Family Interventions

As mentioned earlier in the chapter, several ineffectual family theories of schizophrenia were postulated, but led to very little in terms of actual therapy. The hegemony of psychological therapies arising out of the private therapist's couch was poorly adapted for the everyday reality of families of individuals with schizophrenia.

The goals of family approaches to schizophrenia are to reduce relapse, improve functioning and contain the burden on the family.

The earliest evidence in this area relates to the effect of expressed emotions (EE) on outcome of schizophrenia (Leff & Vaughn, 1985). Expressed emotions are reactions of the family members to the person with psychosis. Initially five areas of EE were identified.

However only three (criticality, hostility and overinvolvement) were found to be clinically meaningful and are elicited through a two to two-and-a-half hour standardised Camberwell Family interview (Vaughn & Leff, 1976a). Brown & Birley (1968) showed that relapse in schizophrenia was preceded by both pleasant and unpleasant events in the weeks before the episode. Subsequently, Vaughn and Leff found that patients with more than 35 hours per week of face-to-face contact with relatives with high expressed emotion were highly likely to relapse over a nine-month period - even if they were on drug therapy - compared with those who were exposed to less than 35 hours per week of the same or to relatives with low expressed emotions (Vaughn & Leff, 1976b). In this study high EE-exposed patients were more likely to relapse compared to low EE patients who were not on medications. An aggregate analysis of 25 studies (Bebbington & Kuipers, 1994) confirmed the role of EE in schizophrenia outcome across different cultures. Butzlaff & Hooley (1998) performed a meta-analysis, which corroborated this and showed that the magnitude of relapse-producing effect of EE varied from highest in Eastern Europe to lowest in Australia. Interestingly, although EE is a robust indicator of outcome in schizophrenia, the Butzlaff analysis found that EE was even more strongly predictive of relapse in depression and eating disorders.

However, expressed emotion intervention requires a specialised interview (Leff & Vaughn, 1985) and work, which may not be always possible in routine clinical care. Might there be a way of providing good-quality family intervention without having to focus directly on structured assessment of EE? It would seem so. A systematic review of psychoeducation of family or individual patients showed a clear effect on relapse (NNT 9, CI 6-22) (Pekkala, 2002). Some studies have addressed psychoeducation as an intervention for the individual and others have delivered it as a family intervention. The evidence as an aggregate is positive. There are over 20 controlled studies on family psychoeducation.

The intervention is delivered in a structured manner through a multidisciplinary team and should last at least nine months although some programmes last up to three years.

It is possible to deliver family interventions to single or multiple families although the latter is likely to be more effective (McFarlane, 1994). The effectiveness may be mediated through the element of support derived from facing a common problem or through having a wider catch of experiences in dealing with something as complex as schizophrenia in the family. The intensity of the intervention itself does not seem to be important (Lehman et al., 2004).

Behavioural methods of change and problem solving are both common ingredients of family intervention. Family treatment of schizophrenia can decrease the relapse rate by almost 50 % (Mari & Streiner, 1994; Pilling et al., 2002b). Studies show that there is an additional advantage of decreasing the family burden (Cuijpers, 1999). Family therapy has also been successfully applied in non-Western settings (Wang & Phillips, 1994; Xiong et al., 1994; Zhang etal., 1993).

In summary, family interventions need to be structured, with adequate duration. They appear to have a specific effect in reducing relapse rates. Family interventions have the advantage that they can be delivered at a time when the family is in crisis either in the first episode of schizophrenia or during a relapse phase.

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