Families’ experience during recovery or nonrecovery from psychosis

Families’ Experience During Recovery or Nonrecovery From Psychosis Donna Tweedell, Cheryl Forchuk, Jackie Jewell, and Lianne Steinnagel This naturalistic qualitative study was conducted to expand understanding of families’ subjective experiences to their relative’s recovery or non recovery from psychosis. Nine families, who had a member with a chronic mental illness who was taking a second generation neuroleptic medication, were interviewed five times over the course of one year. Eight families reported positive outcomes, particularly valuing improved interpersonal relationships. Cautious optimism was restored. Interest in maintaining or establishing collaborative relationships with professionals was affirmed regardless of the length of their relative’s psychotic experience. Nonrecovery punctuated the need for professionals to assist them to maintain hope while comforting them in their sorrow. © 2004 Elsevier Inc. All rights reserved.

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LTHOUGH THE CONCEPT of recovery from mental illness is not a new development, the introduction of a second generation of neuroleptic medications has resulted in increased reporting of this phenomenon in the literature. The opportunity for recovery may become more of a reality for many. However, Metlzer, (1998) and Sheitman and Lieberman, (1998) reported that 20% of consumers with schizophrenia are estimated to be nonresponders even to the new generation of medications. Recovery not only implies alleviation of the influence of psychotic symptoms but reengaging in seeking a meaningful life. Recovery is often a complex, time consuming process. In 1993, Anthony, from his work with consumers of mental health services offered, a definition of recovery as “ . . .a deeply personal, unique process of changing ones’ attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in ones’ life as one grows beyond the catastrophic effects of mental illness”. (p. 15). From a consumer’s perspective, Patricia Deegan (1996) eloquently suggested that “recovery does not mean cure. Rather recovery is an

attitude, a stance and a way of approaching the day’s challenges. It is not a perfectly linear journey. There are times of rapid gains and disappointing relapses. There are times of just living, just staying quiet, resting and regrouping. Each person’s journey of recovery is unique.” (pp. 96 –97). Although families are often the greatest source of support for their relative who suffers from severe mental illness, their perspective on the recovery process is less known. This qualitative study sought to examine the role that medication played in the families’ subjective experience of improvement of psychosis as a step in the recovery process. Parallel research examined the consumers’ experi-

From McMaster University, School of Nursing, and Family Nursing Consultants, Hamilton, Ontario; University of Western Ontario, and Lawson Health Research Institute-London Health Sciences Centre London, Ontario; Centre for Mountain Health Services, Hamilton, Ontario; and Johnson & Johnson, Hamilton, Ontario, Canada. Address reprint requests to Donna Tweedell, RN, MSN, CPRP, Clinical Nurse Specialist, McMaster University, School of Nursing, 32 Chedoke Ave, Hamilton, Ontario, Canada L8P 4N9. E-mail: [email protected] 䊚 2004 Elsevier Inc. All rights reserved. 0883-9417/04/1801-0004$30.00/0 doi:10.1016/j.apnu.2003.11.004

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ence (Forchuk et al. in press) and the staff experience (Forchuk et al., 2003). LITERATURE REVIEW

For several decades there has been considerable literature describing the burden that a relative with severe mental illness places on the family. More recently, families have begun to share with researchers their experiences of a relative’s recovery from psychosis after the introduction of a second generation neuroleptic medication. These studies have shown that both the illness and changes in the illness have an impact not only on the patient but also on the family. Several early qualitative studies looked at families’ experiences as family members with schizophrenia started taking the second generation neuroleptics. The earliest was Conley and Baker (1990) who described three families who experienced difficulties when their relative began to show improvement. Their relative became angry with them and this resulted in mutual withdrawal as they were not used to their relative’s more demonstrative expression of emotion. Mason, Gingerich, and Siris (1990) also reported on the stress experienced by care providers when new medications produced improvement in psychotic, depressive, or negative symptoms. This altered the status quo and called for changes in interactive processes. Both these early studies called for increased psychosocial interventions and support to assist all parties to successfully manage this phase of their relative’s improvement. Several studies described family changes. Meltzer in 1992, reported outcome measures for 54 patients following one year of clozapine treatment. Families reported feeling less anxious, greater social freedom and lesser financial demands. Kotcher and Smith (1993), in a nonexperimental report of their experience of treating over 40 patients, described phase-specific reactions of patients and their families and suggested phase-specific interventions to maintain collaborative working relationships. Stebbin, in her 1995 exploratory descriptive study with a convenience sample of 10 Michigan families reported that while some families were pleased with the clinical outcomes they anguished over the balance of benefits and limiting side effects of clozapine. Their expectations became more realistic as time passed during the course of treatment. Families expressed a need for

an informal or formal source of emotional support to cope effectively with their family member’s clozapine therapies. A few qualitative studies described the positive changes that occurred for family members as their relative improved from psychosis (Dickson, Williams, & Dalby, 1995, Najarian, 1995). These highlighted improved family functioning and needs for support. Recent studies have looked at the experience of family members throughout the illness trajectory. Karp and Tanarugsachock (2000) interviewed 50 family members in an ethnographic study. Family members were found to go through predictable phases. The early frustration, as the family member was diagnosed, evolved into grief and sadness. As the lack of control over the illness was recognized, family members reached a stage of acceptance, but also a withdrawal that included respect for the family member’s struggle. Rose, Mallinson, and Walton-Moss (2002) conducted a grounded theory study of families responding to mental illness. They interviewed 17 families, three times over a 2-year period. The basic social process was pursuing normalcy. A number of specific strategies were employed. Families struggled towards normalcy in the midst of the difficult social context of mental illnesses. The sample combined a number of diagnoses by including schizophrenia, major depression and bipolar disorder. This study added to the literature by looking at the perceptions and changes over time. Milliken and Northcott (2003) examined the subjective and emotional experience of parental care giving in schizophrenia. Twenty-nine parents were interviewed for this grounded theory study. Parents had been in a caregiving role for an average of 11.5 years. This study also found that families moved through phases. The core process was redefining their parental identity. Families experienced being marginalized and disenfranchised. They later embraced the collective experience through association with other parents with similar experiences and eventually became re-enfranchised. PURPOSE

The immediate purpose of this investigation was to describe the families’ subjective experiences of the recovery or nonrecovery process from psychosis over the course of one year from the early

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introduction of treatment of their relative with a second generation neuroleptic medication. The ultimate purpose is to improve the quality of care and support to families during the recovery process. This analysis of families’ experiences is part of a larger study which also examined clients’ and staffs’ experiences. DESIGN

This investigation used a naturalistic qualitative design with an ethnographic method for data analysis. Ethnography is a systematic process of observing, documenting, analyzing, and describing patterns of a group (Leininger, 1985; 1987; 1990). The method used was a series of five semistructured interviews. The focus of inquiry was the subjective experiences of families over 1 year while their relative was taking a second generation neuroleptic medication. A nonprobability, purposive sampling of clients about to commence treatment with clozapine or risperidone, their family members and health care providers was chosen from both a tertiary care psychiatric facility, with inpatient and outpatient services, and a large teaching general hospital in Ontario. The sample size was determined through saturation. Specifically, data was analyzed after four participants were in each set (client, family, and staff). Data from an additional two participants were then analyzed and compared for saturation. No new themes emerged, indicating that the sample size was adequate. Because this was achieved so quickly we purposely chose the next four subjects with briefer experiences with psychosis, i.e., from 1 to 3 years. If the addition of these participants had changed the nature of the descriptions, or added new themes, further data from additional participants would have been added. This process is repeated until further addition of participants does not alter the themes or descriptions. Ten patients, who met the inclusion criteria, i.e., about to commence medication, ongoing problems related to symptoms of psychosis, a diagnosis of schizophrenia and consenting to participate, were asked if they were interested in participating in this research study. Those who agreed were asked if they were willing to have their family included. Family members were approached if they were over 18 years, spoke English or had one member who agreed to act as interpreter as well as partic-

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ipant. The definition of family that we adopted was “whoever the patient defined as family” (Wright and Leahey, 1994, p. 40). Demographic data, including client’s age, sex, marital status, primary residence, and length of illness before initiation of the new neuroleptic, were collected by chart review. Over a period of 12 months, nine families were approached and all signed informed consent before participating. One client, who had been hospitalized for 8 consecutive years, had no surviving relatives. One family was interviewed only twice as the new medication had to be discontinued. They felt that they would not profit from further interview experiences. Each family signed a written consent to be audiotaped and was assigned a code number to ensure confidentiality. Of the nine families, seven witnessed significant improvements in their diagnosed family member over the year in the study. Family members ranged in age from 28 to 78 years. All participants were Caucasian. There were five sets of parents, one widowed mother, one spouse, four sibling-in-laws, three sisters, and four brothers. Family members had witnessed, and many had lived under the influence of, their relatives’ psychoses for anywhere from 3 to 15 years with minimal relief from symptoms despite numerous medication regimes. PROCEDURE

A series of informal, semistructured interviews were conducted with each family. The first interview occurred before initiating the new medication and then every 3 months over a period of 1 year for a total of five interviews. This allowed three views of the family perspective, i.e., during pre- and early treatment, after a 6 month trial when emotional, cognitive and affective change is dramatic and finally during the last 6 months during which change is being consolidated and hopes and aspirations of total recovery are challenged. Generally, these interviews ranging from 1 to 1.5 hours and were conducted in a private room in the hospital or in the family’s home. Times for interviews were arranged at the family’s convenience, sometimes occurring during the weekday evening or on weekends. An interview guide consisting of seven broad questions, based on a review of the literature and our clinical experiences, focused on the experi-

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ences of beginning a new treatment. Family members were asked about their knowledge of the medication, the changes noticed, their hopes and fears, most troubling symptoms and changes in the relationship with their relative. DATA MANAGEMENT AND ANALYSIS

All interviews were audiotaped and transcribed verbatim onto the Martin V.2 qualitative software program. In addition, field notes were recorded by a research assistant during interviews and included in the data analysis. Leininger’s phases of qualitative analysis were used to identify categories and themes Identification and listing of observations and experiences of the domain under study was completed. Raw data and descriptors were combined into meaningful sequential units. Mini patterns were identified and how they related to larger patterns was determined. Several patterns were synthesized to obtain broad, comprehensive, and holistic themes. Theme statements to test or reaffirm phenomena were formulated. Confirmed themes were used to develop hypotheses, make decisions and plan interventions (Leininger, 1985). FINDINGS

Family Knowledge About the Medications None of the nine families proactively advocated for initiation of these new medications. All agreed to a trial of risperidone or clozapine treatment. The possibility of initiating a new medication with eventually, less sedating side effects and greater efficacy, motivated some family members to become active researchers about the medication. Some members read articles, watched television programs, or requested information from the hospital. Two families struggled to explain the action of the drugs at the receptor site or to state that clozapine may affect the white blood cells in a negative way. One family, concerned about the cost of the medication, wondered who would pay after discharge. Most were interested in the medication’s potential to improve symptoms of psychosis “it would clear his mind” or “it would decrease his fears.” All family members were encouraged by the prospect of beginning a new medication, no matter how long their relative had been severely ill. They remained concerned however about some of the potential side effects. The possibility of improvement in symptoms informed their initial experience of recovery.

FAMILY’S ROLE IN THE PROCESS OF STARTING THE MEDICATION

It is difficult to determine if the family’s role in starting the medication had an influence on their experience of recovery with the exception of one family. Estranged, divorced parents came together for two interviews to share their experience of their son’s recovery. Eager that he receive relief from suffering the ravages of a severe mental illness, they skeptically agreed to treatment. Unfortunately, after 3 months, the medication was terminated when he took a knife and excised his right testicle. They expressed anger and sadness at their decision to agree to treatment. Their guarded optimism of recovery was extinguished and they resigned themselves that experiencing improvement in symptoms was not in the cards for them. They went their separate ways believing that they would not participate again as a witness to potential recovery. WHAT HOPES DID THEY HOLD

Families did not use the term “recovery” when they described their hopes and fears. Although the likelihood of a miracle behavioral change has become less potent than first anticipated in the early 1990s, families unanimously hoped for relief of suffering from the symptoms of psychosis. Families expressed their hopes in the following three dimensions. Specifically they mentioned a hope of a return of the former self, “I feel his personality has come back to how he used to be and I have a very good relationship with him.” They longed for their relative to be able to take care of themselves, live independently, or have improved judgment and concentration, or to work and become functional and self-sufficient. One brother shared “I would like to see him become functional, you know that bothers me. I would hope that 10 years from now we are not picking him up at the Men’s Mission or that he has a job . . .as he’s capable of holding”. Many spoke of cautious optimism “we hope it will last”. “that (she) never slips back”, “. . . we would like her to have a life of her own with her own interests, be assertive and less reliant on direction from family members.” Two sets of parents hoped that their adult child would be able to experience pleasure in life again. Several families were afraid to hope for improvement “My hopes are that she regains her

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health, but somehow I have the feeling that you never get over this illness.” Some found it hard to envision what the future might hold “we can’t bank on anything.” Because many of their relatives had a long history of illness, one family eloquently described what the process was like for many of them “This is not unlike the past-Russian roulette, you never know what you’ll get.” Several family members worried about losing hope, while at the same time trying to maintain faith in science. What is noteworthy is that family members’ hopes for themselves as a family recovering from mental illness were not mentioned. WHAT FEARS DID FAMILIES EXPERIENCE

Observing changes in thoughts, feelings and behavior, while taking these new medications, became a large focus of families. They seemed to welcome the opportunity to express their fears. The subjective experience common to these families was anxiety, not unlike any family who has a member with a chronic illness. Families expressed fears about the medication itself. If the medication does not change the face of the illness “what’s next?” Will the relative get worse on this new medication “sort of concerned about the side effects, putting on weight is a big problem, but certainly the white blood cell count and the immune system and that. . . that’s a big problem.” One younger brother feared that alcohol consumption would interfere with the benefits of the medication, as it had in the past, “and it’s a tough thing to ask of 25-year-old guys who are drinking alcohol, so there is always going to be a temptation and we know that.” Many family members feared that their relative might again go off the medication on their own if they felt better. Will it result in “a return of a sense of futility and frustration?” one mother worried. Other members had concerns beyond the medications. Several family members worried about continuing the relative’s dependence on the hospital and the family. Parents were concerned about their own aging and not being available in future for support. “Because, I’m not going to be here forever you know. So what’s going to happen to her after I’m gone? That’s what I worry about. Cause I don’t think she’s gonna be with any of the kids. They have their own families. And because she’s not concerned, she doesn’t seem to worry about what’s gonna be with her.” Siblings also

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expressed concern about future responsibility for their ill brother or sister. Many felt that they had grown apart and some still harbored both resentment and feelings of remembered embarrassments. They expressed concerns about continued fiscal restraints in the healthcare system and resultant downsizing and hospital closures “If (they) need more help in the future will it be there?” As families began to witness improvement in functioning, they spoke about their worries regarding their relative’s increasing independence and the impact that this would have for them if they were uninvolved in planning for their relative’s community reentry. Another family expressed general concerns about their relative’s safety should recovery and return to the community occur. Finally, they feared that there would be less supervision and easily accessible supportive relationships in the community. Recovery was both longed for and feared and vulnerability was viewed as persisting over time for all family members. CHANGES NOTICED IN FAMILY RELATIONSHIPS

All families reported an alteration in family functioning during the study. Positive changes seen in the ill relative elicited a new response from families. This change underscored the primary role that families play in providing a social net. How recovery affects family functioning is unique. In one family, certain behaviors seen at home were now framed by family members as “normal forgetfulness” rather than a symptom of pathology. Families described changes in amount and content of interaction, noted their relative being helpful in the home, showing consideration for a parent, remembering a family member’s birthday. These changes invited family members to respond by increasing their willingness to involve their relative in a special family event (family wedding). After many years, one relative’s new interest in his nieces and nephews resulted in his siblings taking note and allowing renewed contact with them stating proudly, “and he’s held his new nephew.” One mother commented “he can carry on a conversation now . . .and he can start a conversation now. It’s really hard because they (siblings) don’t know how to talk to him, and he didn’t know how to talk to them. But now they can carry on a conversation for a longer period of time . . .”. As families begin to notice change, new challenges

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emerge . . . how might the family begin to see themselves differently? One father resumed helping his daughter to read and understand the newspaper, an activity previously enjoyed together. It was revealing to notice that most families asked their relative few personal questions about the experience of psychosis, but at the same time expressed less worry about them than before initiation of the medication. Families remembered the difficult times and the cognitive, affective and behavioral strategies developed to successfully manage those times. As the need arose they continued to use them successfully. “we’ve always led our own lives.” “It’s too soon to let our guard down yet.” Participatory planning done to make a successful family weekend continued for one family, “And we try, when she’s home, . . .we don’t have spareribs or anything picky. We generally go with pastas or stuff that she doesn’t have a problem with. She doesn’t have the patience, she’s better now, but before she didn’t. We always try to make it a successful weekend.” And “When we bring her home we always try to have something there so that she feels like she is coming home, she’s not just visiting. She belongs here. She’s always had her room and we don’t change. . .other than dusting or something, she’s got some place to come to where she can go and shut the door.” One mother spoke about her relationship with her middle age daughter. “I have to say ‘well, we’re gonna do this today (wash the windows) and if we do something, we do it together-you do it on the outside and I’ll do it on the inside’. But she never says ‘well, I’d like to do this’ or ‘have you done this lately’ or whatever. But, whatever I ask her to do, she will do it without questioning. I’d like to see her say “well mom, I was planning to go to the mall today and I haven’t got time for this or that.” All family members continued to feel a sense of vulnerability during recovery. They struggled with the process of learning to carry on to special family events and leave the ill person behind on a day when symptoms are getting the better of them. One set of parents stated “Well, the thing is she hasn’t got a proven track record that you could leave her by herself for ten minutes without getting in any. . .that’s the thing with us, we both have to be there with her still”. One mother spoke of the

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challenge, even though her son was showing improvement, not to feel down when her son felt down. One husband spoke of the lack of a sexual relationship and wondered if, in his wife’s recovery, this mutual need would ever be met. THE MOST TROUBLING SYMPTOMS

Over the course of the study, families had the opportunity to identify the symptoms that they still found most troubling. As the year progressed and their relative’s symptoms improved, several parents and one spouse continued to express concern about the dramatic positive symptoms (i.e., bizarre delusions and aggressive responses to auditory hallucinations) which, although no longer present, continued to be present in their memories and to trouble them. “Her delusions-about 100 fetuses in her belly. Still pregnant-even though it is over 9 months now. And injuries to herself, smashing things. Compulsion to throw a tantrum, verbally sometimes.” Others continued to be concerned both for their own safety, as well as for their relative’s welfare, due to the unpredictability of symptom manifestations. One mother mentioned “she is, was, always seemed so angry inside her own head. Thinking things that weren’t the case. She would come with the family but feel that people didn’t like her and of course we don’t want her to feel this way, and the feeling of helplessness that you can’t do anything to make a difference.” One set of parents worried “she becomes very agitated and she strikes out. She’s not afraid of anyone at those points, you have to be very careful all the time with her because you just don’t know when you are going to say or do something that is going to upset her.” DISCUSSION

During the initial interviews, before the introduction of the new treatment, family members described the impact of the illness on them. Where the individual lived with their families (five), the impact of illness manifested itself in marital arguments, health problems, social isolation as well as financial problems. Parents shared their feelings of guilt about neglecting their other children over time, and anxiety about the future due to their own aging. Each family member had experienced embarrassment when a public display of illness occurred, felt anger at the injustice of the illness, and had moments of hopelessness and grief. In addi-

FAMILIES’ RECOVERY EXPERIENCES

tion, families described their own behavior, indicating their impact on the illness, i.e., nagging about taking medications as prescribed, or demonstrating low expectations of the individual to assume any responsibility. Several families had attended psychoeducational courses in the past or read the popular literature about schizophrenia and watched made-for-television programs about the illness. However, some families had not had an opportunity to attend courses and, for two families, reading material and television programming was not in their first language. Consequently, all families attended all scheduled interviews, and expressed appreciation for the opportunity to be involved in the research study to share their feelings, thoughts and experiences. It was noteworthy that families did not blame themselves for the illness, rather, they seemed to appreciate the biological nature of the illness. Perhaps we are witnessing the effectiveness of self-help groups to educate the public, and lobby governments about funding mental illness research and practice. Four families reported receiving less attention from professionals as their relative’s illness continued unabated as they aged. This finding was also reported by Dixon, Lyles et al (1999, p. 237). Where indicated, family members were directed to the treatment team members for support beyond the scope of the research project. During the study, stories of courage, resilience and creative problem-solving inspired the nurse researchers. This study further confirmed our belief that mental health professionals need to value the subjective experience of illness, as this promotes mutual appreciation for the roles each can play in the process of recovery. The need for collaboration with patients and their families to enhance positive outcomes for all those suffering from the effects of mental illness is evident. NURSING IMPLICATIONS

Families have been accustomed to sharing their knowledge and experience of the medical story of mental illness. We have provided them less opportunities to share their experience of the illness narrative. Although we have become familiar with the literature on burden of illness, we have been less privileged to hear stories of success and achievement experienced by families. Rose (1996) suggests that nurses cannot assume an understand-

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ing of families’ concerns or that those concerns remain unchanged from those identified in research more than 40 years ago (p. 67). This finding further strengthens the need to actively reach out to families, inviting them to share their stories and their observations of change. Developing new relationships takes courage, persistence, and creativity of all family members which nurses could facilitate by holding conversations with families. Although nurses need to appreciate the family’s need to hope for a restoration of their relative’s pre-morbid personality and functioning they need to help families and their recovering relative to make a place for schizophrenia in the redefinition of the self which does not negate their experience of living along side the mental illness. Families may need help to mourn their lost years together at different stages of recovery. The developmental stage of the family will have an impact on how easily they manage this process. Families need timely information about medications, rehabilitation programs and alternatives in community living, regardless of the length of time their relative has been suffering with mental illness and recovery is not evident. Remaining hopeful sustains both families and their ill relative. Health teaching about medication benefits and side effects needs to be ongoing during treatment. In addition, strategies for encouraging improvement could be provided in individual family or family group format depending on their preferred learning styles. For those who are lucky enough to have significant symptom resolution we are challenged to more effectively understand, interact with and plan treatment for individuals and their families with schizophrenia. Sluzki (1974) suggests that the ability to “conceive (of) the individual as constantly defining and being defined by his relationships to his family and to other meaningful members of his milieu and by his insertion in the community” (p. 484) is a concept that nurses in tertiary care settings need to mindful of in therapeutic work with clients and their families. With the alleviation of the symptoms of psychosis, nurses need to expand their thinking to include both family and community and move away from a focus on management of deficits, symptoms and problems in favor of a strengths and resources focus for intervention. This process may be more challenging for nurses who have worked for many years in a tertiary care setting where the medical

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model predominates. None the less, this approach is more likely to produce more favorable outcomes. Families and clients with chronic and persistent mental illness, regardless of age, need strong advocates to help them gain access to the newer atypical medications as well as to psychosocial rehabilitation programs to support recovery. Clients and families who recover and move away from the intense contact with the hospital report a loss of intimate and supportive relationships. The search begins for new supportive relationships. Inversely, patient recovery and discharge from hospital, often after many years, is a loss for care providers as well. Nurses who are working with families who are struggling to deal with the emergence of intense feelings, painful memories and identity crises need to be aware of the implications of the age of onset of schizophrenia, usually in late adolescence, which is the time that the individual develops a sense of identity as a mentally ill person. Lost time can never be recovered and in some cases nor can earlier hopes and aspirations. The nurse needs to help them mourn their lost years together and to reconcile to an identity that does not exclude their experience with an individual who has a mental illness. The nurse needs to be alert to cues that the family is losing hope and in its place despair is emerging and not withdraw support at this time. Nurses themselves are challenged to maintain a sense of hopefulness, often in the face of client’s failure to recover and to seek support themselves to continue with the families and their relative on the slow journey of recovery with all it’s vicissitudes. SUMMARY

This study has highlighted nine families’ experiences of recovery or non-recovery from mental illness. Treatment environments are changing rapidly. Hospitalization is briefer and families are caring for family members recovering from acute and enduring chronic illnesses in addition to their usual roles. Studies of ethnographies of recovery trajectories that capture the issues, adaptive demands, fears, conflicts, and capabilities across different clients with different personal and situational characteristics can only serve to add to the clinician’s knowledge and skill. Understanding how people maintain hopefulness in the face of difficult circumstances and how we, as clinicians can instill hope in clients and

families in early recovery are important areas for continued investigation. ACKNOWLEDGMENT The authors thank Virginia Savedia, RN, Terry McLean, RN, BA, Canadian Nurses’ Foundation/Pharmaceutical Manufacturers of Canada, Ontario Hospital Nurses’ Alumnae Fund, Hamilton Branch.

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