Family Mental Ilnes

f a m i l y p s y ch o ed u ca t i o n fo r
s e rio u s m e n t a l i lln e s s
EV ID ENC E- B ASED P R AC TIC ES SER IES
s eries ed it o rs :
David E. Biegel, Ph.D.

Elizabeth M. Tracy, Ph.D.
Mandel School of Applied Social Sciences,
Case Western Reserve University
Family Psychoeducation for Serious Mental Illness

Harriet P. Lefley
The Evidence-Based Practices Series is published in collaboration with

the Mandel School of Applied Social Sciences at Case Western Reserve University.
FA M I L Y P S YC H O E D U C A T I O N F O R
S E R IO U S ME N TA L I L L NESS
Harriet P. Lefley
1 2009
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Library of Congress Cataloging-in-Publication Data
Lefley, Harriet P.
Family psychoeducation for serious mental illness / Harriet P. Lefley.
p. cm.—(Evidence-based practices)
Includes bibliographical references and index.
ISBN 978-0-19-534049-5
1. Mental illness—Treatment. 2. Family psychotherapy. 3. Evidence-based psychiatry. I. Title.
RC480.L435 2009
616.89'156--dc22
2008046056
1 3 5 7 9 8 6 4 2
Printed in the United States of America

on acid-free paper
This book is dedicated to consumers with serious mental illness,
and to the families and friends who love them.
This page intentionally left blank
P RE F A C E
When I was asked to contribute a book to a series on evidence-based practices in

mental health treatment, I could only claim some degree of expertise in family
psychoeducation for schizophrenia and other serious mental disorders. However,
this is not my personal area of research. I must rely on the work of the greats in this
field, the pioneers whose work I have noted in the Acknowledgments section.
Although my research has been in other areas of mental illness, family psycho-
education and family education have been a major source of interest to me for at
least a quarter of a century. This book focuses on family psychoeducation, which
targets effects of family interventions on the persons with mental illness. However,
I am including a substantial section on family education, which targets the needs of
their families for coping skills. (Further distinctions between these two concepts
will be carefully discussed in Chapter 2.) Mental illness has a huge impact on fami-
lies, and alleviating psychological distress in caregivers is a legitimate concern for
mental-health professionals.
Several important books have been written about various models of family
psychoeducation and numerous overviews of the research can be found in the
literature. To the best of my knowledge, most of these are cited here and hopefully
integrated into a larger picture of what is actually going on in the field today. To this
end, I have also included descriptions of programs that are not readily available in
scientific journals. This book covers a wide range of models, from randomized
controlled studies to ongoing brief educational courses, with and without evalu-
ation data. The selection is based primarily on family psychoeducation programs
with rigorous research designs and outcome data, those that exemplify evidence-
based practice. However, briefer family education models are also included, con-
tingent on available research findings, but also on a program's longevity, updated
VII
VIII PREFACE
manualization, and number of people served. I have tried to give as broad and
inclusive a picture as possible of what is actually offered to families of individuals
with serious mental illness today, and apologize for any inadvertent omissions.
For practitioners wishing to implement evidence-based family psychoedu-
cation, with full fidelity to the research model, the most valuable resource is the
family psychoeducation toolkit developed primarily by Dr. William McFarlane and
Dr. Lisa Dixon, under the auspices of the Substance Abuse and Mental Health Ser-
vices Administration (SAMHSA). The toolkit is available online and in manual form
(see Department of Health and Human Services, 2003, and www.samhsa.gov).
During the last quarter century, family psychoeducation has proved efficacious
in significantly deterring relapse and re-hospitalization in patients with schizo-
phrenia, bipolar disorder, and various other diagnostic categories, and in many
cases enhancing families’ well-being. Although most of the research has focused
on schizophrenia, this intervention has proved beneficial across a range of severe
psychiatric disorders. But evidence-based family psychoeducation has reached
at best a few thousand families. National Alliance on Mental Illness's (NAMI)
Family-to-Family has been taught to over 125,000 families. Some empirical data are
now available for the effectiveness of this program, as well as for Journey of Hope.
Because there have been numerous other attempts to provide family education,
I decided to include a description of some of these other models, with whatever
data have become available on their outcomes. These may be helpful to clinicians
who wish to implement their own programs, but lack the resources available in
well-funded research projects.
For the past quarter century I have also been engaged in leading a psychoedu-
cational support group for families of people with severe mental illness at one of
the largest psychiatric centers in the southeast. This is an open-ended group, a
free service available to the public as well as to families of our patients. Families
come and go according to need. Some come only during a crisis. Others have come
consistently for ten or more years. Over the years thousands of families have told
me their stories.
When I speak about family experiences and family burden in the forthcoming
pages, much of what I say will be derived from stress theory and from the copi-
ous research on family burden. But research data provide a picture that is only as
comprehensive as the questions asked and answered. Few of the instruments that
measure stressful life events or family burden deal with patients’ access to hospi-
talization, legal constraints, or other aspects of mental-health systems that impede
timely treatment and cause frustration and grief to families. Nor do the research
instruments mention the effects of incorrect theories and ineffective treatments
on the psychological well-being of families. Distancing behaviors and failure to
communicate on the part of mental-health staff are serious aspects of family bur-
den, but they are not found in the measurement scales. Many issues that arise in
PREFACE IX
support-group discussions regarding malfunctioning mental-health systems,

which manifestly contribute to family disorder, are not found in the literature.
So, some of the observations in this book will be based on my years of listening to
families, as well as on citations from theory and research.
In the main, I have tried to present a comprehensive picture of what is currently
available to educate caregivers of people with serious mental illness, to distinguish
the aims of family psychoeducation and family education, and to present an argu-
ment for the usefulness of both. At the end, I speak of the potential for introducing
family psychoeducation as standardized treatment in mental-health systems, and
what we can expect for the future.
Clinicians and clinicians-in-training are well aware of the importance of social
context for recovery from mental illness. In current mental-health systems, not
only service providers, but other patients—consumers in recovery—are fulfill-
ing a long-needed, tremendously important role in helping people recognize their
strengths and lead satisfying lives. But for many consumers, families may be even
more critical, because caring, knowledgeable family members are lifetime support
systems. It is clear that they need information and understanding from the clini-
cians who treat their loved ones. I hope this book fulfills its aim of educating men-
tal-health professionals on the importance of educating families, friends, and all
others concerned with the welfare of persons with serious mental illness.
A C KN O W L E D G ME N TS
Much of this book is based on the pioneering work of Julian Leff, William
McFarlane, Carol Anderson, and the late great innovators Ian Falloon, Gerald
Hogarty, and Michael Goldstein. The research contributions of Robert Liberman,
Kim Mueser, David Miklowitz, Shirley Glynn, Jan Randolph, and Nina Schooler
have provided extremely valuable sources. In the United Kingdom, there are
seminal research findings from Liz Kuipers, Nicholas Tarrier, Christine Barrow-
clough, Paul Bebbington, Max Birchwood, Graine Fadden, Christine Vaughn, and
Dominic Lam. I might also add the contributions of Jose Canive, Steve Lopez, and
Amy Weisman, and anthropologists Janis Jenkins and Kim Hopper, to the issue of
cultural diversity. The writings of Thomas McGlashan and Patrick McGorry have
edified me on the early intervention research and its possibilities. Mary Fristad
at Ohio University has probably done the most important work with children,
applying family psychoeducation to pediatric mood disorders. Although I have
never met them, I have found extremely valuable the research of J. Bauml and
G. Pitschel-Walz in Germany, M.J. Masanet and I. Montero in Spain, L. Magliano
and A. Fiorillo in Italy, and the studies published by M.Phillips, M. Xiang, W.Xiong,
and M. Zhang and their colleagues in China. The Optimal Treatment Project team
of Ian Falloon, Rita Roncone, and their many colleagues in Europe and elsewhere,
continues to add immeasurably to our knowledge. And Bill McFarlane continues
to expand his demonstrably effective multi-family model into ever-widening areas
of research and practice.
Professor Lisa Dixon, University of Maryland, has done invaluable work on
many levels. Her collaboration with Anthony Lehman on the Schizophrenia Patient
Outcomes Research Team (PORT) study first publicized the importance of family
psychoeducation as a treatment modality for schizophrenia (see Introduction).
XI
XII ACKNOWLEDGMENTS
In her continuing overviews of family psychoeducation and her controlled stud-

ies of the Family-to-Family Program of the NAMI, Lisa Dixon has added immea-
surably to our knowledge of what works for people with mental illness and their
families. Susan Pickett-Schenk, University of Illinois, has also added to our knowl-
edge of the effects of family education and Judith Cook to our knowledge of fam-
ily burden. Phyllis Solomon, University of Pennsylvania, and her colleague Jeffrey
Draine have been major, prolific researchers of family support groups and family
education. Edie Mannion and Marilyn Meisel of the Technical Assistance Cen-
ter of Southeastern Pennsylvania, and Robert Coursey, University of Maryland,
were early developers of family education and in their collaborations with Phyllis
Solomon produced important research findings on its effects. Charles Rapp at the
University of Kansas School of Social Welfare and Mental Health Research Labo-
ratory helped develop curriculum and training materials on psychoeducational
approaches that could be used by family support groups (see Wintersteen, 1987, in
Appendix) also Christopher Amenson of Pacific Clinics Institute. There are many,
many others; I wish I could acknowledge them all.
I have known and communicated with most of the researchers mentioned
at some point in my life, and have been greatly enriched by their insights. Some
have remained long-time personal friends. And now I want to express my deepest
appreciation to some very special people with whom I have collaborated for almost
three decades. Professors Agnes Hatfield, Dale Johnson, Mona Wasow, and Diane
Marsh, with whom I have co-authored several books and/or articles, have been
treasured friends and colleagues throughout the years. Agnes Hatfield, professor
emerita, University of Maryland and an early president of NAMI, must be hailed
as a pioneer in conceptualizing and writing about the family experience of mental
illness in terms of stress, coping, and adaptation theory. Her early work in family
education was later specialized in psychoeducational work with elderly caregiv-
ers. Dale Johnson, professor emeritus, University of Houston, also a former NAMI
president, trained generations of clinical psychologists and expanded his interest
in culture, particularly American Indian cultures, into an international perspec-
tive as President of the World Fellowship for Schizophrenia and Allied Disorders.
Professor Mona Wasow, University of Wisconsin, has trained generations of clini-
cal social workers to facilitate rehabilitation and recovery of persons with severe
mental illness. Professor Diane Marsh, University of Pittsburgh, has influenced a
generation of psychologists to become more invested in serving persons with seri-
ous mental illness. Our friendships and collaborations as NAMI members have
been invaluable in conveying the needs of family caregivers to new generations of
clinicians. Dr. Joyce Burland, Director, NAMI Education, Training, and Peer Sup-
port Center, has been an invaluable source of information on NAMI educational
activities and also a valued friend and colleague throughout the years. Nursing edu-
cators Mary Moller and the late Victoria Conn, and psychologists Kayla Bernheim
ACKNOWLEDGMENTS XIII
and Cynthia Bisbee, were early pioneers in developing educational modules for
families. Psychologist Fred Frese and Dr. Penny Frese were pioneers in developing
psychoeducational modules for schoolchildren. I am also grateful to Dr. David
Biegel of Case Western Reserve University for his continuing interest in families,
minorities, and evidence-based practice.
I want to thank all these people for having educated me in the writing of this
book. And I am grateful to many of them for having been and/or continuing to
be my friends. Most important, their work has had an impact on the field and, in
many cases, changed the course of treatment for major psychiatric disorders.
Their research has demonstrably helped people with major mental illnesses, and
probably every one of them has enriched the coping skills of families.
CONTENTS
1 i nt ro du ct i on 1
2 f am i l y i n t e rv e n t io ns in majo r ment al il l n e ss 8
Models and Commonalities
3 f am i l i e s , s ch i z o phrenia, and o t her majo r disor de r s 15

Historical Background
4 the ore t i c a l p remis es and res earc h o verv ie ws 28

The Evidence for Family Psychoeducation
5 mo de l re s e a r c h pro grams 35
Family Psychoeducation
6 ear l y i n t e r v e n t io ns 58
Prodromal, Children, and Adolescents
7 d i v e rs e di a g n os es and s pec ial po pul at io n s 68
8 i nt e r n a t i on a l a nd c ro s s -c ult ural s t ud ies 80

Uniformities and Variations
9 f am i l y e du c a t i on 96
10 tr a i n i n g a n d t raining is s ues 106
11 i mp l e m e n t a t i on in s ervic es 112
12 un re s ol v e d i s s ues in family ps yc ho ed uc ation 122

A Critical Assessment
13 f ut u re t r e n ds in famil y invo lvement in tr e atme n t 129
Appendix 141 References 149 Indexes 167
XV
f a m i l y p s y ch o ed u ca t i o n fo r
s e rio u s m e n t a l i lln e s s
1
I N T RO D U C TI O N
This book focuses on an evidence-based approach to working with families of

persons with serious mental illness (SMI). Division 12 (Clinical Psychology) of
the American Psychological Association has defined evidence-based treatments
(EBTs) in terms of the following criteria: (1) at least two good between-group
design experiments must demonstrate efficacy in one or more of the following
ways: superiority to pill or psychotherapy, placebo, or to other treatment; equiv-
alence to already established treatment with adequate sample sizes; (2) experi-
ments must be conducted with treatment manuals or equivalent clear description
of treatment; (3) characteristics of samples must be specified; and (4) effects must
be demonstrated by at least two different investigators or teams (see Chambless
and Hollon, 1998).
Kazdin (2008) has distinguished EBT from evidence-based practice (EBP),
which “refers to clinical practice that is informed by evidence about interventions,
clinical expertise, and patient needs, values, and preferences and their integration
in decision making about individual care” (p. 147). In this book, we use the broader
concept of EBP in two domains: as an empirically-supported intervention that
includes family support as an integral component of treatment for SMI, and as a
support for families in coping with its disruptive effects.
What is meant by SMI? Coursey, Alford, and Safarjan (1997) noted that this
term replaced “chronic mental illness” during the 1990s because of the demoral-
izing impact of the word “chronic” on clients. Both terms characterize individuals
who have severe and persistent disabilities that result from a psychiatric disorder.
“The term severe was defined as functional limitations in activities for daily living,
social interaction, concentration, and adaptation to change in the environment.
Persistent was defined as likely to last for 12 months. The term serious mental illness
1
2 FAMILY PSYCHOEDUCATION FOR SERIOUS MENTAL ILLNESS
is usually reserved for adults, whereas serious emotional disturbance is the broad title
for the equivalent in children” (p. 205).
Serious mental illness has been defined by the Center for Mental Health Ser-
vices (CMHS) in accordance with Public Law (P.L.) 102–321, which established a
block grant for states to fund community mental health services for adults with
SMI. The law required an operational definition of SMI in order to estimate prev-
alence. In such an estimate, Epstein, Barker, Vorburger, and Murtha (2004, p.6),
note that “The definition of SMI stipulated in P.L. 102–321 requires the person to
have at least one 12-month disorder, other than a substance-use disorder, that met
DSM-IV criteria (American Psychiatric Association, 1994) and to have ‘serious
impairment’ . . . equivalent to a Global Assessment of Functioning (GAF) score of
less than 60 (Endicott, Spitzer, Fliess, and Cohen, 1976).” In the CMHS definition,
functional impairment was more precisely defined as difficulties that substantially
interfere with or limit role functioning in one or more major life activities, including
basic daily living skills (e.g., eating, bathing, dressing) or instrumental living skills
such as managing money, maintaining a household, taking prescribed medication,
or functioning in social, family, and vocational/educational contexts.
Mental disorders differ in diagnosis, type, and intensity of symptomatic behav-
iors, levels of functional impairment, and duration of disability. Diagnostically,
persons with schizophrenia, major affective disorders, and psychotic states are
considered to have an SMI. Adults with major anxiety disorders and other diag-
noses may also be characterized as having an SMI if they have prolonged levels of
functional impairment that preclude leading fully productive lives. Persons with
repeated needs for crisis intervention or hospitalization are considered to have
an SMI.
In the population-based National Comorbidity Survey, Kessler et al. (2006)
attempted to assess the number of persons with SMI in the United States. Respon-
dents with 12-month mental disorders were defined as having SMI if they had at
least one of the following: 12-month bipolar 1 disorder or non-affective psychosis
(NAP). NAP included schizophrenia, schizophreniform disorder, schizoaffective
disorder, delusional disorder, and psychosis not otherwise specified; a 12-month
suicide attempt; at least two areas of role functioning with self-described “severe”
role impairment on the Sheehan Disability Scales (Leon, Olfson, Portera, Farber,
and Sheehan, 1997); and the GAF score previously cited.
Government publications have indicated that “In 2002, there were 17.5 million
adults aged 18 or older with SMI during the 12 months prior to being interviewed.
This represents 8.3 percent of all adults in the United States”(Epstein, Barker,
Vorburger, and Murtha, 2004, p. 15).
The schizophrenias and major affective disorders have comprised 55% of hospi-
tal admissions and 65% of inpatients under care (Lefley, 1996). Most of the research
on family psychoeducation (FPE) has been conducted with families of persons
INTRODUCTION 3
with these diagnoses, and FPE is now a well-established psychosocial treatment

for schizophrenia. In recent years, however, FPE has been extended to other diag-
noses and these are described in subsequent chapters.
In assessing prognosis for major psychiatric disorders, both clinical and com-
munity prevalence studies demonstrate the importance of family and caring
friends for positive outcomes (Evert et al., 2003; Harvey et al., 2007). Family mem-
bers in particular are the people who knew the patient in his or her pre-morbid
state and have shared the confusions, disruptions, and emotional ravages of the
illness. In most cases, a caring family continues to be the most stable resource
for patients throughout a lifetime of stressors, shifting resources, and changing
clinical services.
Estimates of the number of adults with mental illness living with their families
vary between 50% and 84% (Marshall and Solomon, 2004). Research indicates that
75% of persons with schizophrenia have some ongoing contact with family mem-
bers (Lehman and Steinwachs, 1998). Even when they do not live with the patient,
concerned family members find services for their ill relatives, provide social, finan-
cial, and emotional support, and serve as a last resort when the system fails (Brekke
and Mathiesen, 1999; Clark and Drake, 1993).
But to be optimally beneficial, family and other caregivers need education about
the disorders, some knowledge of illness management techniques, and personal
support. FPE is a contemporary, very powerful addition to the armamentarium of
beneficial psychological interventions. In contrast to many models of individual
and family therapy, FPE is evidence-based, with research-based efficacy for reduc-
ing relapse and hospitalization, reducing symptoms, and increasing employability
of persons with severe and persistent mental illness. In achieving these results, a
meta-analysis of the research has demonstrated that psychoeducation for client
alone is not as effective as when families are included (Lincoln, Wilhelm, and
Nestoriuc, 2007). Although the focus is on client outcome, psychoeducation has
also proved effective in reducing family burden and improving well-being of those
struggling to cope with the mental illness of a loved one.
FPE also expands the definition of that which is considered therapeutic. It is an
intervention whose principal beneficiary is another. Although psychoeducation helps
allay a host of problems, it is not considered treatment for the principals involved.
Julian Leff, internationally known as a research psychiatrist, family therapist, and
founder of FPE, points out that when dealing with schizophrenia or other SMI,
“I do not refer to family work as therapy since the family members are not consid-
ered to be in need of treatment. Rather they need to be seen as allies in the struggle
to help the ill person recover from schizophrenia and fulfill their potential” (Leff,
2005, p.3). This firmly places the family in a context very different from that which
initially informed family therapy for schizophrenia (see Chapter 3), and one that is
unfortunately still widely conceptualized in our field. The family is viewed not as a
contributor to psychopathology, but as ongoing support system for mental disor-

ders that are increasingly viewed as biogenic.
Among all the mental health professions, counseling or psychotherapy models
have typically focused on the amelioration of symptoms or distress of individu-
als, couples, or family systems. Whether through insight into childhood conflicts,
recognition of thought distortions, countering emotional dysregulation, or com-
prehending dysfunctional interpersonal relationships, we have targeted changes
in thought, behavior, and family systems to deal with life conflicts. This new tech-
nique demonstrates the efficacy of ordinary education. FPE is so titled because it
transcends simple information-gathering to deal with the psychological issues that
inevitably accompany mental illness in the family. But the basis is state-of-the-art
education—simply improving understanding through learning what is known and
not known about an illness and how to assess and cope with its manifestations.
This is true for both clients and for those who love and support them.
With de-institutionalization—the historical act of emptying large mental
institutions—numerous people with SMI were discharged to families who were
ill-prepared to cope with these new additions to their households. Some had infre-
quent contact with their ill relatives due to institutional policies that tended to dis-
courage visitations from families and from the outside world in general (Rothman,
1971; Terkelsen, 1990). Others had maintained contact but had little knowledge of
mental illness and how to cope with its symptoms. Many accepted this task reluc-
tantly, having established other commitments and priorities. Some families had
totally unrealistic expectations and were unable to handle psychotic behavior or
maintain household stability. And people who had spent long years in institutional
care were catapulted into unfamiliar living arrangements, with their own anxieties
about this change in their lives. Worried caregivers, uncertain of their roles, could
only exacerbate terrors and paranoid ideation.
The need for caregiver preparation was immediately apparent, but most mental
health systems offered nothing to families in the way of training. A few progressive
psychiatrists had started early work with families. They understand the impor-
tance of involving their patients’ support systems, as well as satisfying family
members’ needs for help in managing the illness and alleviating their own distress.
Psychiatrist Richard Lamb, University of Southern California, Los Angeles, was
an early mentor to the Parents of Adult Schizophrenics of San Mateo County, CA
(Lamb and Oliphant, 1978). These parents subsequently became core organizers
of The National Alliance on Mental Illness (NAMI). Psychiatrist Robert Liber-
man began involving families in treatment as early as 1966, as a Harvard resident at
Massachusetts Mental Health Center (Liberman, 1970). In 1973, he introduced psy-
choeducational classes for the families of patients who were attending the Oxnard,
CA Community Mental Health Center, when he was the sole psychiatrist for
500 patients who came from impoverished, often Latino immigrant backgrounds.
INTRODUCTION 5
“After a 45-minute lecture-discussion, I organized the families and their patients

in small groups with clinicians from the Center for more focused problem-solving
and collaboration on a wide variety of problems, goals, and stressors” (Liberman,
King, and DeRisi, 1976; R.P. Liberman, personal communication, April 29, 2008).
Some mental health professionals who were also family members began to
develop training manuals for family education (e.g., Bisbee, 1999; Hatfield, 1990).
Shortly after its organization in 1979, NAMI (then the National Alliance for the
Mentally Ill) began to administer family education in the major psychiatric disor-
ders, as did a few chapters of the National Mental Health Association (now Mental
Health America or MHA). In fact, the last quarter century has seen the emergence
of many different models of helping families cope with the dilemmas of major men-
tal illness. This book tries to present a global picture of these various attempts. We
focus on evidence-based models of FPE, but also present data on a few selected,
mostly manualized examples of the large number of efforts to educate families in
their new roles as community caregivers.
THE SCOPE OF FAMILY CAREGIVING

With the emptying of hospital beds for long-term care, families have now become
the major caregivers and lifetime support systems of persons with major psychiatric
disorders throughout the world (Warner, 2000). In China, over 90% live with their
families (Xiong et al., 1994). In countries with more community resources such as
Italy, where the last long-term hospital patients were discharged in 2000, from 70%
to 84% of persons with schizophrenia now live in the family home (Warner, 2000).
In the United States, ethnic minorities are more likely to live with their men-
tally ill relatives. In a number of studies the figure for Latinos, for example, ranged
from 75% to 85% co-residence vis a vis two-thirds for African-Americans and about
40% for white-Americans (Lefley, 1996). Even when patients live in assisted liv-
ing facilities or mental health center housing, there is ongoing contact and fami-
lies continue to be a significant source of financial, emotional, and social support
(Brekke and Mathiesen, 1999).
It is clear that family education and support are becoming increasingly impor-
tant to facilitate patients’ improvement and to ease caregiver burden. Moreover,
FPE has proved to be a major tool for improving patients’ prognosis. It is now
acknowledged as one of the major EBPs in the treatment of schizophrenia and
other major disorders (Dixon et al., 2001).
FAMILY PSYCHOEDUCATION AS EVIDENCE-BASED PRACTICE

In the early 1990s, The Agency for Health Care Policy and Research and the
National Institute of Mental Health funded The Schizophrenia Patient Outcomes
Research Team (PORT) project to develop and disseminate recommendations

for the treatment of schizophrenia based on existing scientific evidence. PORT
developed 30 recommendations in several categories: pharmacotherapies and
electroconvulsive therapy; psychological treatments (individual and group psy-
chotherapies for patients): family treatments; vocational rehabilitation; and
service system improvements.
Among the family treatments, only FPE was recommended. This intervention
was evaluated at the highest level of evidence from a host of research overviews
(Lehman and Steinwachs, 1998). The PORT recommendations for family treat-
ments were as follows:
Recommendation 24. “Patients who have ongoing contact with their fami-
lies should be offered a family psychosocial intervention that spans at least nine
months and provides a combination of education about the illness, family support,
crisis intervention, and problem-solving skills training. Such interventions should
also be offered to non-family caregivers . . .”.
Recommendation 25. “Family interventions should not be restricted to
patients whose families are identified as having high levels of “expressed emotion”
(criticism, hostility, over-involvement).. . . Studies have found that these interven-
tions offer substantial benefits to patients and families regardless of the level of
expressed emotion.
Recommendation 26. “Family therapies based on the premise that family dys-
function is the etiology of the patient’s schizophrenic disorder should not be used.
Rationale: Research has failed to substantiate hypothesized causal links between
family dysfunction and the etiology of schizophrenia . . . . The presumption that
family interaction caused schizophrenia, especially as an alternative to biologi-
cal risk factors, has led to serious disruption in clinician/family trust without any
evidence of therapeutic effectiveness. The repudiation of the theoretical premise
of these therapies, the lack of empirical studies, and the strong clinical opinion
raising concerns about the potential harm caused by these approaches lead to this
recommendation” (Lehman and Steinwachs, 1998, p. 8).
As is evidenced in the PORT, although our focus is on educating patients’
families and other caregivers, FPE clearly must be incorporated in a multi-modal
approach to treatment. But many researchers, particularly in Europe, view FPE as
an essential component. Based on their research findings, Bauml, Frobose, Kraemer,
Rentrop, and Pitschel-Walz (2006) state categorically that “Psychoeducation, in the
form of an obligatory-exercise program, should be made available to all patients
suffering from a schizophrenic disorder and their families” (p. S1).
In this brief introduction, I have tried to define the basic concepts used in
this book. EBTs are operationally defined in terms of their research criteria and
outcomes. EBP refers to the application of these empirically-supported treat-
ment approaches in work with individual clients, including the training of staff.
INTRODUCTION 7
The broader term, EBP, is used throughout this book because FPE covers two prac-
tice domains. It integrates family support in the treatment of SMI, and it helps
families cope with its disruptive effects. “Serious mental illness” is also defined
in terms of diagnosis, severity, and persistence, along with prevalence data from
national population-based studies.
This chapter then goes on to indicate the scope of families’ involvement with
persons with SMI, both in the extent of residential caregiving and the degree of
social support. Because of prior institutional policies of distancing patients from
family members, de-institutionalization had discharged many patients to caregiv-
ers who had little knowledge of how to care for their relatives with mental illness,
had unrealistic expectations, and did not know how to cope with symptomatic
behaviors. Although the need for caregiver education was immediately appar-
ent, most mental health systems still continued to offer nothing to families in the
way of information or skills training. To fill this need, family education programs
were largely developed outside of mental health systems, by organizations such as
National Alliance on Mental Illness (NAMI) and Mental Health America (MHA).
Concomitantly, new treatments, focusing on reducing symptoms and recidivism
in patients with schizophrenia, began to be developed. Among these was FPE. The
chapter ends with strong recommendations to implement FPE in mental health
systems by Patient Outcomes Research Team (PORT) in the United States, and
as “obligatory” treatment by European researchers as well. Forthcoming chapters
describe various models of family interventions and the historical background that
led to FPE as an empirically-supported treatment for persons with major psychi-
atric disorders.
2
FA M I L Y I N T E RV E N T I O N S IN
M A J O R ME N T A L I L L N ESS
models and commonalities
Across the years, numerous models have emerged to involve or educate families in
the treatment of loved ones with serious mental illness (SMI). As may be seen in
Table 2.1, family interventions may vary in format or participants, basic premise,
treatment modality, and expected outcomes. The basic premise of course informs
the treatment modality and anticipated outcomes. Except for some family therapy
approaches that are based on systemic dysfunction, most family interventions
are primarily intended to satisfy an empirical need for information and skills that
will facilitate illness management. All of these models teach a theoretical model
of illness based on diathesis-stress, described more fully in Chapter 4. All aim at
improving the relationship and quality of life of both patients and families, with
resultant decreases in needs for hospitalization.
Family therapy was the first intervention model that addressed family involve-
ment in the treatment of schizophrenia. The first efforts were largely based on
changing maladaptive family systems that were assumed to generate and per-
petuate psychotic behaviors. The modalities were essential structural or strate-
gic approaches, and the hoped-for outcome was systems change with subsequent
symptom elimination. As indicated in Table 2.1, there are still family therapy
models for treatment of schizophrenia that are based on a premise of family dys-
function such as the Milan School (Selvini Palozzoli et al., 1989), although many
family therapists such as Julian Leff (2005) have renounced the idea of pre-existing
family pathology requiring treatment.
As Marsh (2001) has pointed out, newer models of family therapy address fam-
ily problems without necessarily assuming they are directly related to causing or
exacerbating mental illness in a loved one. Rather, pre-existing family problems
are likely to be exacerbated by illness-related stress. Thus, in addition to education
8
TABLE 2.1 FAMILY THERAPY, CONSULTATION, PSYCHOEDUCATION, EDUCATION, SUPPORT, PARTICIPANTS, MODALITY, PREMISE, AND
EXPECTED OUTCOMES
Participants Modality Premise Outcomes

family therapy Family Systems, strategic Family systemic dysfunction Symptom elimination, systemic
structural change change
family consultation Family, patient Consulting on family- Family need for specific Resolution of family-defined
defined problems expertise problems
family psychoeducation Family, with/without Education, support, illness Familial EE, behavior affects Relapse/symptom reduction:
patient; single or group management, problem patient. outcome; families need lower family burden
format solving help for illness management
and coping
family education Multi-family group, led by Education, support, illness Families need help for coping, Family well-being irrespective
professionally trained peers management, satisfying living own lives of patient outcome
own needs
psychoeducational Multi-family group, led by Education, support, Group sharing helps Family/patient well-being and
support group professionals sharing management coping—advocacy gives improved, resources for
strategies, advocacy for mastery over own life services, research, public
resources and resources for patients education/anti-stigma
family support and Multi-family, led by peers
advocacy group
and support, some family members may benefit from a type of family therapy
that is similar to family psychoeducation (FPE). An example is the medical fam-
ily therapy of McDaniel, Hepworth, and Doherty (1992), designed to assist families
facing serious health problems. Like FPE for SMI, medical family therapy focuses
on strengthening family caregiving skills, reducing family burden, and enhancing
family well-being (Marsh and Lefley, in press). However, as opposed to psychoed-
ucation, none of these models has produced a body of adequate empirical data to
indicate positive outcomes for persons with SMI.
Family consultation addresses the concerns of many families in dealing with illness-
related issues, accessing resources, making informed choice about their use of other
services, or simply prioritizing their needs. Specific needs may involve making deci-
sions about living arrangements, obtaining federal entitlements, finding resources to
deal with concurrent substance abuse, and the like. Bernheim (1994) notes that there
are substantive differences between family consultation and a therapeutic model
of family interventions. Family members are presumed competent to set a service
agenda. “Unlike therapy . . . the family consultant behaves more like an attorney or
accountant, laying out the options and helping consultees assess the relative merits
and risks of each. . . . The family is not regarded as an unidentified patient” (p. 189).
Bernheim further notes that consultants differ from a strictly educational
model by offering specific advice and problem-solving assistance. Unlike the
formal structure and group format of family education, consultation focuses on
immediate needs and agendas. The consultant may also of course refer consultees
to clinical services depending on their needs and desires.
Pioneer family therapist Lyman Wynne and his colleagues offer a model of fam-
ily consultation defined as “the process in which a consultee seeks assistance from
a consultant in order to identify or clarify a concern or problem and to consider the
options available for problem resolution” (Wynne, Weber, and McDaniel, 1986,
p.8). As Marsh (2001) points out, the consultant offers expertise, skill, or compe-
tence, based on a meta-analytic view that incorporates the multiple contexts of
systems involved in resolving the presenting problem. However, the consultee can
reject recommendations and retains primary responsibility for action.
Consultation may be sufficient for some families, particularly if it is offered at
the time of the initial diagnosis and thereafter on an as-needed basis, such as dur-
ing crises or family transitions. Some excellent independently-funded consultative
services have included those offered by the Training, Education, & Consultation
(TEC) Family Center in Philadelphia (see Meisel and Mannion, 1989) and by Inten-
sive Family Support Services in New Jersey (described in McFarlane et al., 2002).
At the TEC Family Center, Mannion (2000) has developed a manual for including
family consultation as a routine offering of mental health facilities. Solomon et al.
(2002) note that this intervention is especially attractive to families whose rela-
tives reject mental health services.
FAMILY INTERVENTIONS IN MAJOR MENTAL ILLNESS 11
Family psychoeducation is one of the major evidence-based treatments (EBTs)

for major psychiatric disorders (Dixon et al., 2001), particularly schizophrenia
(Kuipers, Birchwood, and McCreadie, R.G., 2002) and bipolar disorder (Miklowitz
et al., 2000). The strong empirical evidence for the clinical, social, family, and
economic benefits of FPE will be further elucidated in the section on research
findings.
There are common core elements in all FPE. Included are support for family
caregivers and state-of-the-art information about the illness, its presumed etiol-
ogy, and its treatments. There is information on various medications and their
expected effects and side effects. Illness-management techniques include cop-
ing with symptomatic behaviors, assessing prodromal cues of decompensation,
and crisis management. Families are taught communication skills and techniques
for problem solving. Specific components of various approaches are given in the
section on Model Programs in Chapter 5.
Pitschel-Walz et al. (2001) have defined a variety of interventions as psycho-
education. Models with research findings include family therapy in single-family
or multi-family settings, psychoeducational relatives’ groups, educational lectures
for relatives, counseling groups for relatives, and group therapy for relatives. “Most
of these interventions can be subsumed under the category of ‘psychoeducation’
or at least contain psychoeducation as an essential component. ‘Psychoeducation
is the most common collective designation for an intervention that combines the
imparting of information with therapeutic elements, and the term is internation-
ally acknowledged”(pp. 73–74). This definition, however, conflates briefer models
and those oriented toward family well-being alone with the preferred minimal
nine-month (McFarlane, 2002) intensive models that qualify FPE as a legitimate
evidence-based practice (EBP).
Family education contains essentially the same didactic components as family
FPE. However, it differs in important respects. Education is usually offered to fam-
ilies in groups, typically without the patient present, and rarely involves individual
family assessments. Although several family education models have now yielded
outcome data, family education is not research-oriented. There are no hypotheses
regarding effects on patients. The sessions are not always clinically-based or pro-
fessionally led. Many family education models solicit and incorporate family input
in their design. Sometimes, they offer continuity after the sessions end, in terms of
support groups or involvement in political advocacy groups.
Family education is designed to help key relatives or caregivers understand and
cope with the illness. Solomon (1996) has differentiated between family psycho-
education and family education in terms of anticipated outcomes, distinguishing
symptom and relapse reduction from reduction of families’ distress and burden.
Almost all the controlled studies have focused on patient outcome. However,
shorter-term manualized programs have also been developed for family groups,
with attendant research on participants’ knowledge and well-being, without regard

to other factors.
A hoped-for result is enhancement of the well-being of the total family, includ-
ing of course the patient. Family education is usually much briefer in duration than
evidence-based family psychoeducation. Finally, although much family education
has been offered by professionals, it is also offered by well-trained family members
using manualized materials with similar content. Research data on some of these
efforts are shown in Chapter 9 on family education.
The Psychoeducational Support Group is an open-ended continuous service
offered by a clinical facility to relatives and friends of adults with serious and per-
sistent mental illness. This is a free service for families and friends of patients and
is often open to the general public. Time-limited family interventions, empirically
justified in their own right, nevertheless cannot address unexpected problems that
arise with cyclical psychiatric disorders. The open-ended model offers education,
support, illness management, and problem-solving on an ad hoc basis, specific to
current needs of individual cases, and tailored to lifespan and illness trajectory
issues. In addition to didactics and training in behavior management, the psychoe-
ducational support group offers shared experiences and coping strategies, resource
information, social networking, and cross-parenting in terms of concrete aid for mem-
bers’ relatives. Members also offer living proofs of improvement and recovery. Par-
ticipation serves both long-term and crisis needs and is not time-limited. Although
there are anecdotal accounts of effectiveness in improving patients’ recovery
(e.g., Lefley, 2007), the model has not been subjected to any systematic research.
Family Support and Advocacy Groups are ongoing support groups such as those
offered by NAMI and Mental Health America (MHA). These are typically led by
family members. In many ways the groups fulfill the benefits of shared experiences
ascribed by McFarlane (2002) to the multi-family psychoeducational model.
Family groups normalize reactions of fear, guilt, and grieving. They offer resource
information, exchange of coping strategies, a social network for isolated families,
enhanced problem-solving capability, involvement in advocacy activities, and
positive success stories with renewed hope for recovery. Advocacy organizations
such as NAMI and MHA, focusing on favorable legislation, funding for research
and services, and stigma reduction, offer an action medium for families who wish
to go beyond mutual support and improve the systems that impact their lives.
VARIATIONS AND MERGED MODELS OF FAMILY INTERVENTIONS

Except for structured or manualized models with specific time frames, family
interventions may vary widely in format and content. Content has been adapted
for specific ethnic or cultural groups (Lefley and Johnson, 2002) and for immi-
grant populations. Some examples of these are given in Chapter 8. Other variations
FAMILY INTERVENTIONS IN MAJOR MENTAL ILLNESS 13
include: patient present or absent; single family versus multi-family; time-limited

versus ongoing; diagnosis-specific versus severe mental illness; first episode versus
long-term; mental illness with concurrent substance abuse, or mentally ill crimi-
nal offenders. Some interventions are specifically designed for spouses (Mannion,
Mueser, and Solomon, 1994) or other family members. In some models, FPE may be
primary, but it is merged with and incorporates family therapy techniques (Marsh,
2001; Leff, 2005). McFarlane (1997) has highlighted the benefits of merging multi-
family group psychoeducation with another EBP, assertive community treatment.
FPE addressed to the needs of specific groups are discussed in Chapter 7, following
presentation of some seminal programs and their research findings.
To summarize, in this chapter, we have discussed various models of family
interventions which at one time or another have been utilized, or recommended,
for families of persons with SMI. Family therapy, which is based on a premise of sys-
temic dysfunction has not proved to be effective, but newer models of family ther-
apy, designed to assist families in coping with various types of illness, may be more
beneficial. Family consultation is limited to helping families address specific con-
cerns, but there is little research on its effectiveness. FPE, an empirically derived
treatment, has core elements of support for families, information about the illness
and treatment, and illness-management techniques including communication
skills and problem-solving strategies. Most of this book is devoted to the copious
research base on this model’s effectiveness.
In contrast to FPE, which focuses on patient outcome, family education is
designed to help key relatives understand and cope with the illness and to reduce
family burden, regardless of benefits to the patient. In Chapter 9, various models
are described with data on their effects. We have added two other types of inter-
ventions, both multi-family models. The psychoeducational support group may
be offered by some agencies as an open-ended ongoing supportive resource for
patients’ families or for the general public, with families participating according
to need. There are no data on this model as yet. Finally, there are family support
groups, which are also open ended and continuous, but are usually extensions of
advocacy groups such as NAMI. Some supportive data are available on their effects
(Mannion, Meisel, Solomon, and Draine, 1996).
With the exception of family consultation, which is limited to answering spe-
cific needs of individual families, and to the family therapy model that primarily
focuses on changing the family system, all of these interventions share a common
theme. They offer families support and an understanding of the needs of care-
givers. The educational materials focus on the major mental illnesses and their
treatments, and illness management techniques that include communication
skills and problem-solving strategies. Families may learn about entitlement pro-
grams or helpful area resources, including psychosocial programs and consumer
groups. Most interventions also focus on common psychological issues, alleviating
unjustified guilt and easing family burden. They typically emphasize that caregiv-
ers need to guard their own psychological and physical well-being and have the
right to live their own lives free of worry and pain.
As research, however, only family psychoeducation fully satisfies the EBP
criteria established in the Introduction section, and its supportive findings in vari-
ous sites throughout the world are covered in forthcoming chapters. In Chapter 9,
we also learn about family education, which targets families rather than patients
in terms of outcome variables. Administered by trained family members, rather
than by professionals, two family education programs fulfill almost all the criteria,
including replication by the same researchers. As yet, there has been no attempt to
replicate them by different investigative teams.
3
F A M I L I E S , S C H I Z O P H RE N IA, AND
OT HE R MA J O R D I S O RD ER S
historical background
Family psychoeducation (FPE) is a long-overdue, well-accepted therapeutic

modality that finally provides families with what they have long been requesting—
information, support, and illness-management techniques. These requests seem
so eminently reasonable that one wonders why it took so many years for mental
health systems to comply. This chapter presents some of the background that led
to FPE, a history of theoretical constructs and their correlative therapies, some
of which were damaging rather than helpful to patients and families. With de-in-
stitutionalization and community-based treatment, families have become major
caregivers and support systems for their relatives with severe mental illness. So
the need for clinical understanding of the caregiving experience is increasingly
apparent.
FPE is a welcome and much-needed antidote to an era of now-discredited
theories about schizophrenia. Some attributed etiology to destructive patterns of
parenting or mystifying communication styles. Others viewed symptoms as use-
ful in maintaining a spurious homeostasis in dysfunctional family systems. All the
theories tended to adversely affect the interactions of mental health professionals,
and mental health staff, with the family members of their patients.
In the psychoanalytic tradition, almost all serious psychiatric disorders were
attributed to bad mothering practices in infancy or early childhood. Fromm-
Reichmann’s (1948) concept of “schizophrenogenic mother,” a woman with the
paradoxical features of being cold and rejecting and also overprotective and foster-
ing dependence, was widely accepted, although, as noted by family therapist Froma
Walsh (1988), the concept was never consistently defined or measured. The basic
assumption was that maternal traits and character deficiencies produced destruc-
tive patterns of mothering responsible for the child’s disorder.
15
Discussing concepts of the pathogenesis of schizophrenia, McGlashan (1989)

states that “Virtually all psychoanalytic theorists postulate an experiential dis-
harmony between the mother and her preschizophrenic infant. . . . The purported
central pathogenic elements are dysphoric experiences which become internal-
ized as aberrant psychological structures. Explicitly or implicitly, the psychogenic
models of schizophrenia regard these experiences as sufficient to explain most if
not all cases of the syndrome” (p. 751).
McGlashan further suggests that all theorists implicated the mother in the
arrested development that would generate psychosis. To Harry Stack Sullivan, for
example, the pathogenesis of schizophrenia “begins with a mother who is more
anxious than normal and who imparts this tension to her child as excessive not-me
experiences. The child’s self-system, developing around the time of speech acqui-
sition, overcompensates with excessive dissociation and warps its own further
development” (McGlashan, 1989, p. 748).
In recent years, psychoanalysts have been willing to incorporate current
research findings on the biological basis of many of the psychotic or develop-
mental disorders previously attributed to poor parenting. Glen Gabbard, a lead-
ing psychoanalyst, admits that “To be sure, the field of psychoanalysis has made
a series of historical errors. Among these were the concepts of the ‘schizophreno-
genic mother’ in the case of schizophrenia and the ‘refrigerator mother’ in the case
of early infantile autism. These are egregious examples of the privileging of psycho-
analytic developmental theory over empirical research” (Gabbard, 2005, p. 741).
Gabbard’s concern, however, is with psychoanalytic “arrogance and complacency”
vis a vis scientific research. There seems to be little concern in the psychoanalytic
literature with the toxic effects of these theories on suffering parents trying to
cope with extremely difficult and incomprehensible behaviors and receiving little
help from those who treat their children.
HOSTILITY AND DOUBLE BINDS FROM MENTAL HEALTH PROFESSIONALS

For many years, families felt abandoned and misguided by mental health profes-
sionals who not only failed to cure their children, but often treated them with
ill-concealed hostility and contempt. Despite the caveats against demonstrating
counter-transferential dislike of patients, no such caveats exist with respect to
families. It is very difficult to be understanding or kind to parents who are presumed
to have wreaked such terrible havoc on the children they claim to love.
Johnson (2000) notes, “In no other area of treatment for illness have fami-
lies of the ill been such objects of contempt and scathing criticism by profession-
als as have the families of the mentally ill” (pp. 55–56). He asks us to consider the
descriptions in the literature. A study of families of first-time patients admitted
to a psychiatric hospital offers the following typologies: assertives, altercasters,
FAMILIES, SCHIZOPHRENIA, AND OTHER MAJOR DISORDERS 17
authoritarians, stoics, poltroons, pacifists, stumblers, and do-nothings” (Spitzer

et al., 1982). Another study offers just three categories: over-involved, under-
involved, and pseudo-involved (Krajewski and Harbin, 1982).
Schuman (1983) divided families of hospitalized schizophrenic patients into
just two categories: the “schizophrenic family” in which all members function at
a very low level, and “the family with a schizophrenic member,” in which “there
may be high levels of social or vocational achievement.; on an emotional level,
however, significant members possess low levels of self,. They function with what
Bowen has described as a ‘pseudo-self’ rather than solid self” (p. 43). Reynolds and
Farberow (1981) state: “In addition to genetic factors there seem to be at least five
characteristics attributable to schizophrenic families: (1) excessively closed fam-
ily systems; (2) shared family myths or delusions; (3) paralogic modes of thinking
in all the family members; (4) lack of individuation and self-identity of members
from the family ‘ego mass’. . .; and (5) intense, pathological symbiotic attachments
of the child to parents and of parents to grandparents” (p. 126).
Liem (1980) pointed out that these types of family descriptions have been anal-
ogous to a trait theory perspective, generalizing characteristics that may pertain
for a small sub-group to all families of persons with schizophrenia. They seem pre-
posterous when one considers that schizophrenia is found throughout the world
in numerous family structures, many of whom are described as empathic, patient,
calm, and respectful (Leff and Vaughn, 1985). Nevertheless, these ideas have
permeated the field, generating interactions with families that range from guarded
to hostile and exclusionary.
The early family-therapy approaches to schizophrenia were based on assump-
tions that symptoms had a functional role in the economy of family systems, and
that they would disappear with effective therapy. This essential stance was main-
tained in the Milan school, which saw schizophrenia as part of the family game
(Selvini Palazzoli, Cirillo, Selvini, and Sorrentino, 1989). Shaw (1987) pointed out
that strategic, systemic, or structural family therapies have not proved beneficial
because they are based on a replacement paradigm, which conflicts with the real-
ties of schizophrenia as a legitimate illness and a stress on the family. He notes that
families respond much better to psychoeducational approaches, which are based
on a repair paradigm. In an effort to demonstrate efficacy of an intervention with
no prior research base, a recent Milan School study compared 20 patients treated
with systemic family therapy with a control sample of 20 in routine treatment.
They found that at one year, 15% of the treated group had relapsed versus 65% in the
control group (p<.03). However, this was not sustained. No significant differences
were found the second year of follow-up (Bressi, Manenti, Frongia, Porcellanam,
and Invernizzi, 2008).
Maranhao (1984) has described double messages conveyed by family therapists
who use subterfuge while stressing authenticity. McFarlane and Beels (1983) point
out: “If one accepts that double-bind interactions can create distorted, even irra-
tional, communication, then many ‘therapeutic’ situations can be seen as patho-
genic. For instance, covert blame of the family by professionals is often combined
with overt attempts to help them, while the contradiction is denied” (p. 316).
Numerous reviews of theories both of family etiology and family deviance have
noted that the research has either failed to confirm them, or failed to meet basic
methodological criteria for demonstrating their validity (Parker, 1982; McFarlane
and Beels, 1983; Howells and Guirguis, 1985; McFarlane and Lukens, 1994). Never-
theless, notions of family pathology, and the need to separate families and patients,
have permeated the field for many years. My years of working with families of
persons with schizophrenia and other major psychiatric disorders, and hearing
their experiences, led to the following observations:
“For the most part, inconsistent and often contradictory patterns of help and infor-
mation will persist throughout the course of the illness. In one type of situation,
there is tacit rejection of any communication with the family, except as respondents
to questionnaires on the patient’s history. If the family attempts to learn more, the
common patterns of response are deflection of questions, reluctance to provide
diagnosis or illness information on the grounds of labeling, protestations of confi-
dentiality, and implications that the family’s concern is pathological or self-serving.
In other situations, families may be catapulted into therapy, regardless of their
desires, with the implicit message that the patient’s illness is symptomatic of a fam-
ily problem; but their requests for information and behavior-management training
will continue to be ignored”
(Lefley, 1987, p. 9).
SOURCES OF STRESS AND THE FAMILY BURDEN RESEARCH

In previous writings I have noted several major sources of family stress in coping
with serious psychiatric disorders. These may be roughly categorized as situa-
tional, societal, and, as indicated in the previous section, in too many cases iatro-
genic (Lefley, 2000; Marsh and Lefley, in press). Situational stressors involve both
objective and subjective family burden. Objective burden refers to families’ invest-
ments of time and energy in dealing with the mental illness of a relative. Subjec-
tive burden is the type and degree of psychological distress experienced by family
members.
SITUATIONAL STRESSORS
Service system deficits—difficulties in accessing appropriate treatment—are
frequent aspects of objective burden. These may be due to lack of funding for
adequate crisis or hospital beds, or to legal constraints that often make it difficult
to hospitalize a person who is psychotic and disruptive, but not imminently dan-
gerous to self or others. Families coming to support groups frequently complain of
the agony of finally deciding to hospitalize someone after a destructive psychotic
episode, only to find access denied because the patient has briefly re-compensated
sufficiently to appear rational. Some families have had such frequent contact with
their local police, who arrive only to find the patients have calmed down, that they
are advised to provoke the patient into behaviors that can enable the police to take
him to the Crisis ER.
Families face agonizing decisions when they must call police or obtain an
ex parte order for involuntary evaluation and treatment. They must balance their
needs for peace and stability against infringing on the civil rights and personal
autonomy of someone they love. They may encounter a magistrate’s decision to
reject involuntary treatment, or premature discharge of patients from crisis units,
when they have been briefly stabilized but are still symptomatic. All too often, the
patient will be angry at the family members and react with hostility after discharge,
punishing them with refusal to take prescribed medications.
Extrusion from community programs because of disruptive behaviors, prob-
lems with third-party reimbursements, poor medical oversight, or generally
inadequate community support systems are all highly stressful for families.
Some families suffer from incarceration of their loved ones in the criminal justice
system because of minor misdemeanors, because there are no local jail diversion
programs for people with mental illness. And some families have even seen their
loved ones hurt or even killed, because they menaced a police officer, untrained in
dealing with mental illness.
Subjective burden includes grieving for the loss of the pre-morbid personal-
ity, perhaps once bright with promise, and the loss of the person he or she might
have become. There is also empathic pain for loved ones who may mourn their own
lost aspirations and impoverished lives. Families may have to contend with hos-
tile misjudgments from neighbors or relatives, negative psychological effects on
siblings and young children, social isolation, and economic burdens of the illness.
In many cases, family members may have to cope with agitated or violent
behaviors, threats of violence or suicide, and most commonly, a patient’s rejection
of treatment. In schizophrenia particularly, clinicians speak of “anosognosia,” a
neurologically-based inability to understand that one’s behavior is aberrant, con-
vincing people with mental disorders that there is nothing wrong with them and
that others are falsely accusing them of being ill (Amador, 2000).
Keeping Care Complete is the title of an international study of the experiences and
opinions of 982 family caregivers of individuals with schizophrenia, schizoaffective
disorder, and bipolar disorder (World Federation for Mental Health, 2007). Most
had been ill for more than six years, and almost half (48%) for more than 10 years.
The research was conducted in Australia, Canada, France, Germany, Italy, Spain,
the United Kingdom, and the United States. Across countries, 91% of the respon-
dents stated that effective medication to control symptoms was a top priority.
There were major concerns about treatment disruption and relapse. A large major-
ity of respondents (85%) reported that their relative relapsed. Among them 69%
were hospitalized, 22% tried to commit suicide, and 20% were imprisoned. Some
of the effects of relapse on the caregivers themselves were as follows:
Substantially disrupted caregivers’ lives 61%

Caregivers more fearful of relative’s well-being 56%
Caregivers’ own well-being greatly affected 70%
Caregivers’ mental and physical health worsened 54%
Caregivers’ financial situation worsened 26%
Effective treatment led to positive outcomes such as re-engaging with family

and friends, performing tasks more independently, and learning new skills, hold-
ing a job or volunteer position. More than three-quarters (76%) of the caregivers
wanted doctors to focus on long-term care rather than managing crisis situations,
with the goal of achieving long-term stability (Stephens, 2007; World Federation
for Mental Health, 2007).
SOCIETAL STRESSORS
Societal stressors include the still prevailing stigma of mental illness, generaliza-
tion of stigma to relatives, negative expectancies of recovery, underfunding of
research and services, and general public neglect of a devalued sub-group. A review
of studies of generalization of stigma to relatives found that between a quarter and
half of family members think they should hide their relationship to avoid bringing
shame on the family, and between 20% and 30% of family members reported low
self-esteem because they have a relative with mental illness (Larson and Corrigan,
2008). Lack of parity in mental health care vis a vis general medical conditions has
been a persistent stressor for families and patients with private medical insurance.
National Alliance on Mental Illness (NAMI) and Mental Health America (MHA)
have been working for many years to obtain legislation that would remedy these
discriminatory practices. Leading legislators concerned with mental illness, such
as Peter Domenici and Ted and Patrick Kennedy, have moved the issue forward
and parity seems imminent, but it has taken enormous investments of energy and
many years for the work of advocates to bear fruit.
Among societal stressors, also, is general neglect of the mentally ill population
and consistent underfunding of research and services in the mental health system.
De-institutionalization has closed many state hospitals but the savings have too
rarely been allotted to commensurate community-based services. Perhaps the
greatest societal stressor is from the popular media, which consistently associate
mental illness with violence and murder. Very few newspaper accounts indicate
that people with mental illness are far more often victims than perpetrators (Teplin
et al., 2005). Incarceration of persons with mental illness in the criminal justice
system is an outrage of our times, and many families fear that an acting-out relative
may end up in jail. Inmates who are mentally ill are at the mercy of predators, both
for violent assault and sexual victimization, and rarely receive adequate medical
or mental health treatment (Wolff, Blitz, and Shi, 2007). These prospects are a
constant source of anxiety to families.
Society is still unclear about the distinction between madness and badness and
frequently conflates the two conditions. In many state legislatures, and in many
courthouses, there are still existing conflicts about the Not Guilty By Reason of
Insanity (NGRI) verdict, with the reality of mental illness still in dispute.
IATROGENIC STRESSORS
In the previous section on History, various theories were discussed that implicated
families in the pathogenesis of major mental disorders. Under the section on Hos-
tility and Double Binds from Mental Health Professionals, we find numerous quo-
tations from the psychiatric literature that described families in highly pejorative
terms. Even without strictures regarding confidentiality, how then could mental
health providers feel cooperative or willing to share information with people who
had created such devastating illnesses? For many years, families felt abandoned
and misguided by mental health professionals who not only failed to cure their
loved ones, but often treated them with ill-concealed hostility and contempt.
Many families who come to support groups have been dealing with mental illness
for more than 30 or 40 years. They have lived through this era of family-blaming
theories, and some still volubly complain of their treatment by mental health
professionals.
Iatrogenic stressors are happily diminishing but may still involve attributions
of parental causation and ignorance of family burden. Some clinical educators
unfortunately still teach theories of family pathogenesis. Reported stressors from
clinicians have included failure to provide information and support to caregivers,
misuse of confidentiality to deny needed information, and attitudinal rejection. As
some research has demonstrated, people with means to purchase the best services
that the field had to offer were in no way protected from the fallout of incorrect
theory. Many families of persons with schizophrenia or major affective disorders
invested their hopes in years of highly expensive treatment in leading psychiatric
centers that focused on intensive psychodynamic psychotherapies. Yet, follow-up
studies showed few improvements in patients with major psychotic disorders
(McGlashan, 1984).
THE RESEARCH ON FAMILY BURDEN

According to major researchers Kuipers and Bebbington (2005), family caregiv-
ers of persons with mental illness, usually termed “carers” outside of the United
States, have been the topic of research for more than 50 years. These authors
searched the literature for “carer” and “burden” and found almost 500 entries
during a three-year period alone.
Schene, van Wijngaarden, and Koeter (1998) have probably done the most
extensive work in studying family burden. Their family burden instrument, the
Involuntary Evaluation Questionnaire (IEQ), has been applied in numerous Euro-
pean countries. They look at items such as household characteristics, caregiving
characteristics, help-seeking, coping, and distress, as well as patients’ character-
istics, including the intensity and duration of illness. First applied with 480 family
members of patients with schizophrenia in the Netherlands, the four caregiving
domains found were tension, supervision, worrying, and urging. “These domains
were strongly related to the patient’s symptomatology, contact between the rela-
tive and the patient’s mental health professional, and the number of hours of
mutual contact between the patient and the relative . . . Our findings suggest that
caregiving tasks and problems may be diminished and related distress lowered by
reducing the patient’s symptomatology, increasing relatives’ coping capacities,
and decreasing the number of contact hours” (p. 609). In a further study in several
European countries, with samples of 680 family members of relatives with psycho-
sis, and 260 with major affective disorder, worry, urging, and tension emerged as
major consecutive factors. However, differences were found in the various coun-
tries. The highest burden was reported in Verona, Italy, and the lowest in Amster-
dam and Copenhagen. Santander, Spain, and London were in an intermediate
position. The authors were mindful of cultural differences in the United States,
especially between African-American caregivers, who reported significantly less
support from their family networks, and white caregivers who were significantly
more depressed (Biegel, Milligan, and Putnam, 1991). However, even after correct-
ing for percentage of ethnic minorities, caregivers’ coping, and living situation,
the difference between sites remained. The researchers offered several possible
explanations but essentially felt this remained an area for further investigation
(van Wijngaarden, Schene, and Koeter, 2002).
A review of 28 studies of family burden in major mental illness found that pri-
mary objective burdens involved money management, providing transportation,
continuous supervision, financial assistance, and limitations on caregivers’ own
activities. Primary subjective burdens related to safety and potential violence of
the sick relative, excessive demands and dependency, symptomatic and embar-
rassing behaviors, and family conflicts (Baronet, 1999).
As Ostman (2000) points out, “Researchers very early found that the impact
of mental illness was experienced across a broad spectrum of family life: work,
leisure, income, parenting, family health, relationship with extended family,
friends, and neighbors” (p. 7). Certainly part of objective burden is the inordi-
nate amount of time caregivers often have to spend in taking time off from work,
being late to work, or even having to resign from a job because of extensive family
demands. Income may be diminished not only because of job loss but because of
the financial dependency of the patient. There may be difficulties with obtaining
sufficient insurance coverage (hence the current emphasis on mental health par-
ity legislation) or excessive out-of-pocket costs including large co-payments for
treatment. Impaired health, both physical and mental, is a common correlate of
family burden (Ostman, 2000).
Johnson (1994) analyzed the family burden literature, reviewing findings of
nine surveys and 12 intervention studies to determine whether and how burden
could be relieved. He concluded that first, there were no differences between
schizophrenia and affective disorders in the levels of burden experienced, and sec-
ond, the degree of family burden seemed related to the level of dysfunction of the
relative with mental illness.
Managing disturbed behaviors is a primary issue in FPE and support groups.
Families may have to contend with mood swings and unpredictability, socially
offensive or embarrassing situations in public places, conflicts over money, or abu-
sive behaviors. Conflicts arise regarding poor personal hygiene, excessive smoking,
damage to household property, or sleeping patterns that reverse day and night and
keep the family awake. As indicated above, patients’ rejection of medication is a
common area of contention, particularly when there is a known pattern of relapse.
Negative symptoms of amotivation or anhedonia, delayed response, or refusal to
interact are particularly troublesome for families tying to sustain relationship with
a loved one.
These behaviors are characteristic of various psychiatric disorders, but they
are not universal and their effects within individual families are a function of many
factors. One of these is simply the passage of time. A recent three-year Italian
study using the IEQ found that at baseline, 51% of caregivers experienced signifi-
cant emotional distress. The severity of family burden was associated with higher
levels of patients’ psychopathology and number of needs, and lower levels of their
quality of life and global functioning scores. However, after treatment in a commu-
nity mental health service, at three-year follow-up the only significant predictor of
caregivers’ burden was the baseline level of burden itself (Parabiaghi et al., 2007).
Some commentators have rejected the notion that family burden is a com-
mon correlate or sequela of caring for someone with mental illness. For exam-
ple, Szmukler (1996) has suggested rejecting the term “burden,” which is viewed
as pejorative. Although caregiving burden is a very real experience for many fami-
lies, what is perceived as truly onerous is clearly subject to the assessment of indi-
vidual family caregivers. Instead, he conceptualizes caregiving demands within a
theoretical framework of stress-appraisal-coping, with appraisal as the key vari-
able. He suggests operationalizing the dimensions of caregiving, since specific
dimensions may have positive as well as negative value. Szmukler, Herrman et al.
(1996) developed The Experience of Caregiving Inventory as an instrument that
determines how the “burdens” of caregiving may be appraised and managed by
individual families. Concordant with other findings (e.g., Schene et al., 1998) they
found that the experience of caregiving is multi-dimensional, but that the “mas-
tery” factor is primary. Feeling in control of a situation appears to reflect a global
measure of coping.
The Caregiving Inventory was an assessment of the degree to which caregiv-
ers’ perceived stress and coping styles might predict their subjective burden,
their psychological well-being or morbidity, regardless of the magnitude of objec-
tive burden. However, family members’ response to mental illness is subject to
the trait-state dilemma. Perceptual and coping styles may be stable or may vary
according to situational factors. Mental illnesses are of course variable in course
and often cyclical. Periods of stability and normal functioning may alternate with
periods of profound clinical depression, hypomanic or manic behavior, or actual
psychotic episodes. A caregiver’s trait of cheerful acceptance, or a coping style that
values the helping role, may generate denial of burden during difficult periods and
caregiving gratification during peaceful periods.
Several recent studies have focused on caregiving gratifications, such as a
patient’s companionship and contributions to household tasks. In a study of
725 patients with serious mental illness (SMI) in rural Wisconsin, Greenberg,
Greeley, and Benedict (1994) found that a quarter not only lived with their families,
but offered them substantial help. Between 50% and 80% helped with household
chores, shopping, providing companionship, listening to problems, and shar-
ing news. Social support is a critical variable in positive perceptions of caregiving
(Chen and Greenberg, 2004), and investigators of family gratification have asked
the field to concentrate on prosocial family processes, on families as supportive
resources rather than in need of “fixing” (Greenberg, Knudsen, and Aschbrenner,
2006). In an earlier study in Australia, however, caregiving gratification was con-
tingent on whether or not the patient was symptomatic or relatively well. Almost
one-third of the caregivers reported no gratifications at all and this figure rose to
96% when the patient was ill (Winefield and Harvey, 1994).
In sum, there seems to be a strong association between gratification and
patients’ level of psychopathology and level of functioning. Gratification is par-
ticularly difficult if the person manifests disruptive or aggressive behaviors, or
negative symptoms that distance that individual from meaningful interactions
with others. Psychoeducational training is one avenue toward giving families the
tools to enhance functioning and to create more satisfactory relationships with
loved ones.
THE EXPRESSED EMOTION RESEARCH: THE BEGINNING OF CHANGE

Paradoxically, it was the expressed emotion (EE) research, which again attributed
maladaptive patient behaviors to family interactions, that ushered in the era of
FPE. What was different was that EE was viewed not as an etiological agent, nor as
evidence of a malfunctioning family system, but as an environmental stressor that
could be changed by education.
Expressed emotion (EE) is an empirically-derived construct that has been
extensively explored as a characteristic of family climate and its effects on the
course of psychiatric illness. EE levels are typically derived from comments about
the patient made by at least one family member. These comments are scored on
an instrument, most notably the Camberwell Family Interview (CFI), first admin-
istered in the United Kingdom. There are five relevant scales on the CFI: critical
comments, indicating unambiguous dislike or disapproval; hostility expressed
toward the person rather than the behavior; emotional over-involvement, which
is exaggerated or self-sacrificing or overprotective concern; and warmth based
on sympathy, affection, and empathy (Leff and Vaughn, 1985). In most studies, a
relative is categorized as high-EE if he or she makes six or more critical remarks,
expresses any hostility, or is rated three or more on the over-involvement scale
(Leff, 1989). Families below these cut-off points are characterized as low-EE.
Numerous overviews of the research confirm that high EE in a family member
is predictive of a patient’s greater tendency to relapse (see Lefley, 1992). For many
clinicians, high EE has been viewed in trait terms, an aspect of particular personali-
ties. An example is a demanding father disappointed in his son, unwilling to believe
that he is incapable of controlling positive symptoms, and attributing negative
symptoms to willfulness. Such traits would be difficult to change. Barrowclough
and Hooley (2003) found that attributions of controllability of symptoms distin-
guished high-EE from low-EE relatives. However, Leff (1989) has described cases
of relatives who spontaneously changed from high EE to a stable low-EE state,
and Falloon (1988) noted that critical comments from a high-EE relative generally
decreased after the patient’s recovery from an acute episode.
Weisman, Duarte, Koneru, and Wasserman (2006) have noted that the relation-
ship between familial EE and prognosis has been demonstrated in over 40 countries.
However, the data also show that families from traditional cultures (e.g., Asians and
Hispanics) tend to manifest fewer high-EE responses as compared with British and
Anglo-American families. Weisman and her colleagues found that Anglos were three
times more likely to be rated high-EE on the CFI, and five times more likely when
assessed on a five-minute speech sample. High EE levels may also be triggered by

different behaviors of patients. In a recent review of the literature, Kymalainen and
Weisman de Mamani (2008) pointed out that among relatives of white-American
patients with schizophrenia, high EE was associated with high levels of odd thinking
and symptom relapses, but this was not the case for African-American families.
The data suggest that high EE not only varies with culture, but is fairly mutable
with proper education. Moreover, reduction in high EE may remain stable over
time. For example, a follow-up of a 12-month cognitive–behavioral family inter-
vention in Spain found that EE not only diminished following the intervention, but
remained at the same level five years after it ended (Masanet et al., 2007).
Working with high-EE families has been the mainstay of FPE at the London
Institute of Psychiatry, and this treatment approach has persisted across a range
of interventions, regardless of family relationship or diagnostic category. For
example, in conducting a randomized controlled trial of antidepressants versus
couple therapy to treat depression, selection of subjects was based on the criterion
that the partner had to make more than one critical comment. Also, the therapists
attempted to design specific interventions aimed at directly reducing criticism
by a partner. “However, the techniques used seemed to have little effect on the
patient’s depressive symptoms and were therefore not included in the final version
of the protocol,” (Leff, Vearnals, et al., 2000). In providing a guide for family work
for schizophrenia, Kuipers, Leff, and Lam (2002) stipulated that in their research
and clinical work, they selected families in which at least one member was rated
as high-EE. Their premise was, logically, that this was an efficient use of scarce
resources since that these were the families that needed them most. Their studies
indicated that “for patients living with high-EE relatives, maintenance neuroleptic
drugs and reduced social contact with relatives proved to be associated with sig-
nificantly lower relapse rates (Leff, 1986, p. 102).
However, Leff (1986) had also cautioned that critical, hostile, and emotion-
ally over-involved attitudes were not confined to the relatives of schizophrenic
patients. He pointed out that high EE has also been found in spouses of depressed
patients, husbands of obese women, and parents of anorexic patients and is associ-
ated with poor outcomes. Since that time, high EE has been identified as a char-
acteristic that interferes with recovery from a multitude of conditions, mental
and physical, and that it is scarcely limited to families. It is also found among case
managers, residential staff, and clinicians. Barrowclough (2005) pointed out that
“there is accumulating evidence that high-EE responses in professionals are asso-
ciated with negative outcomes” (p.7). She cites research on case managers and
also her own research on staff–patient relationships in an inpatient facility, where
many staff held the same volitional beliefs as high-EE family members. Patients
were sensitive to staff’s feelings about them, and the more negatively perceived
patients were significantly more like to manifest behavioral disturbances.
The EE concept has also been applied in family interventions with children
with bipolar disorder, on the premise that these children would respond with even
greater volatility to a stressful environment. Fristad, Gavazzi, and Mackinaw-
Koons (2003), for example, acknowledging that there is no existing literature on
EE rates in families of children with bipolar disorder, nevertheless maintain that
reducing high EE in these families has the potential to significantly reduce symp-
tom severity. Yet, it is not clear how much emphasis should be placed on EE if fam-
ily members do not demonstrate hostile criticism or emotional over-involvement.
It has been pointed out in various commentaries that the needs of low-EE families
should not be ignored (Lefley, 1992; Fadden 1998). As FPE was extended in differ-
ent milieux, and as briefer family education models were opened to many thou-
sands of families, the selection of participants based on EE levels became moot.
To sum up, this chapter has presented the historical background that led to the
development of FPE. Theories of family culpability in the development of schizo-
phrenia, and other major psychiatric disorders as well, emerged from both a psy-
choanalytic model of etiology and the premises of early family therapies. Numerous
examples from the literature indicate the extent to which clinicians have been trained
in these models, the disparagement of family members, and the subsequent strained
relations between families and the practitioners who treated their loved ones. Clini-
cians’ reluctance to communicate with families about their relative’s illness, together
with this distancing treatment, are viewed as one source of family stress.
Major sources of stress for families coping with serious disorders are categorized
as situational, societal, and iatrogenic. The literature on family burden deals primar-
ily with the situational stress of living with serious psychiatric disorders. Objective
family burden refers to investments of time and energy in caregiving and coping with
the illness. Subjective burden involves personal appraisal of the demands of caregiv-
ing and the psychological distress and grieving engendered by the suffering of a loved
one. Societal stressors include stigma, which affects both patient and families, and
negative societal attitudes that result in underfunding of services, media-based asso-
ciation of mental illness with violence, and re-institutionalization of patients in the
criminal justice system. Iatrogenic stressors, although happily diminishing, may still
involve attributions of family causation, ignorance of family burden, and refusal to
give information to caregivers or involve them in treatment planning.
The research on family burden is presented. The large body of research on EE
is then discussed as the beginning of change in mental health systems, ultimately
leading to the development of FPE. High EE was viewed not as an etiological agent,
but as an environmental stressor, based on ignorance that could be changed by
education. Although FPE initially focused on high-EE families, many investiga-
tors realized that people of all EE levels need educating, and the importance of
curtailing hostile criticism or emotional over-involvement became just one of
many issues discussed in the didactic training.
4
T HE ORE T I C A L P RE MI S E S AND
R E S E A RC H O V E RV I E WS
the evidence for family psychoeducation
THEORETICAL PREMISES OF FAMILY PSYCHOEDUCATION AND

FAMILY EDUCATION
When we speak of theoretical premises, there are two bodies of theory to
entertain. One relates to basic theories of the etiology and maintenance of major
psychiatric disorders, the other to family functioning. Today, both of these areas
of thought rest on the premise of behavioral response to stress. Hatfield and Lefley
(1987) have written widely of families’ response to a member’s mental illness as
an ongoing stressor evoking coping and adaptation responses. The experience of
mental illness itself evokes a similar theoretical premise of individuals coping with,
adapting to, and surviving a profoundly challenging life stressor (Hatfield and
Lefley, 1993).
A clear theoretical premise underlies all models of family psychoeducation
(FPE). In contrast to previous theories of schizophrenia and major affective dis-
orders, which focused on child-rearing or dysfunctional family systems, psycho-
educational interventions are based on a presumption of diathesis-stress. The
underlying premise is that certain biological deficits make an affected individual
overreact to environmental stimuli that are experienced as stressful, and this may
generate a psychotic break or relapse (Falloon, Boyd, and McGill, 1984; Anderson,
Reiss and Hogarty, 1986; Kuipers, Leff, and Lam, 2002; McFarlane, 2002, et al.). An
extensive body of research has empirically validated this theoretical premise.
It should be noted that although stress theory is the basis of FPE, many other
theoretical tools have been applied in the development of interventions. Behavior
theory, social learning theory, and cognitive theory have been utilized to a con-
siderable extent in various models of FPE. These are indicated in Table 5.1, in the
following chapter.
28
THEORETICAL PREMISES AND RESEARCH OVERVIEWS 29
PSYCHOBIOLOGICAL RESPONSE TO STRESS

Stress is commonly considered a stimulus, an initial triggering event, external to
the organism. However, the father of stress theory, Hans Selye (1976) proposed
that the external stimulus is actually a stressor, whereas stress is the responsive
physiological disequilibrium of the organism. This internal state of stress then
becomes an activator of attempts to resolve the disequilibrium. Presumptively,
psychotic behaviors and other positive symptoms are maladaptive attempts to
attain this resolution.
Hyperarousal and dysregulation are common descriptors of the schizophrenic
syndrome. These descriptors have been applied to various other psychiatric con-
ditions as well, ranging from mood disorders to borderline personality disorder
(BPD) (Linehan, 1993). The assumption that environmental stressors lead to
physiological dysregulation has received various levels of empirical support, but
clear confirmatory evidence was attained in a recent population-based study in
Taiwan. The investigators explored three questions that are highly relevant to
understanding the relationship between, for example, high expressed emotion
(EE) and relapse. “(1) Do chronic stressors predict physiological dysregulation?
(2) Is that relationship moderated by characteristics of the individual and his or
her social environment? (3) Do perceived levels of stress mediate the relationship
between stressors and dysregulation?” (Glei, Goldman, Cuang, and Weinstein,
2007, p. 769).
Data were obtained from a nationally representative longitudinal study of
almost 1000 older adults in Taiwan. Applying regression models, the investigators
examined the relationship between the number of codified stressful life events for a
four-year period, 1996 to 2000. At the end of this period, they looked at physiological
dysregulation based on 16 biomarkers. The biomarkers reflected neuroendocrine
function, cardiovascular function, the immune system, and metabolic pathways.
Sophisticated models tested whether psychosocial vulnerability moderates the
impact of stressors, and evaluated the mediating effects of perception of stress.
Results revealed a positive association between the number of life stressors
and physiological dysregulation. The relationship was stronger for persons with
greater psychosocial vulnerability, such as lower social position and fewer support-
ive networks. There was also some evidence that the level of perceived stress medi-
ates the relationship between chronic stressors and physiological dysregulation.
The authors state that the results give some support to the theory of allostatic load
and support the stress-buffering hypothesis. Thus, even in a presumptively normal
sample of the general population, an individual’s social position, social networks,
and coping ability are associated with physiological response to stress.
Hogarty and his colleagues (1986), focusing on prevention of relapse, noted that
persons with schizophrenia live in a world “that required the vulnerable patient to
make an adaptive response to complex, vague, multiple, or emotionally charged

expectations. The difficult task faced by the patient in correctly perceiving, pro-
cessing, and responding selectively to stimuli seemed capable of precipitating a
cognitive dysfunction (psychosis), perhaps secondary to affective or autonomic
dysregulation” (p. 634). Much of FPE has been based on the premise that their rela-
tives’ psychobiological deficits inform their responses to ordinary life experiences.
Thus, reduction of overstimulation in the family environment, together with the
effects of psychotropic medications in regulating attention and arousal, will result
in reduction of psychotic episodes or relapse.
The damaging effects of high EE must be hypothesized from this model. Cur-
rent research suggests that attribution of purposiveness appears to underlie high
EE. This may convey an unmanageable demand to persons with schizophrenia. At
particular points in time, they are expected to control that which is beyond their
control. This may indeed be a double bind (but clearly as a precipitant of relapse,
not an explanation of the disorder) and may result in a flight into fantasy.
It must be emphasized again that many people become ill and decompensate in
low-EE families, and that family environment is but one source of stress in a world
with multiple perceived threats. External stressors may range from automobile
accidents to war or natural disasters. Such events obviously cannot be controlled
by mental health systems. However, service providers can control administering
education and support to the caregivers who interact with their patients for many
more hours than they are seen in treatment.
FAMILY PSYCHOEDUCATION AS EVIDENCE-BASED PRACTICE:

RESEARCH OVERVIEWS
Numerous overviews of FPE attest to its efficacy in reduction of relapse and
re-hospitalizations, reduction of hospital days, and improvement of family under-
standing and well-being (Fadden, 1998; Dixon, Adams, and Lucksted, 2000;
Falloon, Held, Falloon, Roncone, Held, Coverdale, and Laidlaw, 2002; Pilling,
Bebbington, Kuipers, Garety, Geddes, Orbach, et al., 2002; McFarlane, Dixon,
Lukens, and Lucksted, 2003; Murray-Swank and Dixon, 2004; Pharoah, Mari, Rath-
bone, and Wong, 2006; Glynn, Cohen, and Niv, 2007; Magliano and Fiorillo, 2007).
Tabular descriptions and details of a multitude of studies of FPE may be found in
Dixon, Adams, and Lucksted (2000), McFarlane, Dixon, Lukens, and Lucksted
(2003); the Cochrane Review (Pharoah, Mari, Rathbone, and Wong, 2006), and
Corrigan et al. (2008), among others.
McFarlane, Dixon, Lukens, and Lucksted (2003) reported that these results
have been demonstrated in more than 30 randomized clinical trials. In their analysis,
only three studies had demonstrated no effect (Kottgen, Sonnischen, Mollenhauer,
and Jurth, 1984; Telles et al., 1995; and Linszen et al., 1996). They explained that
the Kottgren et al. study was actually psychodynamically oriented family therapy,
not psychoeducation; In the Linszen et al. study, the control group received well-
designed individual therapy, achieving low relapse rates comparable to the family
intervention. And in the study by Telles et al. a Spanish-speaking immigrant group
showed either no or reverse effects depending on level of acculturation. They
pointed out that positive findings have been demonstrated in other recent studies
in Spain.
In an earlier overview of the research, Dixon and Lehman (1995) found that
randomized controlled trials of family interventions that provided illness educa-
tion, support, problem-solving training, and crisis intervention, with appropri-
ate pharmacotherapy, reduced one-year relapse rates that ranged from 40–53%
to a range of two to 23%. Since that time there have been even more confirmatory
data. A meta-analysis of family interventions found that inclusion of key relatives
in the psychoeducational process reduced re-hospitalization rates by about 20%
for schizophrenic patients (Pitschel-Walz et al., 2001). In their meta-analysis,
Magliano and Fiorillo (2007) reported that among patients whose families
received psychoeducation, the relapse rate at one year ranged from 6 to 12% com-
pared with 41–53% in the control group. At two years, the relapse rates were 17–40%
and 66–83%, respectively. Further, FPE has been effective in improving medica-
tion adherence and in reducing the overall cost of care. The various studies even
indicate the possibility that FPE actually reduces patients’ level of disability. What
are some of the mediating variables? In reviewing European and American stud-
ies, Bauml et al. (2007) pointed out that psychoeducation improves insight and
compliance by providing information and emotional relief to patients and rela-
tives; and lowers the rate of psychotic relapses and re-hospitalizations by ensuring
sufficient dosage levels of antipsychotic medications.
METHODOLOGY OF OVERVIEWS OF THE LITERATURE

Literature overviews generally are based on searches, careful analysis of findings,
and presentation of uniformities and any discordant results. Although we cannot
describe every overview in detail, we present the methodology on several of these
overviews by prominent research teams.
In an early review, Falloon, Held, Coverdale, Roncone, and Laidlaw (1999),
whose own seminal work is presented in subsequent chapters, evaluated studies
published in the international literature since 1980. A search using PSYCHLIT and
MEDLINE data bases was conducted, also reference lists, monographs, and books
were searched including languages other than English. The research methodology
in each study was assessed by at least two reviewers. The team reviewed 43 con-
trolled studies and found about 50% of high quality, methodologically. Attributes
of studies were as follows: random assignment; post-random compatibility; blind,
independent raters; blind subjects; standardized measures of clinical outcome,

social outcome, and family benefits; measures of adverse effects; reliability estab-
lished, explicit inclusion criteria; diagnosis made by standard criteria; age, gender,
and severity of disorder cited; history of previous therapeutic response cited; spe-
cific treatment described; fidelity of treatment assessed; compliance with treat-
ment assessed; statistical analysis appropriate to data; drop-outs accounted for at
the end of study, or intention to treat analysis was done; cost analysis done; dura-
tion of active treatment at least six months with follow-up of at least six months.
Each cohort was studied over at least one year.
The final analysis was based on 22 high-quality controlled studies with treat-
ment extending for at least six months. Outcome variables included all major
psychotic and affective episodes, deaths, hospital admissions, and serious non-
compliance or withdrawal from medication or psychosocial interventions as
poor outcome. On all these variables, there were significantly better results for
patients with the addition of FPE, characterized as “family-based stress manage-
ment” to medication and case management alone. Although fewer studies looked
at social and family benefits, the trends were positive in these areas as well with the
addition of FPE (Falloon, Held, Coverdale, Roncone, and Laidlaw, 1999, p. 268).
McFarlane, Dixon, and Lucksted (2003) published an overview of FPE as part of
a series commissioned by the American Association of Marriage and Family Ther-
apy on family interventions and therapies and the evidence for their effectiveness.
The authors reported results of 30 randomized clinical trials, which overall, indi-
cated that the relapse rate for clients whose families received FPE was around 15%
per year, compared to a consistent 30% to 40% for individual therapy or medica-
tion alone. This team looked at 11 major studies of FPE versus standard treatment
in terms of their N (ranging from 19 to 313, x = 81), duration of treatment (nine to
48 months, x = 22), and single family/multi-family format. They reported signifi-
cant reductions in relapse, and noted similar findings in studies from China, Spain,
Scandinavia, and Britain. (These studies are more fully described in subsequent
chapters.) Other effects of FPE are increased patient participation in vocational
rehabilitation; substantially increased employment rates; decreased psychiat-
ric symptoms, including deficit syndrome, and improved social functioning.
The reviewers also found improved well-being of family members; decreased
family medical illnesses and utilization of medical care; and reduced cost of care
(McFarlane, Dixon, and Lucksted, 2003).
Probably the most comprehensive and exhaustive overview of family inter-
ventions has been done for the Cochrane Data Base of Systematic Reviews, with
continuing updates as more studies are added to the literature (Pharoah, Mari,
Rathbone, and Wong, 2006). However, the Cochrane Review focused exclusively
on schizophrenia treated in routine practice, and was not limited to formally
designated FPE. The Cochrane group investigated all reported randomized or
quasi-randomized studies that focused primarily on families of people with

schizophrenia and schizoaffective disorder and that compared all family-based
psychosocial interventions with standard care in community settings. Studies
were conducted in Europe, Asia, and North America. Their 2005–2006 update
added 1765 participants, for a total N of 4124.
The following comparisons were made of interventions that were five sessions
or more: (1) any family intervention versus standard care; (2) behavioral family-
based versus supportive family-based interventions; (3) group family-based inter-
ventions versus individual family-based interventions; and (4) family intervention
versus standard care. With respect to data collection and analysis, the investiga-
tors independently extracted data and calculated fixed effects relative risk, the 95%
confidence intervals for binary data, and where appropriate, the number needed to
treat on an intention-to-treat basis. For continuous data, they calculated weighted
mean differences.
Participants included both men and women with a wide range of ages, people
with long histories of illness, and those in their first episode. The authors state that
there were no evident dissimilarities between trials from Australia, Europe, the
People’s Republic of China, or the United States.
From this large database, the investigators concluded that family interven-
tions may decrease the frequency of relapse, reduce hospital admissions; encour-
age compliance with medication; improve the general social impairment level of
patients, and improve levels of EE in the family. They state that family interven-
tions do not affect the tendency of individuals or families to drop out of care, nor
do such interventions prevent or promote suicide.
To summarize, in this chapter we provide a distillation of the theoretical prem-
ises underlying FPE and the large research overviews that support its efficacy. FPE
is based on the etiological assumption of diathesis-stress. The basic premise is that
underlying biological deficits make certain individuals overreact to environmental
stimuli that are experienced as stressful. Hyperarousal and emotional dysregula-
tion as responses to perceived stressors are common aspects of many serious psy-
chiatric disorders. According to Selye’s (1976) theory, stress is actually an internal
response to external stressors, a physiological disequilibrium of the organism. The
internal state then becomes an activator of attempts to resolve the disequilibrium.
Psychotic or paranoid behaviors may be maladaptive attempts to attain this reso-
lution. Family relations, particularly when manifested as high EE, that is, the stres-
sor of hostile criticism or the crushing weight of emotional over-involvement, pose
severe demands on the vulnerable organism and may generate decompensation.
With appropriate education, FPE not only reduces these demand characteris-
tics of high-EE relatives but under any conditions helps create an easier, less stress-
ful home environment. By attending to the educational and psychological needs
of caregivers, FPE makes for less family conflict and more competent caregiving.
Together with the effects of psychotropic medications in regulating attention and

arousal, reduction of over-stimulation in the family environment, and more com-
fortable and knowledgeable family relationships, may be the variables that result
in reduction of psychotic episodes or relapse.
Following this explanatory model, the chapter then presents a large number of
comprehensive overviews of randomized controlled studies of FPE, with descrip-
tions of the methodology of several major overviews. Overall, these studies dem-
onstrate significant reduction of relapse and re-hospitalizations, reduction of
days in hospital, and improvement of family knowledge and well-being in patients
whose relatives received FPE in contrast to other or no family interventions.
Investigators postulate that by providing information and emotional relief to both
patients and family members, FPE improves insight and medication adherence,
ensuring sufficient dosage levels of antipsychotic medications and thus reducing
relapse rates. The largest database on family-based interventions in schizophrenia
(N = 4124), in addition to corroborating the hypothesis of greater compliance and
findings of reduced relapse and re-hospitalizations, also found improved levels of
family EE and improved social functioning of patients.
Following theoretical premises and research overviews, the next chapter
describes some of the most important FPE research programs in greater detail.
Since many research findings are based on time-limited interventions, we also
discuss follow-up studies showing long-term effects.
5
M OD E L RE S E A RC H P RO G R AM S
family psychoeducation
The studies that validated family psychoeducation (FPE) as evidence-based

practice (EBP) were initially conducted primarily in the United Kingdom and the
United States. According to Fadden (1998), the most influential studies that initi-
ated the introduction of FPE were produced by four research teams, in their origi-
nal reports and their confirmatory follow-up data. In the United Kingdom, Fadden
cites the research of Leff et al. (1985) in London and Tarrier et al. (1989) in Man-
chester. In the United States, Falloon et al. (1985) in California, and Hogarty et al.
(1991) in Pittsburgh were the major researchers.
Although all provided some combination of education, support, and skills train-
ing, Abramowitz and Coursey (1989) have distinguished these seminal empirical
studies in terms of a specific focus. They state that the Pittsburgh model focused on
the provision of information (Anderson, Hogarty, and Reiss, 1986); the California
(UCLA and USC) model featured skills training (Goldstein and Kopekin, 1981;
Falloon, Boyd, and McGill 1984); and the London Institute of Psychiatry provided a
comprehensive approach of information, skills, and support (Berkowitz, Eberlein-
Fries, Kuipers, and Leff, 1984). To this, we may add that the cognitive–behavioral
interventions of Tarrier et al. (1989) focused on responding to families’ assess-
ment of their own needs (Barrowclough and Tarrier, 1992). These seminal studies
are described in depth in the following paragraphs, as well as those of other major
researchers.
All of the studies relied on reducing family stress and high expressed emotion
(EE), empirically identified as lowering recidivism rates, rather than on theories
of schizophrenia or of coping and adaptation. All focused primarily on the patient
rather than the family. Later, the field would see the expansion of Falloon’s work
in Europe, incorporation of FPE in the early intervention work in Australia, and
35
the emergence of McFarlane’s (2002) multi-family model which is now being

applied in Asia, Australia, and Europe, as well as the United States. This model adds
peer support, including families’ exchange of resource information and coping
techniques, to the basics of FPE. Concomitantly, a number of well-designed and
rigorously controlled studies from other parts of the world, most notably China,
confirmed the cross-cultural importance of FPE in the treatment of schizophrenia
and major affective disorders.
The following is a highly selective list of major programs that generated and
continued FPE as EBP. They are generally presented in historical sequence.
SCHIZOPHRENIA
FAMILY PSYCHOEDUCATION (FPE)

Institute of Psychiatry, London; Royal Free and University College Medical
School, London, University of Manchester, and University of Birmingham. Key
researchers reporting over the years include Julian Leff, Christine Barrowclough,
Paul Bebbington, Ruth Berkowitz, Max Birchwood, Graine Fadden, Liz Kuipers,
Dominic Lam, Angus Strachan, Nicholas Tarrier, Christine Vaughn, et al.
The Expressed Emotion (EE) research emanated from the Institute of Psychi-
atry in London, and Kuipers, Leff, and Lam (2002) have pointed out that in their
research and clinical work, they have selected families in which at least one mem-
ber was rated as high-EE. They state that this does not imply that low-EE families
do not need help; however, high-EE families have a higher priority and they have
had to be selective when trained therapists are in short supply. Their training
manual for family work therefore incorporated this selective emphasis.
In their first trial with 24 patients with schizophrenia (Leff et al., 1982), two types
of family interventions were compared with standard care. High-EE relatives were
randomly assigned to a family therapy condition involving psychoeducation (FPE)
in the home with the patient present (N = 12) or a psychoeducational relatives’ group
with the patient absent (N = 11). (In the final data analysis at the end of two years,
there were 26 relatives who attended and were interviewed at three different time
points.) Both relatives’ groups and FPE sessions were scheduled every two weeks
for nine months. The researchers hoped to determine whether desired changes in
the family could be achieved equally well, regardless of the patient’s participation,
compared with regular outpatient treatment with no family intervention.
The FPE group received a median of 17 sessions in the first nine months, and a
median of 12 between the nine-month and two-year follow-up. The relatives’ group
was similarly scheduled for about the same number of bi-monthly sessions. The
investigators found that relatives’ over-involvement reduced steadily throughout
the trial. They stated that reduction in relatives’ EE, either alone or together with
MODEL RESEARCH PROGRAMS 37
reduced face-to-face contact, appeared to be associated with lower relapse rate. At

nine months, the relapse rate in the FPE group was 8% versus 50% in the standard
care condition. At two-year follow-up, the differences had disappeared—33% in the
FPE versus 36% in the relatives’ group. However, “When these data were combined
with the results of a previous trial, it was found that patients in families assigned
to any form of social intervention had a two-year relapse rate of 40%, significantly
lower than the 75% relapse rate of patients whose families were offered no help”
(Leff et al., 1990, p. 571).
NEEDS-BASED COGNITIVE–BEHAVIORAL FPE

University of Manchester, United Kingdom: Christine Barrowclough, Nicholas
Tarrier, William Sellwood, et al.
Background: This program is of particular interest because it used a family
needs-based approach in delivering psychoeducation. In this respect it was some-
what similar to family consultation, in tailoring the intervention to needs and prob-
lems identified by the families. This intervention extended FPE to outpatients in
regular clinical services with family members who were not necessarily of high-EE
status. The study used a geographical sample in which subjects were entered into
the trials as patient-caregiver units. Potential subjects were identified by screening
hospital admission records, obtaining dual consent, and then assessed on multiple
measures before randomization to two arms of a controlled study. The treatment
group offered a needs-based psychosocial intervention including family support,
and a control group offered family support alone. The planned intervention was
24 weeks in patients’ homes. All patients in both groups were allocated a voluntary
family support worker.
Specific problems were identified by each family and the focus, content and
quantity of interventions were determined by a systematic assessment of care-
giver needs, level of concern, and desire for intervention. For each problem, a
number of psychosocial intervention approaches were identified. Three broad
types of interventions were differentiated: problem-solving techniques, derived
from the behavioral family management of Falloon, Boyd, and McGill (1984);
cognitive–behavioral interventions with families, developed by Barrowclough and
Tarrier (1992); and individual cognitive–behavioral interventions with patients
with psychosis (Haddock, Tarrier, and Spaulding, 1998). Over a six-month period
10 to 20 sessions were available for families, with patients attending at least 50% of
the sessions. Outcome variables were based on patients’ symptom and functional
levels, and medication compliance. Families were assessed for needs, general
health, social functioning, depression, and EE levels.
Results: Among 77 patient–caregiver pairs, at six-month follow-up, relapse
outcomes were significantly superior for family-treated patients versus controls
(24% vs. 46%). There was a significant reduction in the cardinal needs and num-
ber of problems of the needs-based intervention group vis a vis controls, who had
begun with equivalent scores. However, distress and burden scores in both groups
showed a high degree of stability over the six-month period, and there were no
differences between the groups Barrowclough, Tarrier, et al., 1999).
Since that early research, many studies have been generated in the United Kingdom,
particularly in the London and Manchester research groups. The Manchester needs-
based study cited earlier provided consistent results at twelve-month and five-year
follow-ups (Sellwood, Wittkowski, Tarrier, and Barrowclough, 2007). These findings
are described in the long-term follow-up section below and cited throughout this book.
FAMILY PSYCHOEDUCATION AND TREATMENT PROGRAM (FPTP)

University of Pittsburgh, Western Psychiatric Institute and Clinic, Carol Anderson,
Gerald Hogarty.
The Pittsburgh program evolved from evidence in the research literature
on schizophrenia and from years of experience with unsuccessful traditional
approaches to working with families of patients with this disorder. Increasingly
aware of family needs and stresses in coping with schizophrenia, these clinicians
“began to wonder if most ‘real’ family therapy was in fact antitherapeutic. We
began to experiment with other more educational formats” (Anderson, Reiss, and
Hogarty, 1986, p. 2). From the copious research on biological substrates, together
with the research on EE, they concluded that if either environmental demands or
underlying cerebral deficits are sufficiently severe, they are likely to generate a
schizophrenic relapse. Their initial psychoeducational work therefore focused pri-
marily on reducing high EE in families of hospitalized patients in order to facilitate
community re-entry and prevent relapse. In a subsequent evaluation of efficacy,
this model determined the selection of family participants.
The program was designed as “an education and management strategy intended
to lower the emotional climate of the home while maintaining reasonable expecta-
tions of patient performance. . . . This strategy should not be formally designated
as ‘family therapy’.” Rather, through the provision of formal education about the
disorder and strategies for managing more effectively, family members become
allies in the treatment process as their anxiety and distress are decrease. More tra-
ditional attempts to promote disclosure, ‘insight,’ or direct modification of family
systems, including the resolution of intergenerational and marital issues, were, for
the most part, avoided.. . . Treatment sought to increase the stability and predict-
ability of family life by decreasing the family’s guilt and anxiety, and increasing
their self-confidence, and providing a sense of cognitive mastery through the pro-
vision of information concerning the nature and course of schizophrenia as well as
specific management strategies . . .” (Hogarty et al., 1986. p. 634).
The phases of the intervention included: I. Connection, that is, connecting with
the family through joining, empathy, reducing family stresses, establishing a treat-
ment contract with specific practical suggestions; II. Survival Skills Workshop,
concrete data on schizophrenia, understanding of illness and patient’s needs, con-
crete management suggestions, and basic communication skills; III. Re-entry and
Application, focused on maintenance of patient in the community, with increased
tolerance for low-key dysfunction, along with gradual assumption of responsibil-
ity by the patient, reinforcement of boundaries, task assignments, and problem-
solving; IV. Work, Social Adjustment, a period of re-integration into normal roles in
work, school, continued stabilization, with increased attention to needs of other
family members; V: Maintenance increased effectiveness of general family pro-
cesses, with decreased use of therapeutic resources. A detailed description of each
of these stages, including the training and supervision of staff, may be found in
Anderson, Reiss, and Hogarty (1986).
THE RESEARCH DESIGN AND FINDINGS

This was a study of 103 hospitalized patients with schizophrenia from high-EE
households. The research design specifically required that “for at least three
months before admission, the patient had to reside in (and was likely to return
to) a household defined as ‘high’ in EE. A significant other residing in the patient’s
household was rated ‘high’ if he or she expressed six or more critical comments
toward the patient, or had a rating of four or five on a global judgment of emotional
over-involvement, or had a positive rating of hostility (on) the abbreviated form of
the Camberwell Family Interview . . .” (Hogarty et al., 1986, p. 635). Subjects were
randomly assigned to a two-year after-care program of: (1) family treatment and
medication, (2) social skills training and medication, (3) a combination of the first
two conditions, or (4) medications alone.
Results: First-year relapse rates for the treatment group showed a main effect
for family treatment (19% relapse), a main effect for social skills training (20%),
and an additive effect for the combined conditions relative to controls, who had a
41% relapse rate. There was an absence of relapse in any household that changed
from high to low EE. Only the combination of treatment sustained a remission in
households that remained high EE. However, the authors stated that further study
suggested that there appears to be a delay in relapse rather than prevention. More-
over, they cautioned against a tendency to admit only high-EE families to psy-
choeducation as a primary indicator of risk. In their two-year report, it appeared
that FPE was most effective in deterring relapse, and this occurred regardless of
social-skills training. Only 29% of patients receiving FPE relapsed over the two-
year study period, compared with 62% of patients who received pharmacotherapy
alone (Hogarty, Anderson, Reiss, Kornblith, Greenwald, et al., 1991).
BEHAVIORAL FAMILY THERAPY (BFT)

Robert Liberman, Ian Falloon, Michael Goldstein, also Shirley Glynn, David
Miklowitz, Jan Randolph and others, University of California, Los Angeles,
University of Southern California School of Medicine; Kim Mueser, Dartmouth
Medical School; Optimal Treatment Project, University of L’Aquila, Italy, Ian
Falloon and Associates.
BFT was first evaluated by Ian Falloon and his associates (Falloon, Boyd, and
McGill, 1984) using behavioral analysis of families’ needs and teaching families
behavior-management techniques to help the patient and family cope with schizo-
phrenia. As McFarlane, Dixon et al. (2003) note, this approach “follows a sequential
framework of assessment, intervention and ongoing review, and includes a behav-
ioral analysis of the strengths and needs of each family member and the family unit
as a whole, followed by single-family sessions in the home. These sessions focus
on education about schizophrenia, strategies for improved communication, and
the development and rehearsal of problem-solving techniques . . . The model starts
from a strengths perspective, with clinicians assuming that each family member is
functioning at his or her best . . . ” (p. 226). The basic content of the BFT approach may
be found in Table 5.1, Table 5.2, and Table 5.3. For many years, Robert Liberman and
TABLE 5.1 PSYCHOEDUCATIONAL INTERVENTIONS FOR FAMILIES (SCHIZOPHRENIA)
basic premise
Schizophrenia is a brain disorder that is highly sensitive to the social environment. Treatment
requires medication (also psychotherapy and rehabilitation as needed), and techniques to reduce
stimulation and complexity in the environment and facilitate effective knowledge and support of
caregivers. There is no presumption of family dysfunction or psychopathology.
common components
• State-of–the-art information about the disease and its treatments
• Supportive understanding of the family’s experience
• Behavior management and communication techniques
• Problem-solving strategies
theoretical tools
• Stress. Coping and Adaptation Theory (understanding patients’ and families’ response to
illness)
• Social Learning Theory (training skills through repeated role rehearsals, modeling social
reinforcement)
• Cognitive Theory (training to question assumptions about the meaning of symptoms and the
illness)
• Behavior Theory (modifying behavior by setting limits, contingency contracting, shaping, etc.)
TABLE 5.2 THE CONTENT OF FAMILY EDUCATION ABOUT SCHIZOPHRENIA
diathesis-stress model
• Schizophrenia is a biologically-based, stress-related illness that leads to widespread problems in
living, intimate relationships, work, study, personal care, social and leisure activities.
• Diagnosis, symptoms, etiology, drugs. The experience of psychosis, positive and negative
symptoms, handouts, visual aids, etc.
medications
• Expected affects and side effects
• Reasons for antiparkinsonian drugs
importance of drug compliance to forestall relapse

• Prodromal warning signals of tardive dyskinesia
negative effects of street drugs and alcohol
expectancy of change
• Expected slow rate of improvement
stress identification and control

• Improve family’s ability to identify and deal with stressful situations
• Criticisms and emotional over-involvement are reduced
family issues
• Education to reduce guilt, over-responsibility confusion helplessness of family
• Enable family members to be less judgmental and critical, and less invested in fantasies that they
caused or that can cure the illness
• Issues of control and accountability
• Families’ obligations to themselves
patient issues
• Patients are encouraged to come to terms with their illness
• Education aims at reducing denial, encouraging reasonable hopes for gradual improvements
supplanting fantasy with planning action toward attainable goals
• Planning for work and/or productive use of time, social outlets
joint family planning to cope with current stressors

• Anticipatory planning for future stress and avoidance of relapse after intervention ends.
• May use psychoeducational intervention to establish family’s role in treatment- planning,
long-term goals-setting, establish boundaries of confidentiality, etc.
TABLE 5.3 THE BEHAVIOR-MANAGEMENT MODEL OF FAMILY PSYCHOEDUCATIONAL

INTERVENTIONS*
education about schizophrenia

A realistic yet hopeful account of the nature, causes, courses and management of schizophrenia
is presented to patients and their families, with handouts, diagrams, visual aids, and other needed
resources
communication training
Teaching non-verbal and verbal communication skills through repeated role Rehearsal, with in-
structions modeling and social reinforcement
• Non-verbal behavior
• Voice, tone, volume, eye contact, facial expression
• Verbal content of the interaction
• Reciprocity of communication including:
• Reflective empathic listening
• Keeping communication highly specific
• Simplifying content
• Avoiding excessive delays in expressing both positive and negative emotions
• Role modeling, role reversal in simulations, etc.
problem-solving training
Teaching a structured, sequential approach to generating effective solutions to specified family
problems
• Identify a specific problem
• Outline alternative strategies, five potential solutions before making judgment
• Evaluate potential effectiveness of each of listed strategies
• Agree on most effective solution
• Carry out best solution
• Review results; praise efforts
behavior management techniques for coping with

symptomatic behaviors
Contingency contracting
• Two members agree on what they would like to do for each other in a mutual exchange
Token economies
•
Shaping
• Step-by-step prompting and reinforcement for successive approximations
TABLE 5.3 THE BEHAVIOR-MANAGEMENT MODEL OF FAMILY PSYCHOEDUCATIONAL

INTERVENTIONS* (CONT'D)
Time out
• Members excuse themselves from stressful situations when they feel under Pressure-role
model for patient
Setting limits
• Acceptable limits for all family members
Identifying prodromal warning signals of relapse
• Sleep disturbance
• Social withdrawal
• Unco-operativeness
• Unusual ideas, mannerisms
• Irritability
Seek professional help
his associates at UCLA incorporated FPE in psychiatric rehabilitation programs

(Liberman and Liberman, 2003). They developed manuals, videotapes, and other
training materials, and continue involving families in today’s recovery orientation
in mental health care (Liberman, 2008).
RESEARCH DESIGN AND FINDINGS

In the early studies of the California group, patients were randomly assigned to
receive either family or individual treatment. All index patients were scheduled
to receive 40 therapy sessions over a two-year period. Patients were assessed at
nine and 24 months, evaluating each patient’s mental status, social adjustment.
Families were assessed in terms of family burden, and attitudes toward illness
and treatment. Family interactions were assessed at baseline, three months, and
24 months.
Results: Individual therapy patients were far more likely than family therapy
patients to experience a major episode (21 vs. three episodes, respectively) and
these episodes were more than three times as long in duration (69 vs. 21 days).
The mean days of hospitalization were 11% for patients receiving family therapy
versus 50% for patients in the individual therapy condition. There were small
but significant gains in social functioning and social adjustment among patients
who received family treatment, whereas those in individual treatment showed no
overall improvement. At nine-month assessment, fewer family-treated patients
tended to show the same behavioral impairments as at baseline. Again in relation
to baseline, at nine months, significantly fewer family-treated patients displayed

bodily complaints, problems of medication adherence, odd or unusual behavior,
or self-neglect than did the individually-treated cohort. “Improvements in the
family-treated patients appeared most prominent in behavior associated with
the social impairments of schizophrenia, such as withdrawal, bizarre behavior,
and self-neglect . . . One very striking finding was a lack of reported problems with
medication compliance in the family-treated group. This compared with compli-
ance problems reported in nearly 40% of individual patients . . .” (Falloon, Boyd,
and McGill, 1984, p. 344).
Since that early study, Mueser and Glynn (1999, p. 239) reported six additional
controlled studies of long-term FPE with a behavioral orientation, also three with
supportive and one with a family systems orientation. Duration ranged from nine
to 24 months, with a mode of 24 months. In three-quarters of the studies, the psy-
choeducatonal behavioral family intervention was more effective at the.05 level
or better. Falloon’s work in FPE continued in Europe with the Optimal Treatment
Program, described in the following paragraphs.
TREATMENT STRATEGIES IN SCHIZOPHRENIA: BFT AND

MEDICATION LEVELS
Schooler, S. J. Keith, J. B. Severe, S. M. Matthews, A. S. Bellack, I. D. Glick, W. A.
Hargreaves, J. M. Kane, P. T. Ninan, A. Frances, M. Jacobs, J. A. Lieberman, R.
Mance, G. M. Simpson, and M. G. Woerner. NIMH/Western Psychiatric Institute
and Clinic, Pittsburgh, PA 15213, United States.
Background: Previous studies have examined dose reduction and family
treatment in schizophrenia, but none has examined their interaction. This study
assessed the impact of dose reduction of antipsychotic medication and family
treatment on relapse and re-hospitalization during maintenance treatment.
Methods: subjects were 313 male and female outpatients at five centers with a
DSM-III-R diagnosis of schizophrenia or schizoaffective disorder. In a 3 × 2 design,
subjects were randomized to one of three medication strategies using fluphenazine
decanoate under double-blind conditions: continuous moderate dose (standard)
(12.5–50 mg every two weeks); continuous low dose (2.5–10 mg every two weeks);
or targeted, early intervention (fluphenazine only when symptomatic). Sub-
jects also were randomized to 1 of two family treatment strategies (supportive or
applied, i.e., BFT). Supportive family management involved monthly group meet-
ings. The more intensive applied family management involved monthly group
meetings and home visits where communication and problem-solving skills were
taught. Patients and families were treated and assessed for two years.
Results: Both continuous low-dose and targeted treatment increased use of res-
cue medication and relapse; only targeted treatment increased re-hospitalization.
This pattern was consistent across both family treatments; there were no differ-
ences between family treatments.
Conclusions: These findings reaffirm the value of antipsychotic medication in
preventing relapse and re-hospitalization. The absence of family treatment differ-
ences may be because both conditions engaged families (Schooler et al., 1997).
A sub-study of the same groups by Bellack, Haas, Schooler, and Flory (2000)
examined the effects of BFT on communication, problem-solving, and outcome
to determine the impact of the structured communication training. Patients and
family members were videotaped engaging in a 10-min problem-solving conver-
sation at baseline and after the conclusion of the family intervention. Tapes were
subsequently evaluated for changes in communication patterns.
Results: The BFT did not produce differentially improved communication,
and any change in communication was unrelated to patient outcomes. However,
another sub-study in the Treatment Strategies in Schizophrenia project found that
TABLE 5.4 THERAPIST BEHAVIOR
positive reinforcement
• Praise, attention, interest used by therapist to build supportive family milieu for problem
resolution and good communication
shaping
•Therapist selectively reinforces even small signs of improved family relationships
extinction
•Minimum reinforcement through lack of attention, interest, acknowledgement of
inappropriate behavior
modeling
•Therapist models active listening, expression of negative feelings, positive requests for behavior
change
rehearsal
•-Interpersonal situations are acted out with constructive feedback from therapist in every
session, families go over particular problem situations and learn alternative responses
homework
•Practice assignments on the behavior dealt with in the session are given to each member to
report on next session
Note: Table 5.1– 5.4 are largely based on the combined work of the research group at University of South
California and UCLA, primarily Ian Falloon, Robert Liberman, Kim Mueser, Shirley Glynn, Jan Randolph, and
others involved in schizophrenia research.
families who received BFT showed lower levels of family friction and relatives had
less rejecting attitudes toward the patient than families who received supportive
family management only (Mueser, Sengupta, et al., 2001).
MULTI-FAMILY GROUP PSYCHOEDUCATION (MFG)

William McFarlane, Ellen Lukens, et al.; Columbia University and New York State
Psychiatric Institute, New York: Maine Medical Center.
The initial study of MFGs was conducted in 1981, in a small-sample experi-
ment in which 41 patients with schizophrenia were selected during relapses and
randomly assigned to psychoeducational single-family treatment (PSFT), psycho-
educational multi-family group,(PMFG), and a family-dynamic multi-family group
(FDMFG). The treatments offered psychoeducation alone for PSFT, social net-
work expansion for PMFG, and both combined for FDMFG. Treatment was based
on the Anderson–Hogarty–Reiss model previously described.
Results: The PMFG cohort yielded the lowest relapse rate after four years, 50%
versus 78% of the patients in the PSFT and 57% in the PDMFG conditions. The risk
for relapse in the PFMG cell was 33% of the single family treatment, significant at
the .05 level. It was clear that the multi-family format yielded superior results.
The New York State Family Psychoeducation Study followed. Based on their
previous work, McFarlane and his colleagues then compared outcomes in a study in
which 172 acutely psychotic patients with schizophrenia were randomly assigned to
single family or multi-family group (MFG) psychoeducation at six public hospitals in
New York state for two years of treatment. All family clinicians were trained with a
treatment manual and were required to meet competency criteria. All patients were
medicated with maintenance dosages after index hospital discharge. By protocol,
patients in the study could not receive any outpatient individual or family psychother-
apy. Psychotic relapse, symptom status, medication adherence, re-hospitalization,
and employment were then assessed during two years of supervised treatment.
Research Findings: The MFG condition yielded significantly lower two-year
cumulative relapse rates than did the single-family treatment (16% vs. 27%).
Among patients who were not in remission at index hospital discharge, the MFG
advantage was even stronger (13% relapse vs. 33% for single family treatment).
The relapse risk ratio between treatments was 1.3. The relapse rate for both sin-
gle and multiple family group psychoeducation was less than half the expected
rate (65% to 80% for two years). In both conditions, re-hospitalization rates and
psychotic symptoms decreased significantly, and medication compliance was
high. The authors’ conclusion was that MFG was more effective than single-family
treatment, with a cost–benefit ratio of up to 1.34 (McFarlane et al., 1995).
A four-year follow-up permitted an experimental three-way comparison
of PMFGs, psychoeducation in a single-family format, and MFGs without
psychoeducation, using symptom relapse as the outcome criterion. After four

years, the PMFGs were significantly more effective than the single-family inter-
vention, while both MFG formats, with or without psychoeducation, were approx-
imately the same. The relapse rates at four years for the MFGs were 50% with
psychoeducation and 57% without psychoeducation, averaging 12.5% and 14% per
year, respectively. For the single family format, the four-year relapse rate was 78%.
According to the authors, these results indicate a long-term therapeutic effect for
family groups (McFarlane, Link, Dushay, Marchal, and Crilly, 1995).
The Family-Aided Assertive Community Treatment (FACT) Outcome Trials
was a subsequent research program, described in McFarlane (2002). Because 15%
of cases in the earlier studies continued relapsing, the team decided to integrate
MFGs with assertive community treatment (ACT) teams to improve clinical sta-
tus in patients who seemed to be treatment failures. Two studies were conducted,
exploring the effectiveness of the combined model; one comparative, and one
controlled. In the controlled study, 60 persons with schizophrenia were randomly
assigned to ACT combined with either PMFG or crisis family intervention (CFI).
Patients were required to have at least one complicating factor: lack of treatment
adherence, history of violence and/or suicidality, frequent hospitalizations, arrests
or criminal convictions, homelessness, unwanted pregnancy, or substance abuse.
In the PMFG cohort, families and patients participated in group problem-solving
sessions, received pychoeducation, and met weekly with two ACT team members
for two years. In the CFI intervention, FACT team coordination occurred only at
times of crisis, without input of other families.
Results: The PFMG treatment resulted in higher employment activities, includ-
ing sheltered work (33% vs. 19% for CFI)). However, there were no group differ-
ences with regard to hospitalization rates or symptom change for the samples as
whole. For all patients, hospitalization decreased over the two years and, in the
final six months, it was only 30% of the mean pre-treatment rate. All symptoms
decreased from baseline to two years ( p < .001).There was an increase in medica-
tion adherence from intake level ( p < .001). There were also significant improve-
ments in family ratings of objective burden, subjective burden, dissatisfaction with
the patient, and patients’ friction with others (McFarlane, 2002).
Since these findings, there have been other studies confirming the advantages
of MFGs. In a study conducted in Spokane, Washington, participants in MFG
experienced significantly reduced negative symptoms compared with families
of those receiving standard care (Dyck et al., 2000). In another study, caregivers
receiving MFG experienced greater reductions in distress compared with caregivers
of patients receiving standard psychiatric care (Hazel et al., 2004).
In terms of cost–benefit, McFarlane reported that “In Michigan, one county
system documented an 83% net reduction in acute care costs year-to-year
for 50 patients, about one-third on ACT teams, the others young adult clinic
patients . . . Imagine—83% reductions in acute care costs for the USA!” (W.R.
McFarlane, personal communication, August 12, 2008).
McFarlane’s model has been widely utilized in various states in the United
States (McFarlane et al., 1993; McFarlane, McNary, Dixon, Hornby, and Cimett,
2001). Included are clinics in California, Illinois, Maine, Michigan, New Hampshire,
New Jersey, New York, and Ohio. “We have trained nearly a thousand clinicians in
Michigan and there are at least 50 clinics in New York using MFGs . . . Kaiser Perma-
nente has been implementing throughout their Northern California system with
some considerable success—at least one group in each clinic trained. Successful
implementation in Australia, west of Melbourne; large-scale applications in Japan
and China, Norway, and Denmark and the Canary Islands” (W.R. McFarlane,
personal communication, May 12, 2008). In the next chapter, we will see that
McFarlane’s model is widely applied in early intervention studies. The essen-
tials of MFG, and many of its applications, are indicated in McFarlane, 2002. The
general advantages of the group format as a supportive resource for families are
indicated in Table 5.5, and the empirical advantages in Figure 5.1.
THE OPTIMAL TREATMENT PROJECT GROUP(OTP)

Ian Falloon, and the OTP Collaborative Group, ARIETE, Perugia, Italy, University
of Auckland, New Zealand; University of Valencia, Spain; University of Istanbul,
Turkey; Azienda Ospedaliera S. Anna, Como, Italy; University of Gothenburg,
TABLE 5.5 MULTI-FAMILY GROUPS: ADVANTAGES IN COPING
• Empathic understanding of shared experience

• Normalized reactions of fear, guilt, grieving
• Resource information
• Exchange of coping strategies
• Social network for isolated familiesa
• Enhanced problem-solving capabilitya
• Antidote to emotional over-involvement*
• Cross-parenting: concrete aid for members’ relatives—jobs, social support, guardianshipa
• Connections to advocacy organizations
• Examples of success stories
• Reinforcement of hope and mastery
a Also found in McFarlane, W.R. (2002). Multifamily groups in the treatment of severe psychiatric disorders.
Guilford, New York.

100% Standard Care (N ⫽ 203)

Single Family Treatment (N ⫽ 231)
Multiple Family Group Treatment (N ⫽ 266)
Single & Multiple Family Group Treatment (N ⫽ 243)
75%
Cumulative Relapse Rate
59%
50%
29% 28%
26%
25%
0%
Figure 5.1 Cumulative relapse/re-hospitalization rates during 18 to 24 months in randomized controlled

trials of long-term family intervention for schizophrenia. Reprinted with permission from Mueser, Bond, and
Drake (2001). Community-based treatment of schizophrenia and other severe mental disorders: Treatment
outcomes. Medscape General Medicine, 3(1), 1–24.
Sweden; University of Athens, Greece; Norwegian University of Technology

and Science, Trondhem, Norway; Semmelweiss, University, Budapest, Hun-
gary; Keio University, Tokyo, Japan; Meiji Gakuin University, Tokyo, Japan;
Rheinischelandesklinik, Bonn, Germany; University of Berlin, Germany; Depart-
ment of Mental Health, Campobasso, Italy; Te Ara Hou Mental Health Trust,
Auckland, New Zealand.
OTP was set up as an international collaborative group to promote the routine
use of evidence-based strategies for schizophrenic disorders in ordinary clinical
facilities. The strategies are listed as follows:
• Antipsychotic drugs at lowest levels for effectiveness
1. Education about medications, training in adherence, early warning signs of ill-
ness exacerbation
• Education of patients and caregivers in stress-management strategies
• Education on psychotic disorders and their treatments
• Training in effective interpersonal communication and problem-solving
• Assertive case management and outreach
1. Gaining effective social support, including housing, finances, health, and safety
• Early detection and care to resolve clinical and social crises
• Goal-oriented social-skills training (for patients and caregivers)
1. Specific pharmacological and psychological strategies for recurring symptoms
2. Strategies for coping with persistent psychosis, managing negative symptoms,

coping with anxiety and panic, mood swings, dysphoria, suicidal thoughts
(Falloon, 1999; Falloon et al., 2004).
As a demonstration project, the OTP set up an international multi-site study to

evaluate the benefits of applying evidence-based treatment (EBT) for schizophrenia
and other nonaffective psychotic disorders over a five-year period. At its inception,
53 sites in 21 countries were initially selected, and 35 sites continued to participate.
More than 80 centers in over 20 countries began the project since 1994. However, there
were only 14 centers with unselected cases who received optimal treatment for at least
24 months according to the project protocol. These formed the basis of the review.
At the program sites, multi-disciplinary teams were trained to administer the
optimal treatment strategies, with continuous audits of fidelity to the model,
annual independent reviews of services, and further training as needed. A core bat-
tery of global measures was used to assess outcomes, including symptom impair-
ment, psychosocial functioning, and disability scales, and global caregiver stress.
Research Findings
At the end of 2002, 1012 cases have entered the project, with 603 having completed
at least two years of optimal treatment. Complete data was available on 594 cases,
99% of the sample. On clinical, social, and caregiver indices, significant improve-
ments were found after 24 months. There were average percentages changes of
41% on the impairment index, 39% on disability, and 48% less stress on caregivers.
Direct comparison of cases randomly assigned to OTP (N = 146) or routine case
management (N = 114) in four sites (Ankara, Trondehim, Benvento, and Gothenburg)
showed even greater contrast, with OTP cases showing more than twice the ben-
efits of routine case management.
Recovery was assessed at two levels: (1) full (no significant impairment or dis-
ability) and (2) partial (substantial improvement in impairment and disability).
Further analysis showed that 35% of the OTP cases met criteria for full recovery
at 24 months versus 10% of those in routine case management. When a recent-
onset group (onset within 10 years) was considered separately, 43% had made a full
recovery. In sum, “On all measures, the evidence-based OTP approach achieved
more than double the benefits associated with current best practices. One half of
recent cases had achieved full recovery from clinical and social morbidity. These
advantages were even more striking in centers where a random-control design was
used” (Falloon et al., 2004, p. 104).
More recently, an OTP team based at the University of L’Aquila, Italy, focused
primarily on FPE, which they defined as a cognitive–behavioral model. They
describe the following content: “individual evaluation of each member of the
family; assessment of the problem-solving capacity of the family as a whole; educa-

tion regarding the nature of the disorder and its biomedical and psychosocial treat-
ment; identification of early warning signs; improvement of communication skills;
structured problem-solving; personal and family objective setting; social skills
and vocational training; and evidence-based psychological strategies for specific
problems, such as anxiety syndromes” (Roncone et al., 2007, p. 592).
To test the effectiveness of FPE in routine services, 34 mental health profes-
sionals were trained in the Falloon model of FPE and applied it for six months in
17 mental health centers in Italy. Recipients were all family members of persons
with schizophrenia. At baseline and six months later, the patients’ clinical status
and level of disability were assessed, as well as participants’ level of family burden,
social network, and professional support. All assessments were on well-validated
instruments. Of the 71 recruited families, 48 (68%) completed the intervention.
At six months, a significant improvement was found in patient’s clinical status
and social functioning. The percentage of patients with poor or very poor global
social functioning dropped from 50% to 27%. Relatives’ burden and social and
professional support similarly showed significant improvement. Forty percent of
patients and 45% of relatives reported significantly improvement in their social
contacts (Magliano et al., 2006).
MAJOR AFFECTIVE DISORDERS
FAMILY FOCUSED TREATMENT (FFT) FOR BIPOLAR DISORDER (BD)

(MIKLOWITZ AND GOLDSTEIN, UCLA)
According to FFT founders Miklowitz and Goldstein (1997), the six objectives of
FFT are to assist the patient and relatives in the following goals: (1) integrating the
experiences associated with episodes of BD; (2) accepting the notion of vulnerabil-
ity to future episodes; (3) accepting a dependency on psychotropic medication for
symptom control; (4) distinguishing between the patient’s personality and his or
her bipolar disorder; (5) recognizing and learning to cope with stressful life events
that trigger recurrences of BD; and (6) establishing functional relationships after
the episode. BD is considered a disorder that impacts the family. The model begins
with functional assessment of history of the disorder and family interactions.
FPE involves etiology, treatment, and self-management within the vulnerability-
stress model. The sessions are devoted to dealing with resistance; communication
enhancement training relevant to clinical issues; dealing with family problems and
problem-solving techniques; managing crises such as manic relapses, depressive
relapses, suicidal attempts, alcohol and substance abuse and other psychiatric cri-
ses; and termination, including anticipating future problems and treatment needs,
and arranging for follow-up visits.
Research Findings: In a randomized controlled trial, 101 bipolar patients were

assigned to FFT compared with a less-intensive crisis-management intervention. Both
groups received pharmacotherapy. Outcome was assessed every three to six months
for two years. FFT involved 21 sessions of psychoeducation, communication training,
and problem-solving skills training for nine months. Crisis management involved
two sessions of family education and crisis intervention sessions as needed. For
patients whose families received FFT, there were significantly fewer relapses, lon-
ger survival intervals, greater reductions in mood-disorder symptoms, and better
medication adherence than those receiving crisis management alone (Miklowitz,
George, Richards, Simoneau, and Suddath, 2003).
A one-year randomized trial from the Systematic Treatment Enhancement
Program (STEP-D) examined the effects of four psychotherapies for depression in
patients with BDI and BD II disorders. Fifteen clinics tested a total of 293 patients.
They were randomly assigned to intensive psychotherapy (N = 163) or collabora-
tive care (N = 130), the latter consisting of three sessions of education in six weeks.
Intensive psychotherapies were interpersonal therapy, social rhythm therapy,
cognitive–behavior therapy, and FFT. These were given weekly and bi-weekly for
up to 30 sessions in nine months.
Each of the study sites chose to administer one type of intensive psychotherapy,
based on preferences and clinical expertise. Nine sites offered FFT. At the FFT sites,
randomization was stratified further by whether family members were available and
able to participate (53% of the sample). Patients without families were randomly
assigned to other conditions. FFT involved patients and at least one family member and
was implemented in three modules. The material focused on recognizing early warn-
ing signs of recurrence and developing relapse prevention plans that involved multiple
family members. Patients and family members developed a shared understanding of
the importance of medication adherence and reduction of environmental stressors.
Participants received training in effective family communication, with behavioral
rehearsals of effective listening and speaking skills as well as problem-solving skills.
Results: Rates of attrition did not differ across the psychotherapy and collabor-
ative care conditions. Patients in intensive psychotherapy had significantly higher
year-end recovery rates, shorter times to recovery, and were 1.58 times more likely
to be clinically well during any study month than those in collaborative care. There
were no significant differences in the outcomes of the three intensive psychother-
apies. However, the improvement from baseline scores was greatest for the FFT
group (Miklowitz et al., 2007).
More extensive descriptions of multi-family groups for bipolar illness may be
found in Moltz and Newmark (2002). Multi-family psychoeducational interven-
tions for major depressive disorder are outlined in Keitner et al. (2002). These are
comprehensive descriptions but presented without research data.
LONG-TERM EFFECTS
In reviewing the seminal work of Gerald Hogarty at the University of Pittsburgh,
Eack, Schooler, and Ganguli (2007) point out that Hogarty felt that the strongest
effects of FPE on patient relapse accrued primarily in the early course of treatment,
and degraded once the intervention concluded. He seemingly doubted the mainte-
nance of positive effects of family interventions alone. Therefore, we look at some
of the long-term follow-up studies that ensued after the earlier work on FPE.
In the Bauml et al. (2007) report, it was evident that positive effects were found
both at two-year and seven-year follow-ups. The Munich Psychosis Information
Study compared 101 patients with DSMIII-R or ICD-9 schizophrenia randomly
assigned to intervention or control groups between 1990 and 1994. During their
index hospital stay, the intervention group and key relatives each received sepa-
rate group psychoeducation. The main outcome measures were re-hospitalization
rates, number of intervening hospital days, compliance, and mean number of
medication (chlorpromazine) units.
Seven years after the index discharge, 24 intervention and 24 control subjects
were available for study. The rate of re-hospitalization was significantly lower for
the intervention group ( p < .05). During the seven-year period, medication compli-
ance was higher in the intervention group and the mean number of hospital days
spent in a psychiatric hospital was 75 in the intervention group vis a vis 225 days
in the control group ( p > .05). These results at seven-year follow-up were even
more remarkable given the fact that at index admission, patients in the interven-
tion group had a longer duration of illness and more previous hospitalizations than
those in the control group. Bauml et al. (2007) felt that with findings like these,
the integration of patient and FPE into standard therapy for schizophrenia should
become obligatory.
The Salford Family Intervention Project, the first five- to eight-year follow-up
study of FPE for schizophrenia, concluded that the benefits persist over time In
this study, 40 schizophrenic patients who had participated in a family psychoedu-
cation trial during hospitalization, and had not experienced relapse at two years
after discharge, were traced through case notes and hospital records. Percentages
of patients experiencing relapse were compared for the family intervention group,
a high-EE control group, and a low-EE control group, at five and eight years after
discharge. At both time periods, there were significantly fewer relapses in the fam-
ily intervention group than in the high-EE group. The number of relapses in the
low-EE control group was lower than in the high-EE control group, but just failed
to reach significance. The authors concluded that the benefit of FPE and the pre-
dictive power of EE are both sustained over eight years (Tarrier, Barrowclough,
Porceddu, and Fitzpatrick, 1994).
Another randomized-controlled study investigated whether a 24-week needs-

based cognitive–behaviorally oriented family intervention led to improved profiles
of patients with schizophrenia after a five-year follow-up period. The investiga-
tors found that 86.7% of control participants relapsed compared with 53.3% in the
experimental group. Survival analysis indicated that the relapse rate was 2.5 times
higher for patients in routine care than for those receiving family intervention
(Sellwood, Wittkowski, Tarrier, and Barrowclough, 2007).
Veltro et al. (2006) reported a study of 24 Italian community mental health cen-
ter patients with schizophrenia randomly assigned to individual FPE or standard
care. At one year follow-up, FPE produced significant improvements in self-care
and independence skills, fewer positive symptoms, and lower family burden. At
11-year follow-up, patients in the FPE group were less frequently hospitalized
than the standard care group, and more likely to be in contact with mental health
services. An overview of studies conducted during the most recent decade (1997–
2007) pointed out that these were conducted in more real world settings than the
older body of research. Maglinao and Fiorillo (2007) reviewed studies with mini-
mal exclusion criteria. They included patients with a wider range of diagnoses, used
a study protocol very close to usual practice, allowed concomitant treatments, and
examined a broader range of relevant outcomes. They found that FPE reduces
patients’ hospitalizations and relapse rates “even when provided in routine set-
tings to samples of unselected patients, and/or by professionals who had received
a brief training in their use. The effects of these interventions . . . are much more
evident when the control group receives standard care . . . and tend to be weaker
when controls receive intensive individual integrated treatment” (p. 32).
The reviewers indicated that enriched individual treatments are probably as
effective as family interventions, but they are more costly. The data from fam-
ily interventions confirm that FPE has positive effects on the patients’ social
and personal functioning, but that the positive effects on patients’ clinical sta-
tus and disability tend to disappear over time. Booster sessions for families were
recommended.
DOES LENGTH OF TIME OF FAMILY INTERVENTIONS MATTER?

Masanet et al. (2007) have pointed out the field’s continuing interest in the appro-
priate length of time that family interventions should last. They note that in all the
earlier experimental studies, the relapse rate was seen to increase considerably
after the end of the intervention.
In most of the tabular presentations of well-researched programs showing posi-
tive outcomes, durations have ranged from six months to a high of 48 months (for
McFarlane et al., 2003), with a modal 24 months. Yet, five-year follow-up studies
have shown significant long-term effects for interventions as low as six months
(Sellwood et al., 2007). Falloon’s (2003) review has indicated that family interven-
tions may need to extend for as long as 12–18 months in order to sustain lasting results.
Johnson’s (2007) minimum figure is six months. The Patient Outcomes Research
Team (PORT) study (Lehman and Steinwachs, 1998) recommended a nine-month
minimum. The time frame may, of course, depend on the length and frequency of
the sessions. But there are many other factors, including, in real world settings, the
stability and commitment of both the training staff and the families themselves.
Optimal length may be related to whether the intervention is offered for very ill
patients in hospital settings, or for families of patients stabilized enough to live in the
community. It appears, however, that across a range of time frames, salutary long-
term outcomes may be apparent many years after the end of a family intervention.
In their review of current studies, Magliano and Fiorillo (2007) noted that
interventions varied from 12 to 48 sessions, provided weekly to monthly, for six to
24 months. They point out that no study has compared the effects of FPE in terms
of length of time, or degree of intensity, so the best means of exposure still needs
to be clarified.
In this chapter we have attempted to flesh out some of the major studies repre-
sented in the large research overviews of FPE discussed in the preceding chapter.
The earlier studies focused on schizophrenia. Research on FPE for major affective
disorders is discussed under that heading. The studies are generally presented in
historical sequence as new models or adaptations developed. Much of the early
work was done in the United Kingdom at the London Institute of Psychiatry and
University of Manchester, continuing with current applications and a massive
training program initiated by faculty and researchers at the University of Bir-
mingham. As indicated in the previous historical background section, FPE largely
evolved from the research on EE and original FPE research was limited to high-EE
families. These were considered a high-risk group for patients. The original work in
London compared FPE and a relatives group with standard care and found a signifi-
cant reduction in patients’ relapse, although at two-year follow-up, the group dif-
ferences had disappeared. However, it was found that patients in families assigned
to any type of social intervention had a significantly lower relapse rate than patients
who were offered no help for families. Subsequent research at the University of
Manchester developed a needs-based model of cognitive–behavioral intervention
based on families’ self-assessed needs and problems. In contrast to the London
selection process, interventions were also offered to low-EE families. In a random-
ized controlled study, a treatment group receiving needs-based FPE was contrasted
with a control group offering family support alone. Specific problems were identi-
fied by the treatment families and the intervention was determined by caregiver-
identified needs. The needs-based group received problem-solving techniques,
cognitive–behavioral family interventions, and individual cognitive–behavioral
interventions for patients with psychosis. At six month follow-up and subsequent
follow-ups, there was a significant reduction in major needs and number of prob-
lems of the needs-based group vis a vis controls, although distress and burden
scores in both groups remained constant.
Seminal programs in the United States evolved at the University of Pittsburgh,
University of California at Los Angeles, and the University of Southern California.
The original work in Pittsburgh focused on reducing high EE in families, and a
family therapy approach involved connection, a survival skills workshop, and a
re-entry and application phase to maintain patients in the community after hospi-
talization. Work and social adjustment, and maintenance phases focused on con-
tinued stabilization, increased effectiveness of family processes, and decreased
reliance on therapeutic resources. In the first year and follow-up, there was a sig-
nificant reduction in relapse rate of patients receiving FPE compared with patients
receiving pharmacotherapy alone. The Behavioral Family Therapy of Ian Falloon
and associates focused on education, improved communication, and problem-
solving techniques. Research indicated that patients who received only individual
therapy were significantly more likely than those receiving family interventions
to experience a major episode, and to have longer duration of hospitalizations.
Family-treated patients showed significantly less behavioral impairment or self-
neglect, and greater medication adherence at nine month assessment.
In a multi-site NIMH study, Schooler et al. (1997) studied the impact of dose
reduction and family treatment on relapse and re-hospitalization in a 3 × 2 design.
Outpatients with schizophrenia were randomized to one of three double-blind
medication dosage levels (standard dose, continuous low dose, or targeted, i.e.,
only when symptomatic) and one of two family treatments (supportive or BFT).
Results showed that only targeted medication increased hospitalization, and there
were no differences between family treatments.
In the New York State Family Psychoeducation study, family members of
172 patients with schizophrenia were randomly assigned to single or multi-family
group (MFG) FPE at six public hospitals for two years of treatment. At both two-
and four-year follow-ups, MFGs were significantly more effective, with the group
format resulting in significantly lower relapse rates than the single-family format.
Many other studies have confirmed the efficacy of the multi-family model (see
McFarlane, 2002).
The OTP of Ian Falloon and associates continues as an international collabora-
tive group to promote the routine use of EBPs for schizophrenia in clinical facili-
ties, including FPE. Large sample studies indicate the efficacy of these bundled
optimal treatments. In a study focusing on FPE alone, 34 clinicians were trained
in the Falloon model, which was then applied for six months in 17 mental health
centers in Italy for family members of patients with schizophrenia. At six months,
there was significant improvement in patients’ clinical status and social functioning,
and significant reduction of family burden (Magliano et al., 2006).
FPE for major affective disorders includes the Family Focused Treatment (FFT)
for BD developed by Miklowitz and Goldstein (1997). In content, FFT is very close
to the general model of psychoeducation previously described, involving education
on etiology, treatment, and illness-management skills within the vulnerability-
stress paradigm. Crisis management, communication, and problem-solving are
standard, but also dealing with suicide attempts and substance abuse. Research
findings in randomized controlled trials indicated significantly fewer relapses,
symptom reduction, and better medication adherence in patients whose families
received FFT.
A final section on long-term effects showed positive effects at two- and sev-
en-year follow-ups in the Munich Psychosis Information Study in Germany. In
the Salford Family Intervention Project in the United Kingdom, an eight-year
follow-up showed significantly fewer relapses among patients receiving family
interventions. A study of 24 Italian community mental health centers at 11-year
follow-up showed that patients in a group receiving FPE were less frequently
hospitalized and more likely to maintain contact with services.
An overview of the most recent studies, conducted in more real-world set-
tings with samples of unselected patients, found that FPE reduces relapse and
re-hospitalization rates. However, despite the salutary long-term effects cited
earlier, Masanet et al. (2007) had pointed out that in all the earlier experimental
studies, the relapse rate was seen to increase considerably after the end of an FPE
intervention. The chapter ends with a discussion of the field’s continuing interest
in the appropriate length of time that family interventions should last. Magliano
and Fiorillo (2007) noted that no study has compared the effects of FPE in terms
of duration or degree of intensity. Hence, the minimal length of time required to
establish FPE as an EBP has yet to be confirmed by all researchers.
6
E A RL Y I N T E RV E N T I O NS
prodromal, children, and adolescents
Recent years have seen the merger of family psychoeducation (FPE) with other
evidence-based practices (EBPs) in a variety of contexts. McFarlane (2002), whose
extensive research demonstrated the value of multi-family groups, has incorpo-
rated FPE in preventive interventions with young people showing prodromal signs
of schizophrenia. McFarlane began the Portland Identification and Early Referral
(PIER) Program in Portland, Maine, in 2000, working with communities in South-
ern Maine to identify cases of adolescents and young adults manifesting potential
signals of later schizophrenia—increasing social isolation, declining school perfor-
mance, suspiciousness and withdrawal, confused thinking, possible auditory hal-
lucinations, etc. Up to 17 school districts in greater Portland are involved, as well
as health-care workers; however, no program evaluation studies have been pub-
lished as of yet. In 2007, with a $12.4 million grant from the Robert Wood Johnson
Foundation, plans are to add four new sites of 400,000 population each—in
Sacramento, California, Ypsilanti, Michigan, Salem Oregon, and Glen Oaks,
New York (Schmidt, 2007).
Patients in the PIER program are given low-dose medication and counseling
aimed at eliminating stressful situations that could trigger psychotic reactions.
Key psychosocial interventions are FPE and social networks designed to keep
patients in school. These elements are found in most but not all the early interven-
tion attempts that began at the end of the 20th century in the work of investigators
such as Thomas McGlashan and Ian Falloon, who was not only a leading pioneer of
FPE, but also of early interventions for at-risk adolescents.
However, administration of medications to young adolescents is a continuing
source of disagreement in the field. Schmidt (2007) cited Anthony Lehman, Chair
of Psychiatry at the University of Maryland, as warning against using medication
58
EARLY INTERVENTIONS 59
during early prodromal stages unless a psychotic break seems imminent, and
stipulating that decisions must be made on the basis of each individual case. In the
prodromal interventions in Australia, McGorry is quoted as saying that “We would
reserve medication for when it’s clearly indicated,” that is, when psychosis is evi-
dent (Schmidt, 2007, p. 977). In Australia, early interventions utilize psychosocial
methods and omega-3 fatty acids (which may have mood-stabilizing effects) as
frontline treatment rather than psychotropic medications.
The prodrome of psychosis is now a logical target for early identification and
treatment, both for the symptoms, and for risk of future psychosis. However,
recruitment is particularly difficult and sensitive for both patients and families.
Most of the target groups are adolescents, a period during which erratic behaviors
are scarcely unusual. These behaviors are likely to be explained away as due to pre-
cisely that stage in life. The fear of diagnosis, of being acknowledged and labeled
as even having the potential of a mental illness, keeps many individual and fam-
ily members from taking advantage of offered services. Recruitment of prodromal
patients may be fraught with difficulties, but eventually many will seek help. As
McGlashan et al. (2007) note, prodromal status involves both actual and potential
problems. The first is developing or worsening psychological symptoms and dis-
tress, for which they and their families seek help, and the second is the risk of even
greater psychopathology and distress. The practitioner must both treat current
distress and alert patients to their imminent potential for transitioning to psy-
chosis or another mental disorder. Prodromal patients are recruited for treatment
and clinical trials through active outreach to potential health-care oriented refer-
ral sources, such as general practitioners or school counselors. McGlashan et al.
(2007) say that currently most help-seeking prodromal patients make their way to
study centers rather than specialized treatment clinics. In a Prodromal Clinic, they
undergo an intake evaluation, engagement, combined psychosocial treatments
such as supportive therapy or sometimes cognitive–behavioral therapy, case
management and stress management, and family-based treatment.
FPE with prodromal patients is modeled on multi-family group (MFG) psy-
choeducation approaches with first-episode schizophrenic patients (McFarlane,
2001). It is formulated around the stress-vulnerability model of psychosis, and
addresses several domains of risk factors. These include high levels of expressed
emotion (EE) (hostile criticism, over-involvement) in families toward patients,
high levels of stigma aimed at patients and families with resultant social isolation;
and high levels of communication deviance “resulting in poor family focus and
uncoordinated familial collaboration” (p. 721).
Family intervention, usually begins when the patient is admitted to the study,
involves family and patient together, and consists of four treatment stages:
(1) engagement, (2) education, (3) re-entry, and (4) social/vocational rehabili-
tation. The engagement phase establishes rapport and consent of both patient
and family. “The education phase is conducted via workshop sessions about the
biological, psychological, and social nature of psychotic disorders and their man-
agement. Following the workshop, meetings begin twice monthly with the fam-
ily and patent in the multi-group format. Content of sessions includes treatment
compliance, stress reduction, modifying and mollifying life events, avoiding drugs
and alcohol, and modifying expectation while patient and family are dealing with
symptoms and their functional consequences. With time and better symptom
control, the themes change to encompassing social and vocational rehabilitation”
(p. 721).
The authors reinforce McFarlane’s (2002) contention that much of the effec-
tiveness of multi-family psychoeducation results from increasing the size of the
patient’s and family’s social networks by reducing stigmatization and providing
a forum for sharing similar problems and solutions. The many advantages of the
MFG format are indicated in Table 5.5.
FIRST-EPISODE PSYCHOSIS
Various medical centers are now offering family interventions for first-episode
psychosis. An example is The Prevention and Recovery of First-Episode Psychosis
(PREP) program at the University of Illinois Medical Center at Chicago. A multi-
layered treatment approach includes psychoeducation groups for patients and
families along with cognitive–behavior therapy and substance abuse services, case
management, vocational training, and research opportunities.
In Australia, HOMES (Home-Oriented Management of Early Psychosis) is a
home-based program for individuals presenting for the first time with a psychotic
illness. At the Dandenong Hospital in Victoria, 31 patients considered suitable for
home management were assigned to the HOMES program with an acute treatment
phase ranging from 14 to 61 days, with a mean of 37 days. The primary outcome
measure was avoidance of the need for hospitalization.
Each visit entailed assessment of the person’s mental state; a physical exami-
nation; review of relevant events, behaviors, and interpersonal interactions; dis-
pensing of medication; and psychoeducation. This proceeded in a semi-structured
format with patients and families. “Illness education occurs continuously . . . and
more complex information is gradually introduced and often repeated frequently
repeated. The individual’s family are directly involved with the programme and
important management decisions” (Fitzgerald and Kulkarni, 1998, p. 40).
The research protocol was not based on random assignment, but rather assess-
ment of the success of home-based treatment (22 out of 31, or 71%) and compari-
son of the 22 people who did not requite hospitalization with nine who did. Illness
severity was not related to potential for home-based treatment, but rather to the
level of clinician-rated family support and duration of untreated psychosis prior
to treatment. The findings indicated a highly significant difference (p<.007) in the

score of family support between the group successfully managed at home and the
group subsequently hospitalized (Fitzgerald and Kulkarni, 1998).
In two Scandinavian countries, multi-family FPE, based on the MacFarlane
model was implemented for 147 young adults experiencing a first episode of psy-
chosis, and their families. The Treatment and Intervention in Psychosis (TIPS)
Project was carried out in four geographically-defined health-care sectors in
Norway, and one in Denmark. Treatment involved antipsychotic medication, sup-
portive psychotherapy, and MFG treatment. Family members were engaged in three
stages: joining sessions, a multi-family educational workshop, and 90-minute MFG
meetings every second week, organized around problem-solving. All group leaders
had over 60 hours of training and monthly group supervision. Content was modi-
fied to center on families’ shock and denial when confronting first-episode psy-
chosis, reframing expectations, reinforcing observational skills, and focusing on
the stress-vulnerability model of symptom exacerbation. The authors noted that
patients’ willingness to participate declined with age, perhaps with an increasing
wish for independence or diminishing contact with families. Although no outcome
data were offered, since the end of the TIPS project, there has been substantial
expansion of MFGs in the project sites and in other Danish and Norwegian services
(Fjell, Thorsen, Friis, Johannessen, Larsen, et al., 2007). In Zagreb, Croatia, utilizing
a quasi-experimental design, an early-intervention team was compared with treat-
ment as usual for first psychotic episodes. The team offered more structured psy-
choeducation, relapse prevention, and psychosocial interventions, including FPE.
At three years, their patients were significantly more medication-compliant, and
more likely to have returned to work or education. They were less likely to suffer
depression, were less suicidal, less likely to relapse, and more likely to be living with
their families (Agius, Shah, Ramkisson, Murphy, and Zaman, 2007).
FAMILY PSYCHOEDUCATION IN SERVICES

FOR CHILDREN AND ADOLESCENTS
Although FPE was developed primarily for families of adults with schizophrenia,
this intervention is increasingly being offered to families of children with major
affective disorders.
In a review of evidence-based treatment specifically focused on bipolar disorder
(BD) in children and adolescents, Young and Fristad (2007) reviewed four treat-
ments that share a family-based psychoeducational approach and are adjuncts to
medication. Family-focused treatment (FFT); The RAINBOW program; multi-
family psychoeducation groups (MFPG); and individual FPE.
FFT for adolescents was adapted from FFT for adults (Miklowitz et al., 2004).
The basic components are psychoeducation, communication-enhancement
training, and problem-solving training. The goals are to increase medication adher-
ence, enhance adolescents’ knowledge of BD, enhance their communication and
coping skills, and minimize psychosocial impairments caused by the illness. The
family work aims to improve caregivers’ ability to cope and to decrease high EE,
if this is a factor. During psychoeducation, the therapist teaches the family about
adolescent BD, provides information about risk and protective factors, encourages
the adolescent to chart her or his mood, and develops a plan with the family for
relapse prevention. In communication training, families practice active listening,
and in problem-solving, cognitive–behavioral strategies are taught to develop solu-
tions to family conflicts. Miklowitz et al. (2004) reported an average of 38% reduc-
tion in manic symptoms and 46% improvement in manic symptoms at 12-month
follow-up.
The RAINBOW program was developed as an adaptation of FFT for children
between eight and 12 years of age. This is essentially family-focused cognitive–
behavioral therapy (CFF–CBT) for pediatric BD. There are 12 sessions with the
child alone, parents alone, child and parents together, and parents and siblings,
and all are actively engaged, According to Pavuluri et al. (2004), all family mem-
bers receive a card with the RAINBOW ingredients listed, and they are encouraged
to carry it or post it on the refrigerator as a daily mnemonic of required skills. The
acronym stands for Routine; Affect regulation; I can do it! No negative thoughts
and live in the “Now”; Be a good friend and balanced lifestyle for parents; Oh,.
how can we solve the problem?; Ways to get support. The theoretical framework
is based on: (1) the specific problems of children and families coping with BD;
(2) a biological theory of excessive reactivity; (3) the role of environmental stres-
sors in outcome. The RAINBOW acronym is also a reminder of colors associated
with mood variability. A notable component, emphasized by Young and Fristad
(2007), is the session with siblings in which they are encouraged to develop empa-
thy and coping skills. There is also contact with school personnel to offer psychoe-
ducation about BD and suggestions for school-based interventions. In an open trial
of 34 children (mean age 11.3 years), patients showed significant improvements in
bipolar symptom severity, aggression, ADHD symptoms, and global functioning
compared to pre-treatment scores. High levels of treatment integrity, adherence,
and satisfaction were achieved (Pavuluri et al., 2004; Young and Fristad, 2007).
In their early work, the Ohio State University Psychoeducation Program for
Childhood Mood Disorders, had developed two versions of a family psycho-
educational intervention. One was a one-and-half-hour workshop for parents of
children with any major mood disorder who were psychiatrically hospitalized, cov-
ering basic information about childhood mood disorders. “The second version was
multi-family psychoeducation groups (MFPG), designed for outpatient children
with any major mood disorder and their parents. MFPG initially was administered
in six 75-min sessions in a manual-based, multi-family group format . . . Based on
feedback received in our randomized, controlled pilot study, we expanded MFPG

to eight 90-min sessions” (Fristad, Gavazzi, and Mackinaw-Koons, 2003, p. 1002).
The MFPG consists of eight 90-min sessions with parents, with concurrent
sessions for children with another therapist. MFPG focuses on educating families
about the child’s illness and its treatment, decreasing EE, and improving symp-
tom-management, problem-solving, and communication. MFPG is designed for
children with BD or a diagnosis of major depressive disorder, dysthymic disorder,
and depressive disorder not otherwise specified. In the group format, parents gain
support and empathy from peers who are undergoing the same experience. Young
and Fristad (2007) point out that for the children in the MFPG group, it is often
their first opportunity to meet another child with a similar illness. The group for-
mat also enables in vivo practice of social skills and problem-solving strategies.
Families are educated to become more involved members of their child’s treat-
ment team, and to identify other needed services. They are provided with informa-
tion about school services, special education options, and their child’s educational
rights. Tailored to the audience, sessions for both parents and children include
information on childhood mood disorders and their symptoms; medications;
developing problem-solving and coping skills; symptom management, and improv-
ing non-verbal communication skills. A therapeutic technique called “Thinking–
Feeling–Doing” focuses on increasing the parents’ and child’s insights into the
connection between thoughts, feelings, and actions, and to improve their aware-
ness of their own negative mood states. A vital component of the child sessions
is the “tool kit” in which a child generates a list of pleasant and relaxing activities
to choose from to help cope with or overcome a negative mood or interpersonal
conflict.
Research findings: In a pilot study, 35 families (children aged 8–11) were
randomly assigned to either immediate treatment (IMM) in MFPG or a six-month
wait-list (WLC) control group. IMM parents showed significantly more knowl-
edge about mood disorders, improved family interactions, and improved ability
to access appropriate services for their child in comparison to WLC parents. IMM
children reported a significant increase in perceived social support from parents.
However, there was no significant decrease in children’s mood severity (Fristad,
Gavzazzi, and Mackinaw, 2003).
At Ohio University, individual family psychoeducation (IFP) was developed as
a single-family form of the MFPG intervention for families of children with BD who
were unable or unwilling to participate in a group. The original IFP protocol con-
sisted of sixteen 50-minute sessions, alternating between parent-only and child-
only sessions. A “healthy habits” component was introduced to substitute for the
group social skills practice in MFPG, focusing on healthy sleep hygiene, improv-
ing nutrition, and increasing exercise. This was considered important because BD
can be affected by poor sleep habits, diet and exercise are often needed to offset
weight gain triggered by some psychotropic medications, and exercise has proven
beneficial for depression. Based on feedback from parents, the treatment protocol
was expanded to 24 sessions; 20 are manual-driven, and four are “in the bank” ses-
sions to manage crises or reinforce a particularly important topic for the individual
family.
Research findings: In a pilot study of IFP, 20 children with BD and their parents
completed the original 16-session format. They were randomized to the IMM and
WLC conditions. Despite some dropouts with concurrent reduction of sample
size, children’s mood symptoms improved significantly following treatment, and
gains were maintained for 12 months after IFP treatment. EE scores improved
significantly more for IMM than WLC families (Young and Fristad, 2007).
In Hamilton, Ontario, 31 adolescents aged 13–18 years receiving outpatient
services and meeting criteria for major depressive disorder, and their families,
were randomized to usual treatment or usual treatment plus FPE over a period of
24 months. Outcome measures were administered at two weeks, mid-treatment,
post-treatment, and at three-month follow-up. The FPE was developed by the
authors and manualized. The intervention consisted of twelve 90-minute sessions
conducted in the home, involving all family members who agreed to participate.
According to the authors (Sanford et al., 2006), the theoretical models were based
on those used by Falloon, Mikowitz, and other FPE researchers. These were medi-
cal, patient education, stress vulnerability, communication, and coping models.
The aims were to increase understanding of the experience of depression and its
impact on families, to strengthen family communication, and to enhance effective
coping, problem-solving, and management of crises and relapse. The intervention
was in five phases, advancing from introduction to the therapeutic model, family
assessment and goal setting, to education about clinical features and course of ill-
ness, to training in communication skills and family problem-solving skills. The
usual treatment condition consisted of individual or group counseling and or drug
therapy with supportive case management.
Primary outcomes were measures of depressive symptoms with the Reyn-
olds Adolescent Depression Scale (RADS); social functioning—Structured Social
Adjustment Interview (SSAI); family functioning—Family Assessment Device
(FAD); adolescent relationships with mother and father—Adjective Checklist
(ACL); and parent-rated disruptive behaviors—Disruptive Behaviors Checklist
(DBC). Secondary outcomes included adolescent global functioning on Children’s
Global Assessment Scale (CGAS) and adolescent and parent satisfaction were
measured on the Client Satisfaction Questionnaire (CSQ).
Research findings: In social and family functioning (adolescent–parent rela-
tionships) the intervention group moved significantly further than controls
toward more positive functioning and relationships. This was despite lower global
functioning scores for the FPE group at baseline. Depression on the RADS score
decreased during each three-month period in both conditions, approaching signif-

icance in favor of the intervention group (p<.052). There were no group differences
for parent-rated disruptive behaviors. For the adolescent informant, significant
improvements were found for relationships with both mother and father, peer
relationships, and communication, and affective involvement. For eight of nine
outcomes, there was a significant positive effect favoring the FPE group both at
post-treatment and follow-up (Sanford et al., 2006).
Utilizing a quasi-experimental design, McKay, Gonzalez, Quintana, Kim, and
Abdul-Adil (1999) evaluated the effects of a 16-week MFPG comparing families of
children with disruptive behavior with peer families receiving traditional individ-
ual or family therapy. The assessment focused on parental participation, changes
in the child’s behavior after 16 weeks of involvement, and parents’ perceptions of
effects of service use. The evaluation found that participation in the MFGs was
related to higher rates of mental health service use and reduced dropouts from
counseling and group treatments.
In a study reported by Ruffolo (2005), 94 parents of youth with serious emo-
tional disturbance (SED) participated in a randomized controlled trial of adjunc-
tive MFPG. The multi-family intervention was titled the Support, Empowerment,
and Education (SEE) group. The youth were part of intensive case management
(ICM) programs that targeted children and adolescents with histories of inpa-
tient hospitalizations or out-of-home placements. Their mean age at intake was
11.47 years, and the majority were males. The majority of parents were single,
poor, and with unstable histories. The primary research question was whether
ICM plus adjunctive MFPG for parents (ICM-SEE) was more effective than
treatment-as-usual ICM for parents of children with SED to increase parental
skills and supportive resources, and decrease child-behavior problems. The SEE
intervention used a parent/professional leadership approach in a problem-solv-
ing framework. The model emphasized building social supports and increasing
knowledge of children’s mental illness to foster parental empowerment. The group
used McFarlane’s structured problem-solving format, but also encouraged ques-
tions and discussion. SEE met twice a month for a minimum of two hours each,
but used an open-group process for attendance. Parents met for a minimum of six
months, separately from their children. SEE used a structured group format with
problem-solving/solution-finding activities, educational interactive segments,
homework tasks, and skill-building activities, with brief time for informal social-
ization. The primary dependent variables measured at baseline, nine months,
and 28 months were parental use of a social support network, parental problem-
solving and coping skills, and children’s behavioral symptoms on the Child
Behavior Checklist (CBCL) for youth aged 4 to 18 years.
Research findings: For perceived social support, parents in both conditions had
significantly more supportive resources over time, with no significant differences.
For parental problem-solving/coping skills, there was a trend toward greater use of
parent problem-solving and coping skills in the SEE group, but no significant group
differences. With respect to children’s behavioral symptoms, youth behavior in
both conditions improved significantly over time in global scores on the CBCL. In
the ICM-only group, this was at the 0.05 level, and for the ICM-SEE group, at the
0.001 level. Further analysis indicated that for the ICM-SEE intervention group,
clinical T scores on the CBCL decreased significantly on ten scales (internalizing,
externalizing, withdrawn, somatic problems, anxious, social problems, thought
problems, attention problems, delinquency, and aggression). In the ICM-only
condition, there were only four significant changes, in externalizing, withdrawn,
somatic problems, and aggression scales. The parents/caregivers viewed the SEE
group experiences in positive terms and the format as critical to its success. One
important item is that the participants indicated that the on-site child-care and
transportation provisions were central to their participation in the group sessions.
This is an important consideration for all research participants, particularly stud-
ies with families of young children.
In summary, this chapter has focused on the application of FPE to prodromal
interventions and those for children and adolescents with a diagnosis of SED. One
example of the former is the Portland Identification and Early Referral (PIER)
program in Maine, in which teachers and health-care workers in 17 school districts
collaborate to identify prodromal signs of potential schizophrenia. The children
or adolescents have been treated with low-dose medication and counseling, and
key interventions include FPE and social networks designed to keep the children
in school. Four new sites are being added to the Maine project.
The prodromal treatment approach has evoked a controversy over early medi-
cation, which is further discussed, together with recruitment difficulties for early
interventions. McFarlane’s (2001) multi-family model of FPE with first-episode
schizophrenia patients, involving patient and family together, is described,
together with the content of sessions. Crucially important in this intervention
is reduction of stigmatization by expansion of the patient’s and family’s social
networks. This is facilitated by the multi-family model.
We go on to describe the integration of multi-family FPE with other treatments
for first-episode psychosis in various sites, including the TIPS project carried out
in different sectors of Norway and Denmark. Since the end of this project, there
has been substantial expansion of early intervention multi-family groups in other
services in Europe.
Although FPE was developed primarily for families of adults with schizophrenia,
it is increasingly being used with families of children with major affective disorders.
The chapter presents a review of four family interventions in BD of children and
adolescents. These are adjunctive to medication and share the basic components
of FPE (Young and Fristad, 2007). The programs are described in detail in terms
of their manualized content and goals, and the pilot testing that enabled them to
develop appropriate models. Multifamily psychoeducation groups (MFPGs) were
developed for both hospitalized and outpatient children with mood disorders
and their parents, with children and parents receiving separate interventions.
The models are described in some detail. Research that compared families receiv-
ing immediate MFPG treatment with a waitlist control found significantly more
knowledge, improved family interactions, and greater ability to access appropriate
service in the treatment group. Individual FPE treatment was also developed for
families unable or unwilling to participate in a group, alternating between parent-
only and child-only sessions. Materials on healthy sleep hygiene, nutrition, and
exercise were substituted for the social skills practice in MFPG. Research on this
model, comparing treated and waitlist families, found significant improvement in
mood symptoms in the treated group.
Another intervention is described involving adolescents with major depres-
sive disorder and their families, who were randomized to usual treatment or usual
treatment with manualized FPE. The treated group showed significantly more
movement toward more positive social and family functioning than controls. The
adolescents reported significant improvement in relationships with both mother
and father, peer relationships, communication, and affective involvement. Other
studies and research findings are described, indicating that multi-family FPE for
parents was more effective than treatment as usual, or than traditional individual
or family therapy, in terms of improving disruptive behaviors, relationships, and
dropouts from counseling. In another study, targeting underprivileged youth with
SED and their primarily poor, single parents, MFPG with intensive case manage-
ment was compared with the latter alone. When MFPG was added, there was a sig-
nificant decrease on ten behavioral symptom scales (internalizing, externalizing,
withdrawn, anxious, delinquency, aggression, and social, thought, somatic, and
attention problems) vis a vis only four significant reductions with case manage-
ment alone.
The interventions with parents of children and adolescents share some com-
monalities with FPE developed for adults, but obviously there are differences spe-
cific to a younger population. The forthcoming chapter deals with application of
the basic FPE model, which was initially developed for schizophrenia and admin-
istered primarily to parents of adults, to other diagnoses, co-occurring disorders,
and other caregiver groups.
7
D I VER S E D I A G N O S E S A N D SP EC IAL
P O P U L A TI O N S
DUAL DISORDERS: MENTAL ILLNESS AND SUBSTANCE ABUSE

The most recent population-based data indicate that in 2002, an estimated
8.4 million, or 48% of the 17.5 million adults with serious mental illness (SMI), had
received treatment for mental health and substance abuse problems during the
past 12 months. Younger adults, those with families, were more likely than older
adults to receive treatment (Epstein, Barker, Vorburger, and Murtha, 2004).
The role of families in helping dually diagnosed patients may include economic
assistance and direct care (Clark, 2001), or effecting change through insights and
strategies learned through psychoeducation. However, there are limited data on
family psychoeducation (FPE) for persons with mental illness and substance abuse.
In a review of 36 research studies on the effectiveness of integrated treatment for
dually diagnosed patients, FPE is included but no information is offered on its con-
tent or effects (Drake, Mercer-McFadden, Mueser, McHugo, and Bond,1998). A later
review of 26 controlled studies of psychosocial interventions for dual diagnosis, from
1994–2003, did not include family members as participants (Drake et al., 2001).
A family psychoeducational program that specifically targeted dual diagno-
sis was developed by Mueser and Fox (2002). They pointed out that most dually
diagnosed clients tend to have constricted social networks but many have regular
contact with their relatives (Clark, 2001). Family work is important for reducing
caregiver burden, and unless families are educated, they may inadvertently enable
patients’ use of substances. Mueser and Fox developed a new program, Family
Intervention for Dual Disorders (FIDD), adapting the stages of dual disorder treat-
ment to family work.
FIDD includes both single- and multiple-family group formats for all family
participants. The single-family format, provided by a trained clinician, teaches
68
DIVERSE DIAGNOSES AND SPECIAL POPULATIONS 69
the family information and skills needed to manage dual disorders and usually
ranges from nine months to two years. Single-family work involves outreach and
engagement, education, communication skills, and training in problem-solving
for addressing substance use. Immediate goals are to establish a collaboration
and buffer the relatives against negative effects of substance abuse, with long-
range goals of decreased usage. The multiple-family group format is designed to
provide validation and social support to families, offer further information about
coping, and with no time limits, to maintain a connection with the treatment team.
Content areas are fully described in Mueser, Noordsy, Drake, and Fox (2003).
A small pilot study was conducted for six clients whose families completed one
year of treatment. Families had an average of 29 single-family treatments, and four
attended the multi-family group (MFG) regularly. Results indicated that clinicians
could learn to implement the FIDD program, and that families could be engaged
and treated successfully. Most clients demonstrated significant improvements in
substance abuse over one to two years of treatment (Mueser and Fox, 2002).
In the United Kingdom, Barrowclough, Haddock et al. (2001) reported results
of integrated treatment including FPE for patients with schizophrenia and sub-
stance abuse disorder. They conducted a randomized controlled trial of routine
care combined with motivational interviewing, cognitive–behavior therapy, and
FPE in a comparison with routine care alone. In the family intervention, shared
goals were generated and became the focus of conjoint patient/family sessions.
The family intervention consisted of 10–16 sessions, some of which took the form
of integrated family/patient sessions, and some of which involved family members
alone. The final study consisted of 36 patient–caregiver dyads.
Results: From baseline to follow-up at the end of 12 months, the integrated
treatment program produced significantly greater improvement in patients’ gen-
eral functioning, a reduction in positive symptoms and symptom exacerbation,
and an increase in the percent of days of abstinence from drugs or alcohol.
OBSESSIVE–COMPULSIVE DISORDER (OCD)

An 18-session multi-family behavioral family treatment (MFBT) program for OCD
was conducted by Van Noppen (2002) at Brown University School of Medicine in
Rhode Island, involving both patients and families. The major goals were to: estab-
lish a therapeutic alliance; provide psychoeducation on OCD and on exposure and
response prevention; develop and implement a behavioral treatment plan; change
family patterns of communication to reduce hostile criticism, over-involvement,
excessive accommodation, and increase family problem-solving and support. Fami-
lies would learn to devise and implement behavioral contracting, independent
of a therapist. Other goals were to promote feelings of empowerment, altruism,
and empathy, while decreasing feeling of isolation, stigma, shame, and impotence
through the group process. A major goal was to teach OCD patients to utilize self-
instruction through exposure and response prevention, using homework assign-
ments. The clinicians hoped to provide education to enhance insight into OCD and
teach behavioral strategies to manage recurrence of OCD symptoms. The MFG
format was selected with the assumption that “group modeling offers patients a
normative context to refer to when challenging irrational thoughts and unreason-
able behaviors long after the formal group ends” (Van Noppen, 2002, p. 110). The
MFBT model for OCD consists of 12 sessions of group treatment and six monthly
group sessions to consolidate gains and encourage independent problem-solving.
Unfortunately, there are presently no outcome data available on this model.
BORDERLINE PERSONALITY DISORDER (BPD)

At Mclean Hospital in Belmont, Massachusetts, Berkowitz and Gunderson (2002)
have adapted MFG psychoeducation for families of persons with BPD. Their
psychoeducational program for families, with format derived from the work of
Anderson, Hogarty, Falloon, Leff, and McFarlane, is based on emerging concepts
of BPD as a deficit model. These are their basic principles for the structure and
goals of treatment:
1 BPD is characterized by deficits in affect and impulse control; dichotomous

thinking; and intolerance of aloneness.
2 The deficits render the person with BPD handicapped but not disabled. They can
be held accountable for their actions, although change comes slowly.
3 BPD is a chronic disorder characterized by recurrent crises. Crises may resolve
and remit in the absence of stress.
4 Families can influence the course of illness in that they can either diminish the
stresses that cause relapse or inadvertently create them.
5 Living with an ill relative has negative consequences for the family. “A major goal
of current treatment is to diminish stress within the family independent of the
goal of improving psychosocial functioning in the patient” (pp. 276–276).
6 Family members should use education to change their behavior. When they
expect only the patient to change, they do not establish limitations and
boundaries that would motivate the person to change.
7 Stress within the family may have its root alienation between the individual and
family members. Alienation may be diminished by greater understanding of the
internal experience of the patient, the affects and motivations that underlie be-
haviors typical or BPD.
Although this model does not focus on causation, Berkowitz and Gunderson
note that “We do not exempt parents from any causal role in the etiology of the
illness, as is typically done in psychoeducational approaches to schizophrenia,
bipolar disorder, or major depression” (p. 276). They note that relevant to their
neutral stance to parents is the high frequency with which BPD patients have
reported physical, sexual, or emotional abuse by their parents. “Our neutral
approach to causality often enables us to form an alliance with parents who are
highly sensitive to criticism” (p. 277). Their neutrality presumably enables patients
to participate without invalidating their expressed recollections, regardless of
whether they are true or false, since the purpose is to facilitate mutual acceptance
rather than to discuss causality. I have speculated about some of the reasons for
such recollections among persons with BPD, and their effects on parents (Lefley,
2005). This is a disorder of affect dysregulation. People with BPD have great sen-
sitivity to perceived maltreatment or abandonment by others, an unstable sense
of self, and a tendency to idealize or demonize others in relation to personal need.
Frustration and anger may begin in early childhood. Parents’ inability to yield to
unfulfillable demands for attention may generate anger in the child and perceived
or actual abusive behavior of parents who don’t know how to handle the neediness.
Validation of a patient’s feelings is a hallmark of family psychoeducation in BPD,
so patients’ perceptions and recollections cannot be rejected. Although families
are taught to deal with irrational guilt, a neutral therapeutic stance toward patients
and family members is essential.
In structure, the MFG for BPD follows the same three-stage structure as in
schizophrenia: joining, psychoeducation; and coping skills. Their guidelines for
families are as follows: Goals—go slowly; family environment—keep things cool;
managing crises—pay attention but keep calm; addressing problems—collaborate
and be consistent; and limit setting—be direct but careful. Families are advised
on ways to diffuse tension and improve safety when facing extreme rage and self-
destructive behavior, and limit-setting without creating undue hostility.
Research findings: A small pilot study involving eight participating families in
two MFGs, all with daughters with BPD, was conducted. Two outcomes were stud-
ied: patients’ level of functioning and families’ perceived burden. Findings: The first
year of treatment showed a nonsignificant downward trend in self-destructive acts;
66.7% of participants felt that the MFG helped them to modulate angry feelings, and
66.7% felt less burdened. All families felt that the MFG improved their communica-
tion with their daughters, 75% at the level of “very great.” For parents, 91.6% felt that
the treatment had helped them set limits, and 100% felt supported by the group.
After one year of treatment, parents’ concerns about suicidality, unpredictability,
and impulsivity diminished, while concerns about independence, resistance to
suggestions, and separation increased. The authors felt that this reflected a dimin-
ished crisis orientation as the focus of the family moved to psychosocial functioning
rather than crisis resolution (Berkowitz and Gunderson, 2002).
The Gunderson/McLean program and two other FPE programs for families of
people with BPD have been described by Hoffman and Fruzzetti (2007). In the
Hoffman/New York Hospital program, Perry Hoffman and her associates devel-
oped a family intervention based on Linehan’s (1993) dialectical behavior therapy
(DBT) for BPD. Their DBT family skills training (DBT-FST) “stresses the impor-
tance of education, skill development, and environmental change. Specifically,
the program attempts to have family members interrupt the cycle of invalidation
that may play a role in maintaining the borderline disorder” (p. 70). In contrast to
the majority of FPE approaches, especially those in the United Kingdom, which
focus on reducing high expressed emotion (EE) in family members, research
has documented that for persons with BPD, high EE in the form of emotional
over-involvement has positive effects longitudinally. The researchers felt that
borderline patients view emotional over-involvement as caring and validation.
This “suggests that borderline patients need the involvement of family as long as
emotional validation accompanies any criticism or hostility” (p. 70).
DBT-FST includes patients and family members in a group that meets weekly
for approximately six-month sessions organized into two parts. The first part is
didactic, focused on skill development; in the second part, the group applies DBT
skills, manifesting how to effect a balance between acceptance and change.
The Fruzzetti/University of Nevada, Reno family program was developed as part
of a standard outpatient DBT treatment program for persons with BPD. The train-
ing team understood the utility of having family members as well as patients learn
complementary skills and use similar language. “This family intervention program
includes a core FPE component that may be delivered to individual families or in
groups and may include the patient with family members or include only family
members of the patient. Certain core skills from individual DBT are included, such
as mindfulness and components of emotion regulation. In addition, family skills
such as relationship mindfulness, accurate expression, validation, problem man-
agement, and closeness skills (for couples) and parenting skills (for parents) are
included” (pp. 70–71).
The basic premise of the training is that persons with BPD bring certain vul-
nerabilities, whether biologically based or learned, to react negatively to certain
situations. These individuals are at greater risk when living in a family environ-
ment that invalidates their emotions, desires, and beliefs by simply ignoring or not
understanding them, or with criticism or ridicule. Family reactions to BPD behav-
iors may range from harshly critical and judgmental to well-intentioned but ter-
ribly mismatched in comprehension. The premise of this approach is that helping
families and patients find ways to express their experiences accurately will enable
others to validate, and that being validated enables people with BPD to identify
their emotions and wants and express them accurately. These transactional skills
form the basis of DBT training with couples and families. Format may vary. It may
be a couples group, a group for parents of adolescents or young adults, a mixed-
constellation family group, or part of ongoing family therapy. Ongoing individual
family sessions are also provided, enabling assessment and intervention for key
issues such as suicidal behavior, self-injury, aggression, and drug use.
The Family Connections (FC) program was developed by Hoffman and
Fruzzetti within the National Education Alliance for Borderline Personality Dis-
orders, an organization for family members of persons with BPD, as a family edu-
cation version of DBT. The FC program was designed to provide education about
BPD; teach families skills to manage their own negative reactions and those of their
family members and build better relationships; and provide social support from
peers who had lived through similar experiences. The curriculum includes mind-
fulness skills to manage negative emotions and reduce invalidating responses;
family environment skills (understanding interdependence and reciprocity), vali-
dation, and problem-management. To date, most FC programs have been led by
trained family members, as in NAMI’s Family-to-Family program. The authors
state that FC is now available in more than a dozen states, in Canada, and in several
European countries.
Research findings: To date, two open trials have assessed changes in family mem-
bers who participated in Family Connections. Forty-four participants represent-
ing 34 families completed the pre-, post-, and six-month post-baseline self-report
questionnaires. Analyses using hierarchical linear modeling strategies showed sig-
nificant reductions in grief and family burden. There was a significant increase in
mastery from pre- to post-group assessment. These changes were maintained at
six-months post-baseline (Hoffman, Fruzzetti, Buteau, and Neiditch, 2005).
EATING DISORDERS
A study compared the effects of four months of family therapy (FT) vs. multi-
family group psychoeducation (MFG) for anorexia nervosa for female adolescents
(Geist, Heinmaa, Stephens, Davis, and Katzman, 2000). Patients severe enough
to require hospitalization were randomly assigned to each condition. Subjects
assigned to FT received eight 45-min sessions every two weeks for four months,
involving the patient, parents, and siblings. The main objective was to encourage
parents to take an active role in management of the disorder, also to strengthen
the parenting couple through open direct communication. The therapy tried to
distinguish eating disorders from normal adolescent strivings and family conflicts,
while supporting the development of autonomy and maturation in the adolescent.
Subjects assigned to MFG received eight sessions of FPE every two weeks for the
four-month period. Adolescents and their parents attended 90-min classes led
by a dietitian, an occupational therapist, and a psychiatric nurse. The group lead-
ers presented information on the multi-determined nature of eating disorders,
physical and psychological sequelae, weight regulation and consequences of diet-
ing, normal adolescent growth, and physical and psychological consequences
of starvation. The outcome measures, taken every two weeks, included body
weight and psychosocial eating-disorder variables at baseline and four months
after treatment.
Findings: Significant body weight restoration occurred under both conditions,
but no significant change was reported in psychological functioning by either ado-
lescents or parents. The authors surmised that four months may be too short a
time to produce measurable psychological change. However, they concluded that
FPE is an equally effective and less expensive method than family therapy for pro-
viding family-oriented treatment for anorexia nervosa (Geist, Heinmaa, Stephens,
Davis, and Katzman, 2000).
A program in Japan assessed the effects of MFG on patients with eating disor-
ders. Group sessions were held once a month for their relatives. The group met
for five sessions that included both education and problem-solving. EE levels
(measured by the Five-Minute Speech Sample), family function (measured by the
Family Adaptability and Cohesion Evaluation Scales), the family’s mental state
(measured by the Profile of Mood States) and the patients’ symptoms(measured
by the Eating Disorder Evaluation Scales, Global Assessment of Functioning, and
the Anorexic Behavior Observation Scale) were assessed at first and final sessions
in this treatment group-only design. High EE decreased and families’ assessment
of symptoms was significantly improved. Twice-repeated multi-variate analysis of
variance showed significant improvements in the families’ overall mental state and
emotional over-involvement, and in the patients’ anorexic behavior. The investiga-
tors suggested that MFG psychoeducation might help lower distress and encour-
age positive interactions in families, but realized that a randomized controlled
trial is needed to further clarify the efficacy of this treatment (Uehara, Kawashima,
Goto, Tasaki, and Someya, 2001).
BRAIN AND SPINAL CORD INJURY

A group of 27 survivors of brain and spinal cord injury and 28 caregivers partici-
pated in MFGT for 12–18 months in monthly and bi-monthly meetings. Among the
patients, 13 had spinal cord injury (SCI), 11 had traumatic brain injury (TBI), and
three were survivors of both SCI and TBI. The stages of the intervention were as
follows: (1) joining in individual sessions; (2) a group educational workshop; and
(3) problem-solving groups aimed at managing physical and cognitive challenges
and improving psychosocial functioning. The structure and format of the origi-
nal MFGT model was maintained, but content was modified to accommodate the
unique issues of SCI and TBI. In the educational workshop, neuroanatomy basics,
aspects of physical rehabilitation, and typical family responses to injury were dis-
cussed. Medical complications, equipment issues, rehabilitation activities, adap-
tations needed in the home, work, and social environment, and managing a new
self-image were some of the topics addressed. A variety of assessment measures

were used, tapping quality of life, survivor and caregiver anger and depression,
caregivers’ social support and coping styles, and family burden. Qualitative mea-
sures explored participants’ experience in the MFGT groups, perceived effective-
ness, and information and coping skills learned in the group. Research findings:
Survivors of injury reported a decrease in depressive symptoms and anger expres-
sion toward others, and an increase in life satisfaction. Caregivers reported a sig-
nificant reduction in burden. The qualitative data indicated the normalization of
the caregiving experience, the importance of socialization, and improvement both
in knowledge about the injuries and a variety of coping skills. Caregivers described
learning stress-management techniques, communication skills, and management
of medical complications. They also learned strategies to improve self-care and set
appropriate limits (Rodgers, Strode, Norell, Short, Dyck, and Becker, 2007).
SPECIALIZED PSYCHOEDUCATIONAL GROUPS
FAMILIES OF VETERANS: VETERANS ADMINISTRATION PROGRAMS

The Support and Family Education (S.A.F.E.) program was developed specifi-
cally for the Veterans Administration hospital system by psychologist Michelle
Sherman (2006). It includes post-traumatic stress disorder (PTSD) and was
developed as a 14-session professional curriculum for caregivers. Problem-solving
skills, creating a low-stress environment, and coping with stigma are emphasized.
A five-year evaluation showed high levels of participant retention and satisfaction.
Attendance was positively correlated with understanding mental illness, aware-
ness of resources, ability to engage in self-care, and reduced caregiver distress.
SPOUSES OF PERSONS WITH MENTAL ILLNESS

Mannion, Mueser, and Solomon, P (1994) have pointed out the dearth of resources
available for spouses of persons with SMI. They are not always comfortable in
NAMI groups, which tend to have more parental than spousal caregivers, and their
burden tend to be different from those in other relationships. In a study of spouses
of depressed patients, Fadden, Bebbington, and Kuipers (1987) found that female
caregivers experience more burden than males. Burden is especially high if the wife
has become the breadwinner while running the household and often acting as a
single parent. Her role may become an insult to the husband’s self-esteem and his
resentment at his own incapacity may interact with the illness in explosive ways.
FPE was developed largely for schizophrenia, and a disproportionately low
number of persons with this diagnosis have been able to maintain stable partner-
ships over time. In traditional agrarian cultures, where FPE is not readily available,
people with schizophrenia are five times more likely to marry than in the industrial
west (Hopper, 2004). People with bipolar disorder (BD) are much more likely to
marry, so FPE must be adapted to spousal concerns. The family-focused treatment
(FFT) of Miklowitz and Goldstein (1997) at UCLA has been the major model to
specifically tailor its approach to spouses of patients with BD, and their research
has been previously described under Model Programs.
However, there are many married couples who would profit from the briefer
educational models, and Mannion, Mueser, and Solomon (1994) have specifically
addressed this need by designing psychoeducation for spouses under the auspices
of the TEC network of Southeastern Pennsylvania, previously described. Notic-
ing a high drop-out rate of spouses from the general FPE group, they invited all
spouses to join a task force that would collaborate on adapting the general family
workshop to the special needs of “well-spouses.” In a series of meetings, they then
designed a 10-week two-hour group intervention specifically for spouses or part-
ners in committed relationships. In addition to information relevant to schizo-
phrenia spectrum and affective disorders, they adapted for spousal relationships
the skills needed for communications, problem management, limit-setting as a
partner, managing violent and disruptive behaviors, financial issues, and helping
children cope.
Research findings: In pre-post analysis of this treatment group-only study,
significant improvements were found in the well-spouses’ knowledge about the ill-
ness and coping strategies, personal distress, and negative attitudes toward the ill
spouse, both at the end of the three-month intervention and at one-year follow-up
(Mannion, Mueser, and Solomon, 1994).
YOUNG PARENTS WITH MENTAL ILLNESS AND THEIR CHILDREN

Government surveys indicate that among women with a lifetime prevalence of
psychiatric disorder, 68% are mothers. Among men, 54.5% are fathers. For adults
with non-affective psychoses, the prevalence of parenthood for women is about
the same, and is slightly higher for men (Nicholson, Biebel, Katz-Leavy, and
Williams, 2004). Although many of their children may have non-parental care-
givers, more and more people with SMI are living in the community and fulfilling
parental roles. Yet, with few exceptions, there is little in the literature to suggest
that their needs, or their children’s, are being met.
Beardslee et al. (1997) developed an intervention to address the needs of fami-
lies in which one or both parents suffer from an affective disorder. Targeting the
needs of children between the ages of eight and 15 years, they developed and com-
pared two standardized FPE preventive interventions. The families were randomly
assigned to either a clinician-facilitated intervention (CFI), which consisted of
six to 10 sessions for parents and children, or two lectures attended only by
the parents. Parents in the CFI experienced a number of specific behavioral and
attitudinal changes, including increased understanding of their own or their
spouses’ illness and/or a greater focus on their children and increased understand-
ing of their children. Sustained effects of the intervention were reported 1.5 years
after enrollment.
Family Options is a new family-centered, strengths-based program for families
living with parental mental illness. The program was developed in a community-
based psychosocial rehabilitation center in central Massachusetts. Implementa-
tion of the program is now being studied by the Center for Mental Health Services
Research at the University of Massachusetts Medical School. The researchers state
that one focus explores conditions necessary to shift the organization’s paradigm
of working with adults (the parents with mental illness) to working with their
families (Woolsey and Biebel, 2007). The SAMHSA/CMHS funded research is now
studying five programs in the United States that are serving a parent with men-
tal illness, providing support for them and their children and teaching parenting
skills. See Hinden et al. (2002) in Appendix for resource information.
The Family Services of the Training and Education Center (TEC) of Southeastern
Pennylvania offers a variety of workshops and groups for family members of people
with mental illness, including a parenting program for parents with mental illness.
Their training manual for these classes includes the following components: deal-
ing with stress and preventing relapse, including helping your child cope with your
mental illness; understanding child development; setting limits with respect; taking
you children’s feelings seriously; controlling anger and conflict resolution; dealing
with feelings about others caring for your children; and parenting from a distance.
Many of these issues are specific to the needs of young parents who are either rais-
ing their children or coping with their children being raised by others. See Appendix
for training manual. Although we have elsewhere reported findings on TEC’s family
education, no research data are currently available on the parenting classes.
OLDER CAREGIVERS
Future Planning for Relatives with Mental Illness is a program developed by NAMI
of Maryland to help older caregivers prepare for the future care of relatives with
mental illness. A workshop format is used to cover such topics as identifying a rela-
tive's basic needs for care and preparing a written plan to guide future caregivers.
A staff person from the local department of mental health is invited to explain the
public services available. The financial and legal arrangements (estate planning,
wills, trusts, and powers of attorney), which must be arranged, are explained by an
attorney specializing in special needs trust. Approximately 500 individuals have
participated in these workshops to date (Agnes Hatfield, personal communication,
November 20, 2007). This program was also adopted in Madison, Wisconsin.
Although no data are available on the effectiveness of this program, the group
was involved in research on elderly caregivers, 65 years and older, conducted in
two states (Maryland and Florida). This study generated a picture of the needs
of older caregivers, their problems in planning for the future of a loved one with
SMI, and some suggested remedies (Lefley and Hatfield, 1999; Hatfield and Lefley,
2000). Their expressed needs have been a substantial component of the training.
Additionally, a study of siblings’ future role was conducted to determine the extent
to which the “well children” of aging caregivers could replace them after they were
gone (Hatfield and Lefley, 2005). The need for special psychoeducation for both
older caregivers and siblings was further manifested in a longitudinal study of
families of adults with schizophrenia conducted by Jan Greenberg and his associ-
ates at the University of Wisconsin, Madison. Based on a survey of 136 siblings, the
experience of growing up in a less cohesive family environment and threatening or
violent behavior by the ill member were major contributors to positive or negative
relationships in adulthood. The researchers felt that identification of dimensions
of the sibling experience would enable mental health providers to engage siblings
in the treatment process and help promote stronger bonds of affection (Smith and
Greenberg, 2008). Certainly siblings would benefit from learning both the biologi-
cal and psychological substrates of aberrant behaviors, so that they might develop
greater understanding of the actions of their ill family member, and the normaliza-
tion of their own reactions.
In summary, FPE was largely developed for caregivers of adults with schizo-
phrenia, and more recently, major mood disorders, and much of the family research
has focused on caregiving parents. The current chapter deals with the application
of FPE to a variety of other diagnoses and other family relationships. We begin
with co-occurring mental illness and substance abuse. FPE has not been widely
used with dual diagnosis, but a program specifically designed for these patients
was developed by Mueser and Fox (2002). Their Family Intervention for Dual
Disorders (FIDD) includes both single and multi-family formats. With individual
families, a trained clinician teaches the family information and skills for a period
ranging from nine months to two years. They can also participate in the multi-family
group, which has no time limits. A small pilot study of six families participating in
both conditions showed significant improvements in substance abuse over one
to two years of treatment. In the United Kingdom, Barrowclough, Haddock et al.
(2001), studying 36 patient–caregiver dyads, conducted a randomized controlled
trial of routine care combined with motivational interviewing, behavior therapy,
and FPE, compared with routine care alone for dual disorders. The integrated pro-
gram produced significantly more improvement in patients’ functioning, reduced
symptoms, and increased days of abstinence from alcohol or drugs.
FPE models and research findings are presented for family interventions for the
following conditions: OCD, BPD, eating disorders, and brain and spinal cord injury.
The chapter then turns to FPE programs for specialized groups, including families
of veterans, spouses of people with mental illness, young parents with mental ill-
ness and their children, and elderly caregivers of adult children with mental ill-
ness. Research findings on the concerns of older parents, and the role of siblings in
subsequent caregiving, are presented and discussed.
It is clear from this presentation that most of the studies on disorders other
than schizophrenia, and on discrete participant groups, do not fulfill the stringent
evidence-based practice (EBP) criteria described in the introductory chapter.
However, they have their own usefulness for practitioners and students interested
in other diagnostic and caregiver groups and suggest areas where further research
is needed.
In the following chapter, we deal with international and cross-cultural studies,
including both uniformities and variations in content. The focus turns to issues
that may arise in administering FPE not only for specialized populations, but for
families living in other mental health systems and perhaps subscribing to different
cultural norms.
8
I N T E RN A TI O N A L A N D
CR OS S - C U L TU RA L S TU DIES
uniformities and variations
In this chapter, we present a sample of international studies, and a few studies

that primarily focus on ethnic minorities within the United States. Some cultural
variations are to be expected in the form and content of family psychoeducation
(FPE), but there seems to be substantial uniformity in its basic elements. Most
offer the basic content of education about specific mental disorders, together with
illness management and problem-solving techniques. Johnson (2007) has stated
that outcomes have been much the same in all countries, and cites FPE research in
the following nations: Australia, China, Denmark, Germany, India, Ireland, Italy,
Japan, Norway, Spain, Sweden, the United Kingdom, and the United States. Con-
temporary studies from some of these countries, and others, are described in the
following paragraphs. Although most outcomes were positive, there are a few neg-
ative outcomes. Unexpectedly, these appeared more often in a few American and
European studies rather than in more distal cultures such as China. This may have
been due to the exceptionally well-designed and rigorous research coming from
that part of the world.
There is limited knowledge of potential differences among ethnic groups in
countries with large numbers of minority populations. A study of psychoeduca-
tion for low-income, immigrant, predominantly Mexican-American families pro-
duced negative findings and is described in the following paragraphs. In discussing
psychoeducational interventions for African-American, Asian-American, and
Mexican-American families, Jordan, Lewellen, and Vandiver (1995) recommended
attention to the following issues: individualistic versus group orientation (e.g., a
preference for extended family, multi-family format); length of treatment, and
culturally appropriate content and leadership (e.g., differential styles of egalitari-
anism and authoritarianism in conveying information). However, it is unlikely that
80
INTERNATIONAL AND CROSS-CULTURAL STUDIES 81
these strictures have been incorporated in psychoeducation for minority groups,

nor is it known whether they are generalizable across groups that may vary widely
in acculturation and in sociocentric norms.
Special programs for different ethnic communities have been developed in
several English-speaking countries. In the United Kingdom, the Meriden West
Midlands Family Programme has adapted its program for Black and Asian families.
New York State currently has a Family Psychoeducation Training and Evaluation
in Three Diverse Communities project, funded through Substance Abuse and Men-
tal Health Services Administration (SAMHSA) and Center for Mental Health Ser-
vices (CMHS). At this writing, they are in the process of adapting FPE resource kits
for families of persons of African-American, Chinese-American, and Hispanic-/
Latino-American descent with mental disorders. These are very comprehensive
manuals and implementation kits, with content specific to each culture. Family
assessment instruments, fidelity measures, and a cultural competency assessment
scale are ancillary tools.
Bae and Kung (2000) developed a family intervention model for Asian-American
families of patients with schizophrenia. Their five-stage model, which does not
seem to differ substantially from classic FPE models, consists of preparation (build-
ing a therapeutic alliance); engagement (including collaboration with community
leaders, negotiation of service goals, and concrete help); psychoeducational work-
shop (information and survivor skills); therapeutic stage, with individual family
sessions, supplemented by a multi-family support group; and an ending stage, with
ongoing maintenance contacts and consultations. Culturally appropriate treat-
ment such as home-based interventions, collaboration with indigenous healers,
and help with immigration issues are included.
An example of culturally appropriate FPE for Hispanic families is the Univer-
sity of Miami’s Culturally Informed Therapy for Schizophrenia (CIT-S) project
directed by psychologist Amy Weisman de Mamani and funded by the National
Institute of Health. This family intervention, now in progress, involves fortify-
ing a strong sense of family unity and utilizing cultural and spiritual beliefs that
may help families conceptualize and come to terms with the illness, in addition to
education about the illness and teaching effective communication and problem-
solving skills. CIT-S is a 15-session treatment program aimed at creating sup-
portive and knowledgeable home environments. There are three basic segments:
(1) Family Collectivism aims at fostering as strong sense of family unity so that fam-
ily members view themselves as a team working toward a common goal; (2) Edu-
cation is based on the work of Falloon, Boyd, and McGill (1984) and Miklowitz and
Goldstein (1997), with special attention to the role of high expressed emotion (EE)
and attributions; (3) Spiritual Coping aims at helping participants explore and tap
into the spiritual beliefs and values that may help them productively cope with the
illness. “CIT-S is expected to result in lower rates of high EE, increased perceived
collectivism and family cohesion, and the use of more adaptive religious, spiritual,
and philosophical coping mechanisms” (Weisman, Duarte, Koneru, and Wasserman,
2006. 183).
A successful intervention with new immigrants in Australia was reported by
Bradley et al. (2006) who compared consumers and family members who were
randomly assigned to multi-family FPE for non-English-speaking Vietnamese
families, English-speaking families, or to standard care. Participants received
26 sessions for 12 months provided by staff trained by McFarlane. Outcomes were
measured immediately after treatment and 18 months later. The multiple-family
group had significantly lower relapse rates than the standard care group (12%
vs. 36% at 12 months; 25% vs. 63% at 30 months). There were equally beneficial
outcomes for both English- and Vietnamese-speaking families.
An unsuccessful intervention with new immigrants was reported by Telles
et al. (1995) in the United States. Working with low-income, unacculturated
Hispanic-American families, primarily Mexican or Central American, Telles and
her colleagues compared the Behavioral Family Therapy (BFT) of Falloon, Boyd,
and McGill (1984) with traditional case management. Patients with schizophrenia
and their families were randomly assigned, and both treatments were conducted in
the clinic setting, in Spanish. In both conditions, patients were seen weekly for the
first six months, every two weeks for the next three months, and monthly for the last
three months. BFT consisted of patient–family education about schizophrenia, and
training in communication and problem-solving skills. Socio-culturally appropriate
translations and adaptations of the educational and instructional materials were
derived from a pilot study and consensus among the bi-cultural clinicians. Individ-
ual case management involved goal-oriented supportive psychotherapy sessions
with the patient only. Findings: The level of patient acculturation appeared to be
an important factor influencing treatment outcome. Among patients who were
below average in level of acculturation, BFT patients had poorer outcomes at year
one on numerous subscales of the Brief Psychiatric Rating Scale (BPRS) (Overall
and Gorham, 1962) in thought disturbance, anergia, global BPRS severity scores,
and in global level of functioning. However, patients who were above average in
acculturation level showed a reversed, but non-significant pattern of treatment
effects. Overall, the authors state that the efficacy of the two types of treatment did
not differ very much if one considers the sample as a whole. However, among least
acculturated patients, those on BFT had significantly poorer course and outcome
than those receiving case management. The authors concluded that the benefits
of BFT are questionable for culturally diverse populations. “It may even be that a
highly structured, interactive intervention programme, which includes specific
directives and exercises that are culturally dystonic, is experienced as intrusive and
stressful. For example, various traditionally minded and unacculturated subjects
expressed discomfort about communication exercises . . . that involved establishing
eye contact or expressing negative feelings; in speaking to an authority (paternal)

figure, this was considered disrespectful” (Telles et al., 1995, p. 478).
Lopez et al. (2002) have suggested strategies to adapt family interventions for
Hispanic patients with schizophrenia. These include involving the extended fam-
ily, developing trust (confianza), manifesting respect for family elders, and dis-
cussing folk concepts of mental illness. These target issues are similar to those
mentioned by Weisman, Duarte, Koneru, and Wasserman (2006) in their model
of FPE. However, it is of interest that Weisman and her group also seem to focus
on reducing EE as part of their intervention with Hispanic families. Telles et al.
(1995) state that an unexpected finding was the remarkably low level of EE among
their sample of rural immigrants. This finding of low EE is consistent with other
research on Hispanic families (Weisman, Lopez, Karno, and Jenkins, 1993) and
highlights the importance of acculturation as a factor in how best to educate
families.
In Los Angeles, California, Kopelowicz, Zarate, Smith, Mintz, and Liberman
(2003) reported on a study to evaluate the effectiveness of a skills-training pro-
gram aimed at teaching disease management to Latino patients with schizophre-
nia. Their main cultural adaptation was simply including families, so 92 Latino
outpatients and their relatives were randomly assigned to three months of skills
training(ST) versus customary care (CC), and followed for nine months. “The
skills training approach was culturally adapted mainly by including the active
participation of key relatives to facilitate acquisition and generalization of dis-
ease management skills into the patients’ natural environment” (p. 211). The
key relatives consisted on 61 mothers, 12 fathers, three siblings, three offspring,
10 spouses, and three ex-spouses. Patients were assigned to groups of six which met
for 90-min sessions four times a week for skills training, focusing on medications,
and symptom management and problem-solving. Family members were included
in weekly “generalization” sessions with skills-training for relatives, aimed at their
becoming coaches and generalization agents. The comparison group received
treatment as usual. Results: There was a significant main effect for the treatment
group on Medication Management and Symptom Management skills acquisition,
for both learning and generalization, also higher level of functioning, and lower
relapse rates. In the ST group, only 5.1% were re-hospitalized, versus 22.2% in the
CC group, which the researchers attributed to generalization and utilization of dis-
ease-management skills. There were no significant differences in quality of life or
caregiver burden. However, Kopelowicz et al. (2003) characterized all the relatives
in their study as generally low EE, with low caregiver burden and positive expec-
tancies for the future. This is consonant with previous studies of Latino families,
but at odds with currently reported research findings of high psychological distress
among Latino family caregivers of adults with schizophrenia, with 40% at risk for
depression (Magana, Garcia, Hernandex, and Cortez, 2007). Training of caregivers
to facilitate skills generalization is clearly desirable, for patients and families alike,
so more research in this area is clearly required.
Whether or not culturally-adapted content leads to better outcome has yet to
be determined. Most of the rigorously controlled international studies have been
done in the English-speaking countries, several European countries, and China.
Most interventions have not varied significantly in presenting the core elements
of FPE. At the end of this chapter, we describe several studies of family interven-
tions adapted to Chinese culture. One model was fairly similar to those presented
in Western nations. One adapted its model to Confucian values. Still another was
distinctly different from most Western FPE. All of these interventions produced
salutary effects, but with very different content and emphases.
Most studies, both in the United States and elsewhere, essentially focus on short-
term interventions. Many are less than the minimal ten sessions suggested by Cui-
jpers (1999) or the minimal six months suggested by Johnson (2007). Here again,
the issue remains one of sufficient time to produce significant effects on patients’
relapse or functional levels. Nevertheless, the published results do show some
salutary effects in other dimensions. The following are a sample of European and
Asian studies, and one from Latin America. Studies vary widely in sophistication
and rigor, but they do indicate the spread of FPE across various parts of the world.
LATIN AMERICA (CHILE)

With the objective of exploring the effectiveness of PFE in reducing family bur-
den in a developing country, Gutierrez-Maldonado and Caqueo-Urizar (2007),
randomly assigned 22 family caregivers to an FPE group and 23 to a control group.
The latter offered a periodic meeting with staff to monitor effects of the medica-
tions. The study was based in a city of 195,000 inhabitants in the north of Chile.
The FPE program was held once a week for five months, offering five modules for
17 sessions. These were: the family’s experience of schizophrenia; psychoeduca-
tion; skills to improve communication (with role plays organized around Chilean
customs, eating habits, and activities); relatives’ self-care; and evaluation. Results:
family burden decreased significantly in the FPE condition. There were notable
beneficial effects on caregiver emotions (such as shame), behavior, and thoughts
and improvements in social life. Treatment was equally effective in caregivers with
lower educational levels. However, the intervention did not reduce fears about the
patient’s future.
DENMARK
Merinder et al. (1999) conducted a randomized study of the effectiveness of an
eight-session psychoeducational intervention for patients with schizophrenia and
their relatives in two community mental health centers in Denmark. Significant

increases in knowledge of schizophrenia were found among both patients and rela-
tives, and in satisfaction with families’ involvement in care. However, the authors
noted that there were no observable effects on patients in terms of relapse, medi-
cation adherence, insight, psychopathology, or social functioning.
In the Danish National Multicenter Schizophrenia Project, clinicians from
three psychiatric centers established family groups for relatives of patients with
first-episode psychosis. Eight educational sessions were devoted to symptoms,
etiology, and course of psychosis; treatments, psychological and pharmacological;
laws concerning confidentiality and coercion; home environment, with an empha-
sis on reducing EE; problem-solving; and information about organizations for
patients and relatives, social pensions, employment opportunities, housing, and
other issues related to community living. An evaluation of this treatment-group-
only study indicated that 95% of the relatives appreciated the education, but the
highest ratings for learning went to: (1) the opportunity to listen to others with
similar problems, and (2) the group leaders’ attitude toward patient and relatives
(Buksti et al., 2006).
GERMANY
The Alliance Psychoeducation Program (APP) was developed at the Department
of Psychiatry, Technical University of Munich, Germany, as a brief intervention to
be implemented in routine clinical treatment. The APP was developed in coopera-
tion with consumers, family members, and health-care professionals from other
institutions. It consists of “12 modules that cover symptoms and causes of schizo-
phrenia, effects and side effects of medication, warning signs, contingency plan,
psychosocial treatment, tasks of family members, alcohol and drugs and partner-
ship and sexuality, manuals, workbooks, and flip charts are available for each mod-
ule, and videotapes are available for several” (Rummel-Kluge, Pitschel-Walz, and
Kissling, 2007, p. 1226).
Separate groups for patients and family members were held once or twice per
weeks, with two moderators. Multi-professional teams were trained to moderate
in a one-day workshop. The groups met once or twice per week in sessions lasting
60–90 min. On average, patients participated in 7.5 sessions and family members
in six sessions. Data are available for 407 patients and 92 family members from
23 hospitals in this treatment-group-only study. For patients, scores on a knowl-
edge-of-illness questionnaire rose significantly. On the Medication Adherence
Rating Scale (MARS), adherence also improved significantly. Among family mem-
bers, knowledge of illness increased significantly. All participants, including pro-
fessional moderators, reported high satisfaction with the program. The authors
reported that the increase in knowledge and medication adherence resulting from
the brief intervention were comparable to results of the much longer randomized
controlled Munich Psychosis Information Project Study, described in Chapter 5.
However, a seven-year follow-up of the larger study also found a highly significant
reduction in patient-hospitalization days. Nevertheless, the authors concluded
that the brief APP is feasible in routine clinical treatment after only a one-day
training workshop (Rummel-Kluge, Pitschel-Walz, and Kissling, 2007).
An earlier study in Germany by Hornung, Feldmann, Klingberg, Buchkremer,
and Reker (1999) had incorporated FPE as “key person counseling” in a prospec-
tive, randomized clinical trial that also offered medication management training
and cognitive–behavioral psychotherapy to 156 patients with schizophrenia, a
control group engaged in structured free-time activities. At two-year follow-up,
they found that only patients with a favorable prognosis and better social function-
ing seemed to benefit significantly from the intervention. At five-year follow-up,
there were no significant differences between the treated and control groups.
THE NETHERLANDS
Linszen et al. (1996) reported a study in which 76 patients with recent onset schizo-
phrenic disorders were randomly assigned to an individual psychosocial interven-
tion or to an identical intervention combined with behavioral family treatment.
Patients were studied for 12 months of outpatient treatment following hospital
discharge. Overall the relapse rate was only 16%, and adding the family interven-
tion had no effect on relapse. Unexpectedly, patients in low-EE families relapsed
slightly more often during the added family intervention.
SPAIN
In a Madrid hospital, Canive et al. (1996) conducted six weekly classes of 90 min
each for 63 patients and 99 parents of inpatients with schizophrenia. A control
group (non-randomized) received treatment as usual. Mean knowledge scores
increased significantly in the FPE group but there were neither significant group
differences in patient relapse or re-hospitalization rates, nor in family burden or
distress. Lopez (2002) points out several cultural differences of interest. Despite
the negative findings, this study showed a high retention rate of families when com-
pared with predominantly Anglo-Saxon families in FPE studies. Also, the number
of weekly hours of contact between families and patients (62 h) was considerably
higher than the minimum number of hours used to identify high family contact in
much of the EE literature. There was a high level of participation of fathers. Com-
pared with mothers, fathers were more optimistic about outcome and reported
feeling less annoyed with the patient’s behavior. Canive et al. (1996) suggested
that significant differences may exist between Spanish and Anglo families in terms
of the quality of family interactions with their relatives with schizophrenia.
Their findings suggested that FPE intervention need to consider differences
in gender and family roles and underline the importance of engaging fathers in
treatment.
In another study, Montero et al. (2001) conducted a randomized controlled
study comparing a relatives’ group (RG) with single-family behavioral family ther-
apy (BFT), both offered as standard treatment in one catchment area in Valencia,
Spain. Of a total of 87 patients and their relatives, 41 were assigned to the RG and
46 to single-family home BFT. The length of the active intervention was 12 months,
and both groups began with two initial education sessions in which the patient
participated. BFT at home included the patient and encompassed patient and fam-
ily education, training in communication skills, and problem-solving techniques.
RG began with two individual educational sessions, followed by open-group
90-min sessions attended only by relatives. The RG aimed at teaching problem-
solving skills, reducing criticism and over-involvement, reducing social contacts
between patients and relatives, expanding social networks, and lowering expecta-
tions. Results: Of the 87 cases, only 60% completed the full course of treatment.
There was no significant difference in relapse rate. However, the “delusions” and
“thought disorder” scores of patients in the BFT group had significantly decreased
at post-treatment, whereas those in the RG group had not. Among BFT patients,
mean medication dosage levels were significantly lower at post-treatment com-
pared with baseline dosage, but remained stable in the RG group. Social adjust-
ment showed significant improvement in both intervention strategies, but BFT
produced significant changes in more areas than the RG, such as self-care, use
of leisure time, household participation, interpersonal friction, and interest in
getting a job. Both interventions reduced EE levels in relatives. Families of first-
episode patients were less likely to attend the multi-family group than the single-
family condition. This might be expected. The need for individual attention may be
primary in a family undergoing a first episode, as well as rejection of the possibility
of a prolonged illness that would require group support.
ITALY
We have reported under Model Programs and passim on a number of studies from
Italy, most based on the Falloon or McFarlane models. This one specifically tried to
assess two family intervention programs “in a non-Anglo-Saxon cultural context”
(Carra, Montomoli, Clerici, and Cazzulo, 2007, p. 28). Of 101 relatives of patients
with schizophrenia, 50 were randomly assigned to a weekly 24-session informa-
tion group (IG) of behavioral family management; 26 to the information sessions
plus a subsequent support-group program (IG+SG); and the waitlist balance to

a control group in which patients received treatment as usual (TAU). Allocation
was blind as to subsequent participation in a support group. The main aim was to
assess 12-month and 24-month outcomes of the two modes of family intervention
compared to standard community care in Italy. Primary outcome measures were
hospital admission, relapse, treatment adherence, and employment status. For
relatives, objective and subjective burden were measured, as well as the predictive
utility of baseline clinical status and relatives’ EE levels in relation to outcomes.
Results: Patient’s compliance with standard care was greater at 12 months in the
IG condition compared with the TAU control. Reductions in high-EE levels were
significantly more frequent in the IG+SG condition, but other clinical and fam-
ily outcomes did not differ. “However, treatment benefits declined at 24 months,
when baseline high EE was again predictive of patients’ admission and relatives
were more vulnerable to objective burden. Baseline illness severity variables pre-
dicted a number of medium and long-term poor clinical outcomes . . . Effective
family interventions for people with schizophrenia probably require continued
administration of key elements or ongoing informal support to deal with the vicissi-
tudes of illnesses” (Carra, Montomoli, Clerici, and Cazzulo, 2007, p. 23). Although
the authors suggested that their results indicate the need to assess outcomes more
internationally, their findings of continued family needs have been echoed in many
other studies reported here, regardless of cultural context.
CZECH REPUBLIC
A total of 120 patients were recruited upon discharge from two psychiatric
hospitals in Prague. In site A (N = 86), FPE was offered to all patients with schizo-
phrenia spectrum disorders, in site B (N = 34) no education was offered. At site A,
a professionally-led, clinically-based short term eight-hour programme was
offered ro relatives and patients, who participated in separate parallel groups of
8–10 participants in consecutive cohorts. Families received education based on
a stress-vulnerability model. Families were taught to provide a safe, predictable,
stimuli-controlled environment, and patients were given social-skills training. The
program provided a combination of education about mental illness, family support,
crisis intervention, communication, and problem-solving-skills training. Social
networking was encouraged. Findings: At one-year follow-up after discharge in
this quasi-experimental study, FPE participants had a significantly shorter average
length of re-hospitalization than site B non-participants. The investigators stated
that these findings, together with a high turnout of first-episode patients and posi-
tive responses of FPE participants to the training, suggest that involvement of the
family in treatment in the early course of illness could positively influence health
and social outcomes (Motlova et al., 2006).
EUROPEAN COMMISSION STUDY (GERMANY, GREECE, ITALY,

PORTUGAL, SPAIN, AND THE UNITED KINGDOM)
During 2000–2004, the European Commission promoted research to look at
the impact of training programs for staff professionals on implementation and
effectiveness of FPE for schizophrenia in mental health centers in six countries
(Germany, Greece, Italy, Portugal, Spain, and the United Kingdom). Each national
center selected four mental health centers in which two professionals were ran-
domly assigned to two different modes of training and to implementing an inter-
vention. The results of the instruction (Magliano and Fiorillo, 2007) are discussed
in Chapter 10 on training. Here we present the results of the intervention. A total
of 55 patients and 118 relatives received FPE for one year. At follow-up, there were
significant improvements in patients’ clinical status and social functioning. For
families, there was a significant reduction in burden, and in their use of coercion
and resignation as coping strategies. There was an increase in relatives’ positive
communication with the patient, and they reported a higher level of professional
support at follow-up than at baseline (Magliano et al., 2006).
SWEDEN
Berglund, Vahlne, and Edman (2003) explored the effects of FPE on self-assessed
family burden in 31 families of inpatients with schizophrenia. During the patient’s
hospitalization, 14 families received BFT and 17 received conventional family
support. Family burden and attitude were assessed on three occasions during the
hospital stay in this quasi-experimental study. At discharge, self-reported fam-
ily burden was significantly lower for the BFT families at discharge, and attitude
toward continued caregiving was significantly more positive for the BFT families
than the contrast families.
GREECE
Tomaras et al. (2000) investigated two hypotheses: (1) whether FPE combined
with individual psychosocial treatment is more effective than individual psycho-
social treatment in improving prognosis in schizophrenic patients in high-EE
families, and (2) whether FPE actually exerts its effects through reduction of EE.
Forty patients from high-EE families were evenly assigned to individual psychoso-
cial treatment, consisting of vocational and skills training, or to FPE plus individ-
ual psychosocial treatment. The family intervention comprise 13 group sessions.
Patients were treated for 12 months and followed up for the next two years. In the
FPE group, the relapse rate was significantly lower at one year (0 vs. 25%), but was
not significantly different at two-year follow-up. Although relatives’ EE levels were
not significantly affected by the intervention, high EE was a predictor of relapse,

but not of hospitalization, over the two-year period.
TURKEY
This quasi-experimental study investigated whether an FPE program for both
patients and families would affect patients’ compliance with medication and
outpatient appointments, relapse rates, and caregivers’ EE levels. The sample
included 30 inpatients and their caregivers in two psychiatric clinics. In Group A,
both patients and caregivers received FPE; in Group B, only the patients received
psychoeducation. The patients’ program consisted of schizophrenia and its treat-
ments, disease management and coping strategies, and development of an emer-
gency plan. FPE added the effects of family attitudes on the course of the disease.
Results: In Group A, the patients whose families received FPE were significantly
more compliant with medications and outpatient appointment. Relapse in Group
B was 46.7% vs. 20% in Group A. There was no significant difference in EE levels
between the two groups, at onset or six months after the intervention (Cetinkaya
Duman, Asti, Ucok, and Kuscu, 2007).
THAILAND
This report assessed the effects of a one-day psychoeducational program for
91 caregivers of inpatients with schizophrenia. FPE consisted of a didactic session
on schizophrenia, group discussion and communication skill-building. Significant
improvement (paired t-test) was seen in pre-post mean scores of knowledge and
attitudes (Worakul, Thavichachart, and Lueboonthavatchai, 2007).
JAPAN
Zenkaren, the family organization of Japan similar to NAMI, was established in
1965 and has spurred the development of classes for families at various mental
health facilities in Japan. A survey of these facilities found that between 1994 and
2001, the percentage of family support programs structured as psychoeducational
had increased from 18.9% to 48.6%. However, in mental hospitals they found no
change. The researchers indicated that medical fees must be established for FPE
(Goto, 2003).
In a pilot study of short-term FPE for relatives of patients with schizophrenia,
with the aim of introducing this support program into standard care, 46 relatives
of inpatients with schizophrenia attended three or four sessions of psychoedu-
cation. Level of anxiety, distress, subjective burden, and EE were measured dur-
ing and after attendance. Results: In this treatment-group-only study, both state
and trait anxiety were significantly lower, subjective burden and distress signifi-
cantly decreased on the sub-scales for family confusion (which had resulted from
lack of knowledge about the illness and anxiety about the future). There were
significantly fewer difficulties in relationships with the patients. Comparison of
high- and low-EE families showed equal effectiveness, but reduction of subjective
burden and depression was significantly greater in high-EE families (Yamaguchi,
Takahashi, Takano, and Kojima, 2006).
A cost-analysis of FPE for high-EE family members of patients with schizo-
phrenia at high risk for relapse was conducted in a mental health facility in Osaka,
Japan. Family members of a 30-patient FPE group were compared in this quasi-
experimental study with a 24-patient control group with high-EE family members.
The mean outpatient medical cost, duration of hospitalization, inpatient medical
cost, and total medical cost during the follow-up period were compared. The costs
in the FPE group were significantly lower than in the control group. The propor-
tion of patients with a total medical cost greater than the median value was 23%
in the FPE group and 54% in the control group. Conclusions: FPE is cost-efficient
due to the prevention of re-hospitalization (Mino, Shimodera, Inoue, Fujita, and
Fukuzawa, 2007).
CHINA
Cultural uniformities and variations in presentation and content are most appar-
ent in the copious research from China. Some family interventions in China, with
powerful findings, have been based on content quite at variance with that in West-
ern nations, while others, with equally positive findings, have modeled Western
content.
For example, Xiang, Ran, and Li (1994) reported on a controlled study to deter-
mine whether FPE would increase treatment compliance among psychiatric
patients in three rural townships in China. A cohort of 77 patients was randomly
assigned to FPE plus medications or medications only. There were 33 schizo-
phrenic and three affective patients in the trial group, and 36 with schizophrenia
and five with affective disorders in the control group. According to the authors, the
FPE intervention “aimed to teach family members basic knowledge of mental dis-
eases and their treatment, also to help family members identify and solve problems
to increase their knowledge of mental health rehabilitation” (p. 545). Using work-
shops and monthly supervision, the rural Chinese intervention appeared to closely
resemble the Western model. What was probably more culturally adaptive was
the use of family visits, supplemented by general health education through the vil-
lage wired radio network. Results: In the FPE group, highly significant differences
from the control group were found in the following areas: increase in patients’ full
treatment compliance, improvement in social functioning levels, improvement in
clinical status, increase in the percentage of patients who could do some farm work
or housework; and decrease in the percentage of families who thought the patients’
disorders were caused by ghosts or evil spirits and accepted them as a real disease
(Xiang, Ran, and Li 1994).
In other reported research, a psychoeducational program for families of
patients with schizophrenia in five cities in China reduced relapse rates from 35%
to 20% per year, and also demonstrated reductions in patients’ disability levels and
in family burden (Zhang et al., 1993). Included was a study of first-episode patients
(Zhang, Wang, Li, and Phillips, 1994). At the time of discharge from their first stay
in a psychiatric hospital, 78 male schizophrenic patients were randomly assigned
to a family intervention (FPE) group or a standard care control group and were
followed for the next 18 months. “The family intervention consisted of both group
and individual counseling sessions . . . that focused on education about the illness
and on methods dealing with the patient” (p. 96). It appeared that the intervention
closely followed the Western model of FPE.
Results were a significantly lower rate of hospital readmission for the FPE
group than in the control group (15.4% vs. 53.5%, p<.01). Among those who were re-
admitted, the mean period of non-hospitalization after discharge was significantly
longer in the FPE group than in the control group (245 vs. 130 days, p<.01). The clin-
ical status and overall level of functioning of patients who were not re-admitted
were significantly better in the FPE group, and stratified analysis indicated that the
family intervention and regular use of medication had independent and additive
effects on the outcome. During the 18 months after the index discharge, patients
who did not take medication regularly and did not receive the family intervention
were almost eight times as likely to be re-admitted as patients who took medica-
tion and received the family intervention (Zhang, Wang, and Phillips, 1994).
In a large-sample follow-up study with an experimental design, this research
group reported their two-year experience in two cities, Jinan and Shanghai, China,
with completed cases of 682 caregivers in the FPE and 366 in the control groups.
The families in the FPE group received 14 lectures and five group discussions, with
conventional services; the control group received conventional services only. Edu-
cation included coping with psychotic behaviors, psychotropic medications and
their side effects, supervision and care of psychotic patients, methods of social
and vocational rehabilitation, promoting mental health of caregivers, also mar-
riage and family plans for psychotic patients. Results: Compared with controls,
patients in the FPE condition showed a higher rate of recovery and stabilization,
a lower rate of exacerbation of symptoms, and a reduction in annual relapse and
re-hospitalization rates, most at the p<.01 levels. Among the relatives, knowledge
increased, family burden decreased, and psychosomatic health issues decreased
for the FPE group compared with controls (p<.01 for all) (Zhang, He, Gittelman,
Wong, and Yan, 1998).
Nevertheless, some family interventions, also with impressive outcomes, seem

to have deviated considerably from the Western model. A study by Xiong et al.
(1994) seems to have focused on one culturally-appropriate aspect of the Zhang
et al. (1998) intervention reported earlier. Seeking to initiate FPE for families of
patients with schizophrenia, they surveyed the Western literature on various
models of family interventions and discarded them as inappropriate for China.
They reasoned that Western models were all based on goals of making the indi-
vidual less dependent on the family and an independently functioning member of
society. There was also the presumption of an overall mental health-care system
that would provide ongoing services, a situation unavailable in China. Thus their
family-based intervention became a very different model of FPE. They offered the
following rationale:
“The ultimate social goal of families of mentally ill individuals in China is to
develop a sustainable family-based support system for a dysfunctional member.
The cultural and legal obligations of parents toward disabled children continue
until the child is married, when the responsibility is transferred to the patient’s
spouse. The major goals for these parents are to (1) obtain stable employment for
their child, (2) find a spouse for their child—often by minimizing the seriousness
of the illness and offering a potential spouse (usually of lower social status) ben-
efits such as housing . . . and financial assistance; (3) to encourage the young couple
to have their own child as soon as possible as this both secures the marriage and
provides someone to care for the patient in his or her old age; and (4) to prevent
divorce, by giving financial aid and practical help to the spouse. Once the patient’s
acute symptoms are under control, these issues become the major focus of the
counseling sessions; the therapist assists patients and family members in their
dealings with work sites, helps them negotiate the hurdles of marriage, educates
them about the potential problems of pregnancy, and trains the patient to adapt to
the demands of marriage and parenthood” (Xiong et al., 1994, p. 240).
The idea of arranging a marriage for a person with mental illness and mini-
mizing the seriousness of the disability would pose ethical problems for Western
practitioners (see Lefley, 2002). They might also be uneasy with a targeted goal of
having children mainly for the purpose of providing caregiving in the patient’s old
age. Yet, this intervention was based on education that would facilitate fulfilling a
culturally acceptable and pragmatically useful goal. In providing therapeutic case
management and counseling, they undoubtedly enhanced the coping strengths of
the families in question.
What was the outcome? In a randomized controlled trial with three follow-ups,
this family intervention in China had highly significant effects in lower proportion
of re-hospitalization, shorter duration of re-hospitalization, longer duration of
employment, and reduction of family burden (Xiong et al., 1994). It is also possible
that this type of intervention, aimed at giving the patient a more normal life, might
be concordant with the reportedly better prognosis for persons with schizophre-
nia in developing countries (Jablensky et al., 1991). According to the narratives of
persons with schizophrenia, it is clear that in any culture, even the appearance of
a normalized life is more desirable than one of disability and marginality (Barham
and Hayward, 1998).
In contrast to this model is current research from Hong Kong that merged
cultural content (Confucian precepts) with educational content developed in the
West (Chien and Wong, 2007). These authors conducted a randomized controlled
trial of 18 sessions of psychoeducation for families of patients with schizophre-
nia that consisted of four stages based on the multi-family model of McFarlane
(2002)—orientation and engagement (three sessions), educational workshop (six
sessions), therapeutic family role and strength rebuilding (seven sessions), and
termination (two sessions). The program content was selected from results of a
needs assessment of 180 family members. “The program used a culturally sensi-
tive family intervention model, which considered many of the cultural tenets that
were taught by Confucius (for example, valuing collectivism over individualism
and giving great importance during the needs assessment to family and kinship
ties) in respect to family relationships and value orientation” (p. 1004). Multi-
variate analyses of variance shows that participants in the psychoeducation group
reported greater in functioning of patients and families, lower family burden, and
the number and length of patients’ re-hospitalizations over a 12-month follow-up
period, compared with a standard care control group.
In summary, it would seem that despite its underutilization as evidence-based
practice in the United States, FPE is increasingly being applied in many countries
and is proving useful in multiple cultural contexts, rural as well as urban. Most offer
the basic content of education about mental illness, illness-management strategies,
and problem-solving techniques. Despite a very few unexpected negative findings
(with possible explanations), almost all have yielded similar findings of symptom
reduction and fewer needs for hospitalization. Special programs developed for
ethnic communities in the United Kingdom, the United States, and Australia are
described, with materials reflecting cultural values or norms added to basic FPE
content. An FPE intervention among Hispanic families in the United States, which
produced negative findings is fully described, with treatment effects linked to level
of acculturation. In this case, the negative findings were heuristic in suggesting ways
that FPE might be modified for immigrant families. Other suggestions for adapting
FPE content and examples of skills training aimed at teaching disease management
to Latino patients with schizophrenia are presented, with research results.
Examples of FPE and data from a large number of countries, primarily from
Europe and Asia, and one from Latin America, are presented. These studies vary
in rigor, but they all produced positive findings. The European Commission Study
explored both the impact of training for staff professionals and the results of their
FPE interventions in six countries in Europe. In Asia, Thailand, Japan, and China
have also produced positive findings.
The Chinese studies have been particularly rigorous, with fairly large Ns. We
have noted that family interventions in China have been quite variable. Most have
modeled basic Western content, some have added Confucian precepts, and oth-
ers have been based on content quite at variance with the Western model. Yet all
have been well designed and all have yielded positive outcomes, in rural and well as
urban settings. From these findings, the trans-national and trans-cultural appro-
priateness of basic FPE seems to be largely confirmed. However, questions of opti-
mal length of interventions, and the need for and form of cultural adaptation, have
yet to be resolved.
9
F A MI L Y E D U C A TI O N
Mueser and Glynn (1999) have pointed out that none of the short-term
psychoeducational interventions for schizophrenia-spectrum disorders have had
an impact on the patient with the sole exception of a study by Goldstein (Goldstein
and Kopekin, 1981). This was based on a six-week crisis-oriented intervention,
offered to clients and families, immediately following a hospitalization. A control
group received only medication and case management. At six months, significantly
reduced relapse rates were found in the intervention group. However, as Mueser
and Glynn (1999) noted, “despite the positive findings, this study has not been
replicated in over two decades, since it was conducted” (p. 236).
A six-week session for families would now be called “family education” rather
than psychoeducation. As Solomon (1996) has pointed out, family education is not
primarily designed to affect the outcome of the ill relative. So in contrast to fam-
ily psychoeducation (FPE), there is no evidence that brief family education mod-
els affect relapse or re-hospitalization rates. However, Solomon, Draine, Mannion,
and Meisel’s (1996) randomized control trial did find improvement in the ill rela-
tives’ attitude toward medication adherence even though they did not attend the
sessions. And Chien, Chan, and Thomspon’s (2006) randomized controlled trial
in Hong Kong indicated that mutual support groups offering 12 sessions of FPE by
trained family members, without the patient present, improved patients’ function-
ing and re-hospitalization rates even more effectively than 12 more didactic FPE
sessions offered by professionals. As noted in Corrigan et al. (2008), there have been
at least five randomized trials and one quasi-experimental design of family educa-
tion. All studies show positive effects on families. Although there is no uniformity of
outcome measures, there is a certain commonality in the findings. Families report
greater knowledge about serious mental illnesses (SMIs), more understanding of
96
FAMILY EDUCATION 97
the mental health system, reductions in burden, improved self-care, less distress
and anxiety, and greater self-efficacy in coping (see Corrigan et al., 2007).
The following are descriptions of some major family education programs in
the United States (some, as may be seen, are also taught in other countries). Most
programs use internal evaluation such as pre-post knowledge tests, but a few
have been studied with randomized controlled trials and these are indicated in
the following paragraphs. Regardless of outcome data, most programs reach large
numbers of families and should be considered useful. The list is suggestive of the
commonality of the various models, but cannot be considered inclusive. Included
are relevant literature citations for specific programs, some of which may also be
found in the reference list. Contact information for the programs and their manu-
als may be found in the Appendix.
The following are a selection of models that have all been manualized, and have
all been subjected to adequate and sometimes rigorous research designs. They
may offer essentially the same materials as FPE, but they do not satisfy the two cri-
teria that define FPE as an evidence-based treatment for SMI, temporally and in
terms of outcome focus. That is, they are briefer than six to nine months, and they
may focus primarily on benefits to the family participants rather than to the person
with mental illness.
MANUALIZED EDUCATION BY TRAINED FAMILY MEMBERS OR

FAMILY-PROFESSIONAL TEAMS, WITH OUTCOME DATA
We begin with three major family education programs that must be considered at
least on a par with evidence-based FPE, with similar core content. First, they have
all been subjected to randomized controlled studies. Second, they have the follow-
ing characteristics and advantages: family caregivers have been involved in their
construction, so their content is responsive to family needs; they are administered
solely or with the involvement of rigorously trained family members; they have
been constantly updated to incorporate new knowledge, and most have been going
on for many years and have reached thousands of families.
In the United States, brief family education programs have been developed
by the National Alliance on Mental Illness (NAMI). In these programs, carefully
trained family members teach a manualized course to other families about the
causes and treatment of major psychiatric disorders. Families learn illness man-
agement and problem-solving skills. They also learn how to deal with their own
emotional reactions and maintain family stability.
Two programs, Journey of Hope (JOH) and Family-to-Family Education Pro-
gram (FFEP) were both developed under the auspices of NAMI. The purpose was
to serve the educational and support needs of its members, as well as those of
thousands of other families of persons with serious and persistent mental illness.
Because mental health systems offered practically no help to patients’ caregivers,

members of NAMI’s Curriculum and Training Committee had developed local
family education projects and manuals (e.g., Bisbee, 1991). Dr Agnes Hatfield, an
early president of NAMI, initiated family training programs and wrote a book on
family education for professionals and the general public (Hatfield, 1990). How-
ever, according to NAMI’s education director, Dr. Joyce Burland, the first “com-
prehensive family education and support program, created by combining fully
developed projects of the Alliance for the Mentally Ill (AMI) of Vermont (in peer
family-to-family education) and the Lousiana AMI (in peer family support group
facilitation) was founded in 1992 under the Louisiana AMI trademark ‘Journey of
Hope.’ In 1997, the National Alliance for the Mentally Ill (NAMI) assumed a leader-
ship role in family education to ensure that the AMI of Vermont’s ‘family to family’
would continue to be offered as an integral part of NAMI’s ongoing education mis-
sion.The NAMI-sponsored family education course has been renamed ‘The NAMI
Family-to-Family Education Program’” (Burland, 1998).
The eight-week JOH is given in a few states, primarily in Louisiana. NAMI’s
FFEP is a 12-week course. It has been administered nationwide to many thousands
of families of people with SMI. Both programs are taught from a manual. The mate-
rial is constantly updated to incorporate current information and to expand the
number of psychiatric disorders for which adequate information is available.
FAMILY-TO-FAMILY EDUCATION PROGRAM (FFEP)

FFEP is based on state-of-the-art information for families of persons with schizo-
phrenia and schizoaffective disorder; bipolar disorder; major depression; bor-
derline personality disorder; panic disorder, and obsessive compulsive disorder;
co-occurring brain disorders and addictive disorders. Its 12 classes include:
(1) Introduction (normative emotional reactions of family members; goals for
ill relative; understanding illness symptoms; etc.), (2) and (3) Description and
diagnostic criteria for specific disorders as mentioned earlier, types and sub-types,
(4) Basics about the brain, function of key brain areas, research on brain abnormal-
ities, genetic research, etc.,(5) Problem-solving-skills workshop, (6) Medication
Review, (7) Inside Mental Illness (understanding subjective experience of coping
with a brain disorder), (8) Communication skills workshop, (9) Self-care (handing
negative feelings of anger, entrapment, guilt, and grief; balancing caregiver respon-
sibilities, etc.), (10) Vision and potential of Recovery (learning key principles of
rehabilitation), (11) Advocacy (combating stigma and learning how to change the
system), and (12) Review, sharing, and evaluation. The manual has a glossary of
psychiatric terms and definitions and local resource information is available.
According to information received from director Dr. Joyce Burland (personal
communication, November 19, 2007), Family-to-Family has graduated over
FAMILY EDUCATION 99
125,000 people from its classes in the 13 years that records have been kept. It is
now available in 48 states and involves more than 3,500 trained NAMI member vol-
unteers who teach in co-leader pairs. It is estimated that they are now graduating
some 10,000–12,000 people a year. There are nine classes where the various family
members are separated according to their family roles (mothers, fathers, siblings,
spouses, adult children). They are asked to work in these groups to define their
particular family burden (“What is the hardest part of living your particular role in
your family with a member with mental illness?”) In this way, they hope to engen-
der understanding and empathy among the relative groups.
FFEP is now taught in Spanish in many parts of the country. All training materi-
als and the curriculum have been translated into Spanish, and expanding this part
of the program is a priority in NAMI’s strategic plan for the next three years. De
Familia-A-Familia has been hugely successful in Mexico, where over 8,000 people
have graduated from the program in three years. The program is being translated
into Arabic and Mandarin in California with funding from Proposition 63 (which is
slated for mental health purposes). FFEP will go to Italy in the first part of 2008.
Research Findings. In a pilot study, 37 family members who participated in
FFEP were evaluated by an independent research team from the University of
Maryland at baseline, after completing the program, and six months after comple-
tion. Participants demonstrated a significantly greater sense of empowerment
regarding family, community, and the service system, and reduced displeasure and
worry about the ill family member. These benefits were sustained at six months
(Dixon, Stewart, Burland, Delahanty, Lucksted, and Hoffman, 2001b). In a sec-
ond evaluation, 95 consenting family members agreed to four interviews (waitlist,
pre- and post-FFEP, and six months post-FFEP). The variables were objective and
subjective burden, empowerment, and depression. The FFEP was associated with
reduced subjective burden and increased empowerment without changes in objec-
tive burden. Knowledge about SMI, understanding the mental health system, and
self-care also improved. There was no significant decay at six-month follow-up.
The authors concluded that the FFEP is helpful to relatives of persons with SMI by
reducing subjective burden and worry, and increasing empowerment and knowl-
edge of SMI, self-care, and understanding of the mental health system (Dixon,
Lucksted, et al., 2004). In October 2005, the University of Maryland team received
a four-year National Institute of Mental Health grant to continue studying NAMI’s
Family-to-Family program.
JOURNEY OF HOPE (JOH)

The JOH program was initially developed in 1993 to consist of a 12-week education
course and an ongoing support group. Family members could participate in either
or both, depending on their needs. NAMI subsequently supplanted JOH with the
12-week FFEP. NAMI-Louisiana retained the JOH, which was subsequently con-
verted to an eight-week course. In 1997, the JOH curriculum was collaboratively
re-written by a team of families, mental health professionals, and mental health
consumers. The material focuses on the biological causes and clinical treatments
for schizophrenia, schizoaffective disorder, major depression, bipolar disorder,
and obsessive-compulsive disorder. Components are similar to those of FFEP,
including recognizing signs of relapse, medications, side effects, and non-com-
pliance issues, effects of substance abuse, problem-solving and communication
skills, etc. Additionally, the course offers information on the mental health system
and how to work collaboratively with service providers. Families’ predictable reac-
tions are normalized, self-care is emphasized to enhance caregivers’ emotional and
physical well-being, and consumer recovery is an important part of the curriculum.
JOH is taught in non-clinical, public settings and the course and all materials are
free (Pickett-Schenk, Lippincott, Bennett, and Steigman, 2008).
Research findings. Research on JOH was conducted by the Center on Mental
Health Services Research and Policy, University of Illinois at Chicago. The first
evaluation, consisting of survey reports from 424 families who had participated in
JOH from 1993 to 1996, found increased knowledge of the causes and treatment of
mental illness, increased understanding of the mental health service system, and
improved morale. Hierarchical regression analysis found that these program out-
comes were highly predictive of one another. “This suggests that the JOH program
may be successful in helping families attain a broad range of outcomes. Achieve-
ment of these outcomes may allow families to be better able to both help their ill
relative by increasing their ability to manage problem behaviors and secure ser-
vices, and to help themselves by decreasing their feelings of guilt and isolation”
(Pickett-Schenk, Cook, and Laris, 2000).
In a later randomized controlled study of the eight-week JOH course, 462 par-
ticipants were recruited six times in waves from December 2000 through August
2003. In an evaluation conducted in three southeastern Louisiana cities, 231 fam-
ily members were randomly assigned to immediate receipt of the JOH course and
231 assigned to a nine-month waiting-list control group. Participants’ knowledge
levels, problem-solving skills, psychological well-being, and relationships with
their ill relative were assessed at enrollment, three months later at course termi-
nation, and eight months post-baseline. Mixed-effects random regression analysis
found that JOH participants reported fewer depressive symptoms, greater emo-
tional role functioning, and fewer negative views of their relationships with their
ill relatives than peers in the control group. These improvements were sustained
over time and were significant for all even when controlling for demographic dif-
ferences and the clinical characteristics of the ill relative (Pickett-Schenk et al.,
2006). The intervention group also reported significantly greater gains in knowl-
edge about mental illnesses and their treatments, problem-management, and
community resources, and fewer needs for information on coping with both
FAMILY EDUCATION 101
positive and negative symptoms (Pickett-Schenk, Lippincott, Bennett, and

Steigman, 2008).
THE TRAINING AND EDUCATION NETWORK (TEC) OF PENNSYLVANIA

The Training and Education Network (TEC) is a special project of the Mental
Health Assocation of Southeastern Pennsylvania. It is a collaborative of fam-
ily members and mental health professionals who are experienced in providing
psychoeducation to persons with mentally ill relatives. TEC network members
developed and facilitated a 10-week psychoeducational group as one of three
complimentary family educational services from which family members can
choose. The others are family consultation, with the needs of an individual
family addressed by a specialist in phone or face-to-face contacts, and question-
and-answer programs at regularly held meetings.
Research findings. In one study, 183 family members were randomly assigned
to receive individual consultation or group psychoeducation or were placed on a
nine-month wait list. Subjects were primarily white middle-class women with an
adult child with mental illness. The ill relative was not involved in the intervention.
Baseline and three-month follow-up interviews included measures of burden,
grief, self-efficacy, social support, stress, and adaptive coping. Individual family
consultation was administered by a specialist for a minimum of 6 to 15 hours and
11 psychoeducation groups were co-facilitated by a mental illness specialist and a
trained family member. Results: The only significant improvement attributable to
both psychoeducation and individualized consultation was specific self-efficacy,
that is, “confidence in one’s ability to understand mental illness in a relative and to
cope with its consequences” (Solomon, Draine, Mannion, and Meisel, 1996, p. 46).
OTHER FAMILY EDUCATION MODELS
THE PACIFIC CLINIC INSTITUTES MODEL

Christopher Amenson, Ph.D., is faculty chair of the Pacific Clinics Institute, which
has been involved in family training for at least a quarter of a century. According
to Amenson (personal communication, October 23, 2007), Schizophrenia: A Fam-
ily Education Curriculum, includes 12 hours of lectures on schizophrenia focusing
on family understanding, not blaming themselves or the consumer, understand-
ing and accessing evidence-based treatments, and the family’s role in promoting
recovery. There is a companion, Schizophrenia: Family Education Methods that
describes how to set up, recruit families, answer questions, and create a positive
process in the class. Schizophrenia: A Family Education Curriculum, has been taught,
with many revisions, for 25 years to over 50,000 families in eight languages. The
course has been published in English, Spanish, and Japanese and translated by
individual trainers into Mandarin, Cantonese, Vietnamese, Tagalog, and Russian.

“I have trained 120 professionals and family members to teach the course . . . The
course is also on videotape and DVD. Families, who are less comfortable with
public exposure, often take the course at home by tape or DVD. I gave the video
rights to the local NAMI, San Gabriel Valley, which sells them at a nominal fee
(626-577-6697). Locally, we have used my course as a complement to Family-to-
Family with many local families attending both. Different families want different
doses of my information-packed class and the terrific small group process of Fam-
ily-to-Family. I have also written Family Skills for Relapse Prevention for any diag-
nosis. This 10-session course is attended by the consumer and at least one family
member. They monitor symptoms, identify potential triggers, and develop plans in
conjunction with their treatment team for responding to everything from a minor
flair up through advanced directives for involuntary hospitalization . . . When there
is no available family (homeless programs), the course can be taught to the con-
sumer and his case manager or other significant support.” A further discussion
may be found in Amenson and Liberman (2001).
THE THREE R’S PSYCHIATRIC WELLNESS REHABILITATION PROGRAM

The following description was provided by the model’s founder, Dr. Mary Moller, a
professor of psychiatric nursing (personal communication, October 24, 2007).
The Three R’s educational model is an inter-disciplinary model designed to have
a teaching team comprised of an advanced practice nurse, social worker/therapist/
psychologist, and consumer. It was started in Omaha in the mid-l980s. The model
was developed as a community education course for patients, family members, and
also providers who were working with the patients and family members of persons
with mental illness. The Three R’s program has been taught continuously in Tacoma,
Washington since 1991, and was selected as an NIMH Best Practices model in 1994.
As of 2000, 6,281 different people had taken the courses. The Three R’s program has
been given in numerous mental health centers and hospitals in the following states:
Alabama, Arizona, Kansas, Kentucky, Massachusetts, Montana, Nebraska, Ohio,
Oregon, Texas, Utah, Washington, and Wisconsin, also in Edmonton, Alberta, and
London, Ontario, Canada. In 2000, the model also began to be implemented in Israel.
The program is offered under the auspices of the Psychiatric Resource Network,
Tacoma, Washington. It is described more fully in Moller and Murphy (1997) and
Murphy and Moller (1996).
PEBBLES IN THE POND

The following information was provided by co-founder Larry Baker (personal
communication, October 14, 2007). Pebbles in the Pond: Achieving Resilience in
Mental Health is both a 600-page textbook and a psychoeducation curriculum for

12 weekly sessions of three hours each. The program brings together individuals
with severe and persistent mental illnesses, their family members and friends, as
well as the mental health professionals with whom they work. Because of the fund-
ing stream for the program—a community federal block grant and an allocation
from United Way of Pierce county (WA)—the program welcomes community
residents who have an interest in the topics. Both the classes and the textbook are
available without charge.
The program is offered through the Community Education department of Com-
prehensive Mental Health in Tacoma, WA. Four identical sessions are offered each
week in four area mental health centers. The intellectual property, which is “Peb-
bles in the Pond,” belongs to a non-profit educational organization with offices in
Gig Harbor, WA. The organization has a volunteer board of 15 members, over half
of whom are consumers or family members of consumers. The co-authors of the
“Pebbles” book and curriculum are Karen A. Landwehr, M.C., and Larry S. Baker,
M. Div. Between themselves, Karen and Larry have nearly 50 years of experience in
the public-sector mental health system. Currently, “Pebbles” is offered three times
a year—winter, spring, and fall. Individuals can join the class at any time during the
12 weeks. They can pick up classes missed during the next cycle. Some individu-
als have attended the series ten times or more. It becomes an integral part of their
recovery strategies.
In a calendar year, the course draws between 350 and 450 individuals. One of
the unique features distinguishing “Pebbles” from other psychoeducation models
is the simultaneous involvement of consumers, family members, and care provid-
ers. For ten years, the program has utilized pre- or post-session 10-item knowledge
inventories for the first 11 sessions and a comprehensive 50-question review at ses-
sion 12. In developing contract language with funders, 15% overall improvement in
scores was the goal. This envisioned each person attaining one or more important
pieces of information each week. In fact, the participants have far exceeded that
goal. See appendix for more information, also Baker and Landwehr (2007).
The following two models primarily offer training in family education to
educators.
BRYCE HOSPITAL, ALABAMA MODEL

Training in psychiatric patient and family education has been offered since the
1980s at Bryce Hospital in Tuscaloosa, AL. The training (which was originally devel-
oped by Dr. Kay McCrary and Dr. Cynthia Bisbee) consists of a three-day intensive
workshop on the content and process of psychiatric patient and family education
(including study of Dr. Bisbee’s manual, Educating Patients and Families about Men-
tal Illness). This workshop is followed six weeks later by a content examination and
demonstration-teaching of a specific topic. Over 500 people have received this

training in Alabama. They in turn have administered education in mental illness to
numerous families and patients in psychiatric facilities.
The psychiatric patient and family education method is designed to be a spe-
cific details complementary segment of an overall treatment plan that may involve
a variety of treatment modalities, including psychopharmacology, individual or
group psychotherapy, skills training and other rehabilitative methods, family con-
sultation, and family therapy. The format consists of illness management, coping
skills, and diagnostic groupings of depression, bipolar disorder, and schizophrenia;
12-topic curriculum for families addressing the etiology and treatment of mental
illness; management skills (e.g., relapse prevention); rights and responsibilities;
and general coping skills. The manual includes specific handouts and overheads for
each topic. There has been informal research on patient satisfaction and increase
in knowledge, but no controlled research using the specific manual. The manual
contains a 12-item “psychiatric patient education” and “family education” infor-
mation test to assess knowledge about mental illness, which can be used as a pre-
and post-test measure. The manual also includes an “attitude checklist” to assess
attitudes toward mental illness. See Bisbee (1991, 1995) for manual information.
PARTNERSHIP FOR RECOVERY

Like the Bryce Hospital Program, Partnership for Recovery, developed by Patricia
L. Scheifler MSW, PIP, primarily offers manualized education for educators and
service recipients. Patricia Sheifler has authored two Family Education resources.
“Managing Crisis and Emergency Situations,” part of the Team Solutions library of
psychoeducational workbooks. It is currently in its third edition and is published
by Eli Lilly and Company. The workbook is written for family members, caregivers,
and frontline staff and it focuses on teaching calm, non-critical communication
skills. The workbook can be downloaded free of charge from www.treatmentteam.
com. There is no indication that any outcome studies have been conducted using
the workbook. Scheifler’s other family education resource is a video tape, “When
Mental Illness Invades the Family: Developing Practical Communication Skills.”
Like the Bryce Hospital model, this is primarily a teaching program with a variety
of teaching psychoeducational resources authored or co-authored by Scheifler,
and listed in the Appendix.
In summary, family education (FE) shares uniformities of content with FPE
but differs substantially in length, format, target group, and expected outcomes. It
is brief, generally ranging from six to 12 weeks; it is targeted to caregivers—families
and friends; it is always in group form, typically without the presence of the ill fam-
ily member, and its expected outcomes are greater knowledge of illness manage-
ment and reduced distress and burden of family caregivers. There may be a hope,
but there is no presumption of reduced relapse or hospitalization of the ill family

member. Most programs use internal evaluations, some with pre-post knowledge
tests, but only a few have research findings of effectiveness.
FE programs have largely been developed under the aegis of advocacy groups,
most by The NAMI and Mental Heath America (MHA). Two NAMI programs,
taught by well-trained family members, have been manualized and evaluated in
research designs that almost fulfill the EBP criteria, with the exception of replica-
tion by a different research team. These are Journey of Hope (JOH) and Family-
to-Family Education Program (FFEP). Together these 8–12-week programs have
reached many thousands of families, and have been supported by state administra-
tions as a service to families.
This chapter describes these programs in detail with their research findings.
For other research, we note the Training and Education Network (TEC), a project
of the MHA of Southeastern Pennsylvania. TEC is a collaborative of profession-
als and family members who are experienced in providing manualized FE. TEC
also offers family consultation for individual families. In a randomized design,
with individual consultation compared with group FE, both interventions yielded
greater self-efficacy in participants than a waitlist control.
Because many other sites and clinical facilities have developed manuals and
provide education and training to those families who need it, a sampling of other
programs are provided. Although they usually have evaluation forms tapping
knowledge acquisition or satisfaction with the training, for the most part they have
no research data to qualify as EBPs. Yet, these programs are rich in detail, and some
are services for families that have been provided for many years by concerned
clinicians. Their manuals and other publications may be found in the Appendix.
10
T R A I N I N G A N D TRA I N I N G ISSU ES
McFarlane (2002) has probably been most proficient in training staff for
family psychoeducation (FPE) in various states in the United States, as well as in
numerous research programs. In the New York State and Ohio Training and Dis-
semination Programs, staff was trained in two different methods of delivering
family-based interventions; multi-family and single-family FPE. In a six-site study
in New York, clinicians received intensive training in a three-day workshop. This
was repeated annually through the four years of the research, with content varied
to reflect the changing level of care provided by families during this period. Vid-
eotaped family interventions were viewed by senior supervisory staff on a weekly
basis, and clinicians received weekly telephone supervision of 45 min per session
based on the content of the videotapes. Changing the belief system of clinicians,
most of who initially viewed families as somehow causing schizophrenia, was the
first task in disseminating FPE (Dixon and Dunne, 2002). Training of clinicians
was further augmented by orientation and training of administrators and other
key personnel. In the Ohio study, there was an intensive training of staff from five
agencies. Training was in two phases. First was a two-day program with didactic
materials, including books, a treatment manual, and video. The second phase was
planned with participants at each site, paired with a trainer providing three months
of technical assistance and support to each site by phone. Trainees were promised
up to five hours of phone contact with the trainer. The results of the training are
further indicated in the chapters on Model Programs and on Implementation.
McFarlane has also trained staff working in prodromal projects, such as the Port-
land Identification and Early Referral (PIER) project discussed in Chapter 6.
Between 2000 and 2004, the European Commission promoted a study to investi-
gate the effects of both standard and augmented staff training on implementation and
106
TRAINING AND TRAINING ISSUES 107
effectiveness of FPE for schizophrenia. The study involved six European countries
and was carried out by the Departments of Psychiatry of the Universities of Naples
(Italy), Athens (Greece), Lisbon (Portugal), Granada (Spain), and Dresden (Ger-
many), and the Birmingham and Solihull Mental Health Trust (United Kingdom).
Each center chose four mental health services, and each service trained two pro-
fessionals in the FPE model of Falloon, Boyd, and McGill (1985). The aim was to
investigate the possibility of providing FPE in routine clinical settings by training
regular staff, and to assess the difficulties and benefits experienced by staff. The
standard training format, a basic course on FPE, was 40 hours (full-time for five
days). The augmented program consisted of three 2-day monthly modules. The
latter added training for staff to use communication and problem-solving skills to
cope with implementation problems on homework on FPE techniques. The two
professionals from each center were randomly assigned to attend one of the two
training courses and to implement FPE in their center for one year. The 48 train-
ees, all of whom completed the course, consisted of the following disciplines: psy-
chiatrists (31%), nurses (29%), clinical psychologists (15%), social workers (15%),
occupational therapists (2%), and other professionals (8%). In follow-up, the
48 trainees reported a significant improvement in their relationships with patients
and their families, and in clinical results. (The latter are reported in the chapter on
culture.) The most frequent difficulties reported were work overload, difficulties
in integrating family work with other responsibilities, and inadequate time to run
the intervention. There were no significant differences in effects of the two train-
ing programs (Magliano et al., 2005; Magliano and Fiorillo, 2007).
Probably the most continuous training program today is Meriden, the West
Midlands Family Programme in the United Kingdom. Meriden is funded by the
British National Health Service (NHS), and the overall aim of the Meridan Pro-
gramme is to train staff in NHS Trusts providing mental health services in the skills
needed to work with families. Their major training is in Behavioral Family Therapy
(BFT), previously described, the model that has informed most FPE programs.
Since 1998, over 2300 therapists have been trained across the West Midlands and
there are at least 130 trainers representing all professions from all specialty areas.
Families and consumers are actively involved as consultants to the program, and
several have themselves trained as therapists and subsequently as trainers. The
program provides training in a range of special areas, including early psycho-
sis, family work in forensic settings, and delivering caregiver education and sup-
port programs. A number of key areas have been developed including liaison with
primary care and child and adolescent services.
Meriden was developed as a cascade model, “the only one that would be likely
to be successful in training a large number of staff in a short space of time. This
involved the training of staff in each trust to become trainers and supervisors.
These therapists, drawn from all professions, could then offer training courses
within their own service” (Fadden and Birchwood, 2002). Concomitantly, a com-
munity mental health program was developed at the University of Birmingham as a
partnership between local mental health services and the university. Mental health
service providers release staff to engage in the program, and thus are promised a
supply of fully trained staff with supervision from the academic sector. The pro-
gram explicitly adopted a value base focused around the express needs of service
users and their families, similar to the consumer-oriented focus that would later
be emphasized in the President’s Commission report in the United States (New
Freedom Commission on Mental Health, 2003).
Fadden (1998), who helped initiate the successful Meriden Project in the United
Kingdom, has stated that implementation of FPE and staff training is intricately
linked. The successful adoption of FPE in any program depends on a workforce
trained in the skills necessary to work with families as a psychoeducator rather than
as a person administering family therapy. She notes that in the United Kingdom, as in
the United States and elsewhere, the pre-service training of most mental health pro-
fessionals does not equip them with the skills that are needed. Many are not familiar
with the literature, and with the exception of social workers, often have minimal expe-
rience with families. She states that many practitioners find the prospect of simulta-
neously making an alliance with both patients and their relatives quite intimidating.
Research has demonstrated that successful outcomes of FPE are significantly
correlated with therapists’ competencies, and with “treatment integrity,” again the
province of those with training and experience. Moreover, training in FPE often
involves “undoing unhelpful attitudes formed at early stages of training. Beliefs
that parents are responsible for their child’s schizophrenia, or that families are dys-
functional rather than normal people trying to cope with abnormal situations are
still pervasive . . . Another common attitudinal barrier for professionals is the loss
of power and control, which derives from the collaborative style that is intrinsic in
both psychoeducational interventions and interventions with relatives” (Fadden,
1998, p. 302). Fadden suggests that an effective way of producing attitude change is
to use audiotapes or videotapes of families relating their experiences.
In a study reported by Amenson and Liberman (2001), it was noted that two
days of staff training did not produce any change, but intensive training for several
months resulted in implementation of new family programs at a majority of sites.
“Working with Families” was a project to introduce FPE in the Los Angeles Men-
tal Health Department by gaining commitment of top management to designate
family education as a required service. Extensive staff training was conducted for
39 psychologists, social workers, and nurses selected by their program directors.
The three-phase training included essential topics taught for several months (see
Amenson, 1998 for content). Successful implementation included “administrative
support from top management, a congruent treatment philosophy in their clin-
ics, the availability of external consultation, and encouragement from a respected
colleague to use the skills. Two trainees adapted the use of the family education
courses in Japan, and the curricula have been published in Japanese” (Amenson
and Liberman, 2001, p. 591).
Some training sessions for FPE are general and others are targeted to a specific
discipline. A six-session training program for mental health practitioners focused
on increasing their knowledge of families caring for a relative with mental illness,
improving their attitudes about working with families, and increasing their contact
with families. Seventy participants were divided into experimental and control
groups. The trainees showed increased knowledge and improved attitudes about
working with families, but no changes in actual patterns of contact (Thomas, Guy,
and Ogilvie, 1999). Gall, Atkinson, Elliott, and Johansen (2003) studied the effects
of innovations in nursing education in Scotland to support carers of persons with
schizophrenia. They found that nurses reported changes in practice in key areas:
they built collaborative relationships with carers, acknowledged and supported the
carer role, and made progress in identifying carer needs and accessing resources to
meet those needs.
Training to administer FPE is probably insufficient if mental health profession-
als do not receive adequate education on working with families in their pre-service
clinical training (Lefley, 1988). A publication of the Center for Mental Health Ser-
vices specifically addresses the required competencies of mental health staff to
work with families (Glynn, Liberman, and Backer, 1997). They list seven essential
competencies. The worker must have the knowledge and skill to be able to do the
following:
• Develop a collaboration with the family (make a positive first contact, interview
about consumer and family’s history, needs, wants, and assets)
• Offer information on mental illness (answer questions about mental illness, help
families understand the long and variable course of illness, conduct multiple family
groups)
• Enhance family communication and problem solving (teach family communication
and problem-solving skills)
• Help with service system use (help families participate in treatment plan; inform
families about different roles of mental health workers and establish liaison person
for each family; help families understand the language of mental health services,
and assist them in crisis)
• Help the family meet its own needs (establish connection to community resources,
including NAMI affiliates; relieve burden and grief; empower families to become
involved in advocacy; encourage families to learn about stress management skills;
help families use educational materials wisely)
• Help with special characteristics of ill family members (be able help families of
consumers who are treatment refractory; had recent onset of mental illness; are
substance-abusing or in criminal justice system; or families of children with serious

mental illness)
• Manage confidentiality and cultural diversity (manage issues of confidentiality
between family and ill relative; address cultural diversity as it relates to family
involvement) (Glynn, Liberman, and Backer, 1997, pp. 1–2)
Training skills, however, must be incorporated in receptive mental health sys-

tems. In its international initiatives to encourage greater family involvement in
mental health care, the World Fellowship for Schizophrenia and Allied Disorders
(WFSAD) collaborated with FPE pioneers Ian Falloon, Julien Leff, and William
McFarlane in proposing fifteen principles for working with families. These are
relevant to the training of both clinicians and administrators as essentials of all
patient care. They are: (1) co-ordinate all elements of treatment and rehabilitation;
(2) pay attention to social as well as clinical needs of patients; (3) provide optimum
medication management; (4) listen to families and treat them as equal partners;
(5) explore family members’ expectations; (6) address family’s strengths and dif-
ficulties; (7) help resolve family conflicts; (8) address feelings of loss; (9) provide
relevant information for patient and family at appropriate time; (10) provide an
explicit crisis plan and professional response; (11) encourage clear communica-
tion; (12) provide training for family in structured problem-solving techniques;
(13) encourage family to expand their social support networks; (14) be flexible in
meeting the needs of the family; and (15) provide the family with easy access to a
professional in case of need if there is a cessation of work with the family (Froggatt
et al., 2007, pp. 151–154).
To sum up, except for McFarlane’s (2002) continuing work with mental health
personnel in several states, and staff training in Los Angeles by Amenson and
Liberman (2001), training for FPE has been implemented to a greater extent in
Europe than in the Western hemisphere. In 24 mental health services in six Euro-
pean countries, 48 mental health professionals were trained in the Falloon, Boyd,
and McGill (1985) model to determine whether FPE could be provided in routine
clinical settings by regular staff. During follow-up, the trainees reported significant
improvement both in clinical results and in relationships with patients and their
families. As expected, the most frequent difficulties were work overload, conflicting
responsibilities, and inadequate time.
The most continuous training program today is Meriden, the West Midlands
Family Programme in the United Kingdom, which has trained over 2300 thera-
pists since 1998. Meriden has added specialty areas such as family work with early
psychosis and liaison with primary care and child and adolescent programs.
In terms of actual content, Glynn, Liberman, and Backer (1997) list seven
essential competencies for clinical staff to be able to work successfully with fami-
lies. WFSAD, an international mental health advocacy organization that has long
pressed for family involvement in treatment, collaborated with FPE researchers in

proposing 15 principles for working with families. These are relevant to the train-
ing of both clinicians and administrators as essentials of all patient care.
It is clear that successful training is only the beginning of the adoption of new
services. Administrative support, adequate reimbursement, the availability of
sufficient time, both for training staff and for implementing programs, minimal
pressure of competing commitments, and above all, the positive attitudes and
interest of staff are all required for training to transfer to practice. And programs
must make an effort for outreach and engagement of families. These issues are
further discussed in the chapter on Implementation.
11
I M P L E ME N T A TI O N I N S E R V IC ES
Despite the large body of research evidence on effectiveness, family psycho-

education (FPE) has been poorly implemented in most mental health systems in
the United States, with an estimate that only 10% of families participate in FPE
programs (Dixon et al., 2001). This is not unusual, since implementation of all
evidence-based practices (EBPs) for serious mental illness has been seriously defi-
cient. As Torrey et al. (2001) have noted, major professional groups have published
recommendations, guidelines, consensus statements, and treatment algorithms rel-
evant to the care of adults with serious mental illness. Yet evidence-based psycho-
social interventions such as FPE, assertive community treatment, integrated dual
diagnosis treatment, or supported employment continue to be under-represented in
most mental health systems.
In a comprehensive analysis of implementation of McFarlane’s multi-family
model in the real world, Dixon and Dunne (2001) described a carefully constructed
process of research, implementation, and dissemination in four states and assessed
the results as “partial successes and partial failures” (p. 355). A survey of all psychi-
atric institutions in Germany, Austria, and Switzerland found that although 86%
of the responding facilities claimed to offer psychoeducation of some kind, a mean
of 21% of the patients with schizophrenia and only 2% of their family members had
participated (Rummel-Kluge, Pitschel-Walz, Bauml, and Kissling, 2006) in such
programs. There are guidebooks for families on how to become involved in their
relatives’ care (e.g., Glynn and Backer, 1997), but ineffective pressures on men-
tal health systems to incorporate not only FPE, but EBPs in general (Aarons and
Sawitzky, 2006). The following discussion attempts to explore some of the barri-
ers to FPE, on the part of both participants and service providers. Experiences and
problems in implementations, and fidelity issues, are also discussed.
112
IMPLEMENTATION IN SERVICES 113
BARRIERS TO IMPLEMENTATION
Barriers to implementation are both general and specific. As noted by McFarlane,
McNary, Dixon, Hornby, and Cimett (2001), FPE “is not compatible with clini-
cal training of many clinicians. It is more complex than standard medication
treatment, it cannot readily be tried in a brief or easily evaluated form, and the
outcomes—by design—emerge over the long term and are therefore not readily
observable” (p. 936). In response to a request for information on their experiences
in implementing FPE, McFarlane indicated that too many clinicians and adminis-
trators reject the whole concept of EBPs. In some agencies at least “the biggest bar-
rier was rejection of the whole concept of evidence related to practice. The other
barrier was lack of time and ‘productivity’ pressures in agencies” (W.R. McFarlane,
personal communication, May 12, 2008).
Bisbee (2007), an administrator in a major urban mental health authority, has
noted barriers to implementation on the part of service recipients as well as pro-
viders. First, there may be a general reluctance of families and consumers to simply
attend. There may be practical obstacles such as accessibility and transportation,
reluctance to invest time and energy, underestimation of the value of psychoedu-
cation for themselves, fear of increased expectations if they take the training, fear
of generalized stigma, and previous bad experiences with the system. Clinician
and administrator issues may include negative attitudes and beliefs about fami-
lies, job and organizational factors, lack of support from leadership, and insuf-
ficient resources. They may also underestimate the value of psychoeducation for
families.
Barrowclough and Lobban (2008) have empirically confirmed some of these
difficulties with staff, and also with caregivers’ reluctance to participate in family
work. “Several studies of community samples have shown that caregiver participa-
tion in family intervention is relatively low, with only 50% or so of caregivers tak-
ing up the offer of either a support service or family intervention . . . with possibly
higher rates when help is offered at a time of crisis or at first episode” (p. 221).
Brent and Giuliano (2007) used a case example to explore barriers to imple-
menting family interventions in acute and outpatient treatment venues. Their dis-
cussion “highlights the convergence of problems in the mental health-care system
with clinicians’ typical capacities and practices, difficulties intrinsic to the nature
of psychotic-spectrum illness itself, and the burden and stigmatization of families
of the severely mentally ill. Taken together, these factors undercut the implemen-
tation of evidence-based family interventions” (p. 161).
First, there must be efforts to engage families, many of whom are overwhelmed
and reluctant to participate in outside activities that require time and commit-
ment. Some are defensive about needing help. Biegel and Song (1995) studied
facilitators and barriers to caregiver support group participation among 198 lower
socioeconomic status African-American and Caucasian caregivers of persons with

SMI. They found many of the same responses. Barriers included accessibility and
transportation difficulties, lack of time, concerns for confidentiality, and disavow-
ing the need of outside aid in caring for their ill relative.
Murray-Swank and Dixon (2004) state that in clinical practice with persons with
SMI, the degree of involvement and role of family members and significant oth-
ers should be routinely assessed and the key principles of FPE should be initiated
for all interested parties. Families are usually interviewed simply to get a history,
rarely for participation in the patient’s treatment. Yet, as Amenson and Liberman
(2001) have pointed out, administrative interest is essential for the inclusion of
FPE in the spectrum of services in any mental health facility. Unfortunately, many
administrators and program directors still lack knowledge of the research findings
on FPE, despite its obvious cost–benefit in lowering hospitalization rates.
Clinicians themselves may not be current in their personal knowledge base.
They may be unfamiliar with the state-of-the-art information in most FPE courses,
and would have to devote time to new learning. In today’s mental health systems
with ever-diminishing resources, few staff members want to take on extra roles or
responsibilities. For clinicians, there may be a carry-over of old prejudices toward
families and reluctance to afford them any role in the treatment process. They may
have learned in their early training, and still be convinced, that intensive psychody-
namic or systemic family therapies are the gold standard, whereas education has
lesser merit. To these we may add the ever-present problem of reimbursement.
Third-party payers, both private and public, are variable in their reimbursement
policies. Some states, such as Alabama, have a Medicaid code for Patient and Fam-
ily Education and Support, but many do not. In many cases, FPE can be reimbursed
only if administered to individual patients and their families and billed under
another code, such as family therapy.
RESEARCH FINDINGS ON IMPLEMENTATION

The New York State Family Support and Demonstration Project was conducted at
five state-operated psychiatric centers and one city hospital, with 20 clinicians and
a total of 172 families and patients (McFarlane, Dunne, et al., 1993). The project was
conceptualized as having three phases: research, implementation, and dissemi-
nation. The research, designed to compare single- and multi-family approaches,
is more fully described in the chapters on model programs and on training. The
research phase indicated the superiority of multi-family group (MFG) over single-
family approaches, so Phase 2 was initiated to emphasize MFG as the treatment of
choice.
Dixon and Dunne (2002) have noted a large number of variables that affected
both implementation and dissemination of the project. Administrators were less
involved in Phase 2, and clinicians no longer received extra compensation for the
MFGs. Because research was no longer conducted, there was no need for a site
coordinator or interviewers. Moreover, two of the sites had complete administra-
tive turnover, with less commitment from new administrators. The dissemina-
tion phase attempted to use the same teachers and supervisors in other clinical
settings in NewYork state, with the offer of regional training. During this phase,
however, private clinics began competing for Medicare reimbursement, and these
agencies were less responsive to mandates from the State Office of Mental Health.
Participating agencies were required to subsidize the entire effort, and sometimes,
their agency philosophies were at odds with the psychoeducational model. Clini-
cians were often at the pre-master’s level and had no training in the model, and
their supervisors often had little preparation. When funding for the dissemina-
tion phase ended, most of the activity in the regional sites also ended (Dixon and
Dunne, 2002; McFarlane, Dunne et al., 1993).
In another attempt to determine whether research findings could be trans-
lated into FPE in routine clinical practice, a two-state study was conducted with
15 mental health agencies in Maine and 51 in Illinois. In these centers, clinicians
and administrators were trained in McFarlane’s multi-family model of FPE. Par-
ticipants were surveyed after their initial training session, and nine months later.
The initiatives in Maine and Illinois had set a goal of disseminating FPE across
each state. In the Maine Family Support Action Initiatives (MFSAI), they proposed
to provide FPE support for at least two years by trained practitioners. From March
1998 to December 2000, approximately 380 clinicians from 33 agencies, hospitals,
and centers were trained. The implementation design included needs assessment,
epidemiologic profiles of populations and family availability, orientation and
consensus building, clinical training, and ongoing consultation and supervision.
A statewide advisory council encouraged local consensus building by clinicians,
families, and consumers.
The Illinois Family Psychoeducation Dissemination Project trained clinical staff
of 51 agencies in nine service areas that contained approximately 100 mental health
agencies. According to McFarlane, McNary et al. (2001), the states differed in the fol-
lowing important ways: (1) in Illinois, dissemination was initiated by the state mental
health department, promoting adoption in independent non-profit agencies through
regional directors and encouraging voluntary participation; financial incentives
were provided to the implementing centers; (2) Illinois placed much less emphasis
than the Maine initiative on consensus building and community acceptance; (3) few
sites in Illinois used supervision and consultation after the training; (4) direct expen-
ditures in Maine were 25 cents per capita, and in Illinois only one cent per capita; and
(5) the project’s director was involved in Maine mental health services.
An independent evaluation team administered a post-training survey tapping
seven domains: trainees’ demographic characteristics, knowledge, satisfaction,
intention to use the new approaches, beliefs about the agency’s intent and ability
to implement MFG, perceived obstacles, and perceived value of various supportive
resources for implementation.
A total of 537 trainees from 69 sites completed surveys. The most common
perceived obstacles to implementation were growing staff caseloads with intense
pressure, and less time for new approaches; excessive current demands; perceived
lack of reimbursement for non-traditional treatment; longer duration of the MFG
treatment approach; and uncertain about agency financing as a whole.
The overall regression analysis yielded a model that significantly predicted
implementation of MFG at nine months (N = 53). The home state, Maine, made
more progress toward implementation than the Illinois sites. Greater progress was
achieved in sites where there were fewer predicted limitations of the model.
Counter-intuitive findings were: (1) sites where trainees rated inducements as
less helpful make greater progress and (2) sites where trainees rated FPE as less
consistent with current methods made greater progress. Paradoxically, the least
influential factor was the empirical evidence of the superiority of FPE over other
models.
Finally, in terms of actual implementation, as of December, 2000, MFG and
single-family support services had been implemented at 14 sites or 93%, in Maine.
In Illinois, of the 51 core mental health centers comparable to those in Maine, five
sites, 10%, had implemented services and a small number were in the process of
developing them.
The Schizophrenia Patient Outcomes Research Team (PORT) selected the
McFarlane MFG model for dissemination. In Ohio, they then conducted a study to
determine whether either of two dissemination approaches led to changes in ser-
vice delivery at the agency level, and to enhanced family participation at the patient
level. A standard didactic presentation (“road show”) was compared to the stan-
dard presentation augmented by intensive on-site training in the MFG approach.
The road-show was a one-hour presentation that highlighted the recommenda-
tion with evidence from the literature documenting the effectiveness of MFG. The
presentation concluded with breakout group sessions, one organized around the
intervention, the other around participants’ identified role in the agency. Inten-
sive training was in two phases, didactic two-day sessions followed by participants
paired with trainers for ongoing technical assistance and telephone contact, with
an on-site booster session. Results: the four agencies receiving the road-show-
only standard condition did not make any changes in services. Of the five sites that
received intensive training, two implemented the MFG model, one modified exist-
ing programs to incorporate MFG principles, and two made no changes. The inten-
sive training was thus viewed as a partially successful mode of implementing MFG
(Dixon and Dunne, 2002).
APPLICATION AND FIDELITY ISSUES

The Evidence-Based Practices National Demonstration Project (EBPP) at Dart-
mouth Medical School focuses on implementation of empirically-supported
clinical practices for severe mental illness. A team of national experts developed
implementation packages for six EBPs: Medication management; Assertive Com-
munity Treatment (ACT); Family Psychoeducation (FPE): Illness Management
and Recovery (IMR); Integrated Dual Diagnosis Treatment (IDDT); and Supported
Employment SE). Implementation packages developed during Phase I included
instructional videotapes, important research articles, fact sheets, workbooks, and
fidelity scales. During Phase II, implementation packages together with consultation
were field-tested in 52 agencies across eight states (Marshall, 2007).
The Dartmouth EBPP analyzed implementation issues for the five EBPs (elimi-
nating medication management) (Isett et al., 2007). Teams conducted interviews
with state mental health authorities, consumers, families, representatives of local
mental health authorities, and other relevant state agencies. Interviews took place
at two points in time at least one year apart.
With respect to FPE, the following key elements were specified:
For families and other people who provide support to a consumer

Collaboration between family and clinician optimizes the outcome of mental
illness
Family education helps relatives support their loves ones in pursuing recovery
goals
Reducing family stress and improving coping can improve the quality of all
members’ lives
Family support can validate the experiences of all members and facilitate shared
problem-solving
Family collaboration is long-term, not short-term
Structure: joining sessions to develop an alliance with the family, educational
workshop and ongoing education about the illness, and multi-family group with a
focus on problem-solving (Isett et al., 2007)
FPE was implemented in three states, Maryland, Vermont, and New Hampshire,
as part of a patient’s overall treatment plan. Marshall (2007) described the process
as follows:
• Clinicians met with consumers and families individually and jointly and
established rapport. They participated in a one-day educational forum and then
joined a multi-family group that meets bi-weekly for nine months or more.
• Consultants, trained by FPE toolkit developer William McFarlane, M.D., and
Dartmouth staff, were assigned to participating agencies. They provided intensive
training and technical assistance for the first two years of the project. They worked
with state planners to open a Medicaid code so that agencies can bill for individual
and group FPE services. For this project, the State Mental Health Authorities also
provided a $10,000 incentive for start-up costs.
• Implementation monitors visited sites monthly for a period of two-and-a-half
years as participant–observers and also attended key agency events. They
conducted fidelity assessments every six months, including chart reviews and
interviews with key stakeholders such as administrators, clinicians, consumers,
and family members.
MAJOR ISSUES IN IMPLEMENTATION

Marshall (2007) described the process and outcome of implementation in one
fee-for-service mental health clinic. During the course of the EBPP, the clinic insti-
tuted two FPE multi-family groups. The first group consisted of eight clients and
12 family members and met for nine months. The second group consisted of five
clients and seven family members and was still meeting after 12 months at the
end of the EBPP. Nevertheless, “While the FPE staff was able to successfully con-
duct two FPE multi-family groups with high fidelity to the model, the agency was
unable to develop a sustainable FPE program” (p. 116). Problems seemed to con-
sist of staff attrition—loss of psychiatric staff with appropriate training. Although
staff were enthusiastic and observed significant improvements in the wellbeing of
their clients, the agency had no plans to recruit new staff or to integrate the FPE
program into standard services.
In the EBPP study, issues regarding implementation of Family Psychoeduca-
tion were as follows:
1 Reimbursement. Does the consumer need to be present for reimbursement?

A session with collateral individuals may not be reimbursed.
2 Consensus- building and commitment of stakeholders. There were some fears that
FPE within the system might be competitive with NAMI’s Family-to-Family
program, which also receives state money for family education.
3 Training and Appropriate Administration.
The survey indicated questions about the appropriate persons who were com-
petent to provide psychoeducation. Many in the consumer movement believe that
only people who have experienced the illness or have been affected by the illness,
such as family members, can effectively communicate what it is like and what to
expect. Family-to-Family, as indicated, is provided by family members carefully
trained by a psychologist-family member, using manualized materials. Again, this
barrier against incorporating FPE as standard practice seemed like competition
with Family-to-Family or Peer-to-Peer.
The authors acknowledged that respondents were identified and suggested by

the mental health commissioner’s office. This office was most likely to identify indi-
viduals with whom they were familiar, those in the consumer and family advocacy
organizations who served on their planning boards. Thus, a major barrier came from
advocates themselves who, having given up hope for educational services from the
mental health system, had developed their own models of family education.
A further study looked at fidelity outcomes for the five EBPs that were imple-
mented in 53 community mental health centers across eight states. For a two-year
period, the study looked at implementation of supported employment, assertive
community treatment, integrated dual disorders treatment, FPE, and illness man-
agement and recovery in these sites. FPE, assertive community treatment, and
supported employment were at or above the threshold value for fidelity. However,
it is noteworthy that FPE was implemented in an average number of states (three),
but the least number of sites (six initially, and four final sites), in contrast to nine
to 13 sites for the other EBPs (McHugo et al., 2007).
SOME SUGGESTED SOLUTIONS

Marshall’s conclusions regarding implementation of FPE or any EPB were as
follows:
1 Align financial incentives to promote the EBP

2 Revise agency policies to integrate EBP principles
3 Revise agency procedures such as intake and employee position descriptions
4 Educate staff agency-wide to develop understanding of the EBP
5 Integrate EBP process and outcome measures into their quality assurance pro-
cess (Marshall, 2007, p. 121)
The reimbursement issue continues to be problematic. There is considerable vari-

ability both in insurance and Medicaid policies with respect to FPE as a discrete
treatment. In my own work I have discovered that families must be enrolled as
patients themselves in order to receive services, and FPE is generally covered as
family therapy although it is a totally different type of type of intervention.
McFarlane has probably had the most experience in implementing MFG. In the
United States he states that “In New York, Michigan, and Maine, there are special
Medicaid rates and codes for MFG and family work in general, and the Northeast
Medicare carrier adopted specific codes and rates. . . . Many places have tried the
family therapy routine . . . this needs a federal solution” (W.R. McFarlane, personal
communication, May 12, 2008).
Two letters to Psychiatric Services by clinicians and researchers who have been active
in delivering family services offer some solutions to problems of implementing FPE
in community mental health centers (CMHCs). Mueser and Fox (2000) suggest
that the major obstacle is the lack of specific individuals who have the authority to
see that family services are provided. They “propose that each CMHC designate an
individual who is the director of adult family services . . . empowered by the agency
to ensure that appropriate, culturally competent, and collaborative services are
provided to families of persons with serious mental illness” (p. 1452). The authors
provide a job description designating primary functions, which include identifying
and training clinicians in family work; leading and supervising family work; moni-
toring the delivery of family services; developing, implementing, and oversee-
ing family programs; working with a family advocate as a liaison with NAMI; and
participating in continuing education activities. They propose that the director of
family services be on the same level as directors of vocational rehabilitation, dual
disorders, and other service specialty areas.
In a subsequent letter, Mannion, Solomon, and Steber (2001) fully supported
this suggestion and added additional solutions based on meetings with providers,
consumers, family members, and administrators. The three major barriers were
identified as confidentiality issues, providers’ reluctance to deliver a non-billable
service, and the need for staff training for effective collaboration with families.
They suggested the following implementation activities: (1) secure a commitment
from the county mental health administrator for program funding, or to include
family education as an in-plan service when the county shifts to managed care;
(2) implement a single-family model of collaborative family education for des-
ignated family members, complemented with referrals to support groups and
NAMI family education programs; (3) produce a training manual for staff training;
(4) ask all supervisors to identify staff members interested in family education. In
the absence of grant monies to implement EBPs, the authors suggest that “educat-
ing country administrators about the costs of ignoring this problem may help start
the process of system change” (Mannion, Solomon, and Steber, 2001, p. 387).
In this chapter we have presented research findings that indicate a relatively
low degree of adopting FPE in clinical services. Barriers to implementation may
include reluctance on the part of families, clinicians, and administrators. There
may be reluctance from some consumers concerned with independence or con-
fidentiality, although to date there are no empirical data indicating consumer
objections. Many families have practical problems, such as time and distance,
with participation. Clinicians may be reluctant to assume added responsibilities
and may lack the requisite knowledge and skills. Administrators are reluctant
to add services without additional funding and may ignore the long-term cost–
benefits of FPE. Research on implementation of FPE in several states disclosed
the process undertaken and fidelity issues. The major issues identified included
reimbursement and financial incentives; commitment of stakeholders; and train-
ing and appropriate administration. Various solutions were offered by seasoned
FPE researchers and clinicians, such as establishing an agency position for family-
friendly services, staff training, and funding commitments from county or state
mental health administrators.
Research-based FPE, focusing on patient outcome, has reached far fewer
participants than the thousands of families reached by briefer family education
models. As we indicated, there are findings of improved knowledge and family
well-being from the two major family-led educational programs, Journey of Hope
and Family-to-Family. But evidence of positive effects on patients comes primar-
ily from the FPE research. Moreover, the key elements in designing the implemen-
tation research previously discussed specify that more than education is needed.
There must be collaboration between clinicians and family support persons, and
the collaboration must be long-term. This suggests far more than simply educat-
ing families about the illness. It implies a clear role for supportive families in the
treatment plan.
12
UN R ES O L V E D I S S U E S I N F AM IL Y
PSYCHOEDUCATION
a critical assessment
We have discussed a variety of studies of FPE from many different countries. There
have been a few negative or unexpected findings. Among unacculturated Spanish-
speaking immigrant families in the United States, Telles et al. (1995) found that
an empirically-validated model of behavioral family treatment led to significantly
poorer outcomes than did standard case management. In Spain, Canive et al.
(1996) found no differences between an FPE and control group. In a Danish study,
group sharing and mutual support seemed more important than simply gaining
knowledge of psychosis (Buksti et al., 2006). In the Netherlands, Cuijpers and
Stam (2000) found that family support groups were significantly more effective
in reducing family burden than education alone. Linszen et al. (1996) found that
families with low expressed emotion (EE) can find training in communication and
problem-solving stressful, and experience it as criticism rather than helpful. This
may even trigger relapse rather than preventing it.
Yet, the vast majority of studies of FPE are indeed based on developing com-
munication and problem-solving skills, and these show benefits in terms of lower
relapse and re-hospitalization rates, improved social functioning, greater under-
standing of the illness, better adherence to treatment, reduced family burden, and
enhanced family functioning. Schooler et al. (1995) have pointed out that although
family interventions have been offered in various modes of presentation, they have
not differed significantly in outcomes. In a study of what participants themselves
find helpful, Budd and Hughes (1997) found that in addition to knowledge, the
positive impacts of emotional support, backup, and reassurance were even more
valued than behavioral techniques and skills acquisition. And recently, a valuable
tool has been developed by a team of researchers who have conducted numerous
studies of FPE in the Optimal Treatment Project in Europe. The Questionnaire of
122
UNRESOLVED ISSUES IN FAMILY PSYCHOEDUCATION 123
Family Functioning, has been validated as a standardized instrument to evaluate

family psychoeducational treatments (Roncone, Mazza, Ussurio, Pollice, Falloon,
et al., 2007).
Many questions remain, however, with respect to formats, presentations, dura-
tion, and content that will be optimally beneficial to most families and patients.
First, what do participants learn, and how do they apply it? An interesting study
questioned whether there were gender differences in knowledge acquisition dur-
ing a six-week FPE program. Over a 46-month study period, 115 caregivers (58%
female) participated, with a highly significant (p<.001) improvement in six specific
areas of knowledge. However, there were gender differences in types of knowledge
acquired. Females gained more knowledge overall and specifically in the areas of
signs and symptoms, recovery, and caregiver support. Males gained more knowledge
about risk factors, while gains in medication knowledge were equal (McWilliams,
Hill, Mannion, Kinsella, and O’Callaghan, 2007). Aside from the plurality of female
relatives in FPE sessions, are there other distinguishing characteristics of those
likely to attend? A study by Kronmuller et al. (2006) in Germany of FPE groups for
affective disorders found that relatives of male patients were more likely to attend,
and relatives of bipolar patients were more likely to attend than those with unipo-
lar depression. How do we deal with families who are unable to come, or to stay for
the full number of sessions? What resources are available for them?
Is psychoeducation best with individual patients and families, or in multi-
group format, with or without the presence of patients? Of considerable interest
is the study by Chien, Chan, and Thompson (2006) in Hong Kong, which found
the mutual support group, without the patient present, significantly superior to
psychoeducation and standard care. The McFarlane multi-family model is increas-
ingly being utilized in many parts of the world as the most cost-effective form of
FPE, its relative advantages indicated in Table 5.5 and Figure 5.1. It would seem that
regardless of culture, the mutual support offered by family groups may be benefi-
cial to patients even when they do not actively participate in the intervention.
Is a standardized, manualized approach most beneficial in real world settings,
or should format and content be adapted to different populations or to different
cultural groups? Do different family members, such as parents, siblings, spouses,
and adult children require approaches tailored to those relationships? Should con-
tent be adapted to different stages in the family life cycle, or to coinciding stages of
the illness? In a study of parental age and its relationship to family burden, Cook,
Lefley, Pickett, and Cohler (1994) found different concerns at different stages in
the family life cycle. They suggested that among younger patients, FPE might
focus more on managing difficult behaviors and substance abuse. For aging par-
ents, coping with anxieties about their own growing disabilities and planning for
patients’ future after the death of their caregivers may be topics of greatest need.
Indeed, research on aging parents of dependent adults with mental illness clearly
indicates that fears about the future of their loved ones and inadequate planning
are their most worrisome concern (Lefley and Hatfield, 1999; Hatfield and Lefley,
2000). Mental disorders are variable both in course and intensity, and there is cur-
rently a strong emphasis on recovery. In addition to life-cycle changes, is FPE more
effective if it is tailored to stages of recovery? (Lefley, 2007).
Do first-episode or early-intervention patients require a different approach?
Do different diagnoses require a different approach? Is specific content needed
for families of patients with co-occurring substance abuse, forensic problems,
or maladies such as AIDS? And is FPE in itself an adequate treatment, or does it
need to be offered within a larger package of evidence-based services for multi-
problem patients? And for chaotic families facing exceptional difficulties, are
psychoeducational techniques sufficient? Or can some benefit more from adding
multi-systems family therapy (Leff, 2005) or even from systemic family therapy
alone (Bressi et al., 2008) Finally, is time-limited FPE, even the research-based
minimal nine-month model, adequate for disorders that may last for many years
and pose unforeseen problems all of which cannot possibly be addressed? We have
presented evidence here of long-range positive effects in specific dimensions, but
there is also evidence that unanticipated aspects of family burden may clearly arise
over time. Carra, Montomoli, Clerici, and Cazzulo (2007) found that the benefits
of FPE declined after 24 months and that relatives again became more vulnerable
to objective burden. Is FPE an adequate answer, or should service systems make
available ongoing support to caregivers over the course of an illness?
What if the patient has no family? Should psychoeducation be extended to
those in loco parentis, to staff of residential centers or support persons in group
homes? Several reports in the literature indicate that the FPE model can be applied
successfully in non-familial residential settings (Drake and Osher, 1987). Ranz,
Horn, McFarlane, and Zito (1991) reported on a three-component FPE model
that was used to creating a calm, supportive low-demand environment of gradu-
ated expectations in a supervised residence. In contrast to their prior emphasis on
goal attainment, which is often stressful, staff members were trained in support-
ive interaction, a medication-monitoring program, and a behavioral approach to
problem-solving.
Does patient psychoeducation differ in its effects from psychoeducation that
includes their families? Whether alone or as supplemental to psychotherapy, psy-
choeducation has now been incorporated in the armamentarium of treatment
interventions for the clients themselves. As with families, it is offered in individ-
ual and group form. A recent meta-analysis of the research evaluated short- and
long-term efficacy of psychoeducation that is directed solely at the persons with
mental illness vis a vis psychoeducation that includes or is directed toward family
members. The variables of interest were relapse, symptom-reduction, knowledge,
medication adherence, and level of functioning. From an analysis of 199 studies,
19 comparisons of family-client or client-alone psychoeducation met the inclusion

criteria. The authors found that independent of treatment modality, psychoedu-
cation produced a medium post-treatment effect for relapse and a small effect for
knowledge, but no effect on symptoms, functioning, and medication adherence.
Effect sizes for relapse and re-hospitalization remained significant for 12 months
after treatment, but failed significance for longer follow-up periods. Interventions
that included families were more effective in reducing symptoms and preventing
relapse at 7- to 12-month follow-up, whereas effects for psychoeducation directed
at clients alone were not significant (Lincoln, Wilhelm, and Nestoriuc, 2007).
The importance of avoiding high EE is relatively salient in FPE, but the actual
role of high EE in promoting symptomatic behavior is still problematic. While this
is considered almost axiomatic, several findings in the literature question whether
EE is properly assessed, and if so, why there should be negative findings with
certain populations. For example, a study of the effects of integrated treatment,
which included Assertive Community Treatment, FPE, and social skills training,
on medication adherence found that patients living in families with low EE were
less adherent than patients living in families with high EE (Morken, Grawe, and
Widen, 2007). This is a surprising finding, unless the emphasis on avoiding high
EE makes some families fearful of insisting on patients taking their medications.
Another study of EE in families of persons with borderline personality disorder
(BPD) also suggests that responses of people with schizophrenia or bipolar disor-
der may differ significantly from those with BPD (Hooley and Hoffman, 1999). To
recapitulate, high EE in a family member is not only hostile criticism but emotional
over-involvement with the patient. People with schizophrenia and bipolar disor-
der have a greater tendency to relapse under these conditions. On the other hand,
people with BPD seem to respond positively to emotional over-involvement and
do better with these parental behaviors. The authors suggested that heightened
concern and over-protectiveness may be perceived as a kind of validation by peo-
ple with BPD. Another issue relates to the role of criticism and how it is assessed.
A study by Chambless and Steketee (1999) investigated the relationship of EE lev-
els to the outcomes of behavior therapy for obsessive–compulsive disorder (OCD)
and panic disorder with agoraphobia. Controlling all other EE variables, relatives’
hostility was related to six times the risk of a patient dropping out of therapy. How-
ever, contrary to expectations, non-hostile critical comments predicted signifi-
cantly better outcome. Van Noppen (2002) noted that “when delivered without
hostility toward the person as a whole, criticism may be a potential motivator for
OCD patients who use avoidance to neutralize anxiety . . . (It) might push patients
to face their fears, an important ingredient in exposure-based therapy” (p. 109).
Evidence-based FPE was designed primarily by professionals. There has been
subsequent input from families from time to time as models and manuals were
refined. Nevertheless, there are concerns that most models fail to address many
issues that are part of the caregiving experience. Glanville and Dixon (2005) have
noted that while FPE is expected to alleviate family burden, “the definitions and
operationalization of this experience into subjective and objective components
neglects the complexity and the multi-dimensional nature of the caregiving expe-
rience. In addition . . . family interventions have neglected to address the range of
issues and concerns that impact those caring for mentally ill relatives. These two
factors may be significant contributors to the under-utilization of family-based
services by relatives of individuals with schizophrenia” (p. 2005). They note that
the briefer models developed by NAMI, Journey of Hope, and Family to Family, do
address some of these issues. This leads to the question of the role of peer-led ver-
sus professional-led FPE. Although peer-led family education focuses on the needs
of families, the research by Chien, Chan, and Thompson (2006) indicated that
sometimes, FPE groups led by trained family members may be even more effective
than professional-led FPE groups in improving patients’ functioning.
Pollio, North, and Foster (1998) conducted an interesting study in which
participants in a psychoeducational workshop were asked to identify and rank
order the problems they faced in managing mental illness. A total of 355 items were
analyzed for content, and 11 problem categories were identified and ranked. They were
then compared with the content of multi-family psychoeducation programs. The
results suggested important distinctions, particularly in families’ greater emphasis on
negative symptoms and on family relationships. Items of concern to families included
patients’ denial and non-adherence to medications; disruptive and problem behav-
iors; interpersonal and social relationships; issues of dependence and independence;
mood disorders; and especially dealing with negative symptoms of schizophrenia.
Although many of these issues are discussed in FPE, there is differential empha-
sis on didactic components vis a vis dealing with here-and-now problems in fam-
ily relationships. This need was especially evident in a large study of caregiving
burden and burnout among relatives attending 19 FPE groups organized by nine
community mental health centers in the Netherlands. Their findings suggested that
“psychoeducation should concentrate on helping relatives cope with the strain
of the relationship with patient and on improving their ability to cope with the
patient’s behavior” (Cuijpers and Stam, 2000, p. 375).
Finally, does the patient remain the major focus of interest? Or is alleviation of
family burden and caregiver distress an equally legitimate target? It is clear that
most mental health systems are concerned only with their patients, and most men-
tal health professionals are trained to involve others only as in a secondary capac-
ity, as adjuncts to treatment. Our whole professional culture is built on the premise
that the patient is our central concern. Even the “identified patient” of family ther-
apy is the core for whom records are kept and third-party payers are billed.
We return to the original distinction between FPE and family education.
The patient’s progress and the overall well-being of the family are presumably
inter-related, but is it legitimate to target alleviation of relatives’ burden without

any effects on the patient’s illness? Evidence-based psychoeducational interven-
tions were studied in funded research projects, with rigorous designs and adequate
length of time. They had clear outcome measures such as relapse reduction and
symptomatic and functional improvement. Studies of interventions that alleviate
caregivers’ distress, typically limited to family education without the patient pres-
ent, are hampered by the typically briefer time frames and less rigorous sampling.
Many reviews have reported positive effects on families’ burden or distress, but
these are not always significant or consistent with positive outcome of patients
(Kazarian and Vanderheyden, 1992; Solomon, 1996). Johnson (1994) reviewed
six studies of family interventions that focused on relief of family burden. Three
studies had positive effects, and three studies reported no significant effects.
Szmuckler et al. (1996) conducted a controlled trial of six weekly home-based
counseling sessions for caregivers with the patient absent. A control group
received a one-hour educational session. There were no group differences in coping
style or negative aspects of caregiving. The authors concluded “It is easier to influ-
ence understanding of, and attitudes toward the patient than caregiver distress or
coping” (p. 154). Cuipers (1999) conducted a meta-analysis of 16 studies of fam-
ily interventions in which at least one outcome measure involved family burden.
The measure had to refer to an element that connoted subjective burden (e.g.,
psychological distress) or objective burden (e.g., provision of support). The analy-
sis revealed that family interventions can have considerable effects on relatives’
psychological distress, patient–family relations, and family functioning. However,
effects were modest at post-test. Large effects were found in only a subset of six
studies, the majority of which had 13 or more sessions. Cuipers concluded that
interventions with less than 10 sessions have little effects on relatives’ burden.
Cuijpers also concluded that “it is possible that greater effects can be expected
from interventions aimed at partners or relatives of patients with other illnesses
than schizophrenia” (pp. 282–283). This is a very important consideration. As I
have noted previously (Lefley, 2001), it is possible that the behaviors and disrup-
tive effects of schizophrenia are such that more than psychoeducation is needed
to alleviate family burden. Here, opportunities for respite, or adequate residential
facilities that permit the consumer to live outside the family home, may be equally
as or more important than psychoeducation. Additionally, opportunities for advo-
cacy that yields funding for better services or for needed research, antistigma
campaigns, police training, and other efforts targeting changes in public attitudes,
may be greater relievers of burden than simply participating in psychoeducational
groups.
In sum, this chapter has noted that despite some negative or unexpected
findings. The vast majority of studies of FPE have shown impressive effects. For
persons with mental illness, these are manifested in lower relapse and recidivism
rates, improved social functioning, greater understanding of their illness, and bet-
ter adherence to treatment. For their relatives, there is evidence of reductions in
family burden and distress, and improvements in family functioning.
Nevertheless, questions remain as to appropriate format and content, and opti-
mal duration. We have mentioned research on differences in male and female par-
ticipants with respect to areas of knowledge acquisition. Other studies have shown
differences in family attendance according to the sex or diagnosis of the patient.
We question how FPE can be delivered to the many families who cannot attend
FPE sessions, and how resources can be provided to them.
Other questions are posed with regard to patient present or absent, individual
or multi-family format, the importance of manualization, and cultural adaptation.
Should content be adapted to the age of the patient, to different kin relationships,
to different stages in the family life cycle, or different stages in the illness trajectory?
Optimal duration of FPE sessions, even as high as 48 months, cannot deal with unan-
ticipated aspects of family burden that arise during the course of the illness. Is FPE
sufficient without the availability of ongoing clinical support? Finally, with increas-
ing community residence outside of the family home, should FPE be targeted to
case managers or staff of residential facilities rather than to family caregivers?
The continuing salience of high EE as a basic feature of FPE is discussed, in light
of research that demonstrates diagnostic differences in response to emotional over-
involvement. Research also suggests possible dangers in families perceiving the EE
findings as a need to avoid non-hostile criticism or reasonable demands. We also dis-
cuss the complexity and multi-dimensional nature of the caregiving experience, and
the inability of FPE to address the range of problems that may be of greatest concern
to caregivers. Research suggests that families place greater emphasis on issues that
cannot be fully dealt with in FPE. These include patients’ denial and non-adherence
to medications, disruptive and problem behaviors, negative symptoms and moods,
family relationships, and handling issues of dependence and independence.
Finally, we raise the critical question of whether the patient alone should
remain the central concern of clinicians. When families develop specific psycho-
logical and practical needs generated by the illness of one of their members, what
is the responsibility of the patient’s clinician? Are families simply adjuncts to treat-
ment, or is there a need to alleviate their distress? This question may inform the
basic structure and content of psychoeducational interventions.
We also question whether FPE is sufficient to alleviate family burden with-
out adequate residential facilities for consumers to live outside the home and
a treatment system that serves their social as well as psychiatric, medical, and
rehabilitative needs. FPE is arguably just one element in an integrated system of
care. For families and patients, FPE alone is desirable but insufficient. It should
be accompanied by a forum for advocacy that can insure public and legislative
support for a high-level system of care.
13
FUT U RE T RE N D S I N F A M ILY
I N VOL V E ME N T I N TRE A TM ENT
The introduction of any innovation in care must be viewed within the context of barri-
ers, available resources, and incentives. In terms of acceptability, however, perhaps the
zeitgeist is the most important consideration. In this final chapter, we discuss future
trends in mental health care, particularly the roles of different stakeholder groups in
the mental health enterprise. These may affect the availability of evidence-based prac-
tices (EBPs), including family psychoeducation (FPE), in the service repertoire.
Most of this book focuses on mental health systems and policy in the United
States. In terms of government policy, the Community Support Program of the
Center for Mental Health Services (CMHS) was highly instrumental in aiding
the development of the family organization, National Alliance on Mental Illness
(NAMI), as well as the consumer movement, and offering grant inducements to
fund their multiple activities (Lefley, 2008). CMHS also helped provide funding to
individual state administrations for offering the NAMI “Family to Family” program.
More recently, the Department of Veterans Affairs (VA) sponsored a conference,
the Family Forum “to assess the state of the art regarding family psychoeducation
and to form a consensus regarding the next steps to increase family involvement.
The forum reached consensus on these issues: family psychoeducation treatment
models should be optimized by efforts to identity the factors mediating their suc-
cess in order to maximize dissemination, leadership support, training in family
psychoeducation models for managers and clinicians, and adequate resources are
necessary to successfully implement family psychoeducation” (Cohen et al., 2008,
p. 40). Because FPE may not be possible or appropriate for all families, the forum
developed a population-based family services heuristic for working with families
of persons with severe mental illness at different levels of intensity, tailored to
individual needs and circumstances.
129
Some other nations seem to have a more direct policy of helping families who care
for persons with disabilities, including means of communicating with and educating
caregivers (called carers in the United Kingdom and other English-speaking coun-
tries). In the United Kingdom, a government Web site aimed at professionals who
work with carers specifies required services and good practice in the interactions
of service providers and carers. The Carers Equal Opportunities Act of 2004 seeks,
“to give carers more choice and better opportunities to lead a more fulfilling life
by ensuring that carers receive information about their rights to an assessment . . .
Clause 2 ensures that those assessments now consider the carer’s wishes in relation
to leisure, training, and work activities. The third clause provides for cooperation
between local authorities and other public authorities, including housing, education,
transport, and health, in relation to the planning and provision of services that may
help support the carer in their caring role” (United Kingdom Department of Health.
The Carers Act, 2004. Retrieved 10-22-07). Under this Act, many authorities conduct
carer awareness sessions for hospital and frontline staff.
Building Family Skills Together is a two-year implementation and research proj-
ect that aims to implement family psychoeducation as part of routine care within
an Adult Mental Health Service in Melbourne, Australia (O’Hanlon, 2007). The
project focuses on incorporating behavioral family therapy (BFT) within the case
management provided by continuing care teams for people with serious mental
illness (SMI). The project has a significant research component to compare out-
comes for consumers and families receiving BFT with an appropriately matched
control group.
The World Fellowship for Schizophrenia and Allied Disorders (WFSAD) has
advocated an Integrated Mental Health Care Program based on the research
of Ian Falloon and the Optimal Treatment Project (Froggatt, Fadden, Johnson
Leggatt, and Shankar, 2007). Adapted for developing countries, this model could
well form the core of services in the industrialized world as well. The program has
the following steps:
1 Form a patient resource group, consisting of the mental health worker, family
and friends, and the patient.
2 The mental health worker will assess the symptoms and teach about the
disorder, explain the medication, help the family and patient cope with stress
by teaching coping skills; encourage them to find new ways of handing difficult
problems and to practice problem-solving; help with crises in their lives; and
teach them to reward each other.
3 The resource group will meet in regular one-hour sessions for about
10–12 weeks.
4 During this time, the participants would come to understand the mental
disorder, practice new skills, assess problems and goals of patients and family
FUTURE TRENDS IN FAMILY INVOLVEMENT IN TREATMENT 131
members, understand each other’s problems, strengths, and weaknesses, and

use all the resources they could find to develop a good treatment plan.
This book also offers recommendations on what service recipients can do

to affect national mental health policy, although this may vary from county to
country.
Among the trends shaping the future of mental health care in the United States
is the increasingly important role of mental health consumer advocates. Mental
Health, United States, 2004 (Center for Mental Health Services, 2006) reported
that from 1990 to 2002, the number of mental health consumer organizations
doubled to about 2100, with a growing influence on federal policy. The President’s
New Freedom Commission on Mental Health Report (2003) similarly indicated
that such groups will have a larger role in providing information and coordinat-
ing services for persons with mental illness. Daly (2007) notes that “Although
these organizations have many limitations and frequent funding shortfalls . . . they
may be the only entities in the community that interact with each of the disparate
federal, state, and local agencies and provide integrated services, supports, and
opportunities for recovery in one location” (p. 11). A spokesperson for the CMHS
is quoted as saying “The evolution of the consumer movement has a tremendous
impact on federal policy”(p. 11).
DIVERGENT INTEREST GROUPS

Consumer organizations, however, seem to be divided into those that merge self-
help and clinical treatment, with an emphasis on personal problem resolution and
growth, and others that merge self-help with political advocacy for a consumer role
in services (see Kaufman, 1999; Lefley, 2008; Rismiller and Rismiller, 2006). The
consumer movement, which is primarily composed of proponents of consumer
empowerment, seems to have a large number of highly talented and articulate indi-
viduals. It is assumed that all persons who identity as consumers, ex-patients, or
survivors have endured the agonies of mental disorder, social stigma, and demean-
ing experiences. Some have experienced forced treatment and unwanted hospital-
izations, others homelessness or even jail. They have all suffered and a substantial
number feel that the services they received were counter-therapeutic. Yet many
members are highly functional and not necessarily representative of an extremely
heterogeneous group of individuals identified as seriously mentally ill. The issue
of who represents whom may be compounded by the directive of the New Free-
dom Commission on Mental Health (2003) that places equal emphasis on two
approaches; consumer-driven recovery models and clinician-driven evidence-
based practices (EBPs). Most state initiatives plan to devote equal funding and
resources to each approach (Daly, 2007).
Sy Saeed, M.D., Chair of the Department of Psychiatric Medicine of East

Carolina University points out that “Some patient groups regard evidence-based
practices as almost a ‘right-wing conspiracy’ because they run counter to the
recovery model’s emphasis on phenomenological experiences and the autono-
mous rights of those in recovery” (Daly, 2007). Several “prosumers,” clinically-
trained mental health professionals who themselves have a history of mental
illness, have written cogently about the distinction between these two groups with
respect to the recovery vision (Frese, Stanley, Kress, and Vogel-Scibilia, 2001).
These authors state that advocacy for evidence-based practices, such as that
offered by NAMI, is essential for the more seriously disabled consumers. Advo-
cates who focus on consumer empowerment are those who are further along the
road to recovery. These consumers merit increasing autonomy and input into the
types of treatment and services they receive. The authors propose an integrative
theory that maximizes the virtues and minimizes the weaknesses of each model.
They also suggest that graduate and professional schools should be encouraged to
recruit consumers in recovery for their training programs, both as teachers and as
students. This way the programs will benefit from consumers’ experiential input
and provide a scientific background for consumers to become knowledgeable
mental health providers.
Among those consumers designated as seriously disabled are many who lack
insight, refuse to acknowledge their disorder, and reject treatment. Perhaps
because of this, there are paradoxical discrepancies in the value of psychoeduca-
tion for families, and for consumers. Peter Weiden, M.D., Director of the Psychosis
Program in the Department of Psychiatry, University of Illinois Medical Center in
Chicago, has pointed out that it is important to differentiate FPE from patient psy-
choeducation. He noted that among patients with families, FPE has demonstrably
improved medication adherence. However, with patients with schizophrenia, par-
ticularly those who reject the diagnosis, an educational program that explains the
disorder may have completely opposite effects. “We risk the problem of turning
off the very patient we want to help engage in treatment. That is, in my opinion,
one of the central problems to psychosocial interventions to improve adherence
in schizophrenia—the lack of insight and not acknowledging having schizophrenia
or whatever name for the psychiatric disorder is used is a real barrier to engaging
people into taking medication” (Weiden, 2007, p. 2). His research demonstrated
that cognitive–behavioral therapy,by addressing patients’ definition of their prob-
lems, exploring the effects of medications, and eschewing a biomedical explana-
tory model, provided greater treatment adherence than psychoeducation. On the
other hand, it has been pointed out that lack of insight does not prevent patients
from benefiting from illness management training (Gingerich and Mueser, 2005)
and that family psychoeducation has often provided explicit guidelines on how to
collaborate with patients who lack insight (Mueser and Glynn, 1999).
The future may thus be shaped by divergent views within two distinct groups:
(1) clinicians and consumers and (2) families and consumers. With respect to
implementing the New Freedom Commission report’s recommendations, Daly
(2007) notes that “Clinicians . . . are concerned that an emphasis on consumer-
directed care may result in patients and their families telling trained profession-
als how to provide care” (pp. 14–15). Yet the collective term “patients and their
families” may describe two very different constituencies. Families of persons with
severely disabling mental illnesses are likely to prefer professionals to administer
treatment with consumers playing a supportive rather than directive role. The
“patients” in this linked term may declaim their desire for autonomy, but would
probably have no desire or capability to run service systems. “Patients” in this con-
text are different from consumers. Because the definition of consumer is extremely
broad and inclusive of all levels of disability, persons active in the consumer move-
ment may or may not be current recipients of psychiatric services. They may not
even need professional interventions themselves. Their claim to expertise in
administering mental health services comes from prior experience, both with men-
tal illness and with the mental health system, but in most cases, it is idiosyncratic
and based on individual experience rather than standardized training. The issue
is rather different when it comes to Family-to-Family or Peer-to-Peer, programs
administered by people who have been trained with professional state-of-the-art
materials. But these are educational programs, not training for administrative or
clinical positions in mental health systems.
CONSUMERS IN THE MENTAL HEALTH WORKFORCE

The National Council for Community Behavioral Healthcare, an association of
1300 behavioral health-care providers, has published a manual for incorporat-
ing consumers in the mental health workforce (Townsend and Griffin, 2006).
They state that member organizations employ approximately 250,000 staff and
include clinics, community mental health centers, rehabilitation, clubhouse and
residential programs, and community hospitals. The manual was developed to
answer questions on how they can successfully recruit and integrate consumer
staff. Consumers are defined here as persons “diagnosed as having a mental illness
that impedes competitive employment opportunities and/or a history of inpatient
psychiatric admissions” (p. 2). The authors stated that although consumers are pri-
marily hired into specialized peer support positions, they serve in many different
roles at all different levels, including direct service, management, administration,
and board of directors. The manual, however, is oriented primarily toward direct
service and realistically addresses issues involved in this type of employment.
This manual makes a valiant attempt to view consumers both as regular staff
members and as staff members with special needs. On the premise that many
consumers receive disability benefits, jobs are frequently for reduced hours and
minimum pay scales that will not jeopardize receipt of federal entitlements. What
expectations and accommodations are appropriate for employees with a mental
disability? This issue is carefully discussed, together with a list of reported difficul-
ties that can affect their work. Problems may involve screening out environmen-
tal stimuli, sustaining concentration and stamina, handling time pressures and
multiple tasks, responding to negative feedback, and dealing with side effects of
psychotropic medications while working. These issues require understanding and
accommodation in terms of agency policies. Examples given are job restructuring
or reassignment, part-time or modified work schedules, or unpaid leave. And when
a consumer-employee doesn’t work out, there must be clear discharge policies that
do not exacerbate the illness.
The authors attempt to provide guidelines for the complicated employment of
persons with dual identities. There is a salutary sample code of ethics derived from
Hawaii and New Mexico manuals. Happily, the manual states that agencies should
not automatically prohibit “fraternization,” and that consumer-providers should
be able to maintain prior friendships while being clear about maintaining bound-
aries between work and socializing. Yet, agency policy may make it very difficult
to hire someone who is personal friends with, lives in the same facility, or shares
a therapist or support group with agency clients. In areas where the community
of mental health clients is relatively small, this may rule out potentially valuable
applicants. The parameters of “intimacy” and “boundaries” are exceptionally diffi-
cult to resolve for consumer employees. In fact, they are largely derived from older
psychodynamic treatment models and may require redefinition for the field as a
whole.
The vast area of issues covered by the manual suggests that it may be quite dif-
ficult to maintain a constant consumer presence in existing mental health systems.
Yet, it is quite unlikely that states would fund consumer-run mental health services
without a concurrent professionally-run system, nor would society stand for the
elimination of professionals from mental health care. Moreover, the research on
consumer-operated services shows great promise, but rarely the level of effective-
ness required for keeping people stabilized and out of hospitals.
CAN FAMILY PSYCHOEDUCATION LEAD TO

FAMILY ROLES IN TREATMENT?
Glynn, Cohen, Dixon, and Niv (2006) have discussed the potential impact of the
recovery movement on family interventions for schizophrenia. They note that at
a basic level, family interventions are entirely in accord with a recovery orienta-
tion because they are primarily community-focused and deal with the real world.
They also note that consumers’ participation in family psychoeducation has been
correlated with higher consumer scores in knowledge, empowerment, hope, and

optimism (although not in satisfaction with life). Nevertheless, these authors feel
that the interventions generally reflect older models of serious mental illness that
are grounded in assumptions of chronicity rather than of persons capable of taking
responsibility for their own recovery.
Despite this caveat, these authors state “There are aspects of existing family
interventions that resonate with a recovery outlook, including consumer-directed
goal setting and problem focus, educating consumers about their own illness, and
focusing on the whole person by assessing his or her quality of life and not sim-
ply symptom constellations and hospitalizations. Yet there is still work to do to
align family research and services with a recovery orientation, including working
toward recognition of different family constellations, adjusting for illness phases
and unique consumer characteristics, and broader operationalization of family
services” (p. 460). To this end, they recommend systems change that, with con-
sumer consent, promotes making family members a part of the treatment team.
Families’ participation in treatment seems to be a natural concomitant of fam-
ily psychoeducation. People who invest time and interest in psychoeducational
sessions have indicated their commitment to understanding the illness and to
helping their loved ones achieve some degree of recovery. On a practical level, fam-
ily members observe behavioral changes, responses to specific medications, and
prodromal cues of decompensation. They are familiar with diurnal rhythms that
affect mood and sleep patterns, and they can identify stressors. They know good
periods as well as bad. They know patients’ strengths and are usually eager to help
them develop their native talents and capabilities. They can provide valuable infor-
mation as well as receiving it. Their participation in treatment legitimates their
identity as a resource to the team and an ally of the patient.
CONFIDENTIALITY: THE PERVASIVE ISSUE

What happens with confidentiality when families are part of the treatment team?
It is unfortunate that in the mental health field in particular, the boundaries of
confidentiality have been most often defined by service providers rather than by
consumers. Clinicians and agencies can make unilateral decisions not to share
information that they define as confidential, without involving the individual in
the decision. They may also withhold information from the individuals themselves.
There are cases in which patients, denied access to their own psychiatric records,
have had to take legal action to retrieve them (see Lefley, 2000a, 2000b).
Confidentiality is an ethical imperative in most mental health services and
professional organizations. For example, the code of ethics of The National Asso-
ciation of Social Workers (NASW) emphasizes protecting and safeguarding infor-
mation and instructs social workers to receive client consent before fulfilling any
request for release of confidential information (Marshall and Solomon, 2004). In

mental health services, boundaries to information sharing have been especially
strict when applied to patients’ families. This is partially a carryover from the psy-
chotherapeutic model in which the patient’s private disclosures obviously can-
not and should not be shared with others. However, families have long claimed
that they do not want to know intimate details of patients’ thoughts and feelings.
But they do need to know something about the patients’ medications and their
anticipated behavioral effects, potential interactions and side effects, and how
to ensure medication adherence without angering their relatives or encroaching
on their autonomy. Much of this is taught in general terms in psychoeducational
interventions, but in individual treatment plans, medications and dosage levels
may change. Families want to be able to assess accountability and expected level
of performance at different points in the illness trajectory. When necessary, they
want to provide relevant information that may affect both medication regimens
and psychosocial treatments. Many of these issues require ongoing collaboration
with the treatment team, so family members should be involved.
Petrila and Sadoff (1992) have suggested that rigid confidentiality rules should
be carefully examined when they compromise the ability of families to function
effectively as caregivers. They also note that there may be legal liability when
providers fail to share critical information with families and this leads to adverse
consequences, citing various court cases to prove their point. From a recovery per-
spective, however, it is important to acknowledge that it is the patient, not the ser-
vice provider, who is the primary owner of confidentiality. In most cases, this is the
person who should make the decisions regarding its boundaries. Ideally, patients
should be encouraged to sign a release-of-information form designed specifically
for families, an example of which may be found in the Appendix. Another release
form example may be found in Solomon, Marshall, Manion, and Farmer (2002).
If the release form is presented at a time when the patient can provide informed
consent, and as an instrument that is likely to benefit their treatment, patients are
usually willing to authorize the release of relevant information to their families. In
the Pittsburgh area, for instance, where standard confidentiality procedures are
used in the public mental health system, 90% of patients approached in this man-
ner choose to sign the release form (Marsh and Lefley, 2003).
Marshall and Solomon (2004) have described a model intervention that clarified
confidentiality policies regarding release of information to families. Comparison of
an agency receiving this intervention with another agency using standard confiden-
tiality procedures indicated that the intervention produced greater contact, more
information and greater satisfaction from families. They suggested the model may
enhance collaboration between providers, consumers, and families.
If a release form has not been previously signed, it may be highly therapeutic
to have the patient work out the specifics of information-sharing in a conjoint
meeting of consumer, service provider, and family members. Here, the patient is
put in charge of confidentiality and makes decisions regarding specific areas to be
shared, such as diagnosis, names of medications, and medication regimens and
oversight. Such a meeting might also establish contractual commitments, such as
the patient’s degree of participation in household tasks and decision-making, or
the family’s contributions to transportation, educational expenses, and the like.
CONCLUSIONS
More than 20 years ago, The National Forum on Educating Mental Health Pro-
fessionals to Work with Families of the Long-Term Mentally Ill was convened by
National Institute of Mental Health (NIMH) and NAMI. The conference brought
together leading clinicians, researchers, and academicians with mental health pro-
fessionals who had experienced major mental illness in members of their own fam-
ilies. The object was to obtain consensus on a number of the following questions:
“Can we enable clinicians to view families as groups of individuals coping with
inordinate pain, stressors, and life disruptions, rather than as malfunctioning sys-
tems contributing to the patient’s psychopathology? Can we teach them to view
families as an asset rather than a liability, a resource rather than an antagonist
to the therapeutic process? Can we thus enable new generations of clinicians to
develop new models of working collaboratively with families, through provision
of professional expertise, consultation, and liaison with advocacy groups, train-
ing, and partnership in resource development? Can we teach them also to enhance
their own technologies by learning from families about human strengths, coping
strategies, and learned techniques for prevention of relapse? Finally, what are the
best ways of promoting institutional change and acceptance of new paradigms by
mental health professionals?” (Lefley, 1990, p. xviii).
The field has made some progress in recognizing the strengths of consumers
and families, in appreciating the value of collaborative efforts in advocacy, but
most of these questions have yet to be fully answered. FPE is mutually beneficial to
all parties involved. By creating more educated caregivers, psychoeducation helps
consumers and families get along, contributes to recovery, reduces relapse and
re-hospitalization, improves families’ well-being, and thereby benefits providers of
mental health services and society at large. Clinicians interacting with family and
consumer groups are also being educated themselves. They learn the lived experi-
ence of mental illness. They also learn about strengths, insights, coping strategies,
problem-solving, and potential for recovery.
Eventually, greater involvement of families may come about through public
demand. Exposure in the popular media of this new approach to long-term treat-
ment of major psychiatric disorders may be one channel. A long article in the Wall
Street Journal describes “family-based” or “family-focused” therapy, which differs
in premise and structure from traditional family therapy and “forges new territory
on privacy and doctor–patient confidentiality issues” (Bernstein, 2007, p. D1).
The article describes modes of family education and information-sharing, consent
forms that resolve confidentiality issues, and refers readers to popular diagnosis-
specific books by some of the psychoeducators as well as to NAMI’s Family-to-
Family classes.
In Italy, a group of Optimal Treatment Project (OTP) researchers trained by
Ian Falloon are still able to produce evidence of efficacy of FPE in numerous sites.
Yet they point out, “Family psychoeducational treatments are not easy to imple-
ment, because they are not compatible with the theoretical training of many
clinicians, are more complex to organize than standard medication and individual
psychotherapy, and the positive outcomes take a rather long time” (Roncone et al.,
2007). Yet, in the United States, assessments of implementation of FPE in Maine
and Illinois found that many clinicians seemed ready and motivated to try new
approaches. In agencies that implemented FPE, staff trainees were less inclined
to accept barriers or to rely on external inducements. “The successful agencies
were apparently those in which staff viewed fiscal and operational barriers as sig-
nificant, dealt with or neutralized those barriers, and went on to implement MFG”
(McFarlane, McNary, et al., 2001, p. 940).
It may be that FPE will become a part of standard practice in some mental
health systems, and remain absent from others. However, as more and more consum-
ers live their lives in community settings other than the family home, in their own
apartments, in program-affiliated residences, or assisted-living facilities, it may
become increasingly important to offer psychoeducation to residential staff, case
managers, and others involved in community re-entry. Several studies have looked
at applying the family psychoeducational model in non-familial living situations.
They involved lowering high EE in staff and teaching them the rudiments of crisis
intervention, recognizing prodromal cues of decompensation, or simple problem-
solving. The focus was on using FPE when there is no family (Drake and Osher,
1987). Ranz, Horen, McFarlane, and Zito (1991) described using three components
of the FPE model for staff training in a supervised residence. They offered training
in supportive interaction, medication-monitoring, and a behavioral approach to
problem-solving, with resident groups promoting each of these components.
The virtues of psychoeducation clearly go beyond family instruction. They
may well be incorporated in all professional curricula, in pre-service as well as
in-service training for all staff members working with persons with SMI. Because
psychoeducational interventions give far more indications of practicality and
acceptance by service recipients, and produce more salutary outcomes than
many forms of psychotherapy, psychoeducation needs to be accorded respect as a
therapeutic intervention. The current emphasis on incorporating EBPs in clinical
training is hopefully a step in that direction.
SUMMATION
This book is one of a series on evidence-based practices, and family psychoeduca-
tion (FPE) is now a well-accepted treatment for schizophrenia and other forms of
serious mental illness. We began with operational definitions of evidence-based
treatment (EBT) and evidence-based practices (EBP), and have defined FPE as
one EBP in an integrated system of care for serious mental illness (SMI). This term
is then defined, with data on its prevalence, and on the scope of family caregiving in
the lives of people with SMI.
We have noted various models of family interventions, with their basic theoret-
ical premises and expected outcomes. Among these, FPE is the only empirically-
supported family intervention for schizophrenia. It is increasingly being viewed as
an EBP for mood disorders and various disorders of children and adolescents, and
the book presents some of these programs and their supportive research findings.
When we consider the historical background of the emergence of FPE, it
appears that this powerful tool followed from now discredited theories of the
etiology of schizophrenia and the failure of their correlative therapies. Concurrent
with a proliferating body of research on the biological basis of major mental disor-
ders was the movement toward de-institutionalization. Community re-entry gen-
erated a need for families to resume roles as caregivers or support persons, despite
little knowledge of the illness or its treatments. These responsibilities formed
some of the sources of family stress, and there was an emergence of research on
family burden.
The expressed emotion (EE) research that ushered in the era of FPE viewed
families as exacerbating rather than precipitating the illness, and sought ways of
training families to alter behaviors that might trigger relapse. Along with this came
a recognition that families had their own needs for education, illness management,
problem-solving, and other coping strategies.
FPE is based on the theoretical premise of diathesis-stress in the etiology of
major mental illness. The basic notion is that underlying biological deficits in cer-
tain individuals make them exceptionally vulnerable to environmental stimuli
that are perceived as stressful. Family conflict, inappropriate expectations, or a
hostile or emotionally demanding environment may generate hyperarousal and
dysregulation, generating relapse. Data from a large number of meta-analyses
are presented, confirming that FPE reduces relapse and re-hospitalizations, and
improves social functioning, as well as family knowledge and well-being.
We then describe in detail a large number of the seminal FPE research programs
at various sites in the United States and the United Kingdom, with their format,
rationale, content, and research findings. These include both schizophrenia and
affective disorders. Long-term follow-up data are presented that confirm the pro-
longed effects of FPE in helping to prevent relapse.
Although FPE was developed for adults, the basic format is now being applied
in prodromal cases and with serious emotional disturbance of children and adoles-
cents. We describe FPE as a supplement to early interventions with young people
showing prodromal signs of developing mental illness, and its utilization with chil-
dren and adolescents. Applications with diverse diagnoses, including co-occurring
substance abuse, and with special populations are then described. International
and cross-cultural studies are presented, along with their research findings. We
discuss questions of uniformities and variations across ethnic and national bound-
aries, and issues of cultural adaptation.
Family education (FE) is a unique subcategory as an EBP. Family education
is briefer and tailored to needs of families rather than patients. The only studies
that satisfy most criteria of an EBP are of programs offered by advocacy groups
and delivered by well-trained family members, not professionals. Some other
professionally-led programs and models, including those lacking research data,
are presented because of their widespread usage over the span of many years by
thousands of families.
We have discussed training and training issues, and the problems of implement-
ing FPE in mental health services with a discussion of major barriers. An assess-
ment of unresolved issues involves the content of FPE and whether it should be
adapted to the family life cycle, different kinship roles, the trajectory of the illness,
specific diagnoses, and the like. In a critical assessment of the current state of the
mental health system, we look at future trends of families’ involvement in treat-
ment, consumers’ roles in mental health systems, and the relations of the con-
sumer and family movements. We see an important role for families in treatment
planning, which evokes the thorny issue of confidentiality and some suggestions as
to its resolution.
At this juncture, FPE is still widely used in Europe, especially in the Optimal
Treatment Project (OTP) program developed by Ian Falloon and his colleagues.
William McFarlane’s multi-family model is being applied in numerous sites in the
United States and Europe both for long-term patients and as prodromal inter-
ventions. FPE is still alive and well in China. Research continues on this now
well-validated model, and every article, book, and book chapter that deals with
schizophrenia lists FPE as a major evidence-based treatment. The data are there.
The struggle to translate research findings into standard practice goes on.
APPENDIX
RESOURCES FOR CAREGIVERS
BOOKS AND WORKBOOKS

Froggatt, D., Fadden G., Johnson D.L., Leggatt, M., and Shankar, R. (2007). Fami-
lies As partners in care: a guidebook for implementing family work. Toronto: World
Fellowship for Schizophrenia and Allied Disorders.
Glynn, S. and Backer, T.E. (1997). Involving families in mental health services:
Guidebook for families and consumers. Human Interaction Research Institute,
Los Angeles.
Gunderson, J.G. and Hoffman, P.D. (Eds.), Understanding and treating borderline
personality disorder: a guide for professionals and families. American Psychiatric
Publishing Inc., Washington.
Hatfield, A.B. (1990). Family education in mental illness. Guilford, New York.
Miklowitz, D.J. (2002). The bipolar disorder survival guide: what you and your family
need to know. Guilford, New York.
Morey, B. and Mueser, K.T. (2007). The family intervention guide to mental illness.
New Harbinger, Oakland, CA.
Mueser, K.T. and Gingerich, S.L. (2006). The complete family guide to schizophrenia:
helping your loved one get the most out of life. Guilford, New York.
Scheifler, P. (1998). Handling Anger, patient education workbook. Psychiatric Man-
agement Resources, San Diego, California.
Scheifler, P. (1998). Medication Management, patient education workbook. Psychiatric
Management Resources, San Diego, California.
Scheifler, P. (1998). Problem Solving, patient education workbook. Psychiatric
Management Resources, San Diego, California.
141
142 APPENDIX
Scheifler, P. (1997). Team solutions: helping yourself prevent relapse, patient

education workbook. Eli Lilly and Company.
Scheifler, P. and Mullaly, R. (1985). Medication Maze. Intuition Press.
Torrey, E.F. (2001). Surviving schizophrenia: a manual for families, consumers, and
providers. 4th edition. HarperCollins, New York.
Weiden, P.J., Scheifler, P.L., et al. (2001). Treatment resources for understanding
Schizophrenia. (TRUST) Pfizer.
Weiden, P., Diamond, R., Scheifler, P. and Ross, R. (May 1999). Breakthroughs
in Antipsychotic Medications: A Guide for Consumers, Families, and Clinicians.
WW Norton & Co, New York.
Wintersteen, R.T. (1987). Families educating families: a guide for family-run psychoed-
ucatinal workshops. University of Kansas School of Social Welfare, Lawrence KS.
VIDEO
Scheifler, P.L. (1987). When Mental Illness Strikes the Family: Developing Practical
Communication Skills. Videotape, Alliance for the Mentally Ill of Huntsville, 701
Andrew Jackson Way, Huntsville, AL 35801, (205) 534–2628.
Scheifler, P.L. (1997). Getting on the Road to Recovery. Videotape, Alliance for the
Mentally Ill of Huntsville, 701 Andrew Jackson Way, Huntsville, AL 35801, (205)
534–2628.
FOR ADOLESCENTS
Sherman, M.D. and Sherman, D.M. (2007). I'm Not Alone: A Teen's Guide to Living
with a Parent Who Has a Mental Illness. (Focuses on living with a parent who has
schizophrenia, bipolar disorder, or major depression.) Available only through
www.seedsofhopebooks.com or 1-800-901-3480.X118.
ORGANIZATIONAL RESOURCES FOR CAREGIVERS (INCLUDING THOSE IN

COUNTRIES THAT PARTICIPATED IN “KEEPING CARE COMPLETE,” AN
INTERNATIONAL SURVEY OF CAREGIVERS OF PERSONS WITH SERIOUS
MENTAL ILLNESS).
INTERNATIONAL LEVEL
World Federation for Mental Health (WFMH): http://www.wfmh.org
European Federation of Associations of Families of People with Mental Illness
(EUFAMI): http://www.eufami.org
Mental Health Europe (MHE): http://www.mhe-sme.org
APPENDIX 143
Australia
ARAFMI National Council: http://www.arafmiaustralia.asn.au/
Mental Illness Fellowship of Australia: http://www.schizophrenia.org.au
Mental Illness Fellowship of South Australia Inc.: http://mifsa.org
Mental Illness Fellowship of North Queensland: http://www.mifnq.org.au
Mental Illness Fellowship of Western Australia: http://www.mifwa.com
Mental Illness Fellowship Victoria Inc: http://www.mifellowship.org/
The Schizophrenia Fellowship of NSW Inc.: http://www.sfnsw.org.au
Schizophrenia Fellowship Queensland Inc: http://www.sfq.org.au/
Carers Australia: http://www.carersaustralia.com.au/
Germany
BApK: http://www.bapk.de/
France
Advocacy France: http://advocacyfrance.com
Italy
Associazione Aiutiamoli: http://www.aiutiamoli.it
Fondazione Mario Lugli - DI.A.PSI.GRA.: http://www.fondazionelugli.it
Associazione per la Riforma dell'Assistenza Psichiatrica (A.R.A.P.): http://www.
arap.it/dati/roma.html
UNASAM: http://www.unasam.it/index.php
Caffe' Dell'Arte: http://www.caffedellarte.net
Progetto Itaca: http://www.progettoitaca.org
Spain
La Confederación Española de Agrupaciones de Familiares y Personas con Enfer-
medad Mental (FEAFES): http://www.feafes.com/
Canada
The Mood Disorders Society of Canada: http://www.mooddisorderscanada.ca/
The Schizophrenia Society of Canda: http://www.schizophrenia.ca/
The World Fellowship for Schizophrenia and Allied Disorders: http://www.world-
schizophrenia.org/
The Centre for Addiction and Mental Health: http://www.camh.net/
United States
National Alliance on Mental Illness Family-to-Family Program: http://www.
nami.org
144 APPENDIX
Mental Health America (formerly National Mental Health Association) http://

www.mentalhealthamerica.net
Families for Depression Awareness (FDA) http://www.familyaware.org
American Health Care Association: http://www.acha.org
National Alliance for Caregiving: http://www.caregiving.org
Family Caregiver Alliance Web site: http://www.caregiver.org
National Family Caregivers Association: http://www.nfcacares.org/
Well Spouse Association: http://www.wellspouse.org
Depressive and Bipolar Support Alliance (DBSA) http://www.DBSAlliance.org
Source:World Federation for Mental Health.www.wfmh.org retrieved 8-20-07.
RESOURCES FOR EDUCATORS

Barrowclough, C. and Tarrier, N. (1992). Families of schizophrenic patients: Cognitive
behavioural Intervention. Chapman & Hall, London.
Corcoran, J. (2003). Clinical application of evidence-based family interventions.
Oxford University Press, New York.
Department of Health & Human Services, Substance Abuse and Mental Health
Services Administration, Center for Mental Health Services (2003). Family
psychoeducation implementation toolkit. Author.Rockville, MD.
Diamond, R. and Scheifler, P. (2007). Treatment Collaboration, In Evidence-based
mental health practice: A textbook (WW Norton Drake, R.E., Merrens, M.R, and
Lynde, D.W., 2005). Norton, New York.
Froggatt, D., Fadden, G., Johnson, D.L., Leggatt, M., and Shankar, R. (2007). Fami-
lies As partners in care: A guidebook for implementing family work. World Fellow-
ship for Schizophrenia and Allied Disorders, Toronto.
Glynn, S.M., Liberman, R.P., and Backer, T.E. (1997). Involving families in men-
tal health services: Competencies for mental health workers. Human Interaction
Research Institute, Northridge, CA.
Gunderson, J.G. and Hoffman, P.D. (Eds.) (2005). Understanding and treating
borderline personality disorder: A guide for professionals and families. American
Psychiatric Publishing Inc., Washington.
Hatfield, A.B. (1990). Family education in mental illness. Guilford, New York.
Hatfield, A. and Lefley, H.P. (Eds.) (1987). Families of the mentally ill: Coping and
adaptation. Guilford, New York.
Hatfield, A.B. and Lefley, H.P. (1993). Surviving mental illness: Stress, coping and
adaptation. Guilford, New York.
Kawanishi, Y. (2006). Families coping with mental illness: Stories from the U.S. and
Japan. Routledge, New York.
Hinden, B., Biebel, K., Nicholson, J., Henry, A., and Stier, L. (2002). Steps toward evi-
dence-based practices for parents with mental illness and their families. Unpublished
APPENDIX 145
paper prepared for the Center for Mental Health Services, SAMHSA. Center
for Mental Health Services Research, Department of Psychiatry, University of
Massachusetts Medical School, Amherst, MA.
Keitner, G.I. (1990). Depression and families: Impact and treatment. American
Psychiatric Press, Washington DC.
Kuipers, L., Leff, J., and Lam, D. (2002). Family work for schizophrenia: A practical
guide, 2nd edition. Gaskell, London.
Leff, Julian. (2005). Advanced Family Work for Schizophrenia: An Evidence-Based
Approach. Gaskell, London.
Lefley, H.P. (1996). Family caregiving in mental illness. Thousand Oaks, Sage,
California.
Lefley, H.P. and Johnson, D.L. (Eds.) (2002). Family interventions in mental illness:
International perspectives. Praeger, Westport CT.
Lefley, H.P. and Wasow, M. (Eds.) (1994). Helping families cope with serious mental
illness. Harwood Academic, Newark, NJ.
Marsh, D.T. (1992). Families and mental illness: New directions in professional practice.
Praeger, New York.
Marsh, D.T. (1998). Serious mental illness and the family: The practitioner’s guide.
Wiley, New York.
Marsh, D.T. (2001). A family-focused approach to serious mental illness: Empirically-
supported interventions. Professional Resource Press, Sarasota, FL.
Miklowitz, D.J. and Goldstein, M.J. (1997). Bipolar disorder: A family-focused treat-
ment approach. Guilford, New York.
Mueser, K.T. and Glynn, S.M. (1999). Behavioral family therapy for psychiatric disor-
ders, 2nd edition. New Harbinger, California.
Sartorius, N., Leff, J., Lopez-Ibor, J.J., Maj, M., and Okasha, A. (2005). Families and
mental disorders: From burden to empowerment. Wiley, Chichester, UK.
Schaub, A. (Ed.) (2002). New family interventions and associated research in psychiat-
ric disorders. Springer-Verlag, New York.
Smith, G., Gregory, K., and Higgs, A. (2007). An integrated approach to family work
for psychosis: A manual for family workers. Jessica Kingsely, London.
Thorsen, G-R.B., Gronnestad, T., and Oxnevad, A.L. (2006). Family and multi-family
work with psychosis. Routledge, New York.
CONTACTS FOR FAMILY EDUCATION COURSES AND MANUALS

(SEE CITATIONS BELOW FOR RESEARCH ARTICLES ON SPECIFIC
PROGRAMS IN REFERENCES LIST)
Training, Education, & Consultation (TEC) Family Center, Philadelphia, PA.
Mannion, E. (2000). Training manual for the implementation of family education in
the adult mental health system of Berks County, Pennsylvania. Philadelphia: University
146 APPENDIX
of Pennsylvania, Center for Mental Health Policy and Services Research. (see
Mannion and Solomon in References).
Journey of Hope (www.namilouisiana.org) (see Pickett-Schenk in References).
Family-to-Family www.NAMI.org (see Burland and Dixon in References).
Pacific Clinics Training Institute Christopher S. Amenson, Ph.D. Faculty Chair,
Pacific Clinics Institute (http://www.pacificclinics.org/traininginstitute.html)
(see Amenson in References).
Amenson, C.S. (1998). Family skills for relapse prevention. Pacific Clinics Insti-
tute, Pasadena, CA.
Pebbles in the Pond Larry S. Baker, M.Div. and Karen A. Landwehr. M.C.,
Directions in Education, Training & Consultation, P.O. Box 2478, Gig Harbor,
WA98335 (email: pondrippler@hotmail.com)
Baker, L.D. and Landwehr, K.A. (2007). Pebbles in the Pond: Achieving resil-
ience in mental health. Directions in Education, Training, & Consultation, Gig
Harbor, WA.
Partnerships for Recovery Patricia L. Scheifler MSW, PIP (email: plscheifler@
recovery.bz; Web site: www.recovery.bz).
Three R’s Rehabilitation Program (multidisplinary training for mental health
professionals) Dr. Mary D. Moller DNP, ARNP. (www.psychiatricwellness.
com; e-mail: mary@psychiatricwellness.com or marymoller@aol.com) (see
Moller in References).
Bryce Hospital, Alabama Program Cynthia Bisbee, Ph.D.Email: cbisbee@aol.com
Bisbee, C. (1991, 1995). Educating Patients and Families about Mental Illness:
A Practical Guide. 484 Farmington Lane, Pike Road, AL 36064.
Program for Parenting Well, University of Massachusetts Medical School
(www.parentingwell.org) (see Hinden et al. in References).
ONLINE LEARNING COURSES

Scheifler, P.L. (2004). Effective Educational Strategies, Essential Learning, www.
essentiallearning.com. This course helps mental health service providers enhance
their skills for conducting psychoeducation classes.
Scheifler, P.L. (2003). Effective Educational Strategies. University of Medicine
and Dentistry at New Jersey and Eli Lilly and Company, This video teaches mental
health service providers a set of skills for conducting psychoeducation classes.
APPENDIX 147
SAMPLE FORM FOR RELEASE OF INFORMATION TO FAMILIES
CONSENT TO RELEASE CONFIDENTIAL INFORMATION TO

FAMILY MEMBERS
n ame: ___________________ d o b : ___________________ s s # : ____________________
I hereby request and authorize (s pe ci fy pr o v i d e r ) ______________________________

to release information regarding me to the individual(s) listed below. I understand that
the purpose of this release is to improve communication between the above-named agency
and the individual(s) listed below and to assist in my treatment. Treatment began at this
agency on (specif y date )________________________.
* * * * *
I hereby request and authorize you to release the information indicated below to the
following individual(s) (spe ci fy nam e / r e l at i o ns hi p): ________________________
____________________________________________________________________________
You have my permission to release the following information:
___ Name of Therapist ___ Psychological Evaluation

___ Name of Case Manager ___ Scheduled Appointments
___ Treatment Programs(s) ___ Medication
___ Treatment Plan ___ Admission to/Discharge from Any Facility
___ Treatment Summary ___ Discharge Plans
___ Progress Notes
___ Other (SPECIFY): ________________________________________________________
I understand that this gives my consent for the release of information to the individual(s)
listed above. I also understand that this allows the above-mentioned individual(s) to pro-
vide information to my therapist or case manager. I may revoke this release at any time
except to the extent that the person who is to make the disclosure has already acted upon
it. Except as noted above, this release will expire on (s pe ci fy d a t e )____________ or
under the following circumstances:
______________________/_____________ _______________________/_____________
wi t n es s #1 da te pa tient dat e
______________________/_____________ _______________________/_____________
wi t n es s #2 da te pa rent/l egal gu ardi an dat e
(Second witness needed if patient is unable to give verbal consent.)
r e p r in t e d f r o m m a r s h & l efl ey , 20 0 3 .
RE F E RE N C E S
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N A ME I N D E X
A Benedict, P., 24
Bennett, C., 100, 101
Abdul-Adil, J., 65
Berglund, N., 89
Abramowitz, I.A., 112
Berkowitz, C.B., 70, 71
Adams, C., 30
Berkowitz, R., 35, 36
Agius, M., 61
Bernheim, K. F., xii, 10
Alford, J., 1
Bernstein, E., 138
Amador, X., 19
Biebel, K., 76, 77, 145
Amenson, C.S., xii, 101, 102, 108, 109,
Biegel, D.E., xiii, 22, 113
110, 114
Birchwood, M., xi, 36, 108
American Psychiatric Association, 2
Bisbee, C., xii, 5, 98, 103, 104, 113
Anderson, C.M., xi, 28, 35, 38, 39, 46, 70
Blitz, C.L., 21
Aschbrenner, K.A., 24
Bond, G.R., 49, 68
Asti, N., 90
Boyd, J.L., 28, 35, 37, 40, 44, 81, 82, 107, 110
Atkinson, J., 109
Bradley, G.M., 82
B Brekke, J.S., 3, 5
Brent, B.K., 113
Backer, T.E., 103, 109, 110
Bressi, C., 17, 124
Bae, S-W., 81
Buchkremer, G., 86
Baker, L.D., 103
Budd, R.J., 122
Baker, L.S., 102, 103
Buksti, A.S., 85, 122
Barham, P., 94
Burland, J., xii, 98, 99
Barker, P., 2, 68
Buteau, E., 73
Baronet, A.M., 22
Barrowclough, C., xi, 25, 26, 35, 36, 37, 38, 53, 54, C
69, 78, 113
Canive, J.M., xi, 86, 122
Bauml, J., xi, 6, 31, 53, 112
Caqueo-Urizar, A., 84
Beardslee, W.R., 76
Carra, G., 87, 88, 124
Bebbington, P., xi, 30, 36, 75
Cazzulo, C.L., 87, 88, 124
Bebbington, P.E., 22
Center for Mental Health Services, 131
Becker, S., 75
Cetinkaya Duman, Z., 90
Beels, C.C., 17, 18
Chambless, D.L., 1
Bellack, A.S., 45
167
168 NAME INDEX
Chambless, S., 125 Falloon, I.R.H., xi, 25, 28, 30, 31, 32, 35, 37, 40,
Chan, S.W.C., 96, 123, 126 44, 45, 48, 49, 50, 54, 58, 70, 81, 82, 107, 110,
Chen, F-P., 24 123, 150
Chien, W.T., 94, 96, 123, 126 Farber, L., 2
Chuang, Y-L., 29 Farberow, N.L., 17
Cimett, E., 48, 113 Farmer, J., 136
Cirillo, S., 17 Feldmann, R., 86
Clark, R., 68 Fiorillo, A., 30, 31, 54, 55, 57, 89, 107
Clark, R.E., 3 Fitzgerald, P., 60, 61
Clerici, M., 87, 88, 124 Fitzpatrick, E., 53
Cohen, A.N., 30, 129, 134 Fjell, A., 61
Cohen, J., 2 Fleiss, J.L., 2
Cohler, B.J., 123 Flory, J.D., 45
Conn, V., xii Foster, D.A., 126
Cook, J.A., xii, 100, 123 Fox, L., 68, 69, 78, 120
Corrigan, P., 20 Frese F.J., xiii, 132
Corrigan, P.W., 30, 96, 97 Frese, P., xiii
Cortez, R., 83 Friis, S., 61
Coursey, R.D., xii, 1, 112 Fristad, M.A., xi, 27, 61, 62, 63, 64, 66
Coverdale, J.H., 30, 31, 32 Frobose, T., 6
Crilly, J., 47 Froggatt, D., 110, 130
Cuijpers, P., 84, 122, 126, 127 Fromm-Reichmann, F., 15
Frongia, P., 17
D Fruzzetti, A.E., 71, 73
Daly, R., 131, 132, 133 Fujita, H., 91
Davis, R., 73, 74 Fukuzawa, K., 91
Delahanty, J., 99
Department of Health & Human Services. G
Substance Abuse and Mental Health Gabbard, Glen, O., 16
Services Administration., viii Gall, S.H., 109
DeRisi, W.J., 5 Ganguli, R., 52
Dixon, L., xi, xii, 5, 11, 30, 31, 32, 40, 48, 99, 106, Garcia, J.I.R., 83
112, 113, 114, 115, 116, 126 Garety, P., 30
Dixon, L.B., 134 Gavazzi, S.M., 27, 63
Doherty, W.J., 10 Geddes, J., 30
Domenici, P., 20 Geist, R., 73, 74
Draine, J., xii, 13, 96, 101 George, E.L., 52
Drake, R.E., 3, 49, 68, 69, 124, 138 Gingerich, S., 132
Duarte, E., 25, 82, 83 Gittelman, M., 92
Dunne, E., 106, 112, 114, 115, 116 Giulianio, A.J., 113
Dushay, R., 47 Glanville, D.N., 126
Dyck, D.G., 47, 75 Glei, D.A., 29
Glynn, S.M., xi, 30, 40, 44, 45, 96, 103, 109, 110,
E 132, 134
Eack, S.M., 52 Goldman, N., 29
Eberlein-Fries, x, 35 Goldstein, M.J., xi, 35, 40, 51, 56, 76,
Edman, A., 89 81, 96
Elliott, L., 109 Gonzalez, J., 65
Endicott, J., 2 Gorham, D., 82
Epstein, J., 2, 68 Goto, M., 74, 90
Evert, H., 3 Grawe, R.R., 125
Greenberg, J.S., 24, 78
F Greenley, J.R., 24
Fadden, G., xi, 27, 30, 35, 36, 75, 108, 130 Gregory, K., 145
NAME INDEX 169
Griffin, G., 133 Katz-Leavy, J., 76

Gronnestadm T., 145 Katzman, D.K., 73, 74
Guirguis, W.R., 18 Kaufmann, C.L., 131
Gunderson, J.G., 70, 71, 141 Kawashima, Y., 74
Gutierrez-Maldonado, J., 84 Kazarian, S.S., 127
Guy, S.M., 109 Kazdin, A.E., 1
Keith, S.J., 44
H Keitner, G.I., 52
Haas, G.L., 45 Kennedy, P., 20
Haddock, G., 37, 69, 78 Kennedy, T., 20
Harbin, H.T., 17 Kessler, R.C., 2
Harvey, C.A., 3 Kim, L., 65
Harvey, E.J., 24 King, L., 5
Hatfield, A., xii, 28 Kinsella, A., 123
Hatfield, A.B., 5, 28, 77, 78, 98, 124 Kissling, W., 85, 86, 112
Hayward, R., 94 Klingberg, S., 86
Hazel, N.A., 47 Knudsen, K.J., 24
He, Y., 92 Koeter, M.W.J., 22
Heinmaa, M., 73, 74 Kojima, T., 91
Held, T., 30, 31, 32 Koneru, V., 25, 82, 83
Henry, A., 145 Kopekin, H.S., 35, 96
Hepworth, J., 10 Kopelowicz, A., 83, 86
Herman, H., 24 Kornblith, S.J., 39
Hernandez, M.G., 83 Kottgen, C., 31
Higgs, A., 145 Kraemer, S., 6
Hill, S., 123 Krajewski, T., 17
Hinden, B., 145 Kress, K., 132
Hoffman, M., 99 Kronmuller, K-T., 123
Hoffman, P.D., 71, 73, 125, 141 Kuipers, E., 11, 22, 30
Hogarty, G.E., xi, 28, 29, 35, 38, 39, 46, 52, 70 Kuipers, L., xi, 26, 28, 35, 36, 75
Hollon, S.D., 1 Kulkarni, J., 60, 61
Hooley, J.M., 25, 125 Kung, W.W-M., 81
Hopper, K., xi, 76 Kuscu, M.K., 90
Horen, B.T., 124, 138 Kymalainen, J.A., 26
Hornby, H., 48, 113
Hornung, W.P., 86
L
Howells, J.G., 18 Laidlaw, T.M., 30, 31, 32
Hughes, I.C.T., 122 Lam, D., xi, 26, 28, 36
Lamb, H.R., 3
I Landwehr, K.A., 103
Inoue, S., 91 Laris, A., 100
Invernizzi, G., 17 Larsen, T.K., 61
Isett, K.R., 117 Larson, J.E., 20
Leff, J., xi, 3, 13, 17, 25, 26, 28, 35, 36, 37, 70,
J 110, 145
Jablensky, A., 94 Lefley, H.P., 2, 5, 8, 10, 12, 18, 25, 27, 28, 71, 78,
Jenkins, J., xi, 83 93, 109, 123, 124, 127, 129, 131, 135, 136,
Johannesen, J.O., 61 137, 145
Johansen, R., 109 Leggatt, M., 130
Johnson, D.L., xii, 12, 16, 23, 80, 85, 127, 130 Lehman, A., xi
Jordan, C., 80 Lehman, A.E., 31
Lehman, A.F., 3, 6, 54, 58
K Leon, A.C., 2
Karno, M., 83 Lewellen, A., 80
170 NAME INDEX
Li, J., 92 Mintz, 83

Li, S., 91, 92 Moller, M.D., xii, 102
Liberman, D.B., 43 Moltz, D.A., 52
Liberman, R.P., xi, 4, 5, 40, 43, 45, 83, 102, 103, Montero. I., xi, 87
108, 109, 110, 114 Montomoli, C., 87, 88, 124
Liem, J.H., 17 Morey, B., 141
Lincoln, T.M., 3, 125 Morken, G., 125
Linehan, M., 29, 72 Motlova, L., 88
Link, B., 47 Mueser, K.T., xi, 13, 40, 44, 45, 46, 49, 68, 69, 75,
Linszen, D., 30, 31, 86, 122 76, 78, 96, 120, 132, 141
Lippincott, R.C., 100, 101 Murphy, M.F., 102
Lobban, F., 113 Murphy, S., 61
Lopez, S.R., xi, 83, 86 Murray-Swank, A.B., 30, 114
Lopez-Ibor, J.J., 145 Murtha,C., 2, 68
Lucksted, A., 30, 32, 99
Lueboonthavatchai, P., 90
N
Lukens, E., 18, 30, 32, 46 Neiditch, E.R., 73
Nestoriuc, Y., 3, 125
M New Freedom Commission on Mental Health,
Mackinaw-Koons, B., 27, 63 108, 131
Magana, S.M., 83 Newmark, M., 52
Magliano, L., xi, 30, 31, 51, 54, 55, 56, 57, 89, 107 Nicholson, J.M., 76
Maj, M., 145 Niv, N., 30, 134
Manenti, S., 17 Noordsy, D.K., 69
Mannion, E., xii, 10, 13, 75, 76, 96, 101, 120, 136 Norell, D.M., 75
Mannion, N., 123 North, C.S., 126
Maranhao, T., 17
Marchal, J., 47 O
Mari, J., 30, 32 O’Hanlon, B., 162
Marsh, D.T., xii, 8, 10, 13, 18, 136 O’Callaghan, E., 123
Marshall, T., 3, 117, 118, 119, 136 Ogilvie, L.P., 109
Masanet, M., xi, 26, 54, 57 Okasha, A., 145
Mathiesen, S.G., 3, 5 Olfson, M., 2
Mazza, M., 123 Oliphant, E., 3
McCrary, K., 103 Orbach, G., 30
McDaniel, S.H., 10 Osher, F.C., 124, 138
McFarlane, W.R., viii, xi, 10, 11, 12, 13, 17, 18, 28, Ostman, M., 23
30, 32, 36, 40, 46, 47, 48, 54, 56, 58, 59, 60, Overall, J., 82
61, 66, 70, 82, 94, 106, 110, 113, 114, 115, 117, Oxnevad, A.L., 145
119, 124, 138, 140
McGill, C.W., 28, 35, 37, 40, 44, 81, 82, 107, 110
P
McGlashan, T.H., xi, 16, 21, 58, 59 Parabiaghi, A., 23
McGorry, P., xi, 59 Parker, G., 18
McHugo, G.J., 68, 119 Pavuluri M.N., 62
McKay, M., 65 Petrila, J.P., 136
McNary, S., 48, 113, 115, 138 Pharoah, F., 30, 32
McWilliams, S., 123 Phillips, M.R., xi, 92
Meisel, M., 10, xii, 13, 96, 101 Pickett, S., 123
Mercer-McFadden, C., 68 Pickett-Schenk, S., xii, 100, 101
Merinder, L.B., 84 Pilling, S., 30
Miklowitz, D.J., xi, 40, 51, 52, 56, 61, 62, 76, 81 Pitschel-Walz, G., xi, 6, 11, 31, 85, 86, 112
Milligan, S., 22 Pollice, R., 123
Mino, Y., 91 Pollio, D.E., 126
NAME INDEX 171
Porceddu, K., 53 Short, R.A., 75

Porcellana, M., 17 Simoneau, T.L., 52
Portera, L., 2 Smith, G., 145
Putnam, P., 22 Smith, M.J., 78
Smith, V.G., 83
Q Solomon, P., xii, 3, 10, 11, 13, 75, 76, 96, 101, 120,
Quintana, E., 65 127, 136
Someya, T., 74
R Song, L-Y., 113
Ramkisson, R., 61 Sorrentino, A.M., 17
Ran, M., 91, 92 Spaulding, W., 37
Randolph, J., xi, 40, 45 Spitzer, R.L., 2
Ranz, J.M., 124, 138 Spitzer, S.P., 17
Rapp, Charles, xii Stam, H., 126
Rathbone, J., 30, 32 Stanley J., 132
Reiss, D.J., 28, 35, 38, 39, 46 Steber, S-A., 120
Reker, T., 86 Steigman, P.J., 100, 101
Rentrop, M., 6 Steketee, G., 125
Reynolds, D., 17 Stephens, D., 73, 74
Richard, L., 52 Stephens, S., 20
Richards, J.A., 52 Stewart, B., 99
Rismiller, D.J., 131 Stier, L., 145
Rismiller, J.H., 131 Strachan, A., 36
Rodgers, M.L., 75 Strode, A.D., 75
Roncone, R., xi, 30, 31, 32, 51, 123, 138 Suddath, R.L., 52
Rothman, D.J., 3 Sullivan, H.S., 16
Ruffolo, M.C., 65 Szmukler, G.I., 23, 24, 127
Rummel-Kluge, x., 85, 86, 112
T
S Takahashi, A., 91
Sadoff, R.L., 136 Takano, A., 91
Safarjan, B., 1 Tarrier, N., xi, 35, 36, 37, 38, 53, 54
Sanford, M., 64, 65 Tasaki, S.I., 74
Sartorius, N., 145 Telles, C., 30, 31, 82, 83, 122
Schaub, A., 145 Teplin, L.A., 21
Scheifler, P.L., 104 Terkelsen, K.G., 3
Schene, A.H., 22, 24 Thavichachart, N., 90
Schmidt, C., 58, 59 Thomas, C.W., 109
Schooler, N.R., xi, 44, 45, 52, 56, 122 Thompson, D.R., 96, 123, 126
Schuman, M., 17 Thorsen, G.R.B., 61, 145
Sellwood, W., 37, 38, 54 Tomaras, V., 89
Selvini Palazzoli, M., 8, 17 Torrey, W.C., 112
Selvini, M., 17 Townsend, W., 133
Selye, H., 29, 32
Sengupta, A., 46
U
Severe, J.B., 44 Ucok, A., 90
Shah, S., 61 Uehara, T., 74
Shankar, R., 130 Ussurio, D., 123
Shaw, D., 17
Sheehan, D.V., 2 V
Sherman, M.D., 75 Vahlne, J.O., 89
Shi, J., 21 Van Noppen, B., 69, 70, 125
Shimodera, S., 91 Van Wijngaarden, B., 22
172 NAME INDEX
Van Wijngaarden, S., 22 Wolff, N., 21

Vanderheyden, D.A., 127 Wong, K-F., 94
Vandiver,V., 80 Wong, W., 30, 32
Vaughn, C., xi, 17, 25, 36 Wong, Z., 92
Vearnals, C.R., 26 Woolsey, K., 77
Veltro, F., 54 Worakul, P., 90
Vogel-Scibilia, S., 132 World Federation for Mental Health, 19, 20
Vorburger, M., 2, 68 Wynne, L.C., 10
W X
Walsh, F., 15 Xiang. M., xi, 91, 92
Wang, M., 92 Xiong, W., xi, 5, 93
Warner, R., 5
Wasow, M., xii, 145
Y
Wasserman, S., 25, 82, 83 Yamaguchi, H., 91
Weiden, P., 132 Yan. H., 92
Weinstein, M., 29 Young, M.E., 61, 62, 63, 64, 66
Weisman de Mamani, A.G., 26, 81
Weisman, A.G., xi, 25, 82, 83 Z
Widen, J.H., 125 Zaman, R., 61
Wilhelm, K., 3, 125 Zarate, R., 83
Williams, V.F., 76 Zhang, M., xi, 92, 93
Winefield, H.R., 24 Zhang, M.Y., 92
Wintersteen, R.T., xii Zito, J.M., 124, 138
Wittkowski, A., 38, 54
S U BJ E C T I N D E X
Note: f = figure; t = table
A Audiotapes, attitude change and, 108

Australia, research studies in, 60, 82, 130
ACT (assertive community treatment), 46, 125
Austria, psychiatric institutions in, 112
Adolescents, interventions for
antipsychotic medication, 58–59 B
bipolar disorder, 66–67
Behavioral family therapy (BFT)
family-focused treatment, 61–62
content, basic, 40t
major depressive disorder, 64–65, 67
efficacy, 44–46
multi-family interventions, 65–67
family burden and, 89
prodromal cases, 140
focus, 56
Advocacy, 127, 131–132
Meriden program, 81, 107–108, 110
Affective disorders, 51, 123 (see also Bipolar
research studies, 56, 130
disorder)
single-family, 87
African-American families, 80–81
vs. case management, 82
Alabama model, Bryce Hospital, 103–104
Behavior-management model, 42t–43t
American Psychological Association,
BFT. See Behavioral family therapy
Division, 12, 1
Biological deficits, 33
Anosognosia, 19
Bipolar disorder
Antipsychotic medication
in children/adolescents, 27, 61–64
adherence/compliance, 41, 85–86, 90, 125
expressed emotion and, 27, 125
for adolescents, 58–59
family focused treatment, 51–52, 61–62
dose reduction, 44–46, 56
individual family psychoeducation
for first-episode psychosis, 61
for, 63–64
for prodromal signs, 58–59, 66
spousal programs, 76
relapse/re-hospitalization and, 56
type 1, 2
for schizophrenia, 41
Borderline personality disorder (BPD)
ARIETE, Italy, 40
treatment model, 70
Arranged marriages, for mentally ill relatives, 92
expressed emotion and, 125
Asian-American families, 80–81
family psychoeducation programs, 70–73
Assertive community treatment (ACT), 46, 125
symptoms, 29
Attitude changes, from training programs,
BPRS (Brief Psychiatric Rating Scale), 82
108–109
Brain and spinal cord injury, traumatic, 74–75
173
174 SUBJECT INDEX
Brief family education programs. See Family Confidentiality issues, 120, 135–138
education programs Consensus-building, 118
Brief Psychiatric Rating Scale (BPRS), 82 Consumer-driven recovery models, 131
Bryce Hospital, Alabama model, 103–104 Consumers, mental health, 131–134
Building Family Skills Together, 130 Coping, 24, 48t
Cost-benefit analysis, 46–47, 91
C Criminal justice system, 19
Camberwell Family Interview (CFI), 25 Crisis family intervention (CFT), 46
Canada, early interventions in, 64–65 Criticism, OCD and, 125
Caregivers Cross-country differences, in family burden, 22
burden of (See Family burden) Culturally Informed Therapy for
gratification for, 24–25 Schizophrenia (CIT-S), 81–82
international study on, 19–20 Culture
older, programs for, 77–78 cross-cultural studies, 80–95, 140
one-day psychoeducational program expressed emotion and, 26
for, 91 family burden differences and, 22
preparation, need for, 4 sensitivity toward, 94
Caregiving Inventory, 24 Czech republic, research studies in, 88
Carers Equal Opportunities Act of 2004, 130
Cascade model, Meriden as, 1017–109
D
CBCL (Child Behavior Checklist), 65–66 Danish National Multicenter Schizophrenia
Center for Mental Health Services Project, 84–85
(CMHS), 2, 7 Dartmouth Medical School, 40
CFI (Camberwell Family Interview), 25 DBT (dialectical behavior therapy), 71–72
CFT (crisis family intervention), 46 DBT-FST (Dialectical behavior therapy family
Child Behavior Checklist (CBCL), 65–66 skills training), 71
Children, interventions research studies for De-institutionalization, 4
bipolar disorder, 27, 61–67 Delusions, 87
family-focused treatment, 61–62 Denmark, research studies in, 61, 66, 84–85, 122
mood disorders, general, 62–63 Department of Veteran Affairs, Family
prodromal cases, 59–60, 140 Forum, 129
severe emotional disturbance Developmental disorders, biological basis, 16
(SED), 65 Dialectical behavior therapy (DBT), 71–72
Chile, research studies in, 84 Dialectical behavior therapy family skills
China, family caregiving, 5 training (DBT-FST), 71
China, research studies in, xii, 91–95 Diathesis-stress model, 28, 41, 139
Chronic mental illness. See Serious mental Dissemination approaches, 114–116
illness Double-bind interactions, 17–18
CIT-S (Culturally Informed Therapy for Drugs. See Antipsychotic medication
Schizophrenia), 81–82 Dual disorders (mental illness & substance
Clinician-driven evidence-based practice, 131 abuse) family psychoeducation
Clinician-facilitated intervention (CFI), 76–77 programs, 68–69
CMHC (Community mental health Duration of therapy, 54–57, 90–91, 128
centers), 120 Dysregulation, emotional, 29, 33, 139
CMHS (Center for Mental Health Services), 2
Cochrane Data Base of Systematic
E
Reviews, 32–33 Early interventions, 58–67
Cognitive-behavioral therapy, 35, 50, 132 for adolescents (See Adolescents,
family interventions, 53–54 interventions for)
needs-based, 37–38 for children (See Children,
Columbia Unversity Study, 46 interventions for)
Community mental health centers for first-episode psychosis, 60–61
(CMHC), 120 for prodrome of psychosis, 58–59, 66, 140
SUBJECT INDEX 175
Eating disorders, 73–74 Falloon model. See Optimal Treatment Project

EBP (evidence-based practice), advocacy Family/families
for, 132 blaming, 21
EBPP (Evidence-Based Practices National burden of (See Family burden)
Demonstration Project), 117 categories of, 17
EBT. See Evidence-based treatment in China, social goals of, 92
Education, expressed emotion and, 26 of dually diagnosed patients, 68
EE. See Expressed emotion extrusion from community programs, 19
Efficacy of family psychoeducation, 4 involvement in therapy, 137–138
in clinical settings, 50–51 negative attitudes/beliefs about, as
for schizophrenia, 84–85 implementation barrier, 113
in schizophrenia, 84–85, 106–107 as objects of contempt by mental health
short-term vs. long-term, 124–125 professionals, 16–17
Elderly caregivers, programs for, 77–78 with schizophrenic member, 17
Ethnic minorities stressors (See Stressors)
caregiving and, 5 treatment roles for, 134–135
psychoeducation for, 80–84, 94 of veterans, 75
European Commission Study, 89, 94–95, 106–107 working with, competencies for clinical
Evidence-based practice (EBP) staff, 110–111
advocacy for, 132 Family-Aided Assertive Community
definition of, 1, 6 Treatment Outcome Trials (FACT), 46
family psychoeducation as, 5–7, 30–31 Family burden
implementation, 112, 119–121 as barrier to implementation, 113–114
operational definition, 139 international studies on, 89
as “right-wing conspiracy,” 132 male vs. female, 75
use of term, 7 mental illness diagnoses and, 23
vs. evidence-based treatment, 1 objective, 18–19, 27
Evidence-Based Practices National reduction of, 75, 84, 122, 127
Demonstration Project (EBPP), 117 international studies, 93–94
Evidence-based treatment (EBT). See also in schizophrenia, 92
specific types of evidence-based treatment research on, 22–25, 27
definition of, 1, 6 stress-appraisal coping and, 23–24
operational definition, 139 stressors and, 18–20, 21, 27
vs. evidence-based practice, 1 subjective, 18, 19, 27
Experience of Caregiving Inventory, 24 Family caregiving, scope of, 5
Expressed emotion (EE) Family Connections program (FC), 72
caregiver levels, 90 Family consultation, 9t, 10, 13
cross-cultural differences in, 25–26 Family-dynamic multi-family group
definition and measurement of, 25 (FDMFG), 46
high EE, 88–91 Family education
in prodromal patients, 59 characteristics of, 9t
reduction of levels, 87, 138 definition of, 96
relapse and, 29, 39, 53 internal evaluation of, 97
research, 25–27, 36, 139 manual for, 103–104
symptomatic behavior and, 125, 128 models, 96–105 (See also specific models)
in borderline personality disorder, 125 theoretical premises, 9t, 28
in clinical and residential staff 26 vs. family psychoeducation, 11–13, 104–105
low EE, 53, 86, 122 Family-focused treatment (FFT)
in Hispanic Families, 83 for bipolar disorder, 51–52
for children/adolescents, 61–62
F description, 51
FACT (Family-Aided Assertive Community long-term effects, 52–54
Treatment Outcome Trials), 46 for major affective disorders, 56–57
176 SUBJECT INDEX
Family-focused treatment (FFT) (cont.) Family psychoeducation and treatment

objectives, 51 program, 38–39
research findings, 51–52 Family psychosocial interventions, 6
for spouses, 76 Family roles in treatment, 134–135
Family Intervention for Dual Disorders Family Skills for Relapse Prevention, 102
(FIDD), 68–69, 78 Family support and advocacy group, 9t, 12
Family interventions. See also specific treatment Family therapy
models characteristics, 9t
common theme, 13–14 modalities, 8–10
for first-episode psychosis, 60–61 replacement paradigm, 17
limitations of, 126 for schizophrenia, 17
models (See also specific models) systemic, 17
description of, 9–12, 9t theoretical premises, 8, 9t, 13
merged, 12–14 traditional, 138
in non-Anglo-Saxon cultural context, 87–88 vs. multi-family group psychoeducation, for
in schizophrenia, 34 eating disorders, 73–74
stages, for prodromal patients, 59–60, 66 Family-to-Family Education program (FFEP),
variations, 12–13 98–99, 105, 126
Family involvement in treatment, 134–135 FC (Family Connections program), 72
Family Options, 77 FDMFG (Family-dynamic multi-family
Family psychoeducation group), 46
unresolved issues, 122–128 Fear of diagnosis, 59
Family psychoeducation (FPE) FFEP (Family-to-Family Education program),
characteristics of, 9t 98–99, 105, 126
core elements, 11 FFT. See Family-focused treatment
definition of, 139 FIDD (Family Intervention for Dual
effects of, 32, 33–34 Disorders), 68–69, 78
as evidence-based practice, 5–7, 30–31 Fidelity, 119
family roles in treatment and, 134–135 Fluphenazine, 44–45
historical background, 4–5, 139 FPE. See Family psychoeducation
illness-management techniques, 11 Fruzzetti/University of Nevada program, for
indications, 139 (See also under specific BPD, 71–72
diagnoses; specific populations) Future Planning for Relatives with Mental
with individual psychosocial treatment, vs. Illness program, 77–78
individual psychosocial treatment, 89–90 Future treatment directions, 129–140
length of interventions, 54–55 confidentiality and, 135–137
literature overviews, 31–34 consumers in mental health workforce,
long-term effects, 52–54 133–134
multi-family model (See Multi-family group) divergent interest groups and, 131–133
needs-based cognitive-behavioral, 37–38 family participation in, 134–135
for schizophrenia (See Schizophrenia,
family psychoeducation)
G
theoretical premises, 28, 139 GAAF (Global Assessment of
evidence-based practice, 30–31 Functioning), 2
literature overviews, 31–34 Gender differences, in knowledge
psychobiological response to acquisition, 123
stress, 29–30 Germany, research studies in, xii, 85,
toolkit, viii 89, 112, 123
unresolved issues, 122–128 Global Assessment of Functioning (GAF), 2
validation studies, 35 Gratification of caregiving, 24–25
vs. family education, 11, 13, 126–127 Greece, research studies in, 89–90
vs. patient psychoeducation, 132 Gunderson/McLean program, for borderline
vs. standard treatment, 4, 32, 54 personality disorder, 70–71
SUBJECT INDEX 177
H Involuntary Evaluation Questionnaire (IEQ),

22, 23
Health professionals, attitudinal barriers
Involuntary treatment and families, 19
for, 108
Italy, family caregiving, 5
Hispanic families, 81–83, 94
Italy, research studies in, xii, 87–89, 138 (see
Hoffman/New York Hospital Program, for
also Optimal Treatment Project)
borderline personality disorder, 71
HOMES (Home-Oriented Management of J
Early Psychosis), 60–61
Japan, research studies in, 74, 90–91
Homework, 45t
Journey of Hope (JOH), 97–101, 105, 126
Hong Kong, 96
Hospital access, 19 K
Hospitalization. See Relapse/re-hospitalization
Keeping Care Complete, 19–20
Hostile criticism. See Expressed emotion
Hyperarousal, 29, 33, 139 L
I Latin America, research studies in, 84
Latino families, skills training vs. customary
Iatrogenic stressors, 21, 27
care, 83–84
ICM (intensive case management), 65–66
Length/duration of family intervention, 54–57,
IEQ (Involuntary Evaluation Questionnaire),
90–91, 128
22, 23
Literature reviews, methodology, 31–34
IFP (individual family psychoeducation), for
London Institute of Psychiatry, 26, 36, 37, 55
childhood bipolar disorder, 63–64
Illinois Family Psychoeducation M
Dissemination Project, 115–116
Maine Family Support Action Initiatives
Illness-management techniques, in family
(MFSAI), 115–116
psychoeducation, 11
Maine Medical Center (see also McFarlane,
Immigrants, psychoeducation programs
William) 46
for, 82
Major affective disorders
Implementation of FPE in services, 112–121
bipolar disorder (See Bipolar disorder)
application issues, 117–118
family interventions (See Family Focused
barriers, 113–114
Treatment)
Building Family Skills Together, 130
incidence/prevalence, 2
fidelity issues, 117–118
symptoms, 29
international, 112
McLean Hospital program, for borderline
major issues, 118–119
personality disorder, 70–71
research findings, 114–116
Medicaid, 119
suggested solutions, 119–121
Medication. See Antipsychotic
training and, 108
medication
Individual family psychoeducation (IFP), for
Mental Health America
childhood bipolar disorder, 63–64, 67
(MHA), 5, 7, 12, 20
Institute of Psychiatry, London. See London
Mental health consumer organizations, 131
Institute of Psychiatry
Mental health consumers- persons with
Insurance, 119
SMI-SED
Integrated Mental Health Care Program,
adolescents (See Adolescents)
130–131
children (See Children)
Intensive case management (ICM), 65–66
families of (See Family/families)
Intensive Family Support Services, New
incarceration of, 21
Jersey, 10
negative symptoms, 23
Interest groups, divergent, 131–133
number living with family, 3
International collaborative group. See Optimal
rejection of medication, 23
Treatment Project
with substance abuse, family
International studies 80–95. See also under
psychoeducation programs, 68–69
specific countries
178 SUBJECT INDEX
Mental health professionals for first-episode psychosis, 61, 66

attitudinal changes from training, 108–109 implementation, 36, 116
competencies for family interventions, for prodromal patients, 59, 66
109–110 for spinal cord injury, 74–75
hostility/dislike of families, 16–18 for traumatic brain injury, 74–75
theoretical assumptions of, 16–18 Munich Psychosis Information Project,
Mental health services system (see also 53, 57, 87
Implementation of FPE)
parity with medical health care, 20
N
underfunding of, 20–21 NAMI. See National Alliance on Mental Illness
Meriden program, West Midlands Family NASW (National Association of Social
Program, UK, 81, 107–108, 110 Workers), 135–136
Mexican-American families, psychoeducation National Alliance on Mental Illness (NAMI)
for, 80–83 Curriculum and Training Committee, 98
MFBT (multi-family behavioral family Education, Training, & Peer Support
treatment), for OCD, 69–70 Center, xii
MFG (multi-family group). See Multi-family Family-to-Family Education program,
group 98–99, 105, 126
MFSAI (Maine Family Support Action Future Planning for Relatives with Mental
Initiatives), 115–116 Illness program, 77–78
MHA (Mental Health America), 12, 20 historical perspective, 4–5
Milan school, 8, 17 Journey of Hope program, 97–101, 105, 126
Modeling, by therapist, 45t parity of mental health care with medical
Model research programs, 35–57. See also health care, 20
specific model research programs National Association of Social Workers
behavioral family therapy, 40, 43 (NASW), 135–136
in California, 35 National Comorbidity Survey, 2
cognitive-behavioral, 35 National Council for Community Behavioral
family psychoeducation and treatment Healthcare, 133–134
program, 38–39 National Forum on Educating Mental Health
in London, 35 Professionals to Work with Families of
for major affective disorders, 51–57 the Long-Term Mentally Ill (NAMI-
in Pittsburgh, 35 NIMH) 137
research design and findings, 39, 43–44 National Instutute of Mental Health (NIMH),
for schizophrenia 44, 137
behavioral family therapy, 40, 42t–43t, NIMH Multi-site study, 56
43–46, 45t National Mental Health Association (see
family psychoeducation (See Mental Health America)
Schizophrenia, family Netherlands, research studies in, 86, 122, 126
psychoeducation) New Freedom Commission on Mental Health,
Mood disorders. See Major affective disorders 131, 133
Mothering practices, childhood psychiatric New Hampshire FPE implementation in,
disorders and, 15–16 117–118
Multi-family behavioral family treatment New York State Family Psychoeducation
(MFBT), for OCD, 69–70 Study, 45, 56
Multi-family group (MFG) New York State Family Support and
advantages of, 48–49, 48t, 49f Demonstration Project, 114–115
for borderline personality disorder, 71 New York State Psychiatric Institute, 46
for children/adolescents, 62–67 New York Training and Dissemination
comparison with other therapies, Program, 106
46–48, 56, 114 NIMH study, multi-site, 56
cost-effectiveness, 123 Non-billable services, 120
for dual diagnosis, 69 Non-familial resident settings, 124
SUBJECT INDEX 179
Norway, research studies in, 61, 66 Prevention and Recovery of First-Episode

Psychosis (PREP), 60
O Prodrome of psychosis, 58–59, 66, 140
Obsessive-compulsive disorder (OCD), Prognosis, for major psychiatric disorders, 3
69–70, 125 “Pseudo-self” vs. “solid-self,” 17
Ohio State University Psychoeducation PSFT (psychoeducational single-family
Program, for Childhood Mood Disorders, treatment), 46
62–63 Psychiatric patient education
Ohio Training and Dissemination manual, 103–104
Program, 106 Psychoanalysis, historical errors of, 15–16
Older caregivers, 77 Psychoeducational support group, 9t, 12, 13
Omega-3 fatty acids, 59 Psychoeducation groups, specialized, 75–79
Optimal Treatment Project (OTP), xi, 40, Psychopathology, level, caregiver gratification
48–51, 138 (see also, Falloon, Ian) and, 24–25
efficacy, 56, 138 Psychosis, first-episode, 60–61
implementation, 140 Psychosocial interventions, for prodromal
Questionnaire of Family Functioning, schizophrenia, 58–59, 66
122–123 Psychotic disorders, biological basis, 16
research findings, 50–51 Psychotropic medication. See Antipsychotic
steps in, 130–131 medication
Outcome PTSD (posttraumatic stress disorder), 75
long-term effects, 52–54 Public Law 102–321, 2
measures (See Relapse/re-hospitalization)
therapist competency and, 108
Q
Over-involvement. See Expressed emotion Questionnaire of Family Functioning, 122–123
P R
Pacific Clinics Institute model, xii, 101–102 RADS (Reynolds Adolescent Depression
Panic disorder, with agoraphobia, 125 Scale), 64–65
Parents RAINBOW program, 62
effects of poor parenting skills, 15–16 Recovery
young parents with mental illness, 76–77 consumers in the workforce, 133–134
Parents of Adult Children of San Mateo evidence-based OTP approach, 50
County, 4 expressed emotion and, 26
Partnership for Recovery, 104 family interventions, concordance with
Patient Outcomes Research Team (PORT), 6, recovery, 134–135
54–55, 116 Recruitment of prodromal patients, 59
Pebbles in the Pond: Achieving Resilience in Mental "Refrigerator mother," 16
Health, 102–103 Rehearsal, 45t
Peer-led FPE, vs. professional-led, 126 Reimbursement issues, 114, 118, 119
PIER (Portland Identification and Early Relapse/re-hospitalization
Referral), 58, 66, 106 antipsychotic medication and, 44–46, 56
Pittsburgh program, 55–56 expressed emotion and, 25
PMFG (psychoeducational multi-family family psychoeducation and, 32, 57,
group), 46 127–128, 139
PORT (Patient Outcomes Research Team), inclusion of key family members and, 31
6, 54–55, 116 international studies, 86–87, 90, 93–94
Portland Identification and Early Referral long-term effects and, 52–54
(PIER), 58, 66, 106 in schizophrenia, 49f, 53–54, 88, 92
Portugal, research studies in, 89 short-term, 96
Positive reinforcement, 45t multi-family groups and, 45–46
Posttraumatic stress disorder (PTSD), 75 single-family approaches and, 45, 87
Pre-morbid personality, grieving loss of, 19 Release-of-information form, 136
180 SUBJECT INDEX
Reynolds Adolescent Depression Scale “Schizophrenogenic mother,” 15–16

(RADS), 64–65 SEE (Support, Empowerment, and Education
group), 65–66
S Serious mental illness (SMI), 130. See also
S.A.F.E. (Support and Family Education), 75 Major affective disorders; Schizophrenia
Salford Family Intervention Project, 53, 57 definition of, 1–2
SAMHSA/CMHS, viii, 77 (see Substance Abuse incidence/prevalence, 2, 68
and Mental Health Services in young parents with children, 76–77
Administration/Center for Mental Health Service system deficits, as family stressor,
Services 18–19
Schizophrenia. See also Optimal treatment Shaping, 45t
program Single-family treatments, for dual
antipsychotic medication, dose reduction, diagnosis, 69
44–46 Skills training therapy, vs. customary
behavioral family therapy, 82, 87–88 care, 83–84
behavior-management model, 42–43 SMI. See Serious mental illness
caregivers, one-day psychoeducational Societal stressors, 20–21, 27
program for, 91 Spain, research studies in, 86–87, 89, 122
case management, 82 Spanish-language programs, 99, 122
developmental theories, of family Spinal cord injury, 74–75
culpability, 27 Spouses of persons with mental illness,
family burden, 127 programs for, 75–76
family education, 41 STEP-D (Systematic Treatment Enhancement
family psychoeducation, 2–4, 36–37, 40, 90, Program), 52
92, 132 Stigma, generalization to relatives, 20
disability levels and, 92 Stress, psychobiological responses, 29–30
efficacy of, 84–85, 106–107 Stress-buffering hypothesis, 29
with individual psychosocial treatment, Stressors for families
89–90 environmental, 29
multi-family group, 46–48 iatrogenic, 21, 27
needs-based cognitive-behavioral, 37–38 responses to, 33
Pittsburg program, 38–39 situational, 18–20, 27
relapse/re-hospitalization and, 49f, 53–54, societal, 20–21, 27
88, 92 Stress theory, 28
family therapy models, 8 Substance abuse, with mental illness, 68–69
in Hispanics families, 83 Support, Empowerment, and Education group
incidence/prevalence, 2 (SEE), 65–66
inpatient care, 2–3 Support and Family Education (S.A.F.E.), 75
pathogenesis, 15–16 Sweden, research studies in, 89
prodromal signs, 58 Switzerland, FPE implementation in, 112
recent-onset, individual psychosocial Systematic Treatment Enhancement Program
intervention vs. behavioral family (STEP-D), 52
therapy, 86
spousal programs, 75–76
T
with substance abuse, 69 TBI (traumatic brain injury), 74–75
symptoms, 29 TEC (Training, Education and Consultation
treatment strategies, 5, 44–46 Center), 10, 77, 101, 105
Schizophrenia: A Family Education Curriculum, Thailand, 90
101–102 Therapists
Schizophrenia Patient Outcomes Research behavior of, 45, 45t
Team (PORT), vi, 5–6, 7, 54–55, 116 competencies, 108
Schizophrenia-spectrum disorders, 88, 96 double messages of, 17–18
Schizophrenic family, 17 Thinking-Feeling-Doing technique, 63
SUBJECT INDEX 181
Third-party reimbursement problems, 19 dual diagnosis programs, 78

Thought disorders, 87 European Commission Study, 89
Three R’s Psychiatric Wellness Rehabilitation family psychoeducation programs, for
Program, 102 schizophrenia with substance abuse, 69
Time constraints, as implementation London Institute of Psychiatry, 36, 37, 55
barrier, 113 programs for Black and Asian families, 81
TIPS (Treatment and Intervention in United States
Psychosis), 61, 66 FPE implementation in, 117–118
Training, 106–111, 118, 140. See also specific research studies in, 55–56
training programs University of Birmingham, UK, 36
attitudinal changes from, 108–109 University of California at Los Angeles,
for clinical settings, 107 40, 43
competencies, 109–110 University of Manchester UK, 36, 37
components, 138 University of Pittsburgh, 38
content, 110–111 University of Southern California, 40
European Commission Training Study,
106–107
V
in dialectical behavior therapy, 71 Veterans’ families, 75
implementation and, 120 Videotaping, of family interventions, 106, 108
in Europe and U.S. 110 Vietnamese-speaking families, programs
in Meriden Project, UK, 107 for, 82
multi-family vs. single-family, 106
Training, Education and Consultation Center
W
(TEC), 10, 77, 101, 105 Western Psychiatric Institute and
Traumatic brain injury (TBI), 74–75 Clinic, 38, 44
Treatment and Intervention in Psychosis “Working with Families,” Los Angeles Mental
(TIPS), 61, 66 Health Department, 108–109
Treatment compliance, 90, 91–92 World Fellowship for Schizophrenia and
Treatment Strategies in Schizophrenia Allied Disorders (WFSAD), xii. 110, 130
project, 45–46
Turkey, research studies in, 90
Z
Zenkaren Family Organization, Japan, 90
U
United Kingdom
Carers Equal Opportunities Act, 130

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f a m i l y p s y ch o ed u ca t i o n fo r

David E. Biegel, Ph.D.

Family Psychoeducation for Serious Mental Illness

The Evidence-Based Practices Series is published in collaboration with

oxford new york

Copyright © 2009 by Oxford University Press, Inc.

Published by Oxford University Press, Inc.

Oxford is a registered trademark of Oxford University Press

All rights reserved. No part of this publication may be reproduced,

Library of Congress Cataloging-in-Publication Data

Printed in the United States of America

When I was asked to contribute a book to a series on evidence-based practices in

support-group discussions regarding malfunctioning mental-health systems,

In her continuing overviews of family psychoeducation and her controlled stud-

3 f am i l i e s , s ch i z o phrenia, and o t her majo r disor de r s 15

4 the ore t i c a l p remis es and res earc h o verv ie ws 28

7 d i v e rs e di a g n os es and s pec ial po pul at io n s 68

8 i nt e r n a t i on a l a nd c ro s s -c ult ural s t ud ies 80

10 tr a i n i n g a n d t raining is s ues 106

12 un re s ol v e d i s s ues in family ps yc ho ed uc ation 122

13 f ut u re t r e n ds in famil y invo lvement in tr e atme n t 129

Appendix 141 References 149 Indexes 167

This book focuses on an evidence-based approach to working with families of

with these diagnoses, and FPE is now a well-established psychosocial treatment

contributor to psychopathology, but as ongoing support system for mental disor-

“After a 45-minute lecture-discussion, I organized the families and their patients

THE SCOPE OF FAMILY CAREGIVING

FAMILY PSYCHOEDUCATION AS EVIDENCE-BASED PRACTICE

Research Team (PORT) project to develop and disseminate recommendations

Participants Modality Premise Outcomes

Family psychoeducation is one of the major evidence-based treatments (EBTs)

with attendant research on participants’ knowledge and well-being, without regard

VARIATIONS AND MERGED MODELS OF FAMILY INTERVENTIONS

include: patient present or absent; single family versus multi-family; time-limited

Family psychoeducation (FPE) is a long-overdue, well-accepted therapeutic

Discussing concepts of the pathogenesis of schizophrenia, McGlashan (1989)

HOSTILITY AND DOUBLE BINDS FROM MENTAL HEALTH PROFESSIONALS

authoritarians, stoics, poltroons, paciﬁsts, stumblers, and do-nothings” (Spitzer

SOURCES OF STRESS AND THE FAMILY BURDEN RESEARCH

Substantially disrupted caregivers’ lives 61%

Eﬀective treatment led to positive outcomes such as re-engaging with family

THE RESEARCH ON FAMILY BURDEN

THE EXPRESSED EMOTION RESEARCH: THE BEGINNING OF CHANGE

assessed on a ﬁve-minute speech sample. High EE levels may also be triggered by

THEORETICAL PREMISES OF FAMILY PSYCHOEDUCATION AND

PSYCHOBIOLOGICAL RESPONSE TO STRESS

make an adaptive response to complex, vague, multiple, or emotionally charged

FAMILY PSYCHOEDUCATION AS EVIDENCE-BASED PRACTICE:

METHODOLOGY OF OVERVIEWS OF THE LITERATURE

independent raters; blind subjects; standardized measures of clinical outcome,

quasi-randomized studies that focused primarily on families of people with

Together with the eﬀects of psychotropic medications in regulating attention and

The studies that validated family psychoeducation (FPE) as evidence-based

the emergence of McFarlane’s (2002) multi-family model which is now being

FAMILY PSYCHOEDUCATION (FPE)

reduced face-to-face contact, appeared to be associated with lower relapse rate. At

NEEDS-BASED COGNITIVE–BEHAVIORAL FPE

FAMILY PSYCHOEDUCATION AND TREATMENT PROGRAM (FPTP)

THE RESEARCH DESIGN AND FINDINGS

BEHAVIORAL FAMILY THERAPY (BFT)

TABLE 5.1 PSYCHOEDUCATIONAL INTERVENTIONS FOR FAMILIES (SCHIZOPHRENIA)

TABLE 5.2 THE CONTENT OF FAMILY EDUCATION ABOUT SCHIZOPHRENIA

importance of drug compliance to forestall relapse