Schizophrenia Bulletin, Vol. 21, No. 4, 1995
National Institute of Mental Health

Abstract

This article reviews the existing evidence for the efficacy and effectiveness of psychoeducational family interventions in the treatment of persons with schizophrenia. There is substantial evidence that psychoeducational family interventions reduce the rate of patient relapse. There is suggestive, though not conclusive, evidence that these interventions improve patient functioning and family well-being. Interventions with multifamily groups that include the patient may be of superior benefit for subgroups of patients. More research is necessary to determine the critical ingredients of family interventions, to expand the groups of patients included in these studies, and to evaluate a broader range of outcomes.

Schizophrenia Bulletin, 21(4): 631-643, 1995.

Psychosocial interventions offered to families of persons with schizophrenia have been developed and studied over the past 20 years with increasing sophistication and methodological rigor. Although these family interventions differ in their characteristics and methods, they tend to share a common set of assumptions: (1) schizophrenia is regarded as an illness; (2) the family environment is not implicated in the etiology of the illness; (3) support is provided and families are enlisted as therapeutic agents; and (4) the interventions are part of a treatment package used in conjunction with routine drug treatment and outpatient clinical management (Lam 1991). It is imperative to note that these family interventions do not include those traditional family therapies (variously labeled as contextual, symbolic-experiential, structural, strategic, and integrative) derived from the theoretical proposition that behavior and/or communication within the family plays a key etiological role in the development of schizophrenia.

The elements of family interventions most frequently used in differing combinations are psycho-education, behavioral problem solving, family support, and crisis management. Interventions differ in whether they are conducted with individual families or groups of families and whether they are in vivo, in the home, or out of the home. They also differ in whether the patient is included or excluded, the length of the intervention, and the phase of illness of the patient at the time of the intervention.

The construct of expressed emotion (EE) has played a significant role in the evolution of professional interventions directed at families. During a structured interview, families are assigned an EE rating based on observations of critical comments, hostility, and overinvolvement. A body of literature suggests that patients living with families characterized by high levels of EE are more vulnerable to relapse (Koenigsberg and Handley 1986). Thus, many interventions have targeted high EE families because those families are most likely to benefit from the intervention. However, the utility of this construct has been criticized (Lefley 1992). Determining the validity of the EE construct and whether high EE causes relapse is not the purpose of this review and will not be directly addressed. However, EE will be discussed in the context of patient heterogeneity, because many studies reviewed here include only those patients from families with high EE.

The self-help family education movement has had a significant influence on the development of family psycho-education interventions. Pioneers in the family education movement distinguish family education from the professionally driven psychoeducational approaches in that (1) family education is centrally directed at helping the family, not the patient; (2) family education does not assume a medical therapy model, in which a presumption of pathology in the family being treated is implicit; and (3) family education stresses the competencies, not the deficits, of families (Hatfield 1994). Hatfield (1994) and Lefley (1994) acknowledge many overlapping goals and strategies in the family education and professional psychoeducational approaches. Professionally driven psychoeducational interventions have incorporated principles of family education. However, because little controlled research has been conducted on family education protocols (Hatfield 1994), these programs will not be examined in this review.

The review will address the following questions:

1. When added to pharmacotherapy, is there evidence that family interventions are effective for reducing patient relapse and improving functional status and family well-being?

2. Is there evidence that a particular kind of family intervention is superior to others?

3. Is there evidence that patient heterogeneity factors, such as family characteristics, age, gender, race, and phase of illness, influence the effectiveness of these interventions?