Family Psychoeducation for Schizophrenia

As we mentioned previously, family therapy began with hopes for a psychosocial cure for schizophrenia and ran into the intractability of an illness with a strong biological base. Over time, however, the bloom went off the biological-only approach as patients recycled in and out of hospitals following repeated psychotic breaks over the years. The expressed emotion research described in chapter 2 pointed to a promising new approach to treatment that combined medication with a family treatment for reducing negative family interactions. This new approach, termed family psychoeducation, differed in an important way from traditional family therapy in not assuming that family dynamics caused the illness; rather, the family has a role in whether the illness is controlled or the patient has repeated relapses (Anderson, 1983).

There are several forms of family psychoeducational treatment for schizophrenia, including individual family treatment and treatment with groups of families. Patients are generally young adults with schizophrenia or schizoaffective disorders who have experienced a psychotic episode and a hospitalization. The treatment involves a didactic component and a family change component. Families are taught that schizophrenia is a brain disease caused by a variety of factors, some known and some not yet known. It runs in families—that is, it has a genetic component—but family problems do not cause the disease. Once the illness occurs, however, certain psychosocial stresses in the family create risk for relapse, and families can take steps to improve their communication and problem-solving capacities to help prevent relapse. This involves learning to be supportive but not intrusive, to reduce everyday levels of intensity, to avoid heated conflict, and to engage in constructive problem solving. This approach to working with the family (adapted by Anderson, 1983, from structural family therapy) is accompanied by other vocational and rehabilitation services, with the family heavily involved in helping their ill member to become engaged with the community.

In a large number of studies comparing family psychoeducation plus medical management to medical management plus standard supportive counseling for the patient, family psychoeducation has proved to be highly effective in preventing relapse and rehospitalization. Twenty-seven studies reviewed by McFarlane, Dixon, Lukens, and Luksted (2003) found positive results, while only three studies did not. The family psychoeducation treatment groups averaged 50% lower rates of rehospitalization. In recent years, with this finding so well established, researchers have shifted their focus to additional aspects of the illness, particularly its effects on everyday life and participation in community. Results have been positive in these areas as well, with increased patient participation in vocational rehabilitation, higher employment rates, and improved social functioning as a result of family psychoeducation and community support (MacFarlane et al., 2003).

It is ironic that the powerful effects of family therapy have been found for a disorder that the field largely walked away from after the first generation. Giving up on a full explanation of the origins of schizophrenia led the second generation of family therapists to reenter the field of schizophrenia treatment with more humility and produce remarkable results. Unfortunately, however, this evidence-based approach to treating schizophrenia has not yet widely penetrated a treatment field committed in an individual, biomedical approach. Dissemination is a central focus of current efforts by leaders in this important area of work. In the meantime, researchers are also replicating the positives effects of family psychoeducation with schizophrenia with another serious biologically based mental illness—bipolar disorder—where individual treatments outside of psychopharmacological ones have not been especially effective (Rea et al., 2003).