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Family Interventions for Schizophrenia and the

Psychoses: A Review
WILLIAM R. MCFARLANE*

To read this article in Chinese, please see the article’s Supporting Information on Wiley Online Library
(wileyonlinelibrary.com/journal/famp).

Family psychoeducation as a treatment for schizophrenia was developed 40 years ago


almost simultaneously and independently by investigators who at the time were not family
therapists. Although the original goal was to decrease high expressed emotion as a means
of preventing relapse, later variations have gone beyond to focus on social and role func-
tioning and family well-being. Explicitly disavowing the earlier assumptions that family
pathology caused relapse and deterioration, family psychoeducation seeks to engage family
members as more sophisticated partners, complementing interventions by clinicians with
specialized interactions and coping skills that counter the neurologic deficits inherent to
the disorder. It has proved to be one of the most consistently effective treatments available.
Reports on outcome studies now number more than 100, while meta-analyses put relapse
rate reduction at 50–60% over treatment as usual. The most recent application in first epi-
sode and prodromal psychosis, combined with other evidence-based interventions, is yield-
ing perhaps the most promising results yet achieved—substantial return of functioning
and avoidance of psychosis altogether. Reviewed here are its scientific, theoretical, and
clinical sources, a description of the most commonly applied version—the multifamily
group format, selected clinical trials spanning those four decades, international and ethnic
adaptations, and studies on mechanisms of efficacy.

Keywords: Family Intervention; Schizophrenia; Psychosis; Psychoeducational


Multifamily Group; Family Psychoeducation; Early Intervention

Fam Proc 55:460–482, 2016

F amily psychoeducation (FPE) for the psychotic disorders has been established as one
of the most effective psychosocial treatments ever developed. It is a structured method
for incorporating a patient’s family members, other caregivers, and friends into acute and
ongoing treatment and rehabilitation. The descriptor “psychoeducation” can be mislead-
ing: FPE includes cognitive, behavioral, and supportive therapeutic and rehabilitative ele-
ments, utilizes a consultative framework, and shares some characteristics with structural
family therapy. The model most commonly used today is an amalgam of FPE (Anderson,
Hogarty, & Reiss, 1986), behavioral family therapy (Falloon, Boyd, & McGill, 1984), and
multifamily group therapy (McFarlane, 2002). Based on a family–patient–professional
partnership, the most effective models are essentially cognitive-behavioral therapy with
consistent inclusion of family members as collaborators. As a substitute for a family mem-
ber, it can include any friend or para-professional person who is providing support to per-
sons with a severe mental illness. In contrast to most family therapies, the family is not

*Tufts University School of Medicine, Maine Medical Center Research Institute, Portland, ME.
Correspondence concerning this article should be addressed to William R. McFarlane, M.D., Tufts
University School of Medicine, Maine Medical Center Research Institute, 22 Bramhall Street, Portland,
ME 04102. E-mail: mcfarw@mmc.org

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doi: 10.1111/famp.12235
MCFARLANE / 461
the object of therapy but rather a key implementer, as an indispensable colleague with dif-
fering expertise and potential skills. In addition to FPE, many other interventions exist to
assist consumers in the context of their families, and family members themselves, regard-
ing the challenges of severe mental illness. Within this range of potential resources, this
review will address only the clinical intervention of FPE and its effects for the psychotic
disorders.
As a group of related models with common characteristics (World Schizophrenia Fellow-
ship, 1998), FPE:

• Assumes that most involved family members of individuals with mental illnesses need
information, assistance, and support to best assist their ill family member and cope with
the often severe challenges posed to the family system.
• Assumes that the way in which relatives behave toward and with the person with men-
tal illness can have important effects, both positive and sometimes negative, on that per-
son’s well-being, clinical outcomes, and functional recovery.
• Combines informational, cognitive, behavioral, problem solving, communication, and
consultative therapeutic elements.
• Is initiated and led by mental health professionals.
• Is offered as part of a clinical treatment plan for a specific patient/consumer.
• Focuses primarily on benefiting consumer/patient outcomes, but improvements for fam-
ily members (e.g., reducing confusion, exasperation, and emotional distress) are also
essential to achieve those outcomes.
• Includes:

○ content about illness, medication, and treatment management;


○ services coordination;
○ attention to all parties’ expectations, emotional reactions, and distress;
○ assistance with improving family communication;
○ structured problem solving and instruction;
○ implementing individualized coping and rehabilitative strategies;
○ expanding social support networks; and
○ explicit crisis planning with professional involvement.
• Are generally diagnosis specific, although cross-diagnosis models have been developed
and are often the de facto practice.

Around these core elements, FPE programs vary considerably: FPE may take place with
just one family (single-family psychoeducation, SF-PE) or in multiple-family groups
(MFG-FPE). The consumer may be included in all (most common), some, or no sessions.
FPE may vary in the length of sessions, number of sessions, settings (clinic, inpatient,
home based), and overall time span (for maximum efficacy, for months or even years). Dif-
ferent programs may also vary in how much they emphasize cognitive, behavioral, infor-
mational, clinical, rehabilitation, and family systems theory and techniques. FPE
programs seek to enlist the assistance of loved ones and train them to help patients man-
age their illness. “The main goal in working with families is to help them develop the
knowledge and skills instrumental in promoting the recovery of their family member
while eschewing family dysfunction etiological theories of the past” (Jewell, Downing, &
McFarlane, 2009).
Evidence that FPE benefits the most important clinical outcomes has been established,
particularly regarding people with schizophrenia. Family psychoeducation has been
empirically demonstrated in a large number of clinical trials to improve outcomes in
schizophrenia and bipolar disorder to the same or greater degree as antipsychotic

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medication, complementing but doubling its treatment effects. Family intervention is par-
ticularly beneficial in the early years of the course of a mental illness, when improvements
can have a dramatic and long-term effect and while family members are still involved and
open to participation, change in attitude, and interaction with the patient. Patients who
experience frequent hospitalizations or prolonged unemployment benefit substantially
and often dramatically, as do families who are especially exasperated or confused about
the illness or even hostile toward the patient.
As a result, FPE has been deemed an evidence-based practice and has been included in
various treatment guidelines for schizophrenia and other serious mental illnesses: the
U.S. federal Center for Mental Health Services, Schizophrenia Patient Outcomes
Research Team (PORT) (Dixon et al., 2009), and the Presidents New Freedom Commis-
sion (Hogan, 2003). The goals are to improve clinical and functional outcomes and quality
of life for the patient and to reduce family stress and strain as an indispensable means of
achieving those outcomes. It combines the complementary expertise and experience of
family members, patients, and professionals. Given the depth of empirical evidence for
efficacy, it should be applied as widely and as routinely as medication, whenever there is a
family member available. Unfortunately, this does not mean it is commonly available or
fully utilized.

Background and History


Family psychoeducation originated from several sources in the late 1970s. Perhaps
the leading influence was the growing realization that conventional family therapy, in
which family dysfunction is assumed and becomes the target of intervention for the
alleviation of symptoms, proved to be at least ineffective and in many cases damaging
to patient and family well-being. Awareness also grew, especially among family mem-
bers themselves and their rapidly growing advocacy organizations, that living with an
illness such as schizophrenia is demoralizing, frustrating, and confusing for patients
and families alike. In a reciprocal process, the resulting stresses on families often lead
to persisting patterns of interaction that can have equally devastating effects on the
patient and the course of the disorder over time. It became increasingly clear that to
adapt under these circumstances, the family must have the available knowledge about
the illness itself and coping skills specific to a particular disorder, skills that are coun-
terintuitive to most families and many clinicians. It became clear that it was unrealis-
tic to expect families to understand such mystifying disorders and to know what to do
about them, independent of professional guidance. The implication was that clinicians
are a crucial source of that information, guidance, and emotional support.
As to coping skills, families sometimes develop methods of dealing with positive, nega-
tive, and mood symptoms, cognitive deficits, functional disabilities, and the desperation of
their ill relative, although usually through painful trial and error. These successes, how-
ever, are rare. Furthermore, the MFG-FPE model assumes that families need to have
access to each other to learn of other families’ successes and failures and to establish a
repertoire of clinically effective coping strategies that are closely tailored to the disorder,
to the specific family, and to the individual person. Furthermore, family members and sig-
nificant others often provide emotional and instrumental support, case management func-
tions, financial assistance, employment, advocacy, and housing to their relative with
mental illness. Doing so can be rewarding but poses considerable burdens. Family mem-
bers often find that access to needed resources and information is lacking. Too often, the
end result is a family that is so anxious, confused, exasperated, demoralized, or even hos-
tile that their interactions with the patient become risk factors for relapse, exacerbation of
functional deficits, family disruption, and eventual deterioration. Given that perspective,

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clinical investigators began to recognize the crucial supportive role families played in out-
comes after an acute episode of schizophrenia and endeavored to engage families collabo-
ratively, sharing illness information, suggesting cognitively sophisticated interactions and
strategies that promote recuperation, and teaching coping strategies that reduce their
sense and experience of burden. The group of interventions that emerged became known
as FPE.
These approaches recognize that schizophrenic and mood disorders are brain disorders
that are only partially remediable by medication, and that families can have a significant
effect on their relative’s recovery. Functional deficits and behavioral changes in these dis-
orders are exacerbated and even induced by stress. Nevertheless, those deficits are often
the most confusing and burdensome for family members because they usually do not iden-
tify them as part of the disorder, while also finding themselves trying to compensate for
those deficits. The psychoeducational approach shifted away from attempting to get fami-
lies to change their “disturbed” communication patterns toward educating and persuading
families that their interactions with the patient can facilitate recovery by compensating
for those deficits and sensitivities specific to the disorder. For example, some families
interfere with recuperation if in their natural enthusiasm to promote and support pro-
gress they create unachievable demands and expectations, but the same family could have
a dramatically positive effect on recovery by gradually increasing expectations and sup-
porting an incremental return of functioning. This strategy is much like that which is now
standard practice after a heart attack.
Research conducted over the last three decades has supported evidence-based prac-
tice guidelines for addressing family members’ needs for information, clinical guid-
ance, and ongoing support. This research has demonstrated that altering key types
of negative interaction and promoting disorder-specific interaction styles and recovery
skills dramatically improve patient outcomes, while improving family well-being and
meeting their members’ needs. FPE focuses on building on inherent family resiliency
and strengths. Several models have evolved to address the needs of family members.
They include:

1. Individual family consultation (Wynne, 1994);


2. Family psychoeducation (Anderson et al., 1986; Falloon, 1984; Miklowitz & Gold-
stein, 1997) in single-family format;
3. Psychoeducational multifamily group (Kopelowicz et al., 2012; McFarlane, 2002);
4. Modified forms of more traditional family therapies (Marsh, 2001);
5. A range of professionally led models of short-term family education (sometimes
referred to as therapeutic education) (Amenson, 1998);
6. Family-led information and support classes or groups such as those of the National
Alliance for Mental Illness (NAMI) (Dixon et al., 2004, 2011; Pickett-Schenk, Cook, &
Laris, 2000); and
7. Open dialogue, a modern adaptation of systemic family therapy (Seikkula et al.,
2006).

Of these models, professionally led FPE has a deep enough research and dissemination
base to be considered an evidence-based clinical practice, especially in the earliest phases
of the psychotic disorders (Dixon et al., 2001a; Lehman, Carpenter, Goldman, & Stein-
wachs, 1995; Lucksted, McFarlane, Downing, & Dixon, 2012; McFarlane, Dixon, Lukens,
& Lucksted, 2002). Described here are the theoretical background for this treatment
model, major components and technical methods and evidence for its efficacy, effective-
ness, and key mediating processes.

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MAJOR THEORETICAL AND RESEARCH-BASED CONSTRUCTS


Although the scientific evidence is increasingly strong that the major psychotic disor-
ders are based in genetic, neurochemical, inflammatory, and/or neurodevelopmental
defects involving brain function and structure, there is also abundant evidence that the
first onset, progression, and relapse of psychotic or severe mood symptoms are the result
of psychosocial stress. The stress-diathesis or stress-vulnerability model provides a widely
accepted, empirically supported, and useful framework for describing the relationships
among provoking agents (stressors), vulnerability and symptom formation (diathesis), and
outcome (Zubin, Steinhauer, & Condray, 1992). Thus, a genetically or developmentally
vulnerable person, whose inborn tolerance for stress is incompatible with exposure to
either excessive internally or externally generated stimulation, may experience an episode
of psychotic illness. This principle underlies the Biosocial Theory, which states that major
psychotic and mood disorders are the result of the continual interaction of specific biologic
disorders of the brain with specific psychosocial and other environmental factors (McFar-
lane, 2002). Specifically, episodes are induced in biologically vulnerable individuals by
major stresses imposed by role transitions and other life events, social isolation, family
expressed emotion, trauma, chronic anxiety, conflict, criticism, separation from family of
origin, intense sensory stimulation, and experienced stigma, among many others. Most of
these stresses lead to neurochemical alterations, leading to activation of the hypothala-
mic–pituitary axis, and subsequent elevations in dopamine, noradrenaline, and gluta-
matergic neuronal systems. This causal biosocial theory yields an interactive, feedback-
based model for the final stages of onset and subsequent relapse, as compared to a simpler
linear-causal model. In this conceptual framework, subtle symptoms, behavioral changes,
and functional deterioration induce anxiety, anger, rejection, confusion, withdrawal, and
other reactions in family members, friends, and fellow employees or students, which in
turn exacerbate those same symptoms by inducing psychological and ultimately physiolog-
ical and neurochemical reactions in the vulnerable person. The end result is a positive
feedback process that leads to deterioration of both the patient and the family.

Prospective Studies of Family Interaction Prior to Onset


Tienari and his colleagues, and Goldstein and his colleagues earlier, have shown in two
landmark prospective studies that family expressed emotion (EE) and communication
deviance (CD), especially negativity directed toward the at-risk young person, predict
onset of psychosis, interacting with genetic (having a biological mother with schizophre-
nia) or psychiatric risks (already having nonpsychotic symptoms and behavioral difficul-
ties) (Goldstein, 1985; Tienari et al., 2004). In support of the stress (environmental risk)
part of the biosocial theory, Goldstein demonstrated that onset of psychosis in disturbed
adolescents seeking psychological treatment could be predicted by in vivo assessment of
negative family affective style (a form of EE) and deficiencies in clarity and structure of
communication (CD). The results in the Tienari study indicated that risk for development
of schizophrenia spectrum disorders was much higher—37% versus 6%—among geneti-
cally at-risk adoptees reared in families in which there were higher levels of negativity,
family constrictedness, and family boundary problems. There was no increase in incidence
among genetically at-risk adoptees reared in less distressed families. Thus, not only were
certain types of common family interaction implicated in triggering the onset of
schizophrenia in genetically vulnerable children but also healthier family interaction
played a protective role against onset of an illness in genetically predisposed individuals.
These studies imply a more complex but more precise model of etiology, but one that is
more clinically useful. In essence, negative family interactional patterns are as potent and
indispensable factors in onset as are genetic and neurodevelopmental factors, but only

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when those predisposing biological factors are themselves present. This model reflects a
growing literature that documents gene–environment interaction as a mutually causal
process powerfully affecting mental and physical health (Felitti et al., 1998; Reiss, Neider-
hiser, Heatherington, & Plomin, 2000; Repetti, Taylor, & Seeman, 2002). The current
empirical conclusion is that severe psychiatric and medical disorders are the result of
(negative family) nurture acting on (genetically or developmentally abnormal) nature,
specifically defined in each disorder but heavily and equally dependent on both sets of
influences. Furthermore, and in strong disagreement with schizophrenogenic theories,
almost all of the negative family interaction is reactive to the developing or continuing ill-
ness itself. Family psychoeducation thus targets one of the two fundamental etiological
domains in major psychotic disorders.

Expressed Emotion (EE)


High levels of criticism and emotional overinvolvement are strongly predictive of exac-
erbation or relapse of psychotic symptoms (Brown, Birley, & Wing, 1972). In an extensive
meta-analysis, Bebbington & Kuipers (1994) cite the overwhelming evidence from 25 stud-
ies for a predictive relationship between high levels of expressed emotion and relapse of
schizophrenia and bipolar disorder. Cook, Strachan, Goldstein, and Miklowitz (1989),
Strachan, Feingold, Goldstein, Miklowitz, and Nuechterlein (1989), and Goldstein, Rosen-
farb, Woo, and Nuechterlein (1994) found that expressed emotion is a reflection of transac-
tional processes between the patient and family, supporting the conclusion that family
functioning is strongly and negatively affected by aspects of the illness in the patient. That
conclusion is supported by several studies indicating that EE is less pronounced in the
earliest phases of psychosis, and increases over time. Hooley and Richters (1995) found
that criticism and hostility rates rose rapidly in the first few years of the course of illness:
in 14% of families with less than 1 year of illness, and in 50% after 5 years. EE differs
widely across prodromal and chronic patient samples. Parental scores for rejecting atti-
tudes and emotional overinvolvement were all but identical in two independent estab-
lished disorder samples, but were markedly higher than scores in a prodromal sample
(McFarlane & Cook, 2007). These studies strongly suggest that expressed emotion is lar-
gely reactive to cognitive deterioration, disabilities, and emerging negative behavior mani-
fested by the young person developing a psychotic disorder.

Attribution
Relatives’ beliefs about the causes of illness-related behavior have been associated
with expressed emotion. Relatives described as critical or hostile misperceive the
patient as somehow responsible for unpleasant, symptomatic behavior, whereas more
accepting relatives saw identical behaviors as characteristic of the illness itself (Bre-
win, MacCarthy, Duda, & Vaughn, 1991; Dominguez-Martinez, Medina-Pradas, Kwa-
pil, & Barrantes-Vidal, 2014). This is an especially acute risk in the prodromal
phase, during which symptoms and deficits often develop gradually, sometimes
imperceptibly, appearing to be emerging personality or behavioral faults (McFarlane
& Lukens, 1998). As a result, family members are more likely to respond with emo-
tional intensity, criticism, or hostility.

Communication Deviance
Communication deviance, a measure of distracted or vague conversational style, has
been consistently associated with schizophrenia. It was the other factor in the prospec-
tive long-term outcome study that predicted the onset of schizophrenic psychosis

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(Goldstein, 1985). Studies have demonstrated that it is correlated with cognitive dys-
function in the relatives, which is of the same type, but of lower severity, as is seen
in patients with schizophrenia (Wagener, Hogarty, Goldstein, Asarnow, & Browne,
1986). This suggests that some family members have an inherent and probably geneti-
cally derived difficulty holding a focus of attention, with important implications for
treatment design.

Social Isolation
The available evidence across several severe and chronic illnesses indicates that ongo-
ing access to social contact and support prevents the deterioration of such conditions and
improves their course (Penninx, Kriegsman, van Eijk, Boeke, & Deeg, 1996). Family mem-
bers of the most severely ill patients were isolated, preoccupied with, and burdened by the
patient. Brown et al. (1972) showed that 90% of the families with high expressed emotion
were small in size and socially isolated. In addition, social support buffers the impact of
adverse life events (Lin & Ensel, 1984) and is one of the key factors predicting medication
compliance (Fenton, Blyler, & Heinssen, 1997), adherence to treatment, schizophrenic
relapse, quality of life (Becker et al., 1998), and subjective burden experienced by relatives
(Solomon & Draine, 1995). Social network size decreases with number of episodes, is lower
than normal prior to onset, and decreases during the first episode (Anderson, Hogarty,
Bayer, & Needleman, 1984).

Effects of Psychosis on the Family


The psychotic disorders exact an enormous toll on family members, in anxiety, anger,
confusion, received stigma, rejection, and exacerbation of medical disorders (Johnson,
1990). The organization of most families undergoes a variety of changes, including alien-
ation of siblings; exacerbation, or even initiation, of marital conflict; severe disagreement
regarding support versus behavior control; even divorce. Almost every family undergoes a
degree of confusion, demoralization, conflict, and self-blame, which may be reinforced by
some clinicians. Because some family members share subclinical forms of similar mood
control deficits and cognitive abnormalities, treatment for psychotic disorders must be
designed to compensate for those difficulties. Those deficits lead to diminished coping abil-
ity in some family members.

A Model of Reciprocal Causation


These critical family and psychosocial factors lead to onset and relapse of psychosis via
(a) a general and biologically based sensitivity to external and internal stimulation and (b)
a major discrepancy between stimulus complexity and intensity and cognitive capacity.
These processes converge, generating external stresses that induce a spiraling and deteri-
orating process that ends in a major psychosis or onset of a major mood episode. This lar-
ger process is the potential target for FPE and multifamily groups, altering critical
environmental influences by:

• Reducing ambient social and psychological stresses;


• Reducing stressors from negative and overly intense family interaction;
• Building barriers to excess stimulation;
• Buffering the effects of negative life events;
• Promoting patient- and family-specific coping skills; and
• Enhancing social networks and social support.

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MCFARLANE / 467
Thus, the core elements of this treatment are relevant education, training, enhanced cop-
ing skills, and support to family members, friends, and other caretakers—those who pro-
vide support, protection, and guidance to the patient/consumer.

RESEARCH OVERVIEW
A large number of controlled and comparative clinical trials have demonstrated mark-
edly decreased relapse and rehospitalization rates among patients whose families received
psychoeducation compared to those who received standard individual services, reductions
of 20–50% over 2 years. Since 1978, with the publication of Goldstein’s study showing dra-
matic short-term effects of educational and coping skills training intervention, there has
been a steady stream of rigorous validations of the positive effects of this approach on
relapse in schizophrenic disorders. Overall, the relapse rate for patients provided FPE has
hovered around 15% per year, compared to a consistent 30–40% for individual therapy
and medication or medication alone (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998).
It is important to note that medication is not a variable in these studies: The design of
family psychoeducational approaches includes medication adherence as key to promoting
recovery. Therefore, medication is provided in both the experimental and control condi-
tions in almost every instance.
At least 13 literature reviews have been published regarding FPE in schizophrenia, all
finding a large and significant effect for this model of intervention (Baucom et al., 1998;
Dixon, Adams, & Lucksted, 2000; Dixon & Lehman, 1995; Dixon et al., 2001b; Falloon,
Held, Coverdale, Roncone, & Laidlaw, 1999; Jewell et al., 2009; Lam, 1991; McFarlane &
Lukens, 1998; Murray-Swank & Dixon, 2004; Penn & Mueser, 1996; Pitschel-Walz,
Leucht, Bauml, Kissling, & Engel, 2001; Rummel-Kluge & Kissling, 2008; Taylor et al.,
2009; Zygmunt, Olfson, Boyer, & Mechanic, 2002). For example, in an aggregate analysis
of 11 studies of family interventions for schizophrenia, Baucom et al. (1998) found that an
(unweighted) average of 25.5–28% of individuals with schizophrenia suffered a symp-
tomatic relapse or rehospitalization while receiving a family intervention as compared to
63.6% of individuals who received routine treatment alone, an effect size comparable to
that for antipsychotic medication versus placebo. Taylor’s (2009) review was broad in
scope, surveying evidence for all services used by people with “longer term mental health
problems” in the British system, and concluding that FPE should be a central component
of effective treatment of schizophrenia. Zygmunt’s (2002) is the narrowest, reviewing only
literature testing for medication adherence effects and published between 1980 and 2000.
It concludes that “interventions and family therapy programs relying on psychoeducation”
were “typically ineffective” for that outcome. Reviews by Murray-Swank and Dixon (2004),
Jewell et al. (2009), and Rummel-Kluge and Kissling (2008) all come to similar conclu-
sions: FPE as a clinical intervention for schizophrenia is now considered a solid evidence-
based effective practice for reducing relapse and hospitalizations and for several func-
tional outcomes, especially in conjunction with effective psychiatric medication. Rummel-
Kluge further concludes that “studies on psychoeducation in schizophrenia in real-world
settings show results comparable to those in experimental settings.”
In keeping with these conclusions, the U.S. Department of Health and Human Services’
Substance Abuse and Mental Health Services Administration includes McFarlane et al.’s
(2002) multiple-family group model as an evidence-based practice and has released a “tool
kit” developed by U.S. leaders in the field to promote its widespread implementation (U.S.
Department of Health and Human Services, 2004). In addition, PORT treatment recom-
mendations regarding schizophrenia state that family interventions should last at least 6–
9 months and include illness education, crisis intervention, emotional support, and

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training for coping skills. They add that if delivery of this long an intervention is impossi-
ble or unacceptable, adults with schizophrenia and their family members then be offered a
program of at least four sessions (Dixon et al., 2009; Lehman et al., 1998). Other best
practice standards (American Psychiatric Association, 1997; Frances, Docherty, & Kahn,
1996; Frances, Hoffman, Pass, & Andrews, 1987) have also recommended that families
receive education and support programs. In addition, an expert panel that included clini-
cians from various disciplines, families, patients, and researchers emphasized the impor-
tance of engaging families in the treatment and rehabilitation process (Coursey, Curtis, &
Marsh, 2000a,b).
Three studies found no effect for FPE, providing additional insights into the necessary
components and processes (Kottgen, Sonnichsen, Mollenhauer, & Jurth, 1984; Linszen
et al., 1996; Telles et al., 1995). In the Kottgen study, the ongoing sessions were oriented
toward exploring psychodynamic and dysfunctional aspects within the families’ dynamics,
now considered contraindicated for nearly all families of patients with schizophrenia. In
the Telles study, conducted in a Spanish-speaking immigrant sample, there was a
reversed effect for behavioral family management among those from a less acculturated
subgroup and no effect for those from the more acculturated subgroup. Other recent stud-
ies in Spain have demonstrated the same robust effects as the prior studies in English-
speaking countries, suggesting that it was the sample’s immigrant status that may have
negated the effects of family intervention. In the Linszen study, the control group received
individual therapy that was well designed and also achieved low relapse rates comparable
to those in the family intervention sample (15–16% in both conditions). This study tested
family intervention only during an inpatient admission and not during outpatient treat-
ment, for which it was designed. The Linszen study illustrates a general finding: Pro-
grams lasting longer than 3 months had more robust effects. In fact, consistent efficacy
has only been demonstrated in those studies in which intervention was provided on an
ongoing basis, lasting at least 6 months, and incorporated problem solving, coping skills
training, expanded social support, and communication skills training. Thus, the noncon-
firming studies tend to suggest that core elements make a difference, but also that some
patients and families may require cultural and/or contextually specific adaptations of the
approach, and that other methods may also achieve comparable short-term effects.
It has become clear that education alone has at least short-term salutary effects for
family members (Dixon et al., 2011; McFarlane, Link, Dushay, Marchal, & Crilly, 1995a),
but other studies have found that there is no lasting effect on patient clinical or functional
outcomes (Abramowitz & Coursey, 1989). That might be expected given the long-term
course of illness of schizophrenia, eroding gains in understanding under the influence of
the persisting deficits, symptoms, and burdens. Thus, the critical elements include those
that involve changes in behavior and ongoing training in diagnosis-specific and clinically
oriented coping skills training. Increasingly, as the focus of intervention has shifted to
functional aspects, especially employment, the patient has been included in these skills
training and behavioral interventions. In the multifamily group approaches, there is
another element added—ongoing social support and social network expansion—for family
members and the patient.

U.S. RANDOMIZED TRIALS


Previous reviews have documented the significant effects of single FPE (Hogarty et al.,
1986) and family behavioral management (Falloon et al., 1985). MFG-PE has been found
to be superior to SFT-PE in two studies conducted by this author (McFarlane et al.,
1995a; McFarlane et al., 1995b). Across seven sites in New York and New Jersey, relapse
rates were significantly lower by one third in the multifamily format, even though the

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content delivered in the two conditions was identical. Positive symptoms at baseline mark-
edly influenced relapse outcome in MFG-PE and SFT-PE (p < .05) (McFarlane et al.,
1995b). Remarkably, for each one-point increase in the score on the baseline Brief Psychi-
atric Rating Scale (BPRS), the risk of relapse increased by 39% in SFT, but, in stark con-
trast, decreased by 42% in multifamily groups. Moreover, these effects were durable with
continued participation in MFG. For example, in the first study (McFarlane et al., 1995a),
benefits for relapse prevention were maintained across all years of a 4-year study of MFG
for schizophrenia. Among patients who continued in treatment after the 4-year trial, non-
relapsers averaged over 7 years in remission, most having been in low-intensity treatment
for the duration. The average period of remission was 59 of a possible 90 months. The
MFG-PE effect was validated in a randomized trial of 97 adults with schizophrenia and
their family members study conducted by a Washington state team of researchers. They
compared 2 years of MFG-FPE against standard care (Dyck, Hendryx, Short, Voss, &
McFarlane, 2002; Dyck et al., 2000). They found significant effects for relapse and nega-
tive symptoms. In later analyses, they reported that the MFG-FPE condition participants
showed significant decrease in consumer hospitalizations with no net increase in outpa-
tient services use over the 3 years after baseline (Dyck et al., 2002; Michael G. McDonell,
Short, Hazel, Berry, & Dyck, 2006), and significantly reduced family member distress but
no reductions in family burden and no increase in family member active coping or per-
ceived social support (Hazel et al., 2004).
Mueser and colleagues published analyses from the randomized Treatment Strate-
gies in Schizophrenia study (n = 528 consumers + family members) (Mueser et al.,
2001; Schooler, 1986). This large study compared (a) 2-year supportive family man-
agement (SFM; monthly multiple-family information/support meetings) with (b) more
intensive applied family management (AFM) involving individual in-home behavioral
family therapy. Both ran alongside three medication regimens. They found: (1) there
were equal rates of relapse between the two conditions; (2) there was no effect in
either condition on family burden; (3) consumer social functioning improved equally
in both; (4) AFM was associated with family member perceptions of lower family fric-
tion and rejecting attitudes toward consumers; and (5) there was no medication–con-
dition interaction. This was, in effect, a test of MFG without PE against SFT-PE,
suggesting that the social interaction across families in groups by itself produces an
effect comparable to that of SFT-PE.
Kopelowicz and his colleagues documented a significant effect among Latino fami-
lies for MFG enhanced by a module to enhance medication adherence (Kopelowicz
et al., 2012). MFG-PE with adherence was associated with higher medication adher-
ence than MFG standard or treatment as usual. The MFG-PE adherence participants
had a longer time to first hospitalization and were less likely to be hospitalized than
those in MFG standard and treatment as usual. Increased adherence accounted for
one third of the overall effect of treatment on the reduced risk for psychiatric hospi-
talization. The authors concluded that multifamily group therapy specifically tailored
to improve medication adherence through a focus on the beliefs and attitudes of the
target population was more effective than MFG-PE alone, which was more effective
than treatment as usual.

INTERNATIONAL RANDOMIZED TRIALS


Internationally, FPE research has been proliferating, most recently focusing on
family member outcomes as its effectiveness regarding consumer relapse is accepted.
Recent reports have only added to the strong validation of the effects on relapse,
particularly because these later studies have been conducted in a variety of

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470 / FAMILY PROCESS

international and cultural contexts. Reductions in relapse for family intervention,


compared to the control conditions, have been demonstrated in China (Ling et al.,
1999; Zhang, Wang, Li, & Phillips, 1994; Zhao, Shen, & Shi, 1999; Zhao et al.,
2000), Spain (Montero, Gomez Beneyto, Ruiz, Puche, & Adam, 1992; Muela Martinez
& Godoy Garcia, 2001; Tomaras et al., 2000), Scandinavia (Rund et al., 1994), and
Britain (Barrowclough et al., 2001). For instance, Ran et al. (2003) assigned 326 fam-
ily members to usual care, enhanced medication management, or FPE plus medica-
tion management, in rural China, by randomizing conditions by township. In
addition to significantly improved knowledge and caring attitude among family mem-
bers and increased treatment compliance among consumers in the psychoeducation +
medication management condition, at 9 months, the relapse rate among consumers in
that group (16.3%) was half that of the medication only group (37.8%), and approxi-
mately one quarter of the rate of the control group (61.5%) (p < .05). Chien and
Wong (2007) compared 36 weeks of MFG-FPE to usual care, enrolling 84 family
members of people with schizophrenia. MFG-FPE participants showed greater
improvement in both family and consumer functioning, family self-perceived burden
of care, and the number and length of participants’ rehospitalization. In a separate
trial, Chien randomized 76 primary family caregivers of adults with schizophrenia
attending one of two participating outpatient psychiatric clinics (Chien, Thompson, &
Norman, 2008). The study again found significant benefit for 9 months of FPE (vs.
usual care) for consumer and family functioning, reduced burden scores, and shorter
hospitalizations, compared to a control group. A model has been developed specifi-
cally for Asian Americans, designed to fit this population’s different value orienta-
tions and cultural characteristics (Bae & Kung, 2000). These trials suggest that FPE
confers benefits over usual care participants in China, whereas results regarding
treatment compliance and medication adherence remain unclear. That these effects
are additive to, but not substitutive for, antipsychotic medication was illustrated in a
German study (Wiedemann et al., 2001). The investigators found that behavioral
family management did not compensate for the increased risk of relapse posed by
“targeted” drug treatment, in which the patient did not use medication unless experi-
encing prodromal signs or symptoms of relapse.
Beyond China and the United States, there are six randomized studies, some the first
from their country. Reported as the first evaluation of MFG-FPE in Australia, Bradley
et al. (2006) compared outcomes for English-speaking (34 consumer–family member pairs)
and Vietnamese-speaking (25 pairs) participants in schizophrenia spectrum disorders, in
part to investigate the feasibility of using the MFG-PE model cross-culturally and cross-
linguistically. Participants were randomized to case management versus case manage-
ment plus MFG-PE delivered with minimal cultural adjustments advised by an experi-
enced Vietnamese therapist. There was significantly less relapse in the MFG-FPE
condition (3 people (12%) vs. 9 (36%)) during the year of intervention, and a large differ-
ence 6 months after it ended (6 people (25%) vs. 15 (63%)), fewer symptoms, and better
vocational functioning. In survival analyses, time to relapse was 890 days for those in the
MFG condition versus 642 days for control participants, although the duration of relapse
episodes was not significantly different.
Two Italian studies showed similar results. Magliano, Fiorillo, Malangone, De Rosa,
and Maj (2006) had 34 clinicians trained in FPE select 71 families of consumers with
schizophrenia to be randomized to a 6-month SFT-PE program or a wait list. They found
significant improvements in consumer social functioning and self-care, as well as family
member social contacts and perceptions of professional support in the intervention condi-
tion. Family burden improved for both groups. Carra, Montomoli, Clerici, and Cazzullo
(2007) chose random samples from a large pool of family members referred to a family

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MCFARLANE / 471
support center for each of three conditions: treatment as usual (control), 24 weekly group
information sessions, or the same group information sessions followed by two additional
years of MFG-PE. Only compliance with standard care was significantly greater in the
FPE group at 1 year, but this diminished by 24 months. Although expressed emotion was
more often reduced among those in the experimental condition, this effect also had dissi-
pated after an additional year. This may illustrate the limitation of efficacy for education-
only intervention.
In Pakistan, a randomized study of primary family members for 108 persons with
schizophrenia was performed, using a SFT-PE variation translated into Urdu plus medi-
cation management, versus medication management alone (Nasr & Kausar, 2009). The
SFT-PE condition showed significantly greater reduction in burden 6 months after base-
line (i.e., at the end of the intervention) than controls. Kulhara and colleagues randomized
76 consumer–family pairs in India in which the consumer had schizophrenia, to either 9
monthly FPE meetings or 9 months of usual outpatient care (Kulhara, Chakrabarti,
Avasthi, Sharma, & Sharma, 2009). FPE participants showed significantly more improve-
ment in psychopathology, disability, caregiver satisfaction with treatment, and percep-
tions of social support. However, there were no significant differences for treatment drop
out, relapse, caregiver burden, or caregiver coping. The authors also report that the pro-
gram was practical to implement and not expensive.
The universality of this approach seems to have been demonstrated in contexts differ-
ent enough that further generalization in other cultures and countries appears to be likely
to succeed. However, given results that were less than optimal in some of these countries,
further attention to the necessary adaptations appears to be necessary.

EFFECTS ON FUNCTIONING AND WELL-BEING


These and other studies have demonstrated significant effects on other areas of func-
tioning, thereby addressing a frequent criticism of the clinical trials: Relapse is only one
dimension of outcome and course of illness. Many consumers and their family members
are more concerned about the functional aspects of the illness, especially housing, employ-
ment, social relationships, dating, marriage, and general morale and well-being than
about remission, which tends to be somewhat abstract as a goal. Several of the previously
mentioned models, particularly the American versions—those of Falloon, Anderson, and
McFarlane—have used remission as both a primary target of intervention but also as nec-
essary to achieve recovery. In addition, these models all include major components
designed to achieve functional recovery, and the studies have documented progress in
those same domains, as investigators have shifted focus to targeting these more human
aspects of life. Other effects have been shown for:

• Improved family member well-being (Cuijpers, 1999; Falloon & Pederson, 1985; McFar-
lane, Dushay, Stastny, Deakins, & Link, 1996; Shi, Zhao, Xu, & Sen, 2000; Solomon,
Draine, Mannion, & Meisel, 1996; Wang et al., 1999; Zhao et al., 1999);
• Increased patient participation in vocational rehabilitation (Falloon et al., 1985);
• Substantially increased employment rates, when combined with supported employment
(McFarlane et al., 1995b, 1996, 2000);
• Decreased psychiatric symptoms, including deficit syndrome (Dyck et al., 2000; Falloon
et al., 1985; McFarlane et al., 1995b; Zhao et al., 2000);
• Improved social functioning (Montero et al., 2001);
• Decreased family medical illnesses and medical care utilization (Dyck et al., 2002), and
reduced costs of care (Cardin, McGill, & Falloon, 1985; McFarlane et al., 1995b; Rund
et al., 1994; Tarrier, Lowson, & Barrowclough, 1991).

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472 / FAMILY PROCESS

CONCLUSIONS: RANDOMIZED CLINICAL TRIALS OF FPE FOR SCHIZOPHRENIA


Across these various cultures, languages, health systems, methodologies, and interven-
tion variations, it is clear both that there is not one “universal” FPE intervention in use,
and that the core concepts across variations have robust effects for many clinical out-
comes. Many randomized studies show positive results similar to those in the United
States when adapting U.S.- or U.K.-originated FPE models to other cultures, although
others find no results. The prevailing U.S. FPE variations may mesh better with certain
cultures than others, but variable results may also be due to differences in the quality of
cultural adaptations, or to other aspects of the studies’ design, FPE fidelity and delivery,
outcome variables, or measurement. There are not yet enough randomized international
studies to discern global patterns, or complete cross-cultural meta-analyses. FPE
researchers could advance this work by testing cross-cultural hypotheses, perhaps via
replication studies of successful cultural adaptations.

OTHER QUASI-EXPERIMENTAL OUTCOMES RESEARCH TESTING FPE IN


SCHIZOPHRENIA
Aside from randomized controlled trials, other studies of FPE have tested applications
in various settings and countries, providing data on effectiveness in routine applications.
However, their interpretation is often impeded by methodological weaknesses, especially
the absence of a control or comparison group.
Two published studies from Japan indicate active inquiry into FPE. Sota and colleagues
report no differences in the benefits of a shorter versus longer FPE course in post hoc anal-
yses of an uncontrolled study (Sota et al., 2008). Mino and colleagues found substantial
inpatient care cost savings in the 9 months after discharge among people with schizophre-
nia whose relative completed a 9-month FPE course, compared to those who did not; but
no difference in outpatient care costs, which yielded a positive benefit/cost ratio (Mino,
Shimodera, Inoue, Fujita, & Fukuzawa, 2007).
Weine and colleagues reported pre-to-post reductions in medication noncompliance and
hospitalization and increases in family mental health services use in a mixed-diagnosis
sample of 30 families in postwar Kosovo, using a comparison group (Weine et al., 2005).
The authors note that the study resulted in beneficial policy changes in Kosovo’s health
service.
Thara and colleagues reported that their 6-session FPE program yielded a significant
pre-post change in “occupational disability” among 30 family members of people with
schizophrenia in Chennai, India (Thara, Padmavati, Lakshmi, & Karpagavalli, 2005).
They reported no changes in burden, depression, or anxiety, although results are difficult
to interpret with no comparison or control group.
Sherman in the United States has evaluated the SAFE family program she and col-
leagues developed within the Veteran’s Administration (VA). SAFE is a rotating series of
14 monthly cross-diagnosis workshops created within the VA for family members of veter-
ans with serious mental illnesses (Sherman, 2006). As such, it is more education than
therapy. Using an uncontrolled within-group design, she found that the number of work-
shops attended was positively correlated with improved understanding of mental illness
and available VA resources. Furthermore, participant improvement (pre- vs. posttreat-
ment) in self-care was positively related to number of workshops attended. Later evalua-
tion reported high levels of participant satisfaction and attendance, and found an inverse
correlation between attendance and caregiver distress (Sherman, Fischer, Sorocco, &
McFarlane, 2011).

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MCFARLANE / 473
EARLY INTERVENTION AND FPE
Continuing a theme evident since the late 1990s, research in schizophrenia has increas-
ingly focused on the earliest phases of onset, elucidating predictors and effects of early
intervention, while widening the diagnostic scope to include all psychoses. From the per-
spective of FPE, many advances have occurred. Work in the 1990s by Hooley (1995), Fal-
loon (1992), and others indicated that dysfunctional family patterns (including “expressed
emotion”) tended to develop alongside the family member’s illness rather than precede or
cause it. For example, a very low level of rejection and a high level of warmth were found
among 100 families of youth in the prodromal phase of psychosis, compared to samples
with longstanding illness (McFarlane & Cook, 2007). The idea that negative family
dynamics observed among families largely result from the stresses and negative conse-
quences of the illness has led a few research groups to include FPE in clinical approaches
to treat early psychosis or to prevent its manifestation after prodromal signs. Providing
information, support, coping skills, and problem-solving resources to consumers and their
families at an early point may (a) reduce the trauma of illness onset, and (b) prevent devel-
opment of, or ameliorate, maladaptive familial interaction patterns, thereby positively
impacting outcomes for consumers and family members.
In the New York State comparative trial of SFT vs. MFG formats, the relapse rate
among individuals receiving MFG was significantly lower for individuals experiencing
their first episode of psychosis as compared to more chronic patients (19% vs. 44% at
2 years) (McFarlane et al., 1995b). Among the original and early clinical trials of psychoe-
ducation or behavioral family intervention, a substantial proportion of subjects were hav-
ing their first episodes (e.g., Hogarty: 23% (Hogarty et al., 1986); Falloon: 36% (Falloon
et al., 1985); Leff: 44% (Leff et al., 1989); Montero: 70% (Montero et al., 2001)), suggesting
specific efficacy in first-episode psychosis.
That laid the foundation for two Scandinavian studies that incorporated variations in
MFG-FPE into their respective multisite early intervention studies. In Denmark (Thorup
et al., 2005; Jorgenson, et al., 2000), the OPUS study recruited a first-episode sample,
and randomized participants and family members to MFG-FPE plus family-aided asser-
tive community treatment (FACT; McFarlane, Stastny & Deakins, 1992) or to standard
treatment which included neither (Nordentoft et al., 2006; Thorup et al., 2005). Those in
the experimental group showed lower suicide rates, negative symptoms, consumer sub-
stance abuse, and family burden than controls after 2 years (Jeppesen et al., 2005; Peter-
sen et al., 2005). Importantly, in an OPUS subsample of people with schizotypal
personality disorder without a previous psychotic episode, those in the intervention condi-
tion had half the rate of onset of initial psychotic episodes over 2 years as the control
group (Nordentoft et al., 2006). Other authors have found family interventions, especially
MFG-PE, to be beneficial in first-episode situations as well (Addington, Collins, McCleery,
& Addington, 2005; McCleery, Addington, & Addington, 2007). An international survey
concluded that, both as an international consensus of opinion and by evidence levels,
MFG-FPE ranked only behind antipsychotic medication for efficacy in first-episode psy-
chosis (Addington, McKenzie, Norman, Wang, & Bond, 2013).
In Norway, the TIPS study compared outcomes for adults experiencing their first psy-
chotic episode in counties with early intervention to counties with intervention beginning
in the usual (i.e., later) manner. The treatment for all participants consisted of MFG-FPE
with added social skills training, in a quasi-experimental design (Fjell et al., 2007; Johan-
nessen et al., 2001). However, fewer than half of 301 consumers participated in the MFGs;
reluctance to participate increased with age. Although treatment was well received by
those who did take part, there was a long (6–12 months) delay in initiating MFG-FPE,
erasing many advantages of early family intervention.

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474 / FAMILY PROCESS

Similar early psychosis work is now being done in the United States. The Portland
Identification and Early Referral (PIER) is a community-wide public health system for
preventing psychosis (McFarlane et al., 2010, 2014). It shares many elements of the TIPS,
OPUS, and other early intervention studies, including MFG-FPE, FACT, psychotropic
medications by symptom indication, and supported employment and education. A clinical
trial, titled Early Detection and Intervention for the Prevention of Psychosis, tested this
model in six U.S. cities among diverse populations representative of the United States for
a variety of functional, clinical, family, and public health measures (McFarlane, Cornblatt,
& Carter, 2012; McFarlane et al., 2015). The experimental cohorts included both those at
clinical high-risk (prodromal) and very early (i.e., duration less than 30 days) first-episode
psychosis (FEP). There were significant results for psychotic, negative, disorganized and
general symptoms, global outcome, and increase in participation in school and work.
Results for social and occupational functioning were not statistically significant, but both
cohorts’ mean scores were in the normal range after completion of 2 years of treatment,
matching outcomes for the low-risk comparison group receiving community standard or
no treatment. Post hoc analysis disclosed that results for psychotic symptoms were associ-
ated with exposure only to MFG-FPE, but not antipsychotic or antidepressant medica-
tions.
Another multisite clinical trial tested family-focused therapy (FFT) against enhanced
care (three sessions of family education) in prodromal youth (n = 129) (Miklowitz et al.,
2014). Participants in FFT showed significantly greater improvements in attenuated posi-
tive symptoms over 6 months than in the control condition. Negative symptoms improved
independently of psychosocial treatments. Changes in psychosocial functioning depended
on age: Participants more than 19 years of age showed more role improvement in FFT-
CHR, whereas control participants between 16 and 19 years of age showed more role
improvement. The results were independent of concurrent pharmacotherapy. Bechdolf
et al. (2004) found a significant prevention effect for conversion to psychosis in a random-
ized clinical trial of brief MFG-PE combined with cognitive therapy. Based on this and
other early psychosis intervention studies, it is likely that future recommendations for
psychosocial intervention to prevent onset of psychosis will include MFG-PE and psy-
chosis-specific versions of CBT.
A recent multisite effectiveness trial in first-episode psychosis, RAISE, included SFT-
PE, but found no differences in psychotic or negative symptoms or rehospitalization rates,
although there were effects for retention in treatment and quality of life (Kane et al.,
2016). This result contrasts with the superiority of MFG-PE specific to the first episode of
schizophrenia noted previously.

MEDIATING EFFECTS
From a theoretical standpoint, this broad spectrum of effects is mediated either by
numerous intervention components or a smaller number of nodal alterations whose sec-
ondary effects ramify throughout the family system and biological processes within the
affected individual. The second option is strongly supported by the finding that all the effi-
cacious family psychoeducational models reduce family expressed emotion and that doing
so is directly associated with the reduction in relapse found in clinical trials. This linearity
of effects is reassuring, because the intent of the early models, that developed by Leff par-
ticularly, was to reduce expressed emotion. Tarrier, Sommerfield, and Pilgrim (1999) iso-
lated reduction in EE as the key mediator of relapse, and that active involvement of the
relatives in learning new behavioral approaches was essential for reducing EE and allevi-
ating negative outcomes.

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MCFARLANE / 475
However, the better known variants—FPE, family behavioral management, and psy-
choeducational multifamily groups (PMFGs)—have deliberately added important new
dimensions of intervention, tending to support the first theoretical possibility that these
models have several different domains of effect. These include good general clinical man-
agement strategies and empathic engagement of patient and family members in Ander-
son’s model, problem solving, communication skills training, and in-home sessions in
Falloon’s model and multifamily participation in problem solving and expanded social net-
works and social support in the MFG-FPE format. Each of these components is designed
to impact specific and somewhat separate aspects of the illness and the family system, as
well as expressed emotion. A key instance is Falloon’s demonstration that successful mas-
tery of problem solving by family members was more directly associated with relapse pre-
vention than reductions in expressed emotion (Falloon et al., 1985). When a very similar
version of FPE is incorporated, multifamily groups lead to lower relapse rates and higher
employment than single-family sessions (McFarlane et al., 1995a,b). The parsimonious
explanation is that enhanced social support, inherent only in the multifamily format,
reduces vulnerability to relapse, and that effect owes to a reduction in anxiety and general
distress (Dyck et al., 2002). Both of these empirical results strongly suggest a multidimen-
sional effect as the explanation of improved clinical outcomes. That argument is strength-
ened further by recent studies showing dramatic improvements in employment among
people with schizophrenia, especially when combined with supported employment that is
designed to achieve functional goals (McFarlane et al., 1996, 2000). Therefore, both theo-
retical possibilities are supported by present evidence. Many of the effects of these models
are mediated by reductions in expressed emotion, but that effect is enhanced by elements
that focus on general empathic support for families and patients, problem-solving, coping,
and communication skills training and enhanced social networks and support.
Delivery of the appropriate components of FPE to patients and families appears impor-
tant in determining outcomes of families and patients. Several studies (e.g., Greenberg,
Greenley, & Kim, 1995) have demonstrated that programs fail to reduce relapse rates if
they present information without also providing family members with skills training,
ongoing guidance, and problem solving regarding illness management and rehabilitation,
and emotional support. Information-only interventions also tend to be quite brief; a meta-
analysis of 16 studies found that family interventions of fewer than 10 sessions had no
important effects on relatives’ burden (Cuijpers, 1999); there have been no studies that
found that brief, education-only interventions reduce relapse rates. However, the number
of sessions could not explain completely the differential outcomes; length of total time,
allowing for refinement of coping skills and strategies by the family and patient, rather
than number of sessions, may be a factor, as may be the therapists’ styles of dealing with
the emotional reactions of patients and relatives to the educational material. The behav-
iors and disruptions of schizophrenia, in particular, require more than education to
enhance patient outcomes.
An exhaustive review of 729 publications including analysis or data on mediating or
moderating factors was published recently in this journal (Gracio, Goncalves-Pereira, &
Leff, 2016). While definitive conclusions that allow attribution of specific mechanisms to
FPE appear to be lacking, the authors gleaned several consistent findings across these
studies. In responses from family members and patient participants, it is clear that
engagement and relationship building, trust, and collaboration are key, as in almost all
psychotherapies and even in prescribing psychiatric medications. Other factors include
education, almost regardless of the method of delivery. Levy-Frank, Hasson-Ohayon, Kra-
vetz, and Roe (2011) found that both strong therapeutic alliance and PMFG with problem
solving led to equally positive outcomes, including reduction in EE, which in itself
appeared to be correlated with reduction in psychiatric symptoms. FPE is effective

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476 / FAMILY PROCESS

because it provides, at a minimum, a therapeutic alliance with family members and the
affected person, extensive education, and guidance and coping skill training (Gracio et al.,
2016; Kuipers, 2006). The relatives who have experienced MFG-PE and other group fam-
ily interventions invariably attribute positive outcomes to sharing concerns, burdens, and
ultimately coping strategies across family lines, which can be subsumed under expanding
social networks and social support. These are perhaps the most powerful variables known
for predicting not only psychiatric outcomes but also death rates and other key outcomes
from many chronic medical disorders (Putnam, 2000).
These variables may be the explanation of the results claimed by the open-dialogue
approach developed in Lapland by Lehtinen, Seikkula et al. (2006). In spite of having been
tested in only one clinical trial with mixed results, it has been posited as an alternative to
FPE, given its emphasis on engagement, receptiveness, conceptual flexibility, dismissal of
the therapist’s expertise, and positive reframing. The developers appear to be unaware of
controlled trials of SF-PE or MFG-PE in the United States, or of the vast research base for
FPE. This may be the result of the model being based historically on systemic family ther-
apy and psychodynamic individual therapy concepts, in which the family is seen inevita-
bly as a pathological influence, nearly the theoretical opposite of FPE. It is, like many
applications of SF-PE, usually done in the home, with the provision of some education
about psychosis. Interestingly, one outcome was a reduction in incidence of first-episode
psychosis in Western Lapland, as was documented in the PIER study in the United States.
This approach in its current form, which de-emphasizes universally dysfunctional family
pathology, may offer a way to accommodate and assist families that are not easily engaged
in FPE, although it may be at the cost of some reduced reliability of outcome.
The other key mediating variable is fidelity of the intervention itself, relative to the
models designed and tested originally by developers. For instance, McDonell et al. (2007)
documented a nonlinear decline in outcome as fidelity to the MFG-FPE model declined;
only high fidelity MFG implementation replicated relapse results, unlike even moderate,
let alone low, fidelity. Clearly, as in other advanced methods in medicine and technology,
advances in outcomes require adherence to the methods used originally to achieve them.
The evidence strongly suggests that casual modifications and short-cuts lead to dimin-
ished chances for recovery, often to the level of usual care. For a number of historical rea-
sons, the mental health field has been slow to recognize the importance of precise,
scientifically validated methods, as they are in most other fields of modern human endea-
vor.

CONCLUSION
Abandoning the assumption of family pathology, FPE has accumulated a remarkable
record of efficacy, even while being applied in settings and populations vastly different
than those in which it was developed. Meta-analyses have demonstrated reductions in
relapse rates for persons suffering from schizophrenia to 40% of those in control groups,
comparable to, if not larger than, the effect for antipsychotic medication versus placebo.
The multifamily group format reduces those rates by another one third. This record is not
matched by many treatments for any disorder, but does support the efficacy of directive,
cognitive, and behavioral therapies when applied in severe psychiatric syndromes. The
instances in which studies have not replicated those results tend to have deviated substan-
tially from the methods recommended by previous successful clinical trials or, in the case
of some international trials, may have suffered from inadequate adaptation to the regional
culture. That is suggested by the evidence that some culturally specific adaptations of psy-
choeducational multifamily groups, for example, to Latino populations in the United
States or the Vietnamese population in Australia, have been remarkably effective in more

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MCFARLANE / 477
rigorous trials. Recent applications in first-episode psychosis and the prodromal phase of
psychoses have shown promising results, leading to increasing dissemination in the Uni-
ted States and internationally. A partial failing is to fully study and document exactly the
mechanisms by which the approach is effective. It is clear that reducing expressed emo-
tion, the original goal, is necessary but not sufficient; improvements in functioning and
family well-being, when they occur, appear to be related to modifications intended to focus
on coping strategies to address stressors and cognitive impairments. Ultimately, the chal-
lenges in the future are two: to fully implement this approach for the people who will bene-
fit and to continue to seek and test adaptations that might further improve outcomes.

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