Family Intervention for Psychotic and Severe Mood Disorders

Abstract

Family intervention for the severe psychiatric syndromes—psychotic and severe mood disorders—has been established as one of the most effective treatments available, complementing but nearly doubling the treatment effects of medication. Often subsumed under the term family psychoeducation, it is a method for incorporating a patient’s family members, other caregivers, and friends into the acute and ongoing treatment and rehabilitation process. The descriptor psychoeducation can be misleading: family psycho-education includes many cognitive, behavioral, and supportive therapeutic elements; often uses a consultative framework; and shares characteristics with some types of family therapy. On the basis of a family–patient–professional partnership, the most effective models are essentially cognitive-behavioral therapy with consistent inclusion of family members as collaborators. Family psychoeducation can include any layperson or paraprofessional person who is providing support to persons with a severe mental illness. It combines providing clear and accurate education for family members about the psychobiology of the major disorders with training and ongoing guidance in problem-solving, communication, and coping skills, while providing and developing social support. The goals are both to markedly improve clinical and functional outcomes and quality of life for the patient and to reduce family stress and strain as an indispensable means of achieving those outcomes. Family psychoeducation combines the complementary expertise and experience of family members, patients, and professionals. Family psychoeducation has been empirically shown to improve outcomes in schizophrenia and bipolar disorder to the same degree as, or to a greater degree than, medication in numerous research studies. Family intervention is particularly beneficial in the early years of the course of a mental illness, when improvements can have a dramatic and long-term effect and while family members are still involved, open to participation and change in attitude and interaction with the patient. Patients who experience frequent hospitalizations or prolonged unemployment and families who are especially exasperated, confused, and hostile about the illness benefit substantially and often dramatically. When a family member is available, psychoeducation should be applied as widely and as routinely as medication. Family psychoeducation originated from several sources in the late 1970s. Perhaps the leading influence was the growing realization that conventional family therapy, in which family dysfunction is assumed and becomes the target of intervention for the alleviation of symptoms, proved to be, at least, ineffective and perhaps damaging to patient and family well-being. Awareness also grew, especially among family members themselves and their rapidly growing advocacy organizations, that living with an illness such as schizophrenia is difficult and confusing for patients and families alike. The resulting stresses on families often lead to interactions and persisting patterns of interaction that can have equally devastating effects on the patient and the course of the disorder over time. It became increasingly clear that to adapt under these circumstances, the family must possess the available knowledge about the illness itself and coping skills specific to a particular disorder, skills that are counterintuitive to most families. It became clear that it was unrealistic to expect families to understand such mystifying disorders and to know what to do about them independent of professional guidance. The most adaptive family was increasingly seen to be the one that had access to information, with the implication that clinicians are a crucial source of that information. Families develop methods of dealing with positive, negative, and mood symptoms; cognitive deficits; functional disabilities; and the desperation of their ill relative through painful trial and error. These successes, however, are rare. Another critical need is that families have access to one another to learn of other families’ successes and failures and to establish a repertoire of clinically effective coping strategies that are closely tailored to the disorder and to the individual person. Furthermore, family members and significant others often provide emotional and instrumental support, case management functions, financial assistance, advocacy, and housing to their relative with mental illness. Doing so can be rewarding but poses considerable burdens. Family members often find that access to needed resources and information is lacking. Too often, the end result is a family that is sufficiently anxious, confused, or even hostile that their interactions with the patient become risk factors for relapse, functional deficits, and eventually deterioration. Given that perspective, clinical investigators began to recognize the crucial supportive role families play in outcome after an acute episode of schizophrenia and endeavored to engage families collaboratively, sharing illness information, suggesting behaviors that promote recuperation, and teaching coping strategies that reduce their sense of burden. The group of interventions that emerged became known as family psychoeducation. These approaches recognize that schizophrenia and mood disorders are brain disorders that are only partially remediable by medication and that families can have a significant effect on their relative’s recovery. Functional deficits and behavior changes induced by these disorders are often the most confusing and burdensome for family members because the family members usually do not identify them as part of the disorder, but they nevertheless find themselves supporting the affected member to compensate for those deficits. The psychoeducational approach shifted the focus away from attempting to get families to change their “disturbed” communication patterns toward educating and persuading families that their interactions with the patient can facilitate recovery by compensating for deficits and sensitivities specific to the various disorders. For example, a family might interfere with recuperation if in their natural enthusiasm to promote and support progress, they create unreasonable demands and expectations, but the same family could have a dramatically positive effect on recovery by gradually increasing expectations and supporting an incremental return of functioning. Research conducted over the last three decades has supported evidence-based practice guidelines for addressing family members’ needs for information, clinical guidance, and ongoing support. This research has found that altering key types of negative interaction, while meeting the needs of family members, dramatically improves patient outcomes and family well-being. Several models have evolved to address the needs of family members: individual family consultation (Wynne 1994); professionally led family psychoeducation (Anderson et al. 1986; Falloon 1984) in single-family and multifamily group formats (McFarlane 2002); modified forms of more traditional family therapies (Marsh 2001); and a range of professionally led models of short-term family education (sometimes referred to as therapeutic education ) (Amenson 1998). Family-led information and support classes or groups such as those of the National Alliance on Mental Illness (NAMI) are also available (Pickett-Schenk et al. 2000). Of these models, professionally led family psychoeducation has a deep enough research and dissemination base to be considered an evidence-based clinical practice (Dixon and Lehman 1995; Dixon et al. 2001; Lehman et al. 1995; McFarlane et al. 2002). Professionally led psychoeducational models are offered as part of a treatment plan for the patient and are usually diagnosis-specific. The models differ in format (multiple-family, single-family, relatives only, combined), structure (involvement or exclusion of the patient), duration and intensity of treatment, and setting (hospital, clinic, home). They place variable emphasis on didactic, emotional, cognitive-behavioral, clinical, rehabilitative, and systemic techniques. Most have aimed to achieve clinical and functional patient outcomes, although family understanding and well-being are assumed to be necessary to achieve those outcomes. All focus on family resiliency and strengths. Described here are the theoretical background for this treatment model, evidence of its effectiveness, and its major components and technical features.