Reprinted from:

Gingerich, S. L. & Bellack, A. S. (1995). Research-based family interventions for the treatment of schizophrenia. The Clinical Psychologist, 48(1), 24-27.

I. Description of Treatment

Schizophrenia is a chronic mental illness with symptoms which affect patients in multiple and complex ways. While new medications have provided hope for improving the course of the illness for many patients, treatment still requires several types of additional interventions, well-integrated and delivered on a long-term basis. Psychosocial interventions play a critical role in a comprehensive program for the illness of schizophrenia. One of the most prominent advances in psychosocial treatment in the past 15 years has been in the area of family interventions, with several well controlled long-term research studies reporting positive effects on the course of the illness when families are included in the treatment program. Seven studies with long-term follow-up will be reviewed here. Although each study employed different models of family therapy, the interventions share several important components which can be summarized as follows:

1. Education is provided to patients and families about the biological nature of the illness and the principles for treatment (especially medication compliance, attention to early warning signs, reducing stress, and providing a supportive environment).
2. The family is treated as an ally by the treatment team and is discouraged from feeling guilty or to blame for the patient's illness or its course.
3. A psychoeducational workshop is conducted at the beginning of the program. Regular meetings are then held with the family, ranging from weekly to monthly. Support is provided by clinicians and, in most cases, by other families in a group format.
4. The intervention is long-term, usually at least 2 years.
5. Families are assisted in improving their coping methods and their communication with each other.
6. Treatment teams are multi-disciplinary and team members coordinate frequently with each other and outside agencies.
7. Medication is followed closely, with rigorous attempts made to maximize compliance.

Some elements of family intervention seem less critical at this stage of the research. For example, it appears to be effective to treat families alone or in multiple family groups, at home or at the clinic, and to utilize clinicians from a variety of professional backgrounds.

The family intervention model used in the Treatment Strategies in Schizophrenia study (Schooler, Keith, Severe, Matthews, Bellack, Glick, Hargreaves, Kane, Ninan, Frances, Jacobs, Lieberman, Mance, Simpson, & Woerner, 1994) is illustrative. The family clinician invites the patient and as many relevant family members as possible to participate in the family program. Family members include parents, brothers, sisters, spouses, girlfriends or boyfriends, aunts, uncles, etc. Family members (not including the patient as this point) are then invited to a psychoeducational workshop, which is scheduled for a time outside of normal working hours, lasts at least 3 hours and includes coffee break and a light meal. An average of 6 families attend. The focus of the workshop is educational, with "guest speakers" such as doctors, nurses and social workers presenting extensive information about schizophrenia (symptoms, course, role of medication, stress-vulnerability model) and coping strategies in a didactic style, using blackboards, slides, and handouts. Questions and discussion are encouraged during the workshop and clinicians are also available during the breaks. The clinician's role is of a teacher rather than a therapist, providing information, support and suggestions. The clinician also encourages family members to share their experiences with each other, in order to decrease their sense of isolation.

After the workshop, patients and families are invited to ongoing monthly support groups which meet for 90 minutes and continue the theme of the workshop by providing education and support, often using guest speakers to discuss specific topics such as vocational services and stress reduction techniques. The atmosphere is informal and group members are encouraged to interact. Many groups develop their own traditions such as holiday parties or hobby nights. In the Treatment Strategies model, some families also receive individual sessions focusing on learning and practicing specific ways to communicate and solve problems in less stressful ways. In both the groups and the individual family sessions, clinicians reiterate the biological nature of the illness and how families are not to blame.

II. Controlled Trials

Leff, Kuipers, Berkowitz, and Sturgeon (1985) compared their version of family intervention to routine outpatient care for patients who lived with or had frequent contact with relatives who measured high in Expressed Emotion (EE), as measured by the Camberwell Family Interview. The family intervention involved both individual sessions and multiple family support groups. It was aimed at providing education, reducing EE in the family and increasing the patient's independence from high EE relatives. During the first 9 months of treatment, half of the patients who received routine care relapsed, compared to 8% of patients whose families received intervention. After 2 years, there was a 50% relapse rate for the family intervention compared to 75% for the group receiving treatment as usual. However, if the data are analyzed looking only at patients who continued medication, relapse rates are 20% versus a significant difference in favor of family intervention.

Falloon, Boyd, McGill, Williamson, Razani, Moss and Gilderman (1985) compared home-based Behavioral Family Therapy (BFT) to clinic-based individual psychotherapy (n=36). Patients were selected based on having high EE relatives. BFT provides education about the illness, communication skills training and problem-solving training to the whole family, including the patient.

After nine months, there were several advantages for patients treated in the BFT group, including fewer symptom exacerbations (6% versus 44%), increased remission of symptoms (56% versus 22%) and reduced number of hospitalizations (11% versus 50%). After 2 years there continued to be a positive effect for the BFT condition regarding symptoms, with 83% of the BFT patients avoiding a major exacerbation compared to 17% of individually treated patients.

Hogarty, Anderson, Reiss, Kornblith, Greenwald, Javna, and Madonia (1986, 1991) compared medication alone to medication and three psychosocial treatment approaches for patients who lived in high EE households (n=103). One group of patients received social skills training (SST), one group received family therapy (clinic-based) and one group received both SST and family therapy receiving customary care and the other receiving clinic-based Behavioral Family Therapy (BFT). This study included both low and high EE families. After 1 year, 14% of the patients in the family treatment condition experienced symptom exacerbation compared to 53% of patients in the customary care condition. Xiong, Phillips, Hu, Wang, Dai, Kleinman, and Kleinman (1994) conducted a study in China, randomly assigning 63 patients to receive either standard care or standard care plus a family-based intervention. The family intervention included multiple family groups and individual sessions focusing on education, behavioral training, problem-solving and crisis intervention. After 1 year, 33% of the patients who received family treatment relapsed, versus 61% of the control group, and 12% of the family group were rehospitalized, versus 36% of the control group.

Lastly, NIMH's Treatment Strategies in Schizophrenia collaborative study (Schooler et al., 1994) compared three medication strategies (standard dose, low dose, and "targeted" dose) in interaction with two types of family intervention (Applied and Supportive). Although all families were assigned a family clinician for crisis management and attended monthly support group meetings, the Applied condition also included a version of Falloon's Behavioral Family Therapy (Falloon et al., 1985), providing intensive communication and problem-solving training in the home for 1 year. This study is especially noteworthy for large sample size (N=313), multiple sites and comprehensive measurements. Although there were no differential effects found for type of family treatment, both interventions were shown to have a positive effect on reducing relapses. Thirty-two percent of study patients were rehospitalized over the course of 2 years, which is comparable to the results of other studies of family intervention with 2 year follow-up. When the TSS relapse rate is compared to the medication only condition of other studies, it is significantly lower. It is hypothesized that both family interventions contributed protective factors.

III. References

Leff, J., Kuipers, L., Berkowitz, R., & Sturgeon, D. (1985). A controlled trial of social intervention in the families of schizophrenic patients: Two-year follow-up. British Journal of Psychiatry, 146, 594-600, 1985.

McFarlane, W. R., Dunne, E., Luken, E., Newhart, M., McLaughlin-Toran, J., Deakins, S., & Horen, B. (1993). From research to clinical practice: Dissemination of New York State's family psychoeducational project. Hospital and Community Psychiatry, 44, 265-270.

Randolph, E. R., Eth, S., Glynn, S., Paz, G. B., Leong, G. B., Shaner, A. L., Strachan, A., Van Vort, W., Escobar, J., & Liberman, R. P. (1994). Behavioral family management in schizophrenia: Outcome from a clinic-based intervention. British Journal of Psychiatry, 164, 501-506.

Schooler, N, R., Keith S. J., Severe, J. B., Matthews, S. M., Bellack A. S., Glick, I. D., Hargreaves, W. A., Kane, J. M., Ninan, P. T., Frances, A., Jacobs, M., Lieberman, J. A., Mance, R., Simpson, G. M., & Woerner, M. (1994). Relapse and rehospitalization during maintenance treatment of schizophrenia: The effects of dose reduction and family treatment, Manuscript submitted for publication.

Xiong, W., Phillips, R., Hu, S., Wang, R., Dai, Q., Kleinman, J., & Kleinman, A. (1994). Family-based intervention for schizophrenic patients in China: A randomized controlled trial. British Journal of Psychiatry, 165, 239-247.

IV. Books

Anderson, C. M., Reiss, D. J., & Hogarty, G. E. (1986). Schizophrenia and the family. New York: Guilford Press.

Falloon, I.R.H., Boyd, J., & McGill, C. (1984). Family care of schizophrenia. New York: Guilford Press.

Mueser, K., & Glynn, S. (1995). Behavioral family therapy for psychiatric disorders. Boston: Allyn and Bacon.

Mueser, K., & Gingerich, S. (1994). Coping with schizophrenia: A guide for families. Oakland: New Harbinger Publications.

V. Treatment Manuals

Falloon, I.H., Mueser, K., Gingerich, S., Rappaport, S., McGill, C. & Hole, V. (1998). Behavioral family therapy: A workbook. Buckingham Mental Health Services, FACTS project. Available from Dr. Ian Falloon or Susan Gingerich (see "Sources of Training").

McFarlane, W.R., Deakins, S.M., Gingerich, S., Dunner, E., Horen, B., & Newmark, M. (1991). Multiple-family psychoeducational group treatment manual. Available from Dr. William McFarlane (see "Sources of Training").

Psychoeducational Materials to Use with Patients and Families

Bisbee, C.C. (1991). Educating patients and families about mental illness. Gaithersburg, Maryland: Aspen Publishers.

Mueser, K., Ginerich, S., & Rosenthal, C. (1991). Educational family therapy treatment manual. Available from Susan Gingerich (see "Sources of Training").

Wyatt, R.J. (1994). Practical psychiatric practice. Washington, D.C.: American Psychiatric Press.

VI. Sources of Training

Dissemination Coordinator
Camarillo U.C.L.A. Research Center
Camarillo State Hospital
P.O. Box 6022
Camarillo, CA 93011
(Behavioral Family Therapy)

Ian Falloon, M.D.
Mental Health Services at the Department of Psychiatry and Behavioral Sciences
Private Bag 92019
University of Auckland
Auckland, New Zealand
(Training available internationally and in several languages for Behavioral Family Therapy)

Susan Gingerich, M.S.W.
Eastern Pennsylvania Psychiatric Institute
Medical College of Pennsylvania
3200 Henry Avenue, Philadelphia, PA 19129
(Multiple Family Psychoeducational Groups and Behavioral Family Therapy)

Shirley Glynn, Ph.D.
West Los Angeles VA Hospital
Mailing Code B-151J
11301 Wilshire Blvd
West Los Angeles, CA 90073
(Behavioral Family Therapy)

William McFarlane, M.D.
Maine Medical Center
22 Bramhall Street
Portland, ME 04102
(Multiple Family Psychoeducational Groups)

Kim Mueser, Ph.D.
New Hampshire-Dartmouth Psychiatric Center
105 Pleasant Street
Maine Building
Concord, NH 03301
(Behavioral Family Therapy)