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Early Intervention in Psychiatry 2014; 8: 269–275
doi:10.1111/eip.12068
Original Article
Forgotten family members: the importance of
siblings in early psychosis
Siann Bowman,1,2 Mario Alvarez-Jimenez,3 Darryl Wade,4 Patrick McGorry3 and Linsey Howie4
Abstract
Objective: This paper reviews the evidence on the significance of sibling
inclusion in family interventions and
support during early psychosis.
1
Department of Occupational Therapy,
Faculty of Allied Health, and 2La Trobe
Rural Health School, La Trobe University,
3
Orygen Youth Health Research Centre,
Centre for Youth Mental Health, and
4
Australian Centre for Post Traumatic
Mental Health, The University of
Melbourne, Melbourne, Victoria, Australia
Method: This narrative review
presents the current research related
to the importance of family work
during early psychosis, the needs and
developmental significance of siblings during adolescence and early
adulthood, the protective effects of
sibling relationships, and the characteristics of early psychosis relevant to
the sibling experience. It will also
review the evidence of the sibling
experience in chronic physical illness
and disability, as well as long-term
psychotic illness.
of long duration. They play an important role in development during adolescence and early adulthood. These
relationships may be an underutilized
protective factor due to their inherent
benefits and social support. Developmental theories imply that early
psychosis could negatively impact the
sibling relationship and their quality
of life, effecting personality development and health outcomes. The evidence shows that adolescent physical
illness or disability has a significantly
negative impact on the sibling’s
quality of life and increases the risk
for the onset of mental health issues.
Long-term psychotic illness also
results in negative experiences for
siblings. Current evidence shows that
siblings in early psychosis experience
psychological distress and changes
in functional performance. Further
research using standard measures is
required to understand the impact
early psychosis has on the sibling
relationship and their quality of life.
Corresponding author: Ms Siann
Bowman, Department of Occupational
Therapy, La Trobe University, Faculty of
Allied Health, Plenty Road, Bundoora, Vic.
3086, Australia. Email:
s.bowman@latrobe.edu.au
Conclusions: Despite the evidence
that working with families is important during early psychosis, siblings
have been largely ignored. Siblings are
an important reciprocal relationship
Received 14 August 2012; accepted 20
May 2013
Key words: brother and sister, early psychosis, family work, firstepisode psychosis, sibling.
THE IMPORTANCE OF FAMILY WORK IN
EARLY PSYCHOSIS
The rationale for working with families in early
psychosis is clear. Because of the age of the onset
of psychosis, many young people are still living
with, or are in close contact with their parents,
grandparents and family of origin.1 Offering help at
this early stage supports the family’s understanding
of early psychosis, informs them of treatment
options and ensures that their needs are understood
and addressed.2 Expert guidelines for the treatment
of individuals with early psychosis emphasize
the importance and benefits of family-based
© 2013 Wiley Publishing Asia Pty Ltd
interventions and support.3 For example, the
Australian Clinical Guidelines for Early Psychosis4
recommend that comprehensive psychosocial
interventions should be available to families; they
should be fully informed and consulted about treatment options; and families should be offered education, support and appropriate involvement.4
Despite the fact that family-sensitive practices are a
recommended component of treatment, most of
this work is directed towards parents.5
The impact of early psychosis on the mental
health of family members is significant.2,6,7 For
example, Addington and colleagues6 found that
their sample of 238 family members (95% parents
269
Siblings in early psychosis
and spouses) was experiencing significant distress,
burden and difficulties in coping with their child or
partner’s illness. Other studies have found that
family members experience subjective effects such
as stigma, confusion, distress, constant worry,
disagreement within the family about what to do,
isolation, blame, shame, guilt, grief, depression
and helplessness.1,8–10 Objective effects have also
been reported such as financial difficulties, negative
effects on work and employment, constraints on
social activities due to exhaustion, stigma and fear
of leaving their ill child at home alone, disruption
to the household routine due to having to perform
new roles, and effects on health and well-being.2,11
Family interventions in psychosis have been
found to decrease relapse rates, psychotic symptoms, burden of care and hospital admission rates,
and improve treatment compliance, social functioning and health outcomes.12–16
Even though family work is recommended and
has been shown to improve recovery outcomes,
there have only been a few qualitative studies conducted that focused on the particular needs and
characteristics of siblings, and no intervention
studies.
THE RATIONALE FOR INCLUDING SIBLINGS IN
FAMILY WORK
There is an extensive body of research in the field of
developmental psychology that focuses on the
sibling relationship and the important contribution
it can make to development.17 This research shows
that sibling relationships are enduring, interpersonal ties that serve as important contexts for individual development.17 Typically, these relationships
are of longer duration than most other relationships
in people’s lives and provide companionship, emotional support and practical support.18,19 With this in
mind, the onset of psychosis may be critical in terms
of the disruption and potential loss of an important
reciprocal relationship. Disruption to the relationship during this stage of life can have significant
implications, specifically to personality development, identity formation and social support.
The developmental significance of siblings
It has been established within developmental theories that sibling relationships play a critical and
formative role in development during adolescence
and early adulthood.20–25 These theories are useful in
understanding sibling influences and therefore the
disruption and potential loss that may occur with
the onset of early psychosis.
270
Family systems theory contends that all individuals within a family impact upon and have the capacity to affect each other.24,26 The onset of early
psychosis for a family member is therefore very
likely to have substantial impact upon the sibling
and the sibling relationship.
Attachment theory22 has also been applied to
sibling relationships. Normal attachment between
siblings provides companionship, emotional
support and intimacy.19 Researchers have applied
this theory when interpreting sibling loyalties and
have found that children develop strong sibling
attachments when parents do not (or cannot)
provide sufficient warmth or security.27
Social learning theory21 proposes that observational learning, or modelling, is one of the primary
methods by which behaviour is acquired. Because
adolescents can spend so much time with their
siblings, they can be very salient models and influence the development of attitudes, interests and
behaviour.28,29
Festinger’s23 social comparison theory contends
that there is a basic human drive to evaluate oneself
relative to others. He maintained that without these
comparisons, people cannot assess their strengths,
weaknesses or talents. This can be a powerful
dynamic within the sibling relationship and can
contribute to the development of identity. Adolescents have been found to place greater importance
on comparisons with their siblings rather than
peers the same age.30,31
Social provision theory25 proposes that different
social relationships serve different social needs.
Furman and Buhrmester32 found that during adolescence, siblings can provide companionship, intimacy and affection, fulfil roles such as friend,
competitor and role model, and can compensate
for absent relationships such as same age friends or
peers.33 Sibling relationship can fulfil different
social needs at different points during the life
course.
Further, Alfred Adler20 emphasized birth order
as having a significant influence on personality
development. He considered birth order affected
the character a child establishes within the family
and in society with different birth positions resulting in distinctive developmental experiences and
lifestyles.20 Psychologists have conducted more
than 2000 studies on the subject of birth order
since. This theory promotes the acknowledgement
that the experience and needs of siblings in
early psychosis may be different depending on
birth order. Further, the onset of early psychosis
may impact upon the sibling’s personality
development.
© 2013 Wiley Publishing Asia Pty Ltd
S. Bowman et al.
The protective effects of siblings
EARLY PSYCHOSIS AND SIBLINGS
A stable and loving family has been found to
decrease the incidence of mental health problems
in adolescence.34 Protective factors include parental
support, good family climate and cohesion, parental
warmth and involvement, support of autonomy
as well as consistent rules and expectations.
These have been found to reduce psychological
and behavioural dysfunction and are associated
with lower levels of depression and good global
functioning.34–36
There is evidence that social exclusion results in a
higher risk of developing psychosis as well as psychotic relapses.37 Social exclusion and isolation are
frequently experienced by people who develop psychosis and is one of the main concerns of people
with psychosis.38
Sibling relationships provide social support in
terms of companionship and affection.19 Social
support has been demonstrated to reduce the risk
for relapse in young people suffering from psychosis.37 Siblings could play a pivotal role in preventing
social isolation.
Sibling support has been shown to be associated
with better coping and psychological adjustment
after a stressful life event;39 more positive school
attitudes, higher self-esteem and better school functioning;40 less anxiety, aggression and delinquent
behaviour;41 less loneliness and depression;42
high self-esteem and life satisfaction;40 and positive mental health during adolescence and early
adulthood.40,43
In accordance with social defeat theory, the companionship and longevity of the sibling relationship
may reduce the risk of feeling like an ‘outsider’.44
This in itself may reduce the risk of the onset of
psychosis and other mental health conditions.44
Further, new models of psychology such as ‘positive
psychology’45 put a strong emphasis on protective
factors, as opposed to only risk factors, and there is
evidence that strengths-based interventions could
play an important role in promoting functional
recovery in psychosis.46 Sibling relationships may be
an underutilized protective factor in the onset of
mental health conditions due to its inherent benefits and social support.
Sibling relationships supported during early
psychosis may reduce disruption to the contributions they make to each other and promote
positive mental health. This psychological and
social support for the young person experiencing
early
psychosis
may
assist
in
recovery
outcomes such as relapse prevention and social
connectedness.
Even though intervention in early psychosis promotes hope and optimism for a good outcome and
more consistent and expert care to achieve this, the
literature indicates that many siblings will experience their brother or sister requiring hospital
admissions, being non-compliant with treatment,
having persisting psychotic symptoms, engaging in
ongoing substance use, attempting suicide and/or
being physically violent.47–55 The evidence also suggests that individuals can find it hard to access treatment and can resist obtaining help. This can lead to
long periods of untreated psychosis, which can
impact upon the prospects for recovery.56 All of
these factors may disturb the sibling relationship
and have a negative impact upon the sibling’s
quality of life.
© 2013 Wiley Publishing Asia Pty Ltd
Duration of untreated psychosis
A long duration of untreated psychosis (DUP) may
indicate that siblings have witnessed their brother
or sister’s psychosocial decline and the onset of psychosis. The median DUP has been found to be
approximately 8 months in Australia.57,58 The length
of time someone is psychotic before receiving treatment is an independent predictor of the likelihood
and extent of recovery.56,59–61 Studies have discovered
a relationship between DUP and critical comments
by family members in early psychosis.62 It could
therefore be that DUP increases conflicts in the
sibling relationship.
Hospital admissions
Siblings most likely will have witnessed their
brother or sister being admitted to a psychiatric
inpatient unit. In an Australia study, of the 104
young people consecutively accepted into an early
psychosis programme for treatment, 80 (84%)
required a hospital admission within the first
3 months of treatment.55 Fifty-nine (57%) had a
single admission and 21 (20%) had multiple admissions over the course of the 15 months.55 Wade and
colleagues55 also reported that individuals were
often discharged from hospital without full resolution of psychotic symptoms and would therefore
often require readmission soon after discharge.55
Family studies with parents have shown that they
find hospital admissions traumatic and result in
feelings of hopelessness, failure, stigma, fear and
guilt.63 Hospital admissions are likely to have an
impact upon siblings however, there has been no
study that examines this impact.
271
Siblings in early psychosis
Persisting psychotic symptoms
For approximately 40% of families in early psychosis, their child/ brother or sister will continue to
have psychotic symptoms 18 months after treatment has begun.51,64 Persisting psychotic symptoms
is likely to result in the sibling living with difficult
behaviours that can result in fear, detachment,
worry for the future, stigma and increased caregiving responsibilities, as has been found in studies
with parents in early psychosis.1 No study has examined the impact of persisting psychotic symptoms
on the sibling.
Substance use
Up to 74% of young people with early psychosis
misuse substances, particularly alcohol and cannabis.47,51,65,66 Studies have found that persisting substance use over the course of treatment can result in
higher rates of relapse, persisting psychotic symptoms and non-compliance with treatment.51,54
Ongoing substance use is likely to result in a
changed sibling relationship, leading to loss,
detachment and increased burden. There is yet to be
any research conducted in this area.
Suicide attempts
Up to 46% of families in early psychosis will have
experienced their child/ brother or sister expressing suicidal ideation and approximately 20% would
have experienced a suicide attempt.52,53 Dyregrov
and Dyregrov67 implemented a mixed method
study to explore the needs of siblings after losing a
brother or sister to suicide. Data were collected
from 70 siblings divided into two subsamples
(younger siblings living at home; older siblings not
living at home).
The findings showed that one third of younger
siblings had been aware of previous suicide attempts
and knew the triggers. They had kept this from their
parents, which burdened them with guilt. Parents in
the study reported finding it difficult to understand
why the suicide had happened but siblings had different knowledge, which enabled them to have their
own theories as to why it happened. Siblings avoided
telling their parents this so they did not reveal information given to them in confidence or add to their
parents’ suffering. Most importantly, participants
reported they did not communicate their own grief
in order to protect their parents. As a result, they felt
alone. The parents also confirmed that the bereaved
siblings were ‘forgotten’ in the days following the
death.67 Siblings felt only partly looked after by
the family’s network and professionals because most
272
of the attention was directed towards their parents.
This is an important finding and may be relevant
to siblings in early psychosis, as they too may feel
‘forgotten’.
Birth order was relevant to the level of distress
experienced as older siblings experienced less posttraumatic distress than younger siblings.67 The
authors proposed that age, marital status and life
circumstances protected older siblings as they
could avoid intimate exposure to their parents’
despair. Older siblings often have their own core
family and peer group available for support. It is
likely that for siblings in early psychosis, suicide
attempts result in similar feelings of being forgotten,
feeling burdened, guilt for keeping knowledge from
their parents and experience psychological distress,
isolation and anxiety, especially younger siblings
and those living at home.67 No research has been
conducted into the impact of suicide attempts
during early psychosis on siblings.
History of violence
Studies from the United Kingdom, Ireland, Canada
and Australia indicate that up to a third of families in
early psychosis will have encountered their child/
brother or sister exhibiting physical violence.68–70
Long duration of untreated psychosis, persisting
substance use and persisting symptoms contributed to acts of physical violence.68–70
Physical violence is likely to result in distress,
anxiety, anger and have a significant impact on all
domains of quality of life, particularly if the sibling is
living at home. It is also likely to have a damaging
impact on the sibling relationship. There is no literature on the impact of violence on siblings.
PREVIOUS RESEARCH ON SIBLINGS
Chronic illness or disability
There is research on the impact of childhood cancer
(5–15 years) on siblings. This research has found
that siblings experience post-traumatic stress
symptoms, shock, fear, worry, sadness, helplessness, anger and guilt.71–73 They experience a poor
quality of life, particularly in the psychological and
social domains.72 Studies have found that siblings of
childhood cancer survivors were at higher risk for
depression, tobacco use and heavy alcohol use than
the normal population.74–76 Younger sisters and a
shorter time since diagnosis resulted in more psychological distress.73,73
Research shows that adolescent siblings who have
a brother or sister with an intellectual or physical
© 2013 Wiley Publishing Asia Pty Ltd
S. Bowman et al.
disability provide a great deal of caregiving,
experience subjective burden, have trouble with
peer acceptance and find intimate relationships difficult.77 They are a population at risk of depression,
anxiety and psychological distress.78–80
Long-term psychosis
The research in this area has focussed on mostly
older, female caregiving siblings;11,81–84 studies
where siblings are a subset of a larger sample of
key relatives;85 or retrospective studies that have
asked siblings to recall feelings and events over
the previous 20 years.85–87
These studies found that siblings are at risk of
developing survivor guilt86,88 and may experience
long-standing grief due to the lost personality
of their ill brother or sister.82,89 This affects the
sibling’s choice of leisure and vocational pursuits.81,82,90 Common issues include stigma,
fear, worry about the future, lack of understanding about the illness and service system, detachment, anger and burden of care.83–87 Long-term
psychotic illness has been found to negatively
impact the warmth and support within the sibling
relationship.90
Early psychosis
A research group from the United Kingdom have
published two qualitative studies on siblings in
early psychosis. Participants reported feeling
overwhelmed, resentment, blame, guilt, loss and
shame.91 They had stopped inviting friends home,
reported deterioration in their academic and social
performance, and believed that supporting their
parents was their most important role. Sin and colleagues92 found that siblings had complex needs
and experiences and younger siblings had different
needs to older siblings.
Newman, Simonds and Billings,93 also from the
United Kingdom, investigated the experience of
four siblings using narrative analysis. They found
that the female experience was different to the male
experience in terms of the impact upon identity and
roles undertaken within the family. All siblings provided a lot of caregiving and needed more information and support from services.93
Smith, Fadden, O’Shea and Taylor have considered a range of family intervention strategies and
clinical practice issues when working with siblings
in early psychosis such as the importance of
engagement, flexibility, problem solving, provision
of information, support and normalizing.94,95
© 2013 Wiley Publishing Asia Pty Ltd
CONCLUSION
The impact of early psychosis on the sibling relationship is neglected in research despite the potential for this relationship to affect positive outcomes.
These relationships may be an underutilized protective factor due to their inherent benefits and
social support. The characteristics of early psychosis may result in distress and burden for the
sibling, particularly if they live at home. Further
research using standardized measures with a large
sample is required in understanding the impact on
siblings. Targeted support options can then be recommended so that they can receive assistance in
ensuring they maintain good mental health and be
involved in the management of the illness if they
so choose. Siblings may also contribute to the
management of family burden and improve outcomes for the young person experiencing early
psychosis.
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