Family Interventions for Schizophrenia and the Psychoses: A Review

• Author: William R. McFarlane
• Date: 01 September 2016
• Published date: 01 September 2016
• DOI: http://doi.org/10.1111/famp.12235

Family Interventions for Schizophrenia and the

Psychoses: A Review

WILLIAM R. MCFARLANE*

To read this article in Chinese, please see the article’s Supporting Information on Wiley Online Library

(wileyonlinelibrary.com/journal/famp).

Family psychoeducation as a treatment for schiz ophrenia was developed 40 years ago

almost simultaneously and independently by investigators who at the time were not family

therapists. Although the original goal was to decrease high expressed emotion as a means

of preventing relapse, later variations have gone beyond to focus on social and role func-

tioning and family well-being. Explicitly disavowing the earlier assumptions that family

pathology caused relapse and deterioration, family psychoeducation seeks to eng age family

members as more sophisticated partners, complementing interventions by clinicians with

specialized interactions and coping skills that counter the neurologic deficits inherent to

the disorder. It has proved to be one of the most consistently effective treatmen ts available.

Reports on outcome studies now number more than 100, while meta-analyses put relapse

rate reduction at 50–60% over treatment as usual. The most recent application in first epi-

sode and prodromal psychosis, combined with other evidence-based interventions, is yield-

ing perhaps the most promising results yet achieved—substantial return of functioning

and avoidance of psychosis altogether. Reviewed here are its scientific, theoretical, and

clinical sources, a description of the most commonly applied version—the multifamily

group format, selected clinical trials spanning those four decades, international and ethnic

adaptations, and studies on mechanisms of efficacy.

Keywords: Family Intervention; Schizophrenia; Psychosis; Psychoeducational

Multifamily Group; Family Psychoeducation; Early Intervention

Fam Proc 55:460–482, 2016

Family psychoeducation (FPE) for the psychotic disorders has been established as one

of the most effective psychosocial treatments ever developed. It is a structured method

for incorporating a patient’s family members, other caregivers, and friends into acute and

ongoing treatment and rehabilitation. The descriptor “psychoeducation” can be mislead-

ing: FPE includes cognitive, behavioral, and supportive therapeutic and rehabilitative ele-

ments, utilizes a consultative framework, and shares some characteristics with str uctural

family therapy. The model most commonly used today is an amalgam of FPE (Anderson,

Hogarty, & Reiss, 1986), behavioral family therapy (Falloon, Boyd, & McGill, 1984), and

multifamily group therapy (McFarlane, 2002). Based on a family–patient–professional

partnership, the most effective models are essentially cognitive-behavioral therapy with

consistent inclusion of family members as collaborators. As a substitute for a family mem-

ber, it can include any friend or para-professional person who is providing support to per-

sons with a severe mental illness. In contrast to most family therapies, the family is not

*Tufts University School of Medicine, Maine Medical Center Research Institute, Portland, ME.

Correspondence concerning this article should be addressed to William R. McFarlane, M.D., Tufts

University School of Medicine, Maine Medical Center Research Institute, 22 Bramhall Street, Portland,

ME 04102. E-mail: mcfarw@mmc.org

460

Family Process, Vol. 55, No. 3, 2016 ©2016 Family Process Institute

doi: 10.1111/famp.12235

the object of therapy but rather a key implementer, as an indispensable colleague with dif-

fering expertise and potential skills. In addition to FPE, many other interventions exist to

assist consumers in the context of their families, and family members themselves, regard-

ing the challenges of severe mental illness. Within this range of potential resources, this

review will address only the clinical intervention of FPE and its effects for the psychotic

disorders.

As a group of related models with common characteristics (World Schizophrenia Fel low-

ship, 1998), FPE:

•Assumes that most involved family members of individuals with mental illnesses need

information, assistance, and support to best assist their ill family member and cope with

the often severe challenges posed to the family system.

•Assumes that the way in which relatives behave toward and with the person with men-

tal illness can have important effects, both positive and sometimes negative, on that per-

son’s well-being, clinical outcomes, and functional recovery.

•Combines informational, cognitive, behavioral, problem solving, communication, and

consultative therapeutic elements.

•Is initiated and led by mental health professionals.

•Is offered as part of a clinical treatment plan for a specific patient/consumer.

•Focuses primarily on benefiting consumer/patient outcomes, but improvements for fam-

ily members (e.g., reducing confusion, exasperation, and emotional distress) are also

essential to achieve those outcomes.

•Includes:

○content about illness, medication, and treatment management;

○services coordination;

○attention to all parties’ expectations, emotional reactions, and distress;

○assistance with improving family communication;

○structured problem solving and instruction;

○implementing individualized coping and rehabilitative strategies;

○expanding social support networks; and

○explicit crisis planning with professional involvement.

•Are generally diagnosis specific, although cross-diagnosis models have been developed

and are often the de facto practice.

Around these core elements, FPE programs vary considerably: FPE may take place with

just one family (single-family psychoeducation, SF-PE) or in multiple-family groups

(MFG-FPE). The consumer may be included in all (most common), some, or no sessions.

FPE may vary in the length of sessions, number of sessions, settings (clinic, inpatient,

home based), and overall time span (for maximum efficacy, for months or even years). Dif-

ferent programs may also vary in how much they emphasize cognitive, behavioral, infor-

mational, clinical, rehabilitation, and family systems theory and techniques. FPE

programs seek to enlist the assistance of loved ones and train them to help patients man-

age their illness. “The main goal in working with families is to help them develop the

knowledge and skills instrumental in promoting the recovery of their family member

while eschewing family dysfunction etiological theories of the past” (Jewell, Downing, &

McFarlane, 2009).

Evidence that FPE benefits the most important clinical outcomes has been established,

particularly regarding people with schizophrenia. Family psychoeducation has been

empirically demonstrated in a large number of clinical trials to improve outcomes in

schizophrenia and bipolar disorder to the same or greater degree as antipsychotic

Fam. Proc., Vol. 55, September, 2016

MCFARLANE

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