The Current Literature
British Journal of Psychiatry (1992), 160, 272â€”275
Psychosocial Family Intervention A Review of Empirical
in Schizophrenia: Studies
L. KUIPERS, M. BIRCHWOOD and R. G. McCREADIE
â€œ¿This paper reviews the recent empirical studies on psychosocial family intervention in schizophrenia. Six family educational intervention studies and five more intensive family work studies with 2-year follow-up have been included. A series of questions is asked relating to
the effects of such interventions, the efficacy of the different educational models, the active ingredients of these multi-component treatment packages, and the contribution of this new generation of studies to our understanding of the mechanisms through which these
interventions work. Suggestions for further research are made. Finally, from the published manuals, the common components of these diverse, multi-component treatment packages of different family-intervention studies are identified.â€•
The summary quotedaboveisfrom an article by
in this: once researchers are able to move away from
Lam (1991). The present authors comment upon the study.
the â€˜¿we know best, and its your fault' idea to being able to deal with families' genuine problems, real progress can begin to be made. This is in contrast
were invited to
to the 1970s and earlier, when there was almost no
therapeutic family intervention with these families;
This is an impressive and carefully observed paper, looking in detail at the relevant empirical studies. Lam asks important questions about effects, mechanisms, active ingredients, common components, and theoretical issues in psychosocial family interventions in schizophrenia. The paper emphasises that the ten years of published studies have found that there are psychosocial treatments that work. Such inter
it was not attempted,
ventions do not prevent relapse, which was the initial hope, but they do delay it, and it can be argued, as Lam does, that there are benefits both in cost effectiveness and in the social effects of fewer hospital admissions. He makes clear what is currently known about such interventions â€”¿ that education does not change outcome by itself, despite the often repeated requests from relatives that this is what professionals should provide. This suggests that this consumer request can indeed be supplied, but that it is only part, probably the acceptable and articulated part, of what can be offered. It has face validity and is likely to be important in increasing feelings of mastery and self-esteem, but is only the beginning of a process of change. The interventions themselves are marked by a surprising amount of consistency between teams spanning
countries and continents. This suggests that in genuine therapeutic partnerships, families are as able to shape researchers' behaviour as the other
way round. There seems a remarkably helpful shift
was not successful, or families
dropped out. Being empirically driven, this research has had the advantage of adapting and incorporating things that work, rather than being hindered by an ideological position. So far, we mainly only know what is less successful from the study by Kottgen et a! (1984), which seems to show that it is not just thera peutic contact that is important but a specifically psychosocial rather than psychodynamic approach. Paradoxically, other unsucessful studies may also help to illuminate these issues (Vaughan eta!, 1992). Lam's section on theoretical frameworks is one of the few attempts to link theory with these treat ment studies. The research on expressed emotion (EE) seems to have been successful because it has had predictiveutility, aswell asan ability to measure complex family attitudes and behaviour. This has left some freedom to develop a flexible treatment
approach. However, Lam suggests that now, â€œ¿the specificity and quality of family interventionsâ€• can only increase if theoretical links are considered. This â€˜¿cart-before-the-horse' effect of EE research is, however, difficult to deal with. EE has never fitted neatly into available theories of family functioning, and this has probably been part of its usefulness. At its present stage, it is even less likely to fit neatly into predetermined categories. EE is still a measure that spans various diagnoses. Because of a lack of longi tudinal studies, it is unclear what its genesis is. We still do not know clearly how it varies naturally over time, and how this might interact with coping skills,
A REVIEW OF EMPIRICAL STUDIES burden and distress, and changes in patients' symptoms. We do not even have data on its development and extent in the normal population, although there is some information that it is not specific to relatives, but also exists in staff.
Does this matter or not? Research has proceeded so far in delineating useful approaches for families dealing with schizophrenia. These can be refined and extended, and the exact nature of the active ingredients elucidated. The theoretical links Lam proposes seem quite plausible. For them to be useful, Pt
testable studies. This remains to be done. The issue that most studies are still in the research arena and not part of routine practice is alluded to by Lam in his section on training. Unlike medication, which can be quality controlled by the manufacturer and prescribed by qualified practitioners anywhere, [email protected]
their use to be disseminated, clinicians may have to learn new skills. Quality control then has to be exercised to ensure that the skills are actually delivered. This is a new problem and is only gradually being confronted. In the same way that cognitive therapy is now more widely available, it is obvious that these treatments can be extended. Are they then as effective?
This is probably
the main challenge
the next ten years of research in social intervention in schizophrenia.
M. Birchwood The 1980s have seen the publication of the first generation of studies of family intervention in schizophrenia. They are of profound significance, since they appear
often regarded as malignant can be controlled (in the short term at least) through environmental inter vention; this has important implications, not only for the provision of services, but also for the concepts which underpin our thinking about this disorder. This excellent review by Dominic Lam is propitious in offering an opportunity to take stock and consider whether a second generation of such studies is warranted, what issues they should examine, and what form they should take. The paper is positive in its assessment of family intervention studies. It is suggested that we now proceed to â€œ¿dismantling methodologyâ€•, which might uncover the active ingredients of these successful interventions, to broadening the outcome measures, and to the standardisation of training. While I agree with these last two suggestions. I would caution against the first, for two broad reasons.
The first of these is that dismantling methodology implies an excessive reliance on empiricism (versus theory) to advance a degree of understanding which
I do not believe it will be able to deliver. This brings to mind the long series of such studies that took place following the introduction of systematic desensiti sation for fears and phobias. That atheoretical approach did not substantially advance under standing or the efficacy of treatment, which awaited theoretical innovation (e.g. the cognitive model of panic) before further progress could take place. It is,
interior underlying EE (other than the general stress vulnerability model) that is responsible for the apparent diversity of interventions. Lam does a great service
components of the family intervention studies, and one hopes that this will inform the development of a theoretical framework, which alone can improve the specificity and process of family intervention. Secondly, there remains much to be done before we can be confident that these studies are controlling relapse and that the change to the family interior is responsible for this (internal validity). We also have to clarify to what population, with what constraints, and with what outcomes, these results can be generalised (external validity). As Lam indicates, family interventions are labour-intensive packages of care, in which relatively small groups of patients are (suddenly) receiving sustained attention from a team of highly skilled and dedicated clinicians, in addition to the intervention itself; contrast groups by and large receive neither of these. This level of attention alone will, for example, increase a patient's access to services (e.g. attendance at day centres), provide prompt medical intervention (early inter vention was itself a component of the Falloon study), and provide direct and close support of patients and families. Reports of superior short-term outcome that derive from intense community contact with patients (Stein & Test, 1980) and early intervention (Jolley et a!, 1989) lend support to this possibility, which has yet to be adequately controlled for. Lam cites the results
of the Tarrier
that there were no differences in contacts with the clinical team between groups; however, what is more important is that there were marked differences between groups in total contacts with services. Greater attention needs to be made in the next
generation of studies to the care received by the control groups by, for example, instituting a form of case management and medication monitoring, which excludes the family component, independent of the specific intervention team. Unfortunately, there is no equivalent of the double-blind placebo
KUIPERS ET AL
method in psychosocial interventions, yet expectancy effects must be powerful in such new, high-profile
studies, two from the UK and two from the USA,
practisedin different ways, cutsthe relapserate over
Since family interventions
which have clearly shown that family management,
to control relapse in high-EE families only, intervening in an unselected (high- and low-EE) sample of families but keeping the clinical team blind to EE status in both experimental and control groups would offer some experimental control. Improving social functioning is an aim of some interventions (e.g. Barrowclough & Tarrier, 1990) and not others (e.g. Leff et al 1990). The Hogarty study compared drug-only controls with those receiving social skills training, family intervention,
a 9- to 12-month period after treatment, possibly
and family intervention and social skills training
combined. Social skills training significantly reduced the rate of relapse without changing relatives' EE. Also, the rate of relapse among those families
(McCreadie et a!, in preparation) among other things
remaining high in EE after intervention was42% for controls,
33% for family treatment,
29% for social
skills training, and 0Â°lo for social skills training and family intervention combined. This suggests that improved social functioning itself and the intense support and improved social functioning that came with the combined treatment was sufficient to control relapse, and may have contributed to the overall effect of family intervention. The coming era of community care will place added pressures on families, but the relationship of family burden to EE is unclear (Kuipers & Bebbington, 1988). High EE is defined empirically by its ability to predict relapse; however, easing the long-term burden on families may require inter ventions directed to a broader range of families, possibly using different methods. It is for reasons such as this that studies of external validity are of interest to service-orientated clinicians; ultimately, it is to be hoped
that they will answer
â€˜¿what kind of interventions are appropriate for what kind of family, for what kind of outcome?'.
R. G. McCreadie In a replication study reported by Brown et al(1972), a significant association between relatives' level of EE and schizophrenic relapse was found. In the discussion, the authors gave seven â€˜¿tips' to help clinicians help schizophrenic patients and their families: none of these suggested family treatment. Ten years were to pass before the first study from the Medical Research Council (MRC) Social Psychiatry Unit suggested that family intervention reduces relapse rates (Leff et a!, 1982). Lam's review supports the now generally held view that family therapy or management in schizophrenia is a â€˜¿good thing'. He quotes four main groups of
improves patients' social functioning, and may improve the family atmosphere as assessed by the
level of EE. How family therapy helps is not clear, but it seems that education alone is not sufficient. The principal studies quoted in the review are well known to most clinical psychiatrists who are interested assume
in schizophrenia: family
one might therefore
more generally adopted. The most recent review of rehabilitation
asked psychiatric facilities serving more than 80% of the Scottish population about family intervention services: only three out of 21 had such services, and those were at a rudimentary level. Why is this? There are at least three important reasons, all of which are touched on in Lam's review. Firstly, family intervention packages do not prevent relapse, they simply postpone it. Relapse rates are certainly down over the first nine months or one year after intervention. For example, for the family-treatment group, rates range from 6Â°loto 23%, compared with 40% to 53% in the comparison groups. By 24 months, however, the differences were less impressiveâ€”the relapse rate in most studies was about 40% in the family-treatment group. Thus, in the longer term, and clinicians usually have to look after schizophrenic patients in the longer term, results are disappointing. However, the treatment given in the reported studies, although intensive, was relatively short. Lam suggests that a model of therapy which entails working on a continuing basis with families would be more appropriate. Secondly, it is not always easy to convince relatives
of the need for family management. Lam points out that in the study by Leff et a! (1989, not 1988 as his list of references suggests) 5 out of 11 families refused to attend relatives' groups. In a more recent review (McCreadie et a!, 1991), over 50Â°loof relatives refused to participate in a treatment programme. Thirdly, and perhaps most importantly, the family treatments reviewed by Lam are labour-intensive packages. The projects were research-based and were carried out by â€œ¿highly motivated and highly skilled research teamsâ€•. However, can family management be carried out by less skilled and less committed clinicians who may well have many other things to
do in a busy working day? Clearly, Scottish psychiatrists have their doubts, although Lam reports that the MRC Social & Community Psychiatry Unit (where
A REVIEW OF EMPIRICAL STUDIES with appropriate â€˜¿
scales to measure competence
â€˜¿take-up' of such a training by National Health Service professionals and the use made of it will be awaited with interest.
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L. Kuipers,BSC,MSc,PhD,FBPS,SeniorLecturerin Psychology,District ServicesCentre, The Maudsley Hospital, Denmark Hill, London SE5 8AZ; M. Birchwood, Top Grade Clinical Psychologist, All Saints Hospital, Lodge Road, Birmingham B18 .NSD;R. G. McCreadie, BSc,MD,FRCPsych, Director, Department of Clinical Research, Crichton Royal Hospital, Dumfries DGJ 4TG
Psychosocial family intervention in schizophrenia: a review of empirical studies. L Kuipers, M Birchwood and R G McCreadie BJP 1992, 160:272-275. Access the most recent version at DOI: 10.1192/bjp.160.2.272
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