Family psychoeducation as an evidence-based practice

Family psychoeducation programs have emerged as a strongly supported evidence-based practice in the treatment of schizophrenia and bipolar disorder. Over 30 randomized clinical trials demonstrated that psychoeducation programs reduce relapse, improve symptomatic recovery, and enhance psychosocial and family outcomes. Recent work supports family psychoeducation strategies for other disorders, including major depression, obsessive-compulsive disorder, and borderline personality disorder. This review summarizes the research evidence supporting prominent models of family psychoeducation. Professional and peer-led family education programs are also reviewed and differentiated from family psychoeducation. Directions for future research studies to enhance the evidence base and inform treatment recommendations are proposed. Finally, strategies for implementation of family psychoeducation in routine clinical practice are discussed.     

ABSTRACTS OF LITERATURE

Schizophrenia is due to a combination of genetic and environmental factors. The author asserts that there has previously been an error in conceiving the patient as being molded completely by external circumstances. In fact, it is the patient's behavior, which is a transformation of family irrationality, that constitutes schizophrenia. In 75 per cent of cases of schizophrenia seen by the author in private practice, the mother did not fit the image of the so-called “schizophrenogenic mother.” In this technique for teaching family therapy, the students take the roles of the family. Procedures, selection of players, formulating the problem, the value of the experience, and ground rules are described. This is a case report and follow-up over nine years of an alcoholic woman. The patient and husband were treated for 35 sessions by cotherapists in conjoint marital therapy. Although there was improvement in the family patterns and in drinking behavior during the treatment, the improvement did not last after termination. The case suggests that marital therapy in the absence of other treatment interventions is ineffective in changing the long-run course of women alcoholics. Based on the author's practice on an inpatient unit that specializes in the study of aggressive behavior, he describes family dynamics and treatment when the identified patient suffers from “episodic violent behavior.” The sample focuses on adolescents, most of whom had episodes of suicidal behavior and who had some evidence of “organic involvement.” Typical family patterns include overly close alliances by the adolescent with one or both parents and transmission by parents of inconsistent values regarding aggression. Family therapy is seen as the preferred treatment approach and emphasizes family ways of handling dyscontrol episodes and the responsibility of the patient for his or her actions. No results are reported. This study attempts to link family variation and core relationships in types of families with the mental health of children. Sample was from a black, poor, urban community defined in terms of the adults present in the home. Eighty-six family types were found falling into ten major classes. Measures of mental health in children were done on psychological well-being of the children and on Social Adaptational Status. Results indicate that family type is strongly related over time to child's SAS and his or her psychological well-being. Mother-alone families entail the highest risk in terms of social maladaptation and psychological well-being of the child; the presence of certain second adults has important ameliorative functions—mother/grandmother families being nearly as effective as mother/father families, with mother/stepfather families similar to mother-alone in regard to risk. Inferences from this data and implications and interventions are discussed. This is a clinical essay on the role of family therapy for black families. In addition to the usual family stresses, black families are subject to the additional strain of discrimination. Support is achieved mostly from the family and from the kinship network, rather than the community. Treatment strategies for this situation are proposed. This essay reviews recent regulations concerning consent procedures and protection of privacy as they apply to children and their families. Rigorous sample selection, nearly complete follow-up, and objective assessment of outcome are virtually impossible at this point. It is concluded that compliance with current “subjects' rights” regulations sometimes seems potentially more harmful to the subjects than the research itself. One case example is presented in support of the hypothesis that brief family therapy has the potential to lead to individual personality changes that are long-lasting. The identified patient was a 15½ year old boy with the symptom of having a falsetto voice. Father, mother, and child were seen in twelve family therapy sessions with changes in the boy's self-image documented in “man-figure” drawings. Nine-month follow-up revealed no recurrence of the presenting symptom and an improvement in social and familial relationships of the identified patient. This is another in a series of papers from a divorce-counseling project. The focus in this paper is on preventive clinical interventions developed for children of various ages in divorcing families. Developmental assessment was achieved with a “brief” history from the parents, detailed information from school, and “direct observation” of the child. This paper covers treatment strategies, interventions, failures, therapist's role, and professional dilemmas in divorce counseling of 60 families with 131 children between the ages of 3 and 18 at the time of divorce. The technique of counseling was to see one parent and child separately by the same therapist three to six times over a three-month period. This is a research study to provide data on the question of whether the disturbed behavior of parents with a schizophrenic child preexists or is a response to an identified patient's pathology. Method was to administer a conceptual task called the Twenty Questions Task individually to each family member and to the family as a unit with a sample of 36 schizophrenic families, 13 non-schizophrenic controls, and 38 normal controls. Results “indicated that far more schizophrenic sons than control sons were much more efficient individually than with their families.” A number of schizophrenic sons performed competently as individuals, but the subsequent performance of parents and sons together on the same task was generally inferior to that of the son alone. Results suggest that the parental behavior plays a part in the etiology of schizophrenia.     

Characteristics of Schizogenic Families During a Joint Story-Telling Task

For a joint family story-telling task, families with a schizophrenic offspring were compared to normal families on the completeness and clarity of the final composite stories and on their interactional behavior. The composite stories from schizogenic families were more “vague and confused”, fragmented, and less complete as to the five components required to satisfy the task instructions. Schizogenic families displayed more conflict, failure, and confusion during the interactional task than control families, and, fathers and mothers of schizophrenic offspring displayed more “anxiety and tension”, “depressive mood”, “evasiveness” and “lack of interest” than fathers and mothers of normal families. Mothers of schizophrenic offspring were also described as more “hostile” than control mothers. Comparing schizogenic families from which the patient was absent during the task with schizogenic families with the patient present, and with control families, indicated that the central findings were not attributable to the immediate presence and participation of the schizophrenic member.     

Parent and Child Effects on Cognitive Performance: An Experimental Approach to the Etiological and Responsive Theories of Schizophrenia

While many theorists have assumed that the family has an etiological part in the development of schizophrenia, most findings, since they come predominantly from observations after the illness has occurred, could plausibly be interpreted as family responses to the illness. In this experimental study, we constructed artificial families in order to measure independently of each other the effects of parents of schizophrenics on children and the effects of schizophrenic children on parents. Findings from a cognitive task requiring abilities to attend and abstract show that the presence of a schizophrenic child has only minor disruptive effects upon the performance of normal parents; parents of schizophrenics also have little effect upon normal children. Instead, the most consistent effects are those of normal parents on the schizophrenic child. Adolescent schizophrenic patients whose cognitive performance deficit is apparent prior to the experiment show significant improvement after having worked on the cognitive task with normal parents; their cognitive deficit disappears, and their performance is not different from matched normal children. Further investigation will center on the quality of the normal parents' “normalizing” effects.     

Nonverbal Interactional Behavior in the Families of Persons with Schizophrenic and Bipolar Disorders

Whereas verbal interactional behaviors have been repeatedly found to distinguish the families of persons with and without major psychiatric disorders, there has been comparatively little examination of the discriminative value of nonverbal interactional behaviors. We developed the Nonverbal Interactional Coding System to measure “affiliative” and “distancing” nonverbal behaviors in 18 schizophrenic and 18 bipolar patients and their parents during 10-minute interactions conducted during a posthospital period. Bipolar patients and their parents displayed affiliative nonverbal behaviors (“illustrator gestures” or “prosocial behaviors”) for longer durations than schizophrenic patients and their parents. In contrast, parents of schizophrenic patients displayed distancing nonverbal behaviors (looking away) for longer durations than those of bipolar patients. The nonverbal interactional data added to the statistical strength of patients’ and parents’ verbal interactional data in distinguishing between these diagnostic groups. Nonverbal interactional behaviors are important variables to consider in interventions aimed at improving the communication skills of families coping with psychiatric disorders.     

With Onions and Tears: A Multidimensional Analysis of a Counter-Ritual

“Family rituals” and “family myths” are useful concepts for understanding some of the behavior of disturbed families and hence for planning therapeutic interventions. A case of a family of a schizophrenic patient is described in which a “counter-ritual” involving onion-peeling to induce tearing was invented. The intervention addressed the family's inappropriate laughter and denial of sadness and seemed to lead to therapeutic gains for the identified patient and the family. This counter-ritual, as an indirect affect-inducing experience, is analyzed from a variety of perspectives and a partial parallel is drawn to an Iranian cultural ritual. A suggestion is made that more light may be shed on the mechanisms and structures of myths and rituals in families by drawing on studies of myths and rituals in ethnography. “Counter-ritual” is offered as a general concept for a type of active family intervention that involves inventing and employing rituals antithetical to pathological ones engaged in by some families.     

Family-based Psychoeducation for Children and Adolescents with Mood Disorders

Psychoeducation is often used for family members of adult patients with mood disorders. An increase in family’s knowledge of the patient’s illness course and outcome is thought to improve treatment compliance and may reduce relapse rates through identification of early symptoms and risks. While studies on family-based psychoeducation of adult patients with mood disorders have been reviewed, a similar review has not been conducted in patients who are children and adolescents. We conducted a systematic review of studies published between 1980 and 2006 on independently standing psychoeducation programs for families with children suffering from mood disorders. Results revealed eight treatment and preventive psychoeducation studies for families of affectively ill children or children at risk for depression. Findings indicate that psychoeducation models typically adopt a workshop approach incorporating didactic teachings and interactive discussion sessions, with or without specific skills training. Given the paucity of randomized controlled trials and lack of comparability between psychoeducation models, conclusions about the true efficacy of each program as a treatment or an adjunct to the treatment of mood disorders in children and adolescents cannot be made. Further research into psychoeducation for families of children with mood disorders is warranted.     

Relational Control Patterns and Expressed Emotion in Families of Persons with Schizophrenia and Bipolar Disorder

The process of relational control, that is, the negotiation of “who's in charge,” was examined in 40 families of persons with schizophrenia and bipolar disorder. Verbal interaction recorded during problem-solving tasks was coded with the Relational Control Coding System (RCCS). Patterning of message and response sequences was compared by diagnosis of the patient and level of expressed emotion (EE) of the family. Results indicated that patients with either diagnosis assert control more than their parents, that high-EE families compete for control more than low-EE families, and that families of bipolar patients compete for control whatever their EE status. The most dramatic differences in control patterns were in the dual-parent, high-EE families of persons with schizophrenia, in which the patients successfully challenged parents for control, and parents often yielded. It was concluded that EE reflects transactional processes in families that vary by diagnosis of the patient.     

Psychoeducational Multiple Family Groups: Four-Year Relapse Outcome in Schizophrenia

Earlier studies of family psychoeducation and clinical reports on multiple family groups (MFGs) have reported substantial reductions in relapse rates for patients with schizophrenia. These groups offer an expanded social network and thereby may confer a margin of protection against relapse. However, to date, there has not been an empirical trial of this modality. The advent of family psychoeducational and behavioral management strategies provided the basis for an experimental, three-way comparison of psychoeducational MFGs to psychoeducation in a single-family format and to MFGs without psychoeducation, using symptomatic relapse as the outcome criterion. After 4 years, the psychoeducational MFGs were significantly more effective in extending remission than the single-family format, while the MFGs without psychoeducation approximated outcome in the psychoeducational MFGs. The respective relapse rates at 4 years were 50%, 78%, and 57%; MFGs averaged 12.5% and 14% per year. These results point toward an enhanced and independent, long-term therapeutic effect for multiple family groups, when combined with antipsychotic medication and psychoeducation, with especially promising cost-effectiveness.     

Partizipationsverhalten schizophren erkrankter Patienten in Psychoedukationsgruppen

Background

The effectiveness of psychoeducation groups for people with schizophrenia is well documented; however, there are no studies which examined patient participation behavior although this behavior might be critical for accomplishment of the therapeutic goals. This article presents newly developed 4-point Likert scale, the participation quality rating scale (PQRS), together with initial results on practicability, validity, change sensitivity, sociodemographic and clinical correlates and on the question whether participation quality might be a significant predictor of the short and long-term outcome of psychoeducation.

Patient and methods

Within the framework of the Munich Study “Cognitive Determinants of Psychoeducation and Information in Schizophrenic Psychoses” (COGPIP) the individual participation behavior of 97 patients with schizophrenia was examined after each psychoeducational group session (4 weeks). Individual mean PQRS scores were correlated with sociodemographic, anamnestic and clinical variables. In addition to change sensitivity the ability of the scale to predict the acquisition of illness knowledge during psychoeducation was examined as well as readmission during a 9-month follow-up period and the psychopathological endpoint (positive and negative syndrome scale, PANSS).

Results

Practicability and change sensitivity of the PQRS were found to be sufficient. Significant correlations with independently rated illness insight and medication compliance indicated a construct validity of the scale. Higher age, female sex and less pronounced psychopathological symptoms (PANSS) were associated with better participation behavior. Even patients with clearly impaired participation behavior profited from psychoeducation in that they were able to catch up with the delay with regard to illness knowledge. However, the PQRS was not a predictor of readmission during the 9-month follow-up period or of psychopathological endpoints.

Conclusions

The PQRS is qualified as a new tool for the standardized assessment of participation behavior in people with schizophrenia attending psychoeducation groups. The scale can be applied in research as well as clinical contexts in order to further improve understanding of how psychoeducation works and how this kind of supplementary therapy could become even more effective.     

The Conjoint Family Diagnostic Interview and the Family Index of Tension

The present paper is written in response to the, as yet, unmet need for a broadly applicable, clinical rubric for assessing the psychiatric patient's situation in his family. It describes a conjoint family diagnostic interview procedure (CFDI) which enables a clinical interviewer, within a single ninety-minute, problem-focused, conjoint interview, to describe or rate the verbal and nonverbal behavior of a Ten family unit along dimensions relevant to clinical decision-making for the psychiatric patient. A rating instrument, the Family Index of Tension (FIT) will also be described. It provides a convenient format for quantifying the information obtained at the CFDI, facilitating comparisons within and across family systems. Though initially developed and protested on 350 families of hospitalized psychiatric patients, the procedure described appears applicable to all clinical situations in which families, regardless of their composition and background, are seen together with an “identified patient” for purposes of evaluation and treatment planning.     

Optimizing treatment of schizophrenia. Enhancing affective/cognitive and depressive functioning

Recognition and treatment of schizophrenia has largely focused on positive symptoms of the disorder, such as delusions, hallucinations, and disorganization. However, other important symptoms, such as depression, cognition, and social functioning, have not received comparable attention. Fifty percent of schizophrenic patients suffer from comorbid depression, which is a major risk factor for suicide in this population, while 10% to 25% suffer from comorbid obsessive-compulsive disorder. Cognitive deficits commonly observed in patients with schizophrenia include problems with concentration, attention, and memory, as well as problem-solving and verbal skills. These deficits are observed at early stages of the illness and can predict deficits in functional capabilities, such as occupational and social skills, educational attainment, and the ability to live independently. The severity of such impairments affects all patient in this population, including up to 10% of patients working full time and up to one third of those working part time. In light of the debilitating effects of depression, cognitive impairment, and other aspects of affective functioning on the quality of life of patients with schizophrenia, physicians need to partner with their patients to address these concerns and determine an appropriate treatment regimen. This can be done with simple functional-based cognitive questioning, the use of evidence-based psychosocial practices, and psychoeducation on the many pharmacotherapeutic options. It is recommended that depressive or suicidal symptoms of schizophrenia be treated with an antidepressant or mood stabilizer only if the symptoms have not subsided after treatment of the psychosis with an atypical antipsychotic. Additionally, relative to older medications, atypicals have demonstrated benefit in improving some of the cognitive impairments.     

A Psychoeducational Approach to Hypochondriasis: Background,Content, and Practice Guidelines

Patients suffering from health anxiety are difficult to engage in a psychological treatment, although it has now been empirically established that cognitive behavioral treatments are beneficial for many of these patients. A first important step is to change their orientation from a biomedical to a biopsychosocial perspective. One way of promoting this change is to provide focused psychoeducation. A number of studies have shown that group psychoeducation for patients with health anxiety results in a reduction in anxious concerns, depression, and medical services utilization. The purpose of this paper is to describe the background, content, and implementation of a brief course entitled “Coping With Health Anxiety.” The empirical support as well as the potentially active ingredients of this approach are discussed.     

Family Therapy of Schizophrenics with High Risk of Relapse

Three families that demonstrated factors associated with relapse of florid symptoms in a schizophrenic family member underwent a course of 25 sessions of behavioral therapy in a multi-family group. Details of the treatment and assessment procedures are presented along with evidence of significant beneficial change in two families. The problem of providing continuing care for schizophrenic patients and their families is discussed.     

自然自明性的失落——Blankenburg精神分裂理论述评

传统的精神分裂研究,关注的主要是精神分裂的妄想症候群。因为精神分裂中相对特殊的症状,在妄想形式中可以得到最轻易的把握。Blankenburg则认为:精神分裂的本质结构变异是先于妄想的。因此,他致力于在精神分裂的症状贫乏型(主要是青春型和单纯型)中,寻找精神分裂的本质变异。他发现:精神分裂异常中的核心缺损是自然自明性的失落。根据胡塞尔的超越现象学,自然自明性失落有四个原因:与世界关系的改变、时间建构的改变、自我建构的改变、交互主体性的改变。Blankenburg的精神分裂理论,作为二十世纪有关精神分裂的最重要工作之一,对于今天的精神分裂研究仍然有极其重要的意义。     

ADOLESCENTS' PERCEPTION OF POLYGAMOUS FAMILY AND ITS RELATIONSHIP TO SELF-CONCEPT

This study investigated children's perception of the degree of affection present in their monogamous/polygamous families and assessed the influence of the perception on the subjects' self-concepts. It also examined the relationship of polygamy/monogamy to children's self-concepts. A total of 308 adolescents (134 from polygamous families and 174 from monogamous families) in eight secondary schools in Oyo State, Nigeria filled out a questionnaire and Akinboye's (1975) self-concept inventory. The subjects' assessment of their families was categorized into “secure ”and “insecure”. The results indicated that self-concept significantly correlated with the subjects' assessment of their families as “secure ”or “insecure”. Self-concept was also significantly related to the family being polygamous or monogamous. Family structure (polygamy/monogamy), however, showed no significant correlation with children's perception of their family as “secure ”or “insecure”.     

Understanding families in their own context: schizophrenia and structural family therapy in Beijing

Evidence from a number of family intervention strategies demonstrates a beneficial impact on the course of schizophrenia. It appears that different family interventions have generic features that aid the patient to avoid relapse and improve functioning. A significant challenge for researchers is to modify these generic strategies to be sensitive to different cultural groups in order to ensure their effectiveness. Chinese culture, with its distinct cultural norms governing family interaction and intense stigma towards the mentally ill, would seem to raise a particular challenge.
This paper offers an account of an eclectic model of structural family therapy that incorporates psychoeducation and behavioural treatments for schizophrenia as a theoretical guide to working in a cross–cultural context. A Beijing family, consisting of parents and their daughter with schizophrenia, were seen for sixteen months during a trial of family intervention in China. Through structural family concepts, China's sociocultural context of treatment resource constraints, population policy and stigma are examined and the impact of the illness on family organization is explored.     

Sequential analysis as a method of feedback for family therapy process

Abstract

The purpose of this study was to examine the relationship between therapist verbal behavior and family cooperation and resistance during the second session of family therapy with juvenile delinquents. Sequential analysis was used to investigate the impact of one therapist's behavior on family resistance and cooperation in a sample of 12 families. The results of the sequential analysis revealed that therapist “support” and “teach” behaviors were associated with significant increases in the likelihood of family cooperation. The study provides an example of how sequential analysis can be used to inform family therapists about the impact of their behavior on families.