update on family psychoeducation for schizophrenia · pdf fileupdate on family psychoeducation...

Update on Family Psychoeducation forSchizophrenia

by Lisa Dixon, Curtis Adams, and Alicia hucksted

Abstract

The Schizophrenia Patient Outcomes Research Teamand others have previously included family psycho-education and family support in best practices guide-lines and treatment recommendations for persons withschizophrenia. In this article we review in detail 15new studies on family interventions to consider issuesaround the implementation of family interventions incurrent practice. The data supporting the efficacy offamily psychoeducation remain compelling. Such pro-grams should remain as part of best practices guide-lines and treatment recommendations. However,assessment of the appropriateness of family psycho-education for a particular patient and family shouldconsider (1) the interest of the family and patient; (2)the extent and quality of family and patient involve-ment; (3) the presence of patient outcomes that clini-cians, family members, and patients can identify asgoals; and (4) whether the patient and family wouldchoose family psychoeducation instead of alternativesavailable in the agency to achieve outcomes identified.

Keywords: Efficacy, family, family support, psy-choeducation, schizophrenia.

Schizophrenia Bulletin, 26(l):5-20, 2000.

Families of people with schizophrenia often provide con-siderable support to their ill relatives and experience con-siderable burdens (and some benefits) as a result (Leff1994; Cochrane et al. 1997). Many people with schizo-phrenia rely on relatives for emotional support, instru-mental and financial assistance, housing, and advocacy.Therefore, the quality of their relationships greatly influ-ences family and client well-being and outcomes.

Psychosocial interventions for the families of personswith schizophrenia have been developed by mental healthproviders to offer information and support to optimizethese outcomes. The rigor of randomized controlled trialsof family psychoeducation and the consistency of their

findings have formed the rationale for including familyservices in all current best practices treatment guidelinesfor persons with schizophrenia (Dixon 1999).

Among these, the treatment recommendations devel-oped by the Schizophrenia Patient Outcomes ResearchTeam (PORT) strongly endorsed the value of family psy-choeducation (Lehman et al. 1998a). The supporting evi-dence for the following PORT recommendations was out-lined in a review of family psychoeducation prepared byPORT investigators (Dixon and Lehman 1995). These rec-ommendations include the following:

1. Patients who have ongoing contact with their familiesshould be offered a family psychosocial intervention thatspans at least 9 months and provides a combination ofeducation about illness, family support, crisis intervention,and problem-solving skills training. Such interventionsshould also be offered to nonfamily caregivers. (Lehmanetal. 1998a, p. 8)

2. Family interventions should not be restricted topatients whose families are identified as having high lev-els of "expressed emotion" (criticism, hostility, over-involvement). (Lehman et al. 1998a, p. 8)

3. Family therapies based on the premise that familydysfunction is the etiology of the patient's schizo-phrenic disorder should not be used. (Lehman et al.1998a, p. 8)

In spite of the PORT'S endorsement of family psy-choeducation, many questions remain unanswered. Towhat extent is family psychoeducation effective underusual practice conditions rather than just controlledresearch conditions? Who benefits most from family psy-choeducation? Are there contraindications? This reviewwill extend the original PORT appraisal, emphasizingstudies published in the last 3-4 years. Because this recent

Reprint requests should be sent to Dr. L. Dixon, Dept. of Psychiatry,University of Maryland, 701 W. Pratt St., Rm. 476, Baltimore, MD21201.

Schizophrenia Bulletin, Vol. 26, No. 1, 2000 L. Dixon et al.

research has also revealed the negligible extent to whichthese models have been implemented in actual practice,we will also summarize current knowledge about imple-mentation and the other models that have arisen to addressthe unmet needs of families in the real world. We will con-clude with a set of tentative observations or hypothesesabout the role of family members in treatment planning.

Efficacy of Family Psychoeducation

Psychoeducation interventions offered to family membersof people with schizophrenia have been developed withincreasing sophistication over the past 20 years. Althoughthe specific elements and construction of the various pro-grams differ, successful programs share several character-istics: (1) they regard schizophrenia as an illness; (2) theyare professionally created and led; (3) they are offered aspart of an overall treatment package that includes medica-tion; (4) they enlist family members as therapeutic agents,not "patients"; (5) they focus on patient outcomes,although family outcomes are important; and (6) they donot include traditional family therapies which presumethat behavior and communication within the family play akey etiological role in the development of schizophrenia.Family psychoeducation programs offer varying combina-tions of information about mental illness, practical andemotional support, skill development in problem solving,and crisis management. They may be conducted with indi-vidual families or multifamily groups and may take placein the home, in clinical settings, or in other locations.They also vary in length, timing with regard to phase ofillness, and whether or not the person with schizophreniais included in the family intervention.

The construct of "expressed emotion" (EE) has beenimportant to the development of family psychoeducationinterventions. Literature suggests that people with schizo-phrenia living with family members who exhibit high lev-els of EE (critical comments, hostility, and overinvolve-ment) are more likely to relapse (Koenigsberg and Handley1986; Scazufca and Kuipers 1998). This association may belinked to the difficulty persons with schizophrenia have inprocessing complex emotions and in sustaining attention inemotionally charged environments. The concept itself hasbeen criticized, and family members have expressed expe-riencing the EE literature as a resurrection of the family-blaming theories of the 1950s (Lefley 1992). Nonetheless,it is important to note that expressed emotion theory under-lies many professionally created family psychoeducationprograms. Many of these specifically target only "high EE"families.

The extensive 1995 schizophrenia PORT review ofrandomized clinical trials, in concert with other reviews

of family psychoeducation, concluded that "there is a con-sistent and robust effect of family interventions in delay-ing, if not preventing, relapse" (Dixon and Lehman 1995,p. 639). The relapse effect tended to vary according to thelength and content of the programs. Other outcomes weresupported by more modest evidence in the studies avail-able when the PORT review was conducted: family psy-choeducation may improve the patient's functioning—either directly or through fostering skill development—bydelaying disruptive relapses (Falloon et al. 1982; Falloonand Pederson 1985; Tarrier et al. 1988, 1989). The cost offamily psychoeducation can be offset by reductions inhospitalization and other service use (McFarlane et al.1995). The work of Falloon and of Zastowny et al. (1992)also indicated possible benefits of such programs to fam-ily well-being. The review also concluded that brief edu-cation alone shows inferior results compared to interven-tions that also incorporate engagement, support, andskill-building components.

Literature Update

Recent articles pertaining to family psychoeducation werelocated with a Medline search using the keywords "familyand schizophrenia and (interventions or education)." Thesearch encompassed articles published between 1994 and1998 and identified 103 articles. After screening out thosethat did not have schizophrenia and family intervention astheir primary focus, the subset of these articles thatreported randomized controlled trials or other rigorousevaluations of family psychoeducation interventions (n =16) are reported below (table 1). These studies do notmerely attempt to replicate an already strong empiricaldata base supporting family psychoeducation. Rather, theybuild upon this previous work in a variety of ways:Family psychoeducation is tested with participants from awider range of cultural groups than previously, and withthe relatives of recent-onset patients as opposed to solelythose of "chronic" patients. Family psychoeducation iscompared with more sophisticated individual therapymodels than previously available. Also, the recent studiesfocus on a wider range of outcomes, compare differentfamily intervention strategies, and have more extendedfollowup than previous studies.

Studies Conducted With Relatives From a Variety ofCultural Groups. Mingyuan et al. 1993 studied 3,092patients diagnosed with schizophrenia and their familymembers from five cities in China: 2,076 were assignedthe group psychoeducation condition; 1,016 were as-signed to routine services and were controls. The inter-vention was provided in the context of primary-care-

Tab

le 1

. S

um

mar

y of

co

ntr

olle

d f

amily

in

terv

enti

on

tri

als

3 c

Stu

dy

Par

tici

pan

tsIn

terv

enti

on

Co

ntr

ol

con

dit

ion

Res

ult

s

Stu

die

s co

nd

uct

ed w

ith

rel

ativ

es f

rom

a v

arie

ty o

f cu

ltu

ral

gro

up

s

Min

gyua

n et

al.

1993

Xio

ng e

t al.

1994

Xia

ng e

t al.

1994

Zha

ng e

t al.

1994

Tel

les

et a

l.19

95

3,09

2 pe

ople

with

schi

zoph

reni

a an

d th

eir

fam

ilies

; 5 c

ities

in C

hina

,ra

ndom

ly a

ssig

ned

63 p

eopl

e w

ith s

chiz

ophr

enia

and

coha

bitin

g fa

mily

in u

rban

Chi

na,

rand

omly

ass

igne

d

69 p

eopl

e w

ith s

chiz

ophr

enia

+ 8

peo

ple

with

affe

ctiv

eps

ycho

ses

and

fam

ily i

n 3

rura

l com

mun

ities

in

Chi

na,

rand

omly

ass

igne

d

Rel

ativ

es a

nd 7

8 m

en w

ithsc

hizo

phre

nia

afte

r fir

stho

spita

lizat

ion

in u

rban

Chi

na,

rand

omly

ass

igne

d

42 S

pani

sh-s

peak

ing

peop

lew

ith s

chiz

ophr

enia

and

fam

ilies

, ver

y lo

w in

com

e,9

0%

new

imm

igra

nts

toLo

s A

ngel

es,

rand

omly

assi

gned

Gro

up p

sych

oedu

catio

n: 1

0le

ctur

es a

nd 3

gro

updi

scus

sion

s, o

ver

12 m

os +

usua

l se

rvic

es

Pat

ient

and

fam

ily e

duca

tion,

incl

udin

g 2

-3 m

onth

lym

eetin

gs w

ith c

linic

ian,

then

+m

ultif

amily

gro

up,

hom

e vi

sits

,ta

perin

g of

f at

12

mos

as

patie

nt s

tabi

lizes

Wor

ksho

ps,

hom

e vi

sits

,di

scus

sion

s, p

ublic

info

rmat

ion,

mix

ed g

roup

, an

dsi

ngle

fam

ily o

ver

4 m

os +

med

icat

ion

mon

itorin

g

Fam

ily g

roup

and

ind

ivid

ual

fam

ily c

ouns

elin

g m

onth

lyov

er 1

8 m

os; f

amili

es w

ithsi

mila

r pr

oble

ms

grou

ped

toge

ther

+ u

sual

ser

vice

s

1 yr

Fal

loon

's B

FM

(a

very

stru

ctur

ed e

duca

tion,

com

mun

icat

ion

skill

s, a

ndpr

oble

m-s

olvi

ng p

rogr

am,

incl

udin

g pa

tient

) +

sta

ndar

dca

se m

anag

emen

t

Usu

al s

ervi

ces

prov

ided

by

prim

ary

care

clin

ic

Usu

al s

ervi

ces

prov

ided

by

prim

ary

care

clin

ic

Med

icat

ion

and

mon

itorin

g on

ly

Usu

al s

ervi

ces

prov

ided

by

prim

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care

clin

ic

Sta

ndar

d ca

sem

anag

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t

Sig

nific

antly

bet

ter

outc

omes

for

rel

apse

,sy

mpt

oms,

fun

ctio

nal

stat

us,

trea

tmen

tco

mpl

ianc

e

Few

er a

nd s

hort

erre

laps

es,

mor

eem

ploy

men

t at

12

and

18 m

os,

rela

tives

repo

rt s

igni

fican

tly l

ess

burd

en, l

ess

expe

nsiv

e

Sig

nific

antly

im

prov

edm

enta

l sta

tus,

wor

kfu

nctio

n, t

reat

men

tco

mpl

ianc

e, a

ndre

duce

d di

srup

tive

beha

vior

; re

duce

dne

glec

t an

d ab

use

ofill

rel

ativ

e by

fam

ily

Sig

nific

antly

les

s lik

ely

to h

ave

been

hosp

italiz

ed,

stro

ngad

ditiv

e ef

fect

of

cons

iste

nt m

edic

atio

nus

e

Pat

ient

s w

ith l

owes

tac

cultu

ratio

n sc

ore

=m

ore

likel

y re

laps

e(w

ith B

FM

); n

oin

crea

sed

risk

for

patie

nts

with

"hi

gher

"ac

cultu

ratio

n sc

ores

(all

wer

e qu

ite lo

w)

f CD £ p 8 o

Tabl

e 1

. S

um

mar

y of

co

ntr

olle

d f

amily

in

terv

enti

on

tri

als—

Co

nti

nu

ed

Stu

dy

Stu

die

s in

volv

ing

i

Lins

zen

et a

l.19

96

Nug

ter

et a

l.19

97

Run

d et

al.

1994

Par

tici

pan

ts

rela

tives

of

new

-on

set

pat

ien

ts

76 a

dole

scen

ts w

ith r

ecen

t-on

set

schi

zoph

reni

a fr

omac

ross

the

Net

herla

nds

and

fam

ilies

, ra

ndom

ly a

ssig

ned

52 p

eopl

e w

ith r

ecen

t-on

set

schi

zoph

reni

a an

d fa

mili

es in

the

Net

herla

nds,

ran

dom

lyas

sign

ed

24 a

dole

scen

ts w

ithsc

hizo

phre

nia

and

fam

ilies

inN

orw

ay;

12 in

terv

entio

n, 1

2m

atch

ed (

not

rand

om)

cont

rol

Inte

rven

tio

n

Beh

avio

ral f

amily

int

erve

ntio

n=

fam

ily m

eetin

gs w

ithcl

inic

ian

+ fa

mily

edu

catio

nm

eetin

gs d

urin

g in

dex

hosp

italiz

atio

n +

biw

eekl

y to

mon

thly

ind

ivid

ual

illne

ssm

anag

emen

t se

ssio

ns f

orpa

tient

s ov

er 1

yr

18 fa

mily

ses

sion

s ov

er 1

2m

os u

sing

Fal

loon

's b

ehav

iora

lfa

mily

mod

el +

2 fa

mily

educ

atio

n se

ssio

ns w

hile

patie

nt h

ospi

taliz

ed +

usu

alou

tpat

ient

car

e

3-ph

ase

fam

ily t

reat

men

t:en

gage

men

t, pr

oble

m s

olvi

ng,

mai

nten

ance

, ov

er 2

yrs

+us

ual c

are

Co

ntr

ol

con

dit

ion

Sam

e fa

mily

educ

atio

nm

eetin

gsdu

ring

inde

xho

spita

lizat

ion

+sa

me

indi

vidu

alill

ness

man

agem

ent

sess

ions

2 fa

mily

educ

atio

nse

ssio

ns w

hile

patie

ntho

spita

lized

+us

ual o

utpa

tient

care

Usu

al s

ervi

ces

prov

ided

by

inpa

tient

and

outp

atie

ntfa

cilit

ies

Co

mp

aris

on

of

fam

ily p

sych

oed

uca

tio

n w

ith

in

div

idu

al t

her

apy

dev

elo

ped

for

sch

izo

ph

ren

ia

Hog

arty

et a

l.19

9715

1 pe

ople

with

sch

izop

hren

iaan

d fa

mili

es in

Pitt

sbur

gh, P

A,

acro

ss 4

con

ditio

ns i

n 2

rand

omiz

ed t

rials

1. P

erso

nal

rela

pse

prev

entio

n th

erap

y2.

Fam

ily p

sych

oedu

catio

n3.

Per

sona

l re

laps

epr

even

tion

+ fa

mily

psyc

hoed

ucat

ion

Stu

die

s te

stin

g l

ess

inte

nsi

ve o

r b

rief

er f

amily

ed

uca

tio

n m

od

els

Sch

oole

r et

al.

1997

313

peop

le w

ith s

chiz

ophr

enia

or s

chiz

oaffe

ctiv

e di

sord

er a

ndfa

mili

es f

rom

5 s

ites

acro

ss

Med

icat

ion

cond

ition

s(c

ross

ed w

ith f

amily

cond

ition

s):

Gen

eral

supp

ortiv

eth

erap

y

Fam

ilyco

nditi

ons:

1. G

roup

fam

ily

Res

ult

s

Low

sym

ptom

s an

dho

spita

lizat

ion

in b

oth

grou

ps c

ompa

red

with

usua

l rat

es, b

ut in

inte

rven

tion

cond

ition

,pa

tient

s fr

om "

low

EE

"fa

mili

es h

ad s

light

lyhi

gher

rel

apse

rat

e

No

diffe

renc

ebe

twee

n co

nditi

ons

for

fam

ily E

Ele

vels

or

patie

ntre

laps

e

Sig

nific

antly

low

er n

umbe

rof

pat

ient

s w

ith 2

rela

pses

in fa

mily

trea

tmen

t;le

ss e

xpen

sive

No

posi

tive,

sig

nific

ant

effe

cts

for

fam

ilyps

ycho

educ

atio

nco

mpa

red

with

#1

or #

3

Low

rel

apse

acr

oss

both

fam

ily c

ondi

tions

,co

mpa

rabl

e to

oth

er

1 S' to illeti, 26, o 8 r D S3'

o

Tab

le 1

. S

um

mar

y of

co

ntr

olle

d f

amily

in

terv

enti

on

tri

als—

Co

nti

nu

ed

Co

ntr

ol

Stu

dy

Par

tici

pan

tsIn

terv

enti

on

Mod

erat

e do

seLo

w d

ose

Tar

gete

d ea

rly i

n sy

mpt

omex

acer

batio

n

6 in

divi

dual

wee

kly

in-h

ome

coun

selin

g se

ssio

ns w

/o p

atie

ntfo

cusi

ng o

n sc

hizo

phre

nia

educ

atio

n an

d pr

oble

m s

olvi

ng

6-1

5 hr

s in

divi

dual

ized

cons

ulta

tion

over

3 m

os10

2-h

r w

eekl

y m

ultif

amily

grou

p ps

ycho

educ

atio

nal

mee

tings

Bot

h in

clud

ed u

sual

ser

vice

s.

Ong

oing

mul

tifam

ilyps

ycho

educ

atio

n gr

oups

+A

CT

, ove

r 2

yrs

FA

CT

incl

udin

g m

ultif

amily

psyc

hoed

ucat

ion,

ove

r 18

mos

con

dit

ion

psyc

ho-

educ

atio

nm

onth

ly2.

#1

+ m

onth

lyho

me

visi

ts f

orco

mm

unic

atio

n,pr

oble

m s

olvi

ng(n

ot c

ontr

ol)

Sin

gle

2-hr

info

rmat

iona

lpr

esen

tatio

nab

out

schi

zoph

reni

a

Wai

t lis

t,us

ual

serv

ices

Inte

rmitt

ent,

cris

is-o

nly

fam

ilyin

terv

entio

n +

AC

T

Con

vent

iona

lvo

catio

nal

reha

bilit

atio

n

Res

ult

s

fam

ily i

nter

vent

ion

stud

ies;

mod

erat

em

edic

atio

n do

se g

ave

best

res

ults

, ac

ross

fam

ily b

oth

cond

ition

s;no

sig

nific

ant

inte

ract

ions

Sig

nific

ant

repo

rted

impr

ovem

ent

inre

latio

nshi

p an

dun

ders

tand

ing;

no

effe

cts

show

n fo

rbe

tter

care

givi

ng o

rre

duce

d bu

rden

No

diffe

renc

e ac

ross

cond

ition

s fo

r ex

tent

of

fam

ily c

onta

ct w

ithm

enta

l hea

lth s

taff;

som

e si

gnifi

cant

incr

ease

of

fam

ilym

embe

r se

lf-ef

ficac

yre

ill r

elat

ive

Low

sym

ptom

s an

dho

spita

lizat

ion

in b

oth

grou

ps c

ompa

red

with

usua

l rat

es, b

ut n

odi

ffere

nces

bet

wee

nco

nditi

ons;

ong

oing

inte

rven

tion

grou

p ha

dbe

tter

empl

oym

ent

outc

omes

FAC

T c

ondi

tion

show

edsi

gnifi

cant

ly m

ore

com

petit

ive

jobs

and

Psy o I a 8 o" s 1 dO2 1 S'

Co lleti 3 £ to p\

o to o

Szm

ukle

r et

al.

1996

Sol

omon

et a

l.19

96,

1998

McF

arla

ne e

tal

. 199

6

McF

arla

ne e

tal

., su

bmitt

ed

the

U.S

., ra

ndom

ly a

ssig

ned

to a

3x2

des

ign;

3 m

edic

atio

nco

nditi

ons

and

2 fa

mily

cond

ition

s

"Prin

cipa

l car

egiv

er"

of 6

3pe

ople

with

sch

izop

hren

ia in

Vic

toria

, Aus

tral

ia,

rand

omly

assi

gned

183

rela

tives

of

peop

le w

ithsc

hizo

phre

nia

on th

e U

.S.

east

coa

st,

rand

omly

ass

igne

dto

3 c

ondi

tions

68 p

eopl

e w

ith s

chiz

ophr

enia

rece

ivin

g A

CT

and

fam

ilies

inM

aine

, ra

ndom

ly a

ssig

ned

69 u

nem

ploy

ed p

eopl

e w

ithm

ajor

psy

chia

tric

dis

orde

rre

ceiv

ing

AC

T a

nd fa

mili

es in


3

O

I

tria

lio

n

CD

I•2.

2ouo

CO

EE

Tabl

e 1.

Its

i

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based mental health services. It consisted of ten standard-ized lectures and three discussions presented by psychia-trists in each community over the 12-month length of theprogram. Those in the intervention group fared signifi-cantly better than controls on a number of measuresincluding relapse rate, positive and negative symptoms,functional disability, ability to work, and treatment com-pliance. Families experienced reduced burden and hadincreased knowledge.

Xiong et al. (1994) randomized 63 people with schiz-ophrenia living with family in urban China to treatment asusual (control) or culturally specific family education thatincluded the patient. In the intervention, biweekly meet-ings in the first 2-3 months provided families with infor-mation on schizophrenia and established a relationshipbetween family and clinician. Phase 2 then involvedmonthly single-family meetings with the clinician, multi-family group sessions, home visits, and extended familyoutreach, all emphasizing problem-solving skills and ill-ness management. After the patient's functioning and thefamily's coping strategies improved, the program movedinto "maintenance" phase—attendance at monthly multi-family groups and briefer quarterly clinician meetings. At12 and 18 months, patients in the intervention group hadexperienced significantly fewer and shorter hospitaliza-tions, less social dysfunction, and longer employmenttenure. Their family members reported significantly lowerlevels of burden than control families, and the interven-tion was less costly than standard treatment.

Xiang et al. (1994) conducted a 4-month family inter-vention in which 69 people with schizophrenia and 8 withaffective psychoses in three rural communities in Chinawere randomly divided into two conditions: family inter-vention plus drug treatment (intervention), and drug treat-ment only (control). The family intervention consisted ofperiodic workshops, family visits, discussions betweenhealth workers and family, local public informationalbroadcasts, and monthly supervision sessions for the facil-itating doctors. The intervention group showed significantpositive changes not found among the control groupincluding enhanced treatment compliance; lessenedneglect and abuse of the ill relative; and improved mentalstatus, improved work functioning, and decreased disrup-tive behavior on the part of the ill relative.

Zhang et al. (1994) compared hospitalization ratesbetween 39 first admission men with schizophrenia ran-domly assigned to a family intervention involving groupand individual counseling sessions every 1-3 months and39 similar patients randomly assigned to usual treatmentin urban China. During the intervention, families facingsimilar issues were grouped together; home visits wereoccasionally used for families not attending the groupmeetings. After 18 months, patients in the intervention

10

Family Psychoeducation Schizophrenia Bulletin, Vol. 26, No. 1, 2000

group were significantly less likely to have been hospital-ized than controls. Regular medication use had significantindependent and additive effects on outcome, so that peo-ple in the intervention group who also took medicationregularly were 7.9 times less likely to be hospitalized overthe duration of the study than controls who did not.

Telles et al. (1995) compared the effectiveness andcross-cultural applicability of behavioral family manage-ment (BFM) and standard case management (CM) in pre-venting exacerbation of symptoms and relapse among 40low-income Spanish-speaking people diagnosed withschizophrenia, in Los Angeles, CA. Most participantswere first generation immigrants. Patients were randomlyassigned to the two conditions. BFM is a highly structuredprogram comprising education about schizophrenia, com-munication skills, and problem-solving training. Its struc-ture was not modified, although the sociocultural contextwas taken into account as this sample was different fromthose usually presented with BFM. For the total sample,BFM did not differ from CM in any outcomes. Amongpatients and families least assimilated to U.S. culture,BFM was significantly related to greater risk of symptomexacerbation. Among slightly more acculturated patientsand families there was no effect across family treatmentconditions. The authors emphasize the important influenceof sociocultural factors in the effectiveness of variousinterventions.

Studies Involving Relatives of New-Onset Patients.Linszen et al. (1996) studied relapse among 76 young(15—26 years old) persons with recent-onset schizophreniain the Netherlands. Subjects were randomized into twogroups: individual psychosocial program (IPI, controlgroup), or IPI plus a behavioral family intervention (IPFI,intervention group). During hospitalization, all familymembers attended three to four educational sessions.Groups were randomized at discharge and stratified bylevel of expressed emotion, after which patients in bothgroups met biweekly for 5 months, then monthly for 7months, with clinicians in illness management sessions atthe clinic (IPI). Family members of people assigned to theIPFI group also met with clinicians, following a similarschedule and a curriculum modeled on Falloon's BFM(psychoeducation, communications training, and problem-solving skills training). Twelve months after discharge,relapse rates were very low for both treatment groups.The overall relapse rate during the outpatient interventionwas 16 percent. There was no positive effect from theaddition of the family intervention. In the IPFI group,patients from "low EE" families relapsed slightly moreoften to a near significant extent. The authors speculatethis may reflect the BFM program adding stress to suchfamilies by focusing on (unneeded, for them) communica-

tions training rather than (needed) emotional support.Nugter et al. (1997) studied 52 individuals with

recent-onset schizophrenic disorders and their families inthe Netherlands. The same research group performed thisstudy and the study by Linszen et al. (1996) already dis-cussed. During hospitalization all patients received usualcare, and all families were offered two psychoeducationalmeetings. At discharge they were randomly assigned toindividual outpatient treatment (IT) or IT plus familytreatment. The outpatient family treatment consisted of 18sessions over 12 months of clinic-based BFM (Falloonand Pederson 1985), focusing on education and communi-cations and problem-solving skills training. The overallrelapse rates were again low, ranging from 21 percent to23 percent depending on criteria used. The addition offamily psychoeducation to the IT did not affect family EElevels or patient relapse rates. The authors surmised thatthe BFM family treatment does not meet the needs offamilies of new-onset patients, as they may believe thatthe illness will not recur.

Rund et al. (1994) provided families of 12 Norwegianadolescents (aged 13-18) diagnosed with early-onsetschizophrenia spectrum disorders (9 with schizophrenia)with a three-part family intervention. The interventionbegan while the patient was hospitalized and lasted 2-3years. During the inpatient phase, the families receivedbimonthly family sessions using a structured curriculum,and a day-long informational seminar about mental ill-ness. After discharge, they received monthly family ses-sions in the home and one or more additional day-longseminars. When the patient was stabilized, family sessionswere dropped back to every other month and were aug-mented by phone support as needed. Outcomes were com-pared with those for a matched (not random) comparisongroup of adolescent patients with schizophrenia. Theauthors found no differences between the two conditionsin the number of patients who had one relapse over 2years; however, only 8.3 percent of the intervention grouppatients relapsed twice over the 2-year interval comparedwith 58 percent of the control group. Psychosocial func-tioning was nearly significantly better in the experimentalcondition. The family condition was less expensive thantreatment as usual because of nonsignificantly lower totalweeks of hospitalization in the family treatment group.

Comparison of Family Psychoeducation With IndividualTherapy Developed for Schizophrenia. Hogarty et al.(1997) compared four manualized treatment conditions: per-sonal relapse-prevention therapy, family psychoeducation,personal relapse-prevention therapy plus family psychoedu-cation, and general supportive therapy in a total of 97 peoplediagnosed with schizophrenia who lived with their families.The therapies were delivered for 3 years postdischarge in

11


Pittsburgh, PA, at the Western Psychiatric Institute andClinic. Personal therapy was developed specifically for per-sons with schizophrenia. It was "designed to forestall thelate (second-year) relapse common among modern psy-chosocial approaches...and to enhance personal and socialadjustment through the identification and effective manage-ment of affect dysregulation that was believed to either pre-cede a psychotic relapse or provoke inappropriate behaviorthat was possibly generated by underlying neuropsychologi-cal deficits" (Hogarty et al. 1997, p. 1506). The family ther-apy condition was similar to that previously evaluated byHogarty et al. (1986). This study included 29 (27%) new-onset patients and families with both high and low levels ofEE. The overall relapse rate in this study was very low, withonly 44 (29%) patients having a psychotic relapse over 3years. Only 24 (16%) patients experienced a nonpsychoticaffective relapse over 3 years. The study found no signifi-cant effects of personal therapy or family therapy in fore-stalling relapse, although personal therapy was nearly sig-nificantly superior in preventing psychotic relapse. Theauthors note that the remarkable survivorship of personscompleting the study in the supportive therapy conditionmay account for the lack of personal therapy or family treat-ment effects. One-third of the supportive therapy patientshad treatment-related terminations; supportive therapypatients who continued in the study had a 76 percent sur-vivorship at 1 year, and 72 percent at 2 years. Authors alsonote that the supportive therapy condition in this study wasvery comprehensive and benefited from years of acquiredknowledge in conducting research in schizophrenia at theWestern Psychiatric Institute and Clinic.

Studies Testing Less Intensive or Briefer FamilyEducation Models. Schooler et al. (1997) randomized313 people with schizophrenia or schizoaffective disor-der from five sites across the United States into one ofthree medication conditions (continuous moderate dose,continuous low dose, or targeted early intervention onlyduring symptom exacerbation) and one of two familytreatment strategies (supportive family management[SFM], or applied family management [AFM]). AFMwas modeled on the behavioral family management pro-gram created by Ian Falloon. Over 2 years, SFM familiesattended monthly group meetings in which educationand support were provided, while AFM families did thesame and received monthly home visits focusing oncommunication and problem-solving skills. Both familyconditions also had access to crisis intervention servicesfrom the research teams. There were no relapse differ-ences across the family treatment strategies, althoughhospitalization rates under both conditions were similarto those reported in family treatment literature and lowerthan those for usual (no family intervention) treatment

(25% over a 2-year period). The authors attribute thelack of difference to the high level of engagementattained in both conditions and to the enhanced staff andservices availability built into the research protocol(compared with usual services).

Szmukler et al. (1996) randomly assigned the "princi-pal caregiver" of 63 people with schizophrenia admittedto a psychiatric hospital in Victoria, Australia, to a single1-hour informational presentation about schizophrenia(control) or to six counseling sessions (one per week) ofeducation and assistance in problem solving. These ses-sions were conducted at home without the patient.Participants in the counseling sessions reported significantimprovement in understanding their ill relative and havinga more positive relationship at 3 and 6 months postinter-vention. However, there were no group differences onreports of the negative aspects of caregiving or in copingstyle.

Solomon et al. (1996) randomly assigned 183 familymembers of people with schizophrenia from a large eastcoast U.S. city to one of three conditions: (1) 6-15 hoursof individualized consultation, (2) ten 2-hour weekly fam-ily psychoeducation group meetings, or (3) a 9-monthwait-list control. Postintervention measures found that theconsultation model increased participants' sense of self-efficacy regarding their ill relative(s) and that the psy-choeducation group meetings had the same effect for rela-tives who had never before participated in a support oradvocacy group for family members. There were no dif-ferences among conditions in the extent of family contactwith mental health professionals (Solomon et al. 1998).The authors also speculated that other benefits wouldlikely develop as family members used and practiced newskills.

McFarlane et al. (1996) examined outcome differencesfor 68 people with schizophrenia receiving assertive com-munity treatment in Maine depending on whether their fam-ilies were involved in family intervention only during crises(crisis family intervention) or more consistently and inten-sively in ongoing multifamily psychoeducation groups(ongoing family intervention). Participants were randomlyassigned between groups and followed for 2 years. Patientsin both conditions experienced hospitalization and symptomseverity levels lower than expected with usual treatment.These did not significantly differ between the different fam-ily conditions. However, patients in the ongoing familyintervention group had near-significant mean employmentrates for the 2-year period (32% vs. 19%). During the periodfrom 4 to 20 months, the ongoing family interaction grouphad significantly higher employment rates. Authors specu-lated that enhanced employment is tied to reduced familystress, enabling the identified patient to better tolerate workstress.

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McFarlane et al. (submitted) continued their exami-nation of the combination of family psychoeducation andassertive community treatment on vocational outcomes.They compared the outcomes of 69 unemployed personswith a major psychiatric disorder (65% schizophreniaspectrum) randomly assigned to family-aided assertivecommunity treatment (FACT) or to conventional voca-tional rehabilitation. Subjects were followed for 18months. The study was conducted in an urban suburb ofNew York City and in a more rural area of New YorkState. The family condition consisted of multifamily psy-choeducational groups as implemented in several otherstudies conducted by McFarlane, but embedded within anassertive community treatment team. Results indicate thatFACT subjects had significantly more competitive jobsand more total earnings. For the schizophrenia subsample,there was significant treatment by time interactions fornegative symptoms and general psychopathology favoringFACT. There were no differences between conditions forhospitalization. In this study, it is difficult to assess thedifferential impact of the assertive community treatmentand the multifamily groups.

A Long Followup of an Original Family Psychoedu-cation Study. Tarrier et al. 1994 studied the effect onrelapse of patients' relatives participating in psychoeduca-tion as followup to a larger British study. They traced 40people with schizophrenia who had not relapsed during 2years after a randomized control trial of behavioral familyintervention aimed at reducing EE and relapse risk. Thosewho had been in the 9-month family intervention condi-tion showed significantly fewer relapses at 5 and 8 yearsthan the "high EE" control group, and had profiles muchmore similar to the "low EE" control group. The authorsinterpret this as suggesting the intervention moved "highEE" families to "low EE" status.

Analysis and Synthesis

How do these studies inform the recommended services tofamilies of persons with schizophrenia? Taken as a group,these more recent studies confirm the potential advantagesand benefits of services to families and family psychoedu-cation identified by the PORT and other reviews(Goldstein 1994; Leff 1994; Penn and Mueser 1996).However, they raise important caveats as outlined below.

What Is the Control or Comparison Condition? Thefour studies from China show a dramatic impact of familypsychoeducation in reducing relapse and improving otheroutcomes. In contrast, family psychoeducation confers nobenefit in relapse reduction in the two Dutch studies or in

the 1997 study by Hogarty and colleagues of personaltherapy in Pittsburgh. While these groups of studies differin a variety of ways, one of the important differences isthe nature of the comparison conditions. In the Dutch andPittsburgh studies, family psychoeducation was comparedto highly developed individual treatment models. Relapserates were low for all groups. In China, the comparisonconditions were bare bones individual services. Thus,individual therapy is not static but is itself changing andgrowing with research and changes in service systemssuch as managed care. The studies by McFarlane and col-leagues were implemented within assertive communitytreatment teams, another type of service model thatreduced relapse rates dramatically. The addition of multi-ple family groups did not reduce relapse but did improveemployment outcomes. The point is that in predicting theadded value of family psychoeducation for relapse reduc-tion, it is important to consider the nature of the standardor comparison treatment. Enriched individual models orother innovative programs may be as effective as familypsychoeducation for relapse reduction, especially in thecontext of improved medications. On the other hand, fam-ily psychoeducation is likely to show added benefit interms of relapse reduction in settings with basic, unen-riched services such as those common in the public sectorduring this era of cost containment.

What Are the Goals of Family Interventions? Therecovery paradigm for consumers and families has under-lined the importance of looking beyond relapse whenassessing program efficacy: Client and family functioningand quality of life must also be considered. The Chinesestudies confirm the role of family psychoeducation inreducing patient functional disability and improvingemployment. They also suggest that the well-being offamilies improves with reduced burden and increasedknowledge. McFarlane's work yields compelling data onthe potential of multifamily groups to increase employ-ment. The enhanced self-efficacy obtained in Solomon etal.'s study of family consultation and the family educationprogram and the improvements in client-family relation-ships in the study by Szmukler et al. should not be dis-missed. Unfortunately, even when they are measured,nonrelapse outcomes are usually secondarily reported.

Is There an Optima! or Best Type of FamilyIntervention? A Critical Ingredient? The schizophreniaPORT recommendations specified that family interven-tions should be at least 9 months long. Indeed, Szmukleret al. and Solomon et al. both comment on interventionbrevity (6 weeks and 3 months, respectively) as possibleexplanations for the limited impact of interventions theystudied. However, the intervention reported in Xiang et al.was only 4 months long, with positive effect. The tension

13


between the increased feasibility and possibly reducedefficacy of a shorter intervention program demands fur-ther research. The optimal intervention length maydepend on program goals. Family programs intending toreduce patient relapse and improve patients' functionalstatus must be at least 9 months, if not longer. Shorterprograms may influence knowledge, attitudes, and thequality of relationships. Interestingly, the followup studyby Tarrier et al. showed reduced hospitalization at 5 and 8years after an only 9-month intervention, a testament tothe durability of changes produced by the program.

The comparison between applied and supportive fam-ily management as investigated in the TreatmentStrategies in Schizophrenia study (Schooler et al. 1997) isprovocative. Both family interventions were equallyeffective for the reported outcomes. That is, the additionalproblem-solving techniques taught in the applied programdid not add to the capacity of the model to reduce relapse.(There has also been some debate as to whether the familymembers actually acquired the skills taught in the appliedcondition [Liberman and Mintz 1998]). However, it iscritical to recognize that all the families in both modelsreceived extensive education, information, and support.Compared with studies of patients whose relativesreceived no family program, all families in Schooler etal. 's study appeared to derive benefit. It is also interestingto note that in the two Dutch studies, families in both thefamily treatment and the comparison conditions partici-pated in educational groups during the inpatient phase.The extent to which families benefited from participatingin this component of the program is unknown. More workis clearly necessary to delineate the critical components offamily psychoeducation programs.

For Whom Does Family Psychoeducation Work Best?The notion that one family program would meet the needsof all families and patients is counterintuitive. Phase ofillness, family and patient life cycle stages, and culturalbackground are among the many participant factors thatmay influence the effectiveness of a given family pro-gram. Rund et al. (1994) found that the most symptomaticpatients benefited most from the family intervention. Fourstudies (Rund et al. 1994; Zhang et al. 1994; Linszen et al.1996; Nugter et al. 1997) focused on patients early in thecourse of schizophrenia. In two of these studies, relapsewas reduced for clients in families that received the inter-vention. It is therefore difficult to draw conclusions aboutthe differential merits of family psychoeducation for per-sons and families in early versus later phase of illness. Atthe very least, the qualitative nature of the interventionshould be tailored somewhat for new-onset versus morechronic diagnoses. The reactions of "first break" familieswere noted to differ from families that have been dealing

with the illness and an ill relative for a longer period oftime (Linszen et al. 1996; Nugter et al. 1997; Solomon etal. 1996).

While none of the new studies reported here wasrestricted to families classified as being high in expressedemotion, Linszen et al. (1996) did stratify patients by lev-els of EE (low vs. high) before condition assignment.Nugter et al. (1997) measured expressed emotion andreported the relationship between patient outcome andchange in EE ratings. Linszen et al. (1996) hypothesizedthat the near-significant increase in relapse observed inpatients of "low EE" families receiving the family inter-vention may be due to the fact that the family modelemphasizes communication and conflict skills training.They suggested that the intervention increased the stresslevels of these families by implying something was wrongwith their family interaction styles. While the data do notsupport offering family psychoeducation only to familieswho have first been assessed and classified as being highin expressed emotion, they do underscore the importanceof families examining their own needs and understandingthe goals and methods of a particular program' before join-ing it.

The work by Telles et al. (1995) addressed the issueof adapting family psychoeducation along cultural (inaddition to individual) lines. Their findings emphasizedhow differences in family "acculturation" influenced theefficacy of the behavioral family management model.However, the larger issue conveyed is that the programdid not meet the needs of certain families because of theircultural background, even though technical aspects suchas language were accommodated.

More positively, the Chinese programs spell outstrategies the authors used to create family programs thatfit with local practices and existing health care systems inrural and urban China (Mingyuan et al. 1993; Xiang et al.1994; Xiong et al. 1994; Zhang et al. 1994). Other work(Shankar 1994; Susser et al. 1996) has also suggested thatindividual as-needed consultation models may work betterin communities where mental health is less professional-ized, and so group psychoeducation or treatment pro-grams are less accepted.

Is Family Psychoeducation Effective as Part of UsualPractice? The first generation of research in family psy-choeducation established positive outcomes in rarefiedresearch settings with highly trained research staff andselected patients. However, truly effective interventionswork under usual practice conditions. The conduct ofresearch inevitably alters "usual practice" in a variety ofways, and the closer a study comes to approximatingusual practice, the less methodologically rigorous it tendsto be. Therefore, assessment of effectiveness requires

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some speculation. It appears that for the most part, thefamily interventions described in the studies reviewedhere were creations of research and did not resembleusual practice. However, several studies with positivefindings were carried out in clinical environments morerepresentative of usual care (e.g., the studies in China;Rund et al. 1994; McFarlane et al. 1996; Solomon et al.1996). A study of McFarlane's multifamily psychoeduca-tion group is currently being conducted in the State ofWashington by Dennis Dyck. This study modifiesMcFarlane's original study of this model by implementingthe program in an outpatient managed care setting at siteswith remote supervision and technical assistance. Theearly results from this study are promising (Dyck, per-sonal communication), although it is premature to drawany conclusions.

The Current Status of Implementation of FamilyInterventions. The fact that so many of the family inter-vention studies use "usual treatment" as their control con-dition points out that access to family services is not thenorm. The PORT study found that only 31 percent of asample of persons who had family contact and who werereceiving treatment for schizophrenia reported that theirfamily received information about the illness (Lehman etal. 1998a, 19986; Dixon et al. 1999a). Young et al. (1998)evaluated the quality of care for a cohort of persons withschizophrenia. They found that of the 68 percent ofpatients with close family contact, 39 percent receivedpoor quality care as measured by the absence of any fam-ily contact. Family contact between clinicians and familymembers that does occur is likely to be informal ratherthan a part of a specific treatment program or model(Dixon et al. 1999a).

Barriers to implementation of family psychoeducationcome from providers and payers, family members, and insome cases from consumers. Mental health professionalshave expressed concern about the cost and length of struc-tured family psychoeducation programs (9 months to 2years), the interest of families in such programs, and confi-dentiality (Dixon et al. 1997). A PORT-sponsored dissemi-nation of McFarlane's multifamily psychoeducation groupmodel found the following obstacles to implementation:lack of program leadership and conflict between the phi-losophy and principles of McFarlane's model and typicalagency practices. Wright (1997) found that job and organi-zational factors were much more predictive of the fre-quency of mental health professionals' involvement withfamilies than were professionals' attitudes. Bergmark(1994) noted the persistence of psychodynamic theory as abarrier in that some families perceive psychoeducationprograms as family blaming, thereby inhibiting collabora-tion between professionals and families.

The World Schizophrenia Fellowship StrategyDevelopment Group identified the following barriers toimplementation of family programs (World Schizo-phrenia Fellowship 1997): stigma against mental illness,psychoeducation treatments not seen as important, con-flicted relationships between consumers and caregivers,varying models of family intervention, inadequate train-ing of professional work force, costs, and structural prob-lems in many mental health systems.

Family advocates have also expressed concern aboutthe time commitment, the exclusion of families whose rela-tive is not currently receiving treatment, psychoeducation'sroots in EE theory, and the focus on patient relapse as theoutcome of interest rather than family well-being (Solomon1996). Consumers also sometimes do not provide permis-sion for providers to be in touch with family members.

What Has Filled the Gap? FamilyEducation by Families

Despite the positive effects of professionally led familypsychoeducation interventions that are documented byexisting research, relatives of people with schizophreniahave experienced a paucity of services. Involved familymembers often report dissatisfaction with the mentalhealth system and the professionals that compose it,especially around issues of information and supportavailability, access to clinicians, and inclusion in theirill relatives' treatment (Spaniol et al. 1987; Solomonand Marcenko 1992; Hatfield et al. 1994; Greenberg etal. 1995; Struening et al. 1995). Families have createdself-help groups and organizations to help fill thesegaps and advocate for system reform. In this country,the National Alliance for the Mentally 111 (NAMI) is thebest-known national group. Primarily, family membersattend self-help and support groups to receive emotionalsupport and accurate information about mental illnessand mental health services (Heller et al. 1997a; Helleretal. 1997 b).

In addition to ongoing support groups, The NAMI-sponsored Family-to-Family Education Program as wellas the Journey of Hope Program have enjoyed wide-spread support by State governments (Dixon et al.19996). These 12-week courses for family memberscombine information, skill building, and support—andso share many of the goals and strategies of family psy-choeducation. However, while psychoeducation tends tobe clinic based and delivered by mental health profes-sionals, family-to-family education is community ori-ented, based on theories of stress, coping, and adapta-tion, and is delivered by trained peer family members(Solomon 1996). It is also open to anyone with a family

15


member who has serious and persistent mental illness;unlike most professionally led programs, the personwith schizophrenia does not need to be receiving treat-ment in order for the family member to participate.These practices follow from the program's primary con-cern with family well-being, while professionally ledfamily psychoeducation tends to emphasize patient out-comes. Their shorter length and volunteer leadershipoften mean family-to-family programs are less expen-sive than psychoeducation as well. Unfortunately,research on family-to-family education is not as exten-sive as research on family psychoeducation (Dixon andLehman 1995). Since no evaluations using comparisonor control groups have been conducted, the efficacy ofthese programs cannot yet be evaluated.

The other alternative model of family interventionthat has evolved is the more individualized "family con-sultation" model discussed in the work of Mingyuan etal. (1993), Xiang et al. (1994), and Zhang et al. (1994)in China, and Shankar's (1994) work in India.Consultation was also an arm of the study by Solomonet al. (1996, 1998). In this model, although educationand groups may be available (or not), the primary focusis on private consultation between the family membersand a trained clinician or family member consultant.The consultant's purpose is to provide whatever advice,support, and information is needed, tailored to the spe-cific needs of the family as they articulate them.Consultations occur when the family requests them andmay lead to other referrals, simultaneous involvementin other programs, or termination or restart at any time.As with the family-to-family education model, the effi-cacy of consultation cannot be assessed because virtu-ally no research has been conducted.

Conclusions and Recommendations

The data supporting the efficacy of family psychoeduca-tion remain compelling. Such programs should remain aspart of best practices guidelines and treatment recommen-dations. The recent literature suggests that assessing theappropriateness of family psychoeducation for a particularpatient and family should consider the following ques-tions, to which affirmative answers would increase theappropriateness of family psychoeducation for an individ-ual patient and his or her family:• Are the family and patient interested in participating in

family psychoeducation?• To what extent is the patient involved with the family

and what is the quality of that relationship?• Are there clear patient-related outcomes that clinicians,

family members, and patients can identify as goals,such as decreased relapse or increased employment?

• Would the patient and family choose family psychoedu-cation instead of alternatives available in the agency orcommunity to achieve outcomes identified?

The role of other family intervention models mightinclude a consultation to assist the family and patient incoming to a decision about participation in family psy-choeducation. Peer-led family education programs con-ducted outside of the service system clearly have a rolewhen the patient is not in treatment or is unwilling to givepermission for the family to participate in it, making rela-tives ineligible for professionally led family psychoeduca-tion. Although again there is little research on the peermodels, they may also serve certain needs psychoeduca-tion does not or have particular strengths because they arepeer led and emphasize family well-being. Support offamily-to-family models by mental health professionalswill be valuable in addressing these unknowns. At thispoint, however, professionally led family psychoeduca-tion models that at least have support, information, andcrisis intervention components appear to be the only onesdocumented as useful in achieving patient improvement.

This review also highlights the incompleteness of ourknowledge, the widespread lack of dissemination andimplementation of family psychoeducation, and thepotential existence of other effective service models.Research must address the following issues:• We need to better understand the state of affairs regard-

ing services for relatives of people with serious mentalillnesses. Currently available information is inadequateto accurately describe what services and support familymembers are or are not getting, and from what sources.Rectifying this will require addressing multiple issues:patients, families, providers, finances, and service orga-nizations. In some cases, the details of family needs arenot even well understood.

• We need to devise more sophisticated evaluations of fam-ily interventions to better discern what works for whom atwhat cost. These evaluations need to identify key criticallyeffective "ingredients" and best practices in general andconsider the differing needs of diverse family members.

• To make an actual contribution to family members' andconsumers' lives, such research must be applied todeveloping even more beneficial models of family inter-vention. This may mean creating programs (or compo-nents of programs) that address the differential issues ofparents versus siblings of adults with schizophrenia, orfamily members of people whose illness is of recentonset versus those who have been dealing with the ill-ness for years, for example. Research may also consideroptimal combinations of models: structured group andconsultation; peer and professional.

• Other work must address the systems-level problems. Wehave some clues as to why family services, even proven

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low-cost ones, are unavailable in most places. However,the dynamics of these obstacles, and their dismantling,have not been addressed. The many political and eco-nomic issues of doing so in the current and future mentalhealth system must be taken into consideration, as mustquestions about successful family services shiftingresponsibilities and costs of care onto families. Dissem-inating and implementing successful models requiressimultaneous top-down and bottom-up efforts in the men-tal health system—gaining the support of managing insti-tutions and companies as well as the involvement offront-line providers, family members, and consumers.

• Underpinning these various research directions is also aneed to better understand the role of family members inthe illness management, coping, course of illness, andrecovery of the individual with schizophrenia. Inquiryin this area, as others, must be driven by appreciationfor the full biopsychosocial model, rigorous research,and the strengths and stresses of all parties.

When this work is done, we hope family psychoedu-cation and family-to-family programs will be much moreaccessible to family members who want them. In themeantime, family-provider interactions will continue totake place most often in the daily course of the consumer'sreceiving services. Providers, consumers, and families willcontinue to work in their local communities to find andcreate the relationships and resources that can address con-sumer and family-member needs in the absence of provenand prepackaged intervention programs.

The literature regarding family-member services con-tains many suggestions for doing this with optimal effec-tiveness. Family members invariably express needs forinformation, skills, and support. Commonalties among theinterventions reviewed in this paper directly address theseneeds and can be adapted for provider use outside of formalpsychoeducation programs. First, providers can offer familymembers information about schizophrenia and other mentalillnesses, illness management, navigating the mental healthsystem, and community resources they might find helpful.Such information should not be offered only once, but con-sistently. Many consumers and family members will wantmore detailed and sophisticated information as time andtheir knowledge base increase—providers can and do antici-pate this and offer both conversation and written materialsthat are tailored to current needs.

Second, providers can assist family members inlearning communication and problem-solving skills.Mental illness brings many disruptions and fears into afamily, often causing considerable conflict. While infor-mation can create understanding, effective communica-tion, negotiation, and problem solving can make diffi-cult and emotional conversations constructive. Someproviders may decide to see a client and his or her

involved family members together to discuss tenets ofgood communication, methods of conflict resolution,and how to use them. Others may want to frame suchinterventions as family therapy, or facilitate families'taking part in community-based workshops. Ongoingassistance to identify and resolve conflicts as they arisecan both support the family and teach skills in vivo.

Third, family members need support. Good rela-tionships with mental health providers and enhancedability for family members to support each other areboth helpful. Additionally, consumers and family mem-bers may need help understanding and responding toreactions others in their support system may have tomental illness, especially stigma. Moreover, they maydesire contact with people who have schizophrenia or arelative with it, to share experiences and information.Self-help and support groups for family members, andfor consumers, are increasingly common in communitymental health centers, self-help organizations, and otherfacilities. Providers may want to know about those intheir area, as well as State or national organizations thatmight have such information.

The three provider actions summarized above assumecompetencies that some providers may not have. Providerswishing to serve families and consumers better may firsthave to teach themselves about surrounding communityresources. They may have to examine their own abilities toconduct family therapy, or to teach communications andcoping skills. If these abilities are found wanting, providersmay need to invest in increasing their capacities beforeoffering such services, or refer consumers and families toother providers for these services. They may need to take alead in creating community resources as well.

Underlying all of these components are the relation-ships among family members, consumers, and providers.The actions outlined above require investments of timeand interaction. The most successful formal programs listbuilding rapport and trust as important ingredients. Bothare perhaps even more important when working to meetfamily and consumer needs without the structure of for-mal family psychoeducation programs.

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The Authors

Lisa Dixon, M.D., M.P.H., is an Associate Professor ofPsychiatry at the University of Maryland School of Medicine,Baltimore, MD. Curtis Adams, M.D., is an AssistantProfessor of Psychiatry at the University of Maryland Schoolof Medicine. Alicia Lucksted, Ph.D., is a Senior ResearchAssociate at the University of Maryland School of Medicine.

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