Family psychoeducation and schizophrenia: A review of the literature

Journal of Marital and Family Therapy, Apr 2003 by McFarlane, William R, Dixon, Lisa, Lukens, Ellen, Lucksted, Alicia

Family psychoeducation has emerged as a treatment of choice for schizophrenia, bipolar disorder major depression, and other disorders. More than 30 randomized clinical trials have demonstrated reduced relapse rates, improved recovery of patients, and improved family wellbeing among participants. Interventions common to effective family psychoeducation programs have been developed, including empathic engagement, education, ongoing support, clinical resources during periods of crisis, social network enhancement, and problem-solving and communication skills. Application of family psychoeducation in routine settings where patients having these disorders are usually treated has been limited, reflecting attitudinal, knowledge, practical, and systemic implementation obstacles. Through consensus among patient and family advocacy organizations, clinician training, and ongoing technical consultation and supervision, this approach has been implemented in routine clinical settings.

Our purpose here, as part of the series commissioned by the American Association for Marriage and Family Therapy (AAMFT) on family interventions and therapies and the evidence for their effectiveness, is to describe family psychoeducation, the basis for its status as an evidence-based practice (EBP), and barriers to implementation. Proposed strategies for overcoming those barriers are also described. Although the focus is on results and developments since the last such review in the Journal of Marital and Family Therapy (Goldstein & Miklowitz, 1995), we start with a brief overview of this work for those who are new to it.

Family psychoeducation originated from several sources in the late 1970s. Perhaps the leading influence was the growing realization that conventional family therapy, in which family dysfunction is assumed and becomes the target of intervention for the alleviation of symptoms, proved to be at least ineffective and perhaps damaging to patient and family well-being. As efforts to develop and apply family therapy to schizophrenia and other psychotic disorders waned, awareness grew, especially among family members themselves and their rapidly growing advocacy organizations, that living with an illness such as schizophrenia is difficult and confusing for patients and families alike.

It became increasingly clear that, under these circumstances, a well-functioning family has to possess the available knowledge about the illness itself and coping skills specific to a particular disorder, skills that are counterintuitive and only nascent in most families. Given that perspective, the most adaptive family was increasingly seen to be the one that has access to information, with the implication that the treatment system is a crucial source of that information. As to coping skills, many families develop methods of dealing with positive (psychotic) and negative (functional and cognitive deficits, such as flattened affect, loss of energy and apathy) symptoms, functional disabilities, and the desperation of their ill relatives through painful trial and error. These successes, however, are rare. A critical need is for families to have access to each other to learn of other families' successes and failures, and to establish a repertoire of coping strategies that are closely tailored to the disorder. Further, family members and significant others involved in the lives and care of adults with serious mental illnesses often provide emotional and instrumental support, case management functions, financial assistance, advocacy, and housing to their relative with mental illness. Doing so can be rewarding but poses considerable burdens (Adamec, 1996; Cochrane, Goering, & Rogers, 1997; Leff, 1994; McFarlane, Lukens, et al., 1995). Family members often find that access to needed resources and information is lacking (Adamec, 1996; Marsh, 1992; Marsh & Johnson, 1997).

Even with this new perspective, it took over 10 years for interest and effort in involving families in the treatment of persons with severe mental illness to be revived, and then it emerged with an entirely different ideology. Investigators began to recognize the crucial role families played in outcome after an acute episode of schizophrenia had occurred and endeavored to engage families collaboratively, sharing illness information, suggesting behaviors that promote recuperation, and teaching coping strategies that reduce the families' sense of burden (Anderson, Hogarty, & Reiss, 1980; Falloon, Boyd, & McGill, 1984; Goldstein, Rodnick, Evans, May, & Steinberg, 1978; Leff, Kuipers, Berkowitz, Eberlein-Vries, & Sturgeon, 1982). The group of interventions that emerged became known as family psychoeducation.

The psychoeducational approach recognizes that schizophrenia is a brain disorder that is usually only partially remediable by medication, and that families can have a significant effect on their relative's recovery. Thus, the psychoeducational approach shifted away from attempting to get families to change their "disturbed" communication patterns towards educating and persuading families that how they behave toward the patient can facilitate or impede recovery by compensating for deficits and sensitivities specific to the various psychotic disorders. For example, a family might interfere with recuperation if. in their natural enthusiasm to promote and support progress, they create unreasonable demands and expectations, but the same family could have a dramatically positive effect on recovery by gradually increasing expectations and supporting an incremental return of functioning.