'Psychosocial' interventions with families and their effects on the course of schizophrenia: a review

Parental Expressed Emotion and Youth Psychopathology: New Directions for an Old Construct

Levels of parental expressed emotion (EE) are prospectively associated with the symptomatic course of a range of childhood psychiatric disorders. This article reviews the literature linking parental EE to youth psychopathology and proposes a novel framework for understanding its mechanisms of action. We find that, despite noteworthy methodological limitations, parental EE is linked consistently to a more deleterious course of mood, anxiety, and psychotic disorders in youth. Its mechanism of action is unknown. Models of "toxic family stress" (referring to frequent, sustained, and uncontrollable stress without protective influences) provide one framework for understanding how high EE environments interact with individual biological vulnerabilities to promote illness onset and recurrence. Research aimed at understanding biological responses (e.g., stress reactivity, arousal) to familial EE is needed. Such work may inform efforts to understand how EE affects the course of psychiatric disorders and may guide the development of novel interventions emphasizing emotion regulation strategies.

A Hostel-Based Psychoeducational Intervention for Schizophrenia: Program Development and Preliminary Findings

Past research on interpersonal relationships and schizophrenia has typically focused on the relationships between clients and their families. However, many ex-patients live in other settings, such as boarding houses and hostels, where their main contact is with other residents. This paper represents a preliminary demonstration of a program to reduce levels of negative communication within two hostels, using a multiple baseline design. The intervention comprised a seven-session group program that was adapted from a psychoeducational family approach. Negative communication within hostels was measured in a brief interview with each resident. Results showed a marginally significant effect of the program on critical comments within the interviews.

Feasibility of a supported self-management intervention for relatives of people with recent-onset psychosis: REACT study

BACKGROUND

Relatives of people with psychosis experience high levels of distress and require support. Family interventions have been shown to be effective in improving outcomes but are difficult to access and not suitable for all relatives.

AIMS

To assess the feasibility and effectiveness of a supported self-management package for relatives of people with recent-onset psychosis.

METHOD

A randomised controlled trial (n = 103) comparing treatment as usual (TAU) in early intervention services with TAU plus the Relatives' Education And Coping Toolkit (REACT) intervention (trial identifier: ISRCTN69299093).

RESULTS

Compared with TAU only, those receiving the additional REACT intervention showed reduced distress and increased perceived support and perceived ability to cope at 6-month follow-up.

CONCLUSIONS

The toolkit is a feasible and potentially effective intervention to improve outcomes for relatives. A larger trial is needed to reliably assess the clinical and cost-effectiveness of REACT, and its impact on longer-term outcomes.

A Behavioural Family Intervention with a Schizophrenic Patient: A Case Study

A schizophrenic patient and his family were provided with a nine month multi-component behavioural intervention programme as part of a controlled study. The patient was at high risk of relapse according to the High EE status of his parents. Multiple outcome measures were used to assess the efficacy of the programme. The components of the intervention are described in detail, and the specificity of component effects in this case are examined. Given the methodological limitations of this type of study, it is not possible to demonstrate conclusively intervention effects in the case reported. However, following the intervention the relapse rate of the patient was reduced, his social functioning improved and the EE status of his parents changed from High to Low.

Behavioural Psychotherapy and Schizophrenia: The Past, the Present, and the Future

Behavioural therapists have been involved with the management of schizophrenia since the emergence of the discipline in the 1950s. It has been stated recently that behaviour therapists have lost interest in serious mental illness. However, in the last few years great advances have been made in behavioural approaches to the management of schizophrenia. Controlled trials of family management methods have indicated that: relapse rates can be reduced, the patient's social functioning increased and family burden decreased. These approaches also have economic benefits over traditional services. Furthermore, other methods, such as early signs monitoring followed by early intervention and self-management of drug resistant residual symptoms, have also shown promise. The development of these innovative behavioural approaches is especially important in an era of community based mental health services.

The Cognitive-Behavioural Treatment of Hallucinations and Delusions: A Preliminary Study

Five patients suffering from chronic and distressing psychotic symptoms were treated with a cognitive-behavioural approach designed to modify their beliefs that their auditory hallucinations were real, and to enhance their ability to control psychotic experiences. Four of the patients reported an increase in their ability to control hallucinations, but only one of these also reported a decreased frequency of hallucinating and a reduced belief in the reality of hallucinations. The discussion focusses on the implications for future interventions in this area.

Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale?

Schizophrenia is a severe and disabling disorder with considerable psychological, social and economic costs. Over the last 15 years there has been a significant development in the use of cognitive behaviour therapy for psychosis (CBTp) in the treatment of schizophrenia, with 20 randomised controlled trials having been published. The majority of this work has been with alleviating medication resistant symptoms in chronic patients, but preliminary work has also been carried out with speeding recovery in acute schizophrenia and in relapse prevention and early intervention. A review of these studies indicates modest effect sizes, with the strongest evidence available for chronic patients. There is evidence that the effect size of the trials is significantly and negatively correlated to their methodological quality. We conclude cautiously that overall there is good evidence for the efficacy and effectiveness of CBTp in the treatment of schizophrenia.

Multiple family group interventions in first episode psychosis: Enhancing knowledge and understanding

Families play a major role in promoting recovery and preventing relapse following the first psychotic episode. This paper presents a multiple family group education programme for the families of clients with first episode psychosis. The educational needs of the families are also discussed. The results of this evaluation show that the programme improved the families' perceptions of their overall knowledge and understanding of mental illness and its treatment. This evaluation demonstrates the efficacy of such groups and the key role of community mental health nurses in providing family interventions.

The management of schizophrenia: cognitive behavioural therapy

Over the past decade advances in the management of schizophrenia in the community have involved increasing emphasis on the psychosocial dynamics of care, coordinated through a care programme approach, and the introduction of new medication. In particular, the use of cognitive behavioural therapy (CBT) has been shown to be an effective means of tackling symptoms associated with schizophrenia (Jones et al, 1998). While some of the techniques used in CBT may be too advanced for untrained therapists to use, the approach described in this article may be used by registered mental health nurses and community professionals. This approach includes medication adherence, coping strategies, questioning style, the prevention of patient relapse and dealing with relatives.

Burden of care, psychological distress and satisfaction with services in the relatives of acutely mentally disordered adults

This project aimed to examine the views of relatives nominated as the "most significant other person" by acutely mentally disordered patients who were newly referred to either a community-based (n = 24) or a district general hospital based (n = 17) psychiatric service. Relatives were asked about their satisfaction with these services, the psychological impact on them of caring for a mentally disordered relative, and levels of subjective and objective burden of care at the time of referral and 6 months later. The findings of this study suggested that the initial severity of an acute psychiatric disorder rather than the type of psychiatric service provided is more strongly associated with objective and subjective levels of burden. At follow-up, psychological distress as measured on the General Health Questionnaire (GHQ) was associated with the objective burden of caring for a relative with psychosis or major affective disorder, but not other conditions. Dissatisfied relatives tended to be those who remained distressed at 6 months according to GHQ scores or those recording continually high levels of subjective burden on the Burden of Care Schedule (BCS). Interventions to reduce subjective and objective burden should be targeted at the group demonstrating persistent stress.

An overview of family interventions and relapse on schizophrenia: meta-analysis of research findings

The purpose of this overview is to appraise the studies on the efficacy and effectiveness of family interventions in decreasing relapse in schizophrenic patients. The studies were identified by means of a computerized MEDLINE search, and the scanning of review articles and the reference lists of the primary articles identified. More than 300 citations were reviewed, and the potentially relevant articles revealed six randomized controlled trials that were included in this meta-analysis. The criteria for selecting potential studies as well as for the meta-analysis were tested by means of an inter-rater reliability check that showed a good agreement between two independent raters (kappa = 0.83, and kappa = 0.82, respectively). There were independent assessments of the quality of the studies selected, and data extraction comprised a descriptive information of the study population, the types of interventions, and the relevant outcome measurements. The total number of patients included in the six trials was 350 (181 in the control group and 169 in the experimental group). Regarding the decrease of relapse in the experimental group, the pooled odds ratios and their 95% confidence intervals were: 0.30 (0.06, 0.71) for six months; 0.22 (0.09, 0.37) for nine months; and 0.17 (0.10, 0.35) for the 2-year follow-up. Two to five patients needed to be treated to avert one episode of relapse in a nine-month follow-up. The changes in Expressed Emotion status between experimental and control group combining nine months and one year follow-ups were shown to be marginally significant (P < 0.06), in favour of the experimental group. Emotional over-involvement was also marginally significant (P < 0.07), and there was no statistical difference in the distribution of criticism and hostility. In addition, the experimental group showed a significant increase with drug compliance and a reduction in hospitalization over time. These findings are discussed in light of the potential ingredients in the efficacy of family interventions by focusing on the limitations of using relapse as primary outcome in the assessment of efficacy trials with schizophrenic patients.

The burden of schizophrenia on the family. A study from Nigeria

The burden of schizophrenia on rural and urban Nigerian families was studied using a standardised questionnaire. Rural families experienced more burden; however, the difference was significant only in respect of financial burden. Rural families of schizophrenics were shown to be more prone to minor psychiatric morbidity than urban families. Policies should be instigated to reduce such burden.

Psychosocial factors, arousal and schizophrenic relapse. The psychophysiological data

This annotation describes psychophysiological research that has examined the hypothesis that autonomic hyperarousal is a possible mediating factor between schizophrenic relapse and psychosocial influences such as expressed emotion (EE) and life events. We review several studies that have measured psychophysiological activity in schizophrenic patients while in the presence of their relatives. The findings from this area of research are compared with those of other psychophysiological studies of schizophrenia which have employed more traditional laboratory tasks such as the electrodermal response-habituation paradigm. Finally, some conclusions are drawn regarding the clinical implications of psychophysiological research, and areas for future investigation are suggested.

Training community psychiatric nurses for psychosocial intervention. Report of a pilot study

Community psychiatric nurses were trained to deliver psychosocial intervention to clients with a diagnosis of schizophrenia living at home with relatives. The training package consisted of family assessment, health education, and family stress management strategies. In a 'quasi-experimental' design, a sample of families (n = 54) were recruited to either a control or experimental condition and followed up for 12 months. A number of favourable outcomes were observed in the experimental group, including improvements in the client's target symptoms, personal functioning, and social adjustment. Relatives' satisfaction with services increased and reports of their own minor psychiatric morbidity improved.

Recent developments in expressed emotion and schizophrenia

Expressed emotion (EE) has substantial scientific support as a predictor of relapse of positive symptoms. The median relapse rate in a high-EE environment is 48%, compared with 21% in a low-EE environment. This effect does not seem to be due to confounding with other variables, but it is subject to limitations in its scope of application. EE probably determines relapse through its effect on emotions and symptom control. A stress-vulnerability model of relapse is advanced that incorporates biological factors as well as cycles of mutual influence between symptomatic behaviour, life events, and EE. Aversive types of behaviour in patients and their relatives are seen as understandable reactions to stress that are moderated by social perceptions and coping skills. Families have made positive achievements, including the provision of non-invasive support.

Prediction of relapse of schizophrenic patients: Camberwell Family Interview versus content analysis of verbal behavior

In a replication of the study by Gottschalk et al. (1988), expressed emotion scores derived from the Camberwell Family Interview were compared with Anxiety and Overt Hostility Outward scores from a content analysis of verbal behavior based on a 10-minute speech sample from parents of 49 German schizophrenic inpatients. The scores from the two methods were significantly correlated, but only expressed emotion scores predicted relapse during a 12-month followup. Scores from the Gottschalk-Gleser content analysis did not exceed chance level in prediction of relapse.

The Sydney intervention trial: a controlled trial of relatives' counselling to reduce schizophrenic relapse

The result of a psychosocial intervention which aimed to reduce schizophrenic relapse through relatives' counselling is presented. Thirty-six schizophrenic patients living in high Expressed Emotion (EE) parental households were randomly allocated to an intervention or control group. The parents of patients allocated to the intervention were offered ten weekly sessions of counselling. The patient was not included in these sessions. Patients in both groups received standard after-care of medication and support. Relapses in the intervention group, although fewer, were not significantly different from the control group. Given the impressive evidence in favour of family interventions in reducing relapse rates in schizophrenic patients possible reasons for this result are discussed. Aspects of the intervention described here, exclusion of the patient, no control over the patients' medication or involvement with their management, short duration of intervention and lack of individual assessment, could explain this finding. This negative result is important in indicating what factors should be included in an effective psychosocial intervention.

Expressed Emotion in families of chronic schizophrenics and its association with clinical measures

A controlled clinical study on the outcome of family intervention in chronic schizophrenics is being carried out in Athens. All subjects participating in the study reside with their families and attend a vocational rehabilitation unit. Those belonging to families characterized by high "Expressed Emotion" (EE) are randomly assigned to either the experimental or the control condition. The former receive family intervention combined with individual treatment, the latter individual treatment alone. 75 subjects have entered the study, and 121 relatives were interviewed with the Camberwell Family Interview. 40 patients (53.3%) were found to belong to high EE families. The present article presents the results of the baseline assessment. It was found that the EE status of the family was significantly associated with measures of psychopathology and social functioning (BPRS, GAS, DAS, number of residual symptoms). Further analyses revealed that these associations exist only when all key relatives express high EE. The implications of these findings are discussed.

Psychosocial family intervention in schizophrenia: a review of empirical studies

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.

Family interventions for schizophrenia

Studies that have attempted to reduce schizophrenic relapse by the use of family interventions are described. Results from studies that implemented behavioral family interventions with patients who were identified as high risk because of the expressed emotion status of their relatives have demonstrated that relapse rates can be significantly reduced over a 2-year postdischarge follow-up period. A number of ongoing studies, especially those that are investigating the interaction of family interventions and different medication regimes, are also discussed. Areas for further investigation are identified, for example: the use of multiple outcome measures, the use of single-case studies and the development of ideographic assessment measures, the interaction of biological and environmental influences, the alleviation of the burden of care, the involvement of the consumer in services, the development of behavioral formulations and analysis of family engagement and compliance, staff training in intervention methods, and the translation of research results into clinical practice.

Life events and relapse in schizophrenia. A one year prospective study

Results from a one year prospective study of a relationship between major and minor life events (all other events), and relapse in twenty-two schizophrenic (DSM III-R) patients are reported. Seven (33%) patients relapsed during the one year of follow-up. Relapsed patients had experienced significantly more independent major and minor life events during the one year compared to non-relapsed patients. The independent events experienced by the relapsed patients occurred twice as often in the three month period prior to the relapse as compared to any other period among the relapsed, or the non-relapsed patients. These findings are discussed in the context of the prospective design of this study and the inclusion of minor as well as major events.

Social functioning in schizophrenic patients. I. The effects of expressed emotion and family intervention

The relationship between the social functioning of schizophrenic patients and the EE levels of their relatives is examined. Patients living with a high EE relative function significantly worse than those living with low EE relatives. This appeared to be due to a poorer social functioning in patients who lived with hostile relatives. Patients who participated in a nine month behavioural family intervention showed greater improvements in social functioning than control groups. The improvements could not be explained as being due to medication since high neuroleptic dosage over nine months was associated with poorer social functioning.

Expressed emotion and psychosocial intervention: a review

For thirty years research has been consistently demonstrating the validity of the concept of 'High Expressed Emotion' (HEE). After early pioneering work by Brown it was established that environmental influences, particularly, the emotion expressed by relatives to sufferers of schizophrenia, are strongly implicated in relapse. Consequently, the predictive validity of HEE has been revealed in a number of cross-cultural studies around the world. In addition, there is strong evidence from well designed intervention studies, that relapse, in schizophrenic clients living at home, can be prevented by the manipulation of social and environmental factors. The combined body of research that has now accumulated allows an hypothesis to be made about the aetiology of the illness, schizophrenia, itself. This theory has been described as the 'stress vulnerability' model. The paper concludes that psychosocial intervention strategies are effective but that, unfortunately, to date, their application has been mostly restricted to the intervention studies themselves.

Group sociotherapy: a psychoeducative model for schizophrenic patients and their families

The clinical and research community have identified critical issues in educating schizophrenic patients and their families about schizophrenia. A review of the literature, a comprehensive alternative model, and descriptive modules inherent in an effective group sociotherapy program are offered for schizophrenic patients in remission and for their families. The model provides advantages for monitoring patients on an outpatient basis and has applicability to mental health clinic, day hospital, and day treatment center programs.

The community management of schizophrenia. A controlled trial of a behavioural intervention with families to reduce relapse

Schizophrenic patients were recruited into a trial of a prophylactic behavioural intervention with families. Families with at least one high Expressed Emotion (EE) relative were randomly allocated to one of four intervention groups: Behavioural Intervention Enactive; Behavioural Intervention Symbolic; Education Only; Routine Treatment. Patients from low-EE families were randomly allocated to two groups: Education Only or Routine Treatment. Relapse rates over nine months after discharge were significantly lower for patients in the two Behavioural Intervention, compared with Education Only and Routine Treatment groups. There was little difference between the two low-EE groups. Patients returning to high-EE relatives showed significantly higher relapse rates than those returning to low-EE relatives, in groups not receiving active intervention. Changes from high to low EE occurred in the Behavioural Intervention groups, and similar although less extensive changes occurred in the Education Only and Routine Treatment groups. Changes in criticism and marked emotional over-involvement (EOI) occurred generally in high-EE groups but were larger in magnitude in the Enactive and Symbolic groups. Reduction of hostility only occurred in the Behavioural Intervention groups. These results give partial support for the causal role of EE in relapse. There were no significant differences between the groups with respect to contact with the psychiatric services or medication.

The assessment of psychophysiological reactivity to the expressed emotion of relatives of schizophrenic patients

The measure of expressed emotion (EE) of the relative has been found to be an important predictor of schizophrenic relapse. Electrodermal measures were recorded when the schizophrenic patient was talking to an experimenter, and when the patient was talking to a relative. Although there were no differences during the relative-absent period, patients with a high-EE relative present exhibited significantly higher frequencies of non-specific skin-conductance responses (NS-SCRs) than patients with a low-EE relative present. Patients show a significant decrease in NS-SCRs on the entry of low-EE, but not high-EE relatives. Patients with high-EE relatives show overall higher levels of skin-conductance levels (SCLs) than patients with low-EE relatives. Although patients with high-EE relatives rate themselves significantly more tense and anxious on self-rating scales, there are no significant correlations between self-ratings and electrodermal measures. The use of electrodermal reactivity as an assessment measure of relapse risk is discussed.

Assessing the functional value of relatives' knowledge about schizophrenia: a preliminary report

An instrument for assessing and evaluating what relatives know about schizophrenia was evaluated as both a pre- and a post-test for an educational programme. The Knowledge About Schizophrenia Interview (KASI) places emphasis on the functional value of the reported knowledge rather than on the recall of information; it is quick, easy to administer, can be rated reliably, and has face-validity for the relative. The educational programme increased scores from pre-test to a post-test one week after the programme. Relatives with high criticism ratings on the Camberwell Family Interview had lower scores at both tests. Relatives of less chronic patients showed lower scores at pre-test and acquired significantly more information from the programme, while relatives of more chronic patients were less influenced by the information sessions.

The burden of care: the impact of functional psychiatric illness on the patient's family

This paper reviews the literature on the effect of severe mental illness on other members of the patient's family. The burdens of caring for a patient at home are considerable. They often affect the caring relative's social and leisure activities, and financial problems arise frequently. Relatives have difficulties in understanding and coming to terms with illness-related behaviour. 'Negative' symptoms are often a particular problem. Despite their burden, relatives do not complain much, although they receive little support, advice or information from the professionals engaged in treating the patient; much is now known about the difficulties relatives face, but we still need to know how they can best be helped. Failure to do this will have bad effects on both relatives and patients.

Providing information to relatives about schizophrenia: some comments

There has recently been an increased interest in providing relatives of schizophrenic patients with information about the illness and how to manage the patient at home, due partly to the development of psychosocial intervention programmes (which frequently include an educational component) and a consumer demand for such information in an era of community care. Studies which describe the effects of such educational programmes are reviewed, and two different models of information acquisition are contrasted. These models have different implications, in terms of outcome measures, on how educational programmes should be evaluated. Guidelines are offered for practitioners wishing to give information to relatives.

Mindlessness and brainlessness in psychiatry

The theme of this address—that brain and mind are as warp and woof in the fabric of psychiatry—may seem so much a truism as to be a banal choice. I think not. Despite the lip service paid to brain-mind integration, its implications are daily contravened in both theory and practice. At least, this is so in the country where I reside. If the problem is more extreme in the States, as most everything seems to be, recall the words Sir Aubrey Lewis (1953) wrote in commenting on Anglo-American contrasts, some 30 years ago: “the chief differences between your psychiatric scene and ours are differences only of quantity and tempo.” Think of me, then, as an anthropologist describing an exotic foreign culture and reporting on the strange customs of the natives, in hope of shedding light on your own.

Family therapy and schizophrenia: recent developments

A review of recent studies of family interaction as a causal factor in the development of schizophrenia suggests a paucity of evidence supporting this point of view. However, research has suggested family variables may influence the course and outcome of schizophrenia. The impact of schizophrenia on the family has recently received more attention. Some research has identified differences between families of schizophrenics and the families of other diagnostic groups and controls. Whether these studies are beginning to influence the theory and practice of family therapy is discussed. Recent studies suggest the combination of long-acting medication and 'psychosocial' interventions may reduce the relapse rate of schizophrenia in the short term. This research suggests that family therapists must re-evaluate their role in the management of schizophrenia.

Expressed emotion and relapse

The relatives of 82 patients in a study of first episodes of schizophrenia were interviewed within six weeks of the index admission; 77 patients were subsequently discharged, and were followed to relapse or readmission. Analysis of relapse-free survival time was used to examine whether the components of 'expressed emotion' predicted relapse or response to neuroleptic medication: 'critical comments' by relatives was the only component present often enough to be used and was inversely related to 'social contact'. When preadmission duration of illness, and neuroleptic medication following discharge (identified previously as significant predictors of outcome) were taken into account, neither 'critical comments' nor 'social contact' were related to outcome nor to response to medication. The constellation of factors suggested as pathogenic was present only in a minority of cases: many patients lived alone and of those that were with families, most were not in high face-to-face contact with other members. The failure of the components of 'expressed emotion' to predict outcome or response to neuroleptic medication suggests that at best, such factors are weak predictors of liability to relapse. Their influence is unlikely to be comparable in magnitude to that of neuroleptic medication.