Kuipers, PO 77, Institute of Psychiatry, London SE5 8AF, UK. Email:
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E.K. has received funding for some clinical sessions by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust, and Institute of Psychiatry, King's College London.

Declaration of interest


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Cognitive model of caregiving in psychosis

  • Elizabeth Kuipers (a1), Juliana Onwumere (a1) and Paul Bebbington (a2)
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