McFarlane, W. R., Dixon, L, Lukens, E, Lucksted, A. (2003). FAMILY PSYCHOEDUCATION AND SCHIZOPHRENIA: A REVIEW OF THE LITERATURE. Journal of Marital and Family Therapy 29(2), pp.223-245
The goal of this article is
looking for effectiveness/evidence-based practice of family interventions
and therapies for family psychoeducation around schizophrenia. This
is especially important since conventional family therapy is counter-indicated
for such families.
Families had to cope with schizophrenia
with its positive and negative symptoms and therefore had to learn from
each other. After all, families often provide emotional/instrumental
support, case management functions, financial assistance, advocacy and
housing to their relative with a mental illness.
A new approach: family
psychoeducation: to know how to help the sufferer in a way that leads
to best recuperation. This approach recognizes that schizophrenia is
a brain disorder, partially relieved by medication. There was a shift
from an attempt to change communication style in the family to compensation
of deficits + stopping the accidental interference with recuperation.
This approach leads to family’s higher reported overall functioning
of the whole family. Psychoeducational approach is evidence-based: cognitive/behavioral/supportive
therapeutic elements. There are many kinds of family psycho-education
approaches, which all have resiliency and strengths as their common
denominator. They differ in format, intensity and duration of treatment.
But they do agree on the critical elements:
goals for
working with families:
To achieve the best
possible outcome for the individual with the mental illness through
treatment and management that involves collaboration among professionals,
families and patients.
To alleviate suffering
among the members of the family by supporting them in their efforts
to foster the loved one’s recovery.
principles
for working with families: models of treatment supported with
demonstrated effectiveness required clinicians working with families
to:
coordinate all elements
of treatment and rehabilitation to ensure that everyone is working towards
the same goals in a collaborative, supportive relationship
pay attention to
the social as well as the clinical needs of the patient
provide optimum
medication management
listen to families
and treat them as equal partners in treatment planning and delivery
explore family members’
expectations of treatment programs for the patient
assess family’s
strengths and limitations in their ability to support the patient
help resolve family
conflict through sensitive response to emotional distress
address feelings
of loss
provide relevant
information for patient and family at appropriate times
provide an explicit
crisis plan and professional response
help improve communication
among family members
provide training
for the family in structured problem-solving techniques
encourage family
to expand their social support networks – i.e. participation in multi-family
groups and/or family support organizations such as the National Alliance
for the Mentally ill
be flexible in
meeting the needs of the family
provide the family
with easy access to a professional in case of need if the work with
the family ceases
evidence-based
family intervention models: several models were developed to
address the needs and concerns of the families of people with mental
illness, including:
behavioral family
management
family psychoeducation
relatives groups
family consultation
professionally-led
models of short-term family education (“therapeutic education”)
behavioral family
management:
behavioral analysis of the
family for its strengths, and individual needs within the family. Its
an in-hope model with focus on education around the schizophrenia –
i.e. communication, problem-solving. It is strengths-based.
Family psychoeducation
empirically based,
with intense engagement with the family. Stable symptom recovery and
relapse prevention, based on family’s needs.
This approach is
based on structural family therapy [joining the therapist style/boundary
work]. Boundary work is needed not because the family here would be
enmeshed but rather a barrier to stimulation – i.e. sensitivity to
stimulation and cognitive disability which biologically inherent to
schizophrenia.
Relapse is a major
impediment to clinical and functional improvements. Remission is the
time for functional gains, which serve as a protective factor against
kevel of relapse.
Family’s functioning
is seen as good unless proven otherwise.
Psychosis is seen
as traumatic to the brain and immediate social support is needed for
recuperation.
Calculated steps
are made in order to regain functionality during recovery from a psychotic
episode.
family psychoeducation
-this modality has 3 parts:
psychoeducational
behavioural management
Multifamily group
– the element of group is helpful for improved social functioning.
This group addresses the isolation, stigmatization, financial and psychological
burden. The three components of the group include
Joining
with the family in single-family sessions for
educational purposes: focusing
on relapse prevention and fostering social treatment
Move from stability
to increased community functioning: behavioral management for social
and vocational rehabilitation
Making the group
a long-term support group for social contact, support and clinical monitoring
Relatives groups
in-home at first
psycho-educational
component is in the home. And then a group, excluding the patient
this approach is
cross-modality
meant to reduce
isolation
Family consultation
individual families
meet the professional to address concerns as they arise. There is no
pre-set agenda
this modality is
good for when scheduling is hard or issues are few
Short term models
i.e. individual
or group sessions for caregivers. Some groups for clients as well
focus is well defined:
could be on self-efficacy [conclusion that one can deal with the situation],
education or coping mechanisms
RESEARCH REVIEW
Family psychoeducation
for people afflicted with schizophrenia is highly effective when compared
to standard care or medication
expanding social
network and social support for families and patients in a effective
therapeutic strategy
short term effects
of psychoeducational/coping skills training seem to be effective
family psychoeducation
reduces relapse beyond medication
3 counter-indications of
family work with schizophrenia
work around family
dysfunction in psychodynamic exploration
working with immigrants
1 study shows lower
relapse in individual rather than family/supportive sessions. But personal
adjustment was better in family psychoeducation
-even those exceptions show
that the core of psycho-ed. Works.
multi-family groups:
more cost efficient and more effective than single-family sessions,
especially for first episode
Outcome measures of functionality
were expanded, beyond the remission measure, due to criticism from families:
housing
employment/vocational
rehabilitation
social functioning/relations
dating/marriage
general morale
decreased psychiatric
symptoms
improved family-member
well-being
decreased family
medical illnesses and medical care
reduced cost of
care
mediating effects:
mediating effects could be
seen as either:
broad spectrum of
intervention components; family psychoeducation, family behavioral system,
psychoeducational multifamily groups. Might be more effective in relapse
prevention than expressed emotion reduction.
nodal alterations
– which effect the whole family/biological system. This approach seems
to reduce expressed emotion and thus relapse.
The point is that both positions
have empirical grounding, which implies that functional improvement
involves multi-dimensional aspects.
-studies show that the appropriate
components for family support include more than just info-giving –
it needs to also skills training for families. This was found to be
true too for other disorders, most well developed = for bipolar (i.e.
mania episodes were less debilitating for the family, due to the acquired
skills). But in bipolar, more biological effect than expressed emotion
effect on relapse. In groups, bipolar sufferers can join the groups
more than schizophrenic suffers. In terms of technique, it is more recommended
to do the joining within group-work when client is not in a manic state.
Future directions for
research:
more needs are needed
to be described about the patient/consumer’s outcomes/experiences.
Relapse prevention has to be discussed on client’s terms/goals, i.e.
employment;
minimal ingredients
of family interventions need to be clarified – i.e. same outcomes,
regardless of intensity. So comparable minimal components have to be
found;
evaluation of benefit
has to be developed further – still need to explore the combination
of family psychoeducation with other modalities of support;
research is needed
to clarify the idea of different families, each in different situations.
i.e. multifamily work is beneficial mostly to those clients who are:
influenced by higher Expressed Emotion, that the client had his
first episode, or that symptoms are only partially relieved by medication;
modification of the established modalities of psychoeducation have to
be explored;
long-term follow-up
on outcomes is called for.
Barriers to implementation
of family psychoeducation
-psychoeducation might be helpful
but there are barriers such as low # of people able to do the approach,
as well as to train.
Patients/family members:
transportation
time
competing demands
for time/energy. i.e. if families see psychoeducation as another responsibility
to assume, they will keep away
stigma of being
associated with a psychiatric illness
possible past bad
experiences
hopelessness, lack
of knowledge of benefits of program, confidentiality issues and loss
of autonomy
clinician/program administrator
under-appreciation
lack of knowledge
of the approach’s utility and benefits. Some may be more comfortable
with the medical/medication way of thinking and that family work is
seen as superfluous in working with schizophrenia. Organizations may
not see the benefits of the psychoeducational programs and see confidentiality
issues as barriers and not opportunities for adaptability.
Cost in light of
no re-imbursements. Problem with this approach: medication route is
much more prolonged. Because of inevitable public funding issues, horizons
may be too narrow to think long-term programming, and staff members
are too overburdened to try something new. Short term goals and organizational
crises are too much the norm for them to implement something as psychoeducational
programming.
Strategies for overcoming
barriers to implementing family psychoeducation
Patient/family members
offer sessions at
home – flexibility
explain the benefits
of the program (i.e. improved everyone in the family’s lives, not
only the client) – to deal with families’ fear of hopelessness and
stigma
Clinical/program administrators
-program must be tailored to
the local and cultural settings, workload and other specific stressors
of the clinicians/agencies, and clientele disposition. Local/specific
barriers may have to be worked out. The rationale for family psychoeducational
approaches might have to be spelled out:
it is evidence based
Reduces crisis
More effective case
management
Client/family satisfaction
Clinicians enjoy
this approach
Mental health authorities/government
-complex interplay between
interests of governments and various leveled health/mental health authorities.
One must work at the resistance to change, so common to large bodies
of authority. Sometimes, larger local organizations could be the driving
force behind advocating for the family psychoeducational programs.
Family-to-family programs
-volunteer programs were reported
to be helpful
Conclusion:
Family psychoeducation
has established its efficacy and effectiveness as an evidence-based
practice. It is not widely used though! Professional awareness as to
its benefits and cost-effectiveness needs to be increased/disseminated.
Families need to be seen more as a resource than the problem-source!
Families are appreciative and have a profound need for support of the
professionals around guidance, support, and information!