Family Therapy for Schizophrenia: Co-Occurring Psychotic and

Substance Use Disorders

Jennifer D. Gottlieb,1 Kim T. Mueser,1 and Shirley M. Glynn2
1
Boston University
2
University of California, Los Angeles, CA

People with schizophrenia have a high prevalence of co-occurring substance use disorders, which is
related to a worse course of psychiatric illness, more frequent relapses, and increased depression and
suicide, compared with those with schizophrenia alone. The Family Intervention for Dual Diagnosis
(FIDD) program, which includes psychoeducation and goal setting and focuses on building communi-
cation and problem-solving skills within the family, can aid in decreasing the stress related to having a
close relationship with someone with a dual disorder. Here, the case of a young man with psychosis
and marijuana dependence is examined. This article describes how the FIDD intervention helped him
with his problematic substance use, as well as to build skills within his relationship for increased
empathy and reduced interpersonal stress.  C 2012 Wiley Periodicals, Inc. J. Clin. Psychol: In Session

68:490–501, 2012.

Keywords: schizophrenia; psychosis; substance use disorders; serious mental illness; dual disorders;
family therapy; behavioral family therapy

Schizophrenia is a severe mental illness characterized by psychosis, apathy, social withdrawal,

and cognitive impairment. With the development and validation of a growing range of evidence-
based treatments for schizophrenia, the previously held notion that the disorder is intractable
and untreatable has been debunked. Nevertheless, schizophrenia continues to be one of the most
disabling psychiatric disorders, and the World Health Organization has ranked it as 1 of the top
10 leading causes of disability worldwide.
People with schizophrenia, as well as other severe mental illnesses (SMI) such as bipolar
disorder and treatment-refractory major depression, have a high prevalence of co-occurring
substance use disorders (or dual disorders). The rates of lifetime substance abuse of about 50%
are much higher than the lifetime prevalence of substance use disorders in the general population
(about 15%). Clients with dual disorders have a worse course of psychiatric illness than persons
with SMI alone, including more frequent relapses and rehospitalizations, homelessness, poor
health, legal problems, and increased depression, hopelessness, and suicide (Drake, O’Neal, &
Wallach, 2008).
Over the past two decades a growing consensus has emerged that traditional approaches to
treating dual disorders, such as having separate clinicians treat each disorder or treating the so-
called primary disorder first followed by treating the so-called secondary disorder, are ineffective.
To replace these outdated approaches, integrated treatments have been developed that target the
treatment of both disorders at the same time, by the same clinician. Most integrated treatment
programs have focused on group or individual interventions (Barrowclough et al., 2010), or
their combination. Although progress has been made in integrated treatment, the results from
controlled studies are inconsistent, and improvements are often modest at best, suggesting a
need to improve their effectiveness.

This research was supported by Grant No. MH62629 from the National Institute of Mental Health National
Institute on Drug Abuse. This paper is subject to the National Institutes of Health Public Access Policy.
The authors appreciate the following persons for their contributions to this study: Cori Cather, Lindy Fox,
Roberto Zarate, Haiyi Xie, Greg McHugo, Robin E. Clark, Rosemarie Wolfe, and Karen Sullivan.
Please address correspondence to: Jennifer Gottlieb, Center for Psychiatric Rehabilitation, Boston Univer-
sity, 940 Commonwealth Ave. West, Boston, MA 02215; e-mail: jgott@bu.edu

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 68(5), 490–501 (2012) 

C 2012 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21852

 Family Therapy for Schizophrenia 491

One potentially fruitful area may be working with the family. Dual disorders can have delete-
rious effects on relatives by increasing their burden of care and leading to interpersonal conflict.
Family members are more likely to hold a relative with a dual disorder responsible for his or her
psychiatric symptoms than relatives with only SMI, and tense and stressful family relationships
may contribute to more frequent symptom relapses (Pourmand, Kavanagh, & Vaughan, 2005).
This strain can result in the loss of family support, leading to housing instability, homelessness,
and a more severe course of both disorders.
Family treatment has been repeatedly shown to be effective for SMI (Dixon et al., 2010).
Similarly, there is ample documentation of the efficacy of family-based treatment for substance
use disorders (Stanton & Shadish, 1997). However, until recently, less attention had been paid
to working with families of people with dual disorders. Increasing family coping skills and
decreasing the stress of having a close relationship with someone with a dual disorder could
enable families to provide critical supports that contribute to improved outcomes. With this in
mind, the Family Intervention for Dual Diagnosis (FIDD) program was developed (Mueser,
Noordsy, Drake, & Fox, 2012). Described in more detail below, the FIDD program includes
psychoeducation and focuses on building communication and problem-solving skills in family
members, including the client.
In a recent randomized controlled trial (Mueser et al., 2012), the FIDD program was asso-
ciated with client improvements in psychiatric, substance abuse, and functional outcomes over
the 3-year study period, and benefited relatives across a range of outcomes. Clients in FIDD,
compared with brief family psychoeducation, had significantly less severe psychiatric symptoms
and psychotic symptoms, and there was a trend for them to improve more in overall functioning.
Relatives in FIDD acquired more knowledge of dual disorders and mental health functioning
than those in psychoeducation alone. Although continued study of FIDD is needed, these find-
ings support the utility of family intervention for dual disorders, as well as the added benefits of
communication and problem-solving training.

FIDD
The FIDD program was adapted from the behavioral family therapy model for severe mental
illness (Mueser & Glynn, 1999). FIDD is based on an expanded conceptualization of the stress-
vulnerability model of SMI and is informed by the stages of change, modified for use with those
who have dual disorders.

Expanded Stress-Vulnerability Model

This model posits that SMI (as well as co-occurring substance use) is caused by a psychobio-
logical vulnerability determined by genetic and other biological factors, and that the course of
the disorders (symptoms, relapses, functioning) is influenced by the dynamic interplay among
psychobiology, stress (e.g., life events, exposure to high levels of interpersonal conflict), the social
environment (e.g., social support), and client coping skills (e.g., social skills, stress management
skills). Accordingly, the course of SMI can be improved by reducing biological vulnerability
through medications and minimizing substance use, reducing socioenvironmental stress, im-
proving social support, and improving coping skills.
The FIDD program was designed to address the goals that follow from the stress-vulnerability
model through a combination of three strategies: (a) providing information about dual disorders
and their treatment to facilitate medication adherence and the family’s ability to make informed
treatment decisions; (b) teaching communication and problem-solving skills to reduce family
stress, increase social support, and facilitate the ability of family members to achieve their
personal goals; and (c) tailoring those skills to the unique needs of each family.
492 Journal of Clinical Psychology: In Session, May 2012

Stages of Treatment
The stages of change model, which proposes that people alter unhealthy behaviors by proceeding
through a sequence of distinct motivational states, was adapted for FIDD (Mueser et al., 2003).
Four stages are identified, each characterized by a unique pattern of behavior with an explicit goal
for that stage. During the engagement stage, the client does not have a therapeutic relationship
with the clinician, and the clinician’s goal is to establish such a relationship through regular
contacts. During the persuasion stage, a therapeutic relationship has been established but the
client continues to abuse substances with no clear desire to reduce; hence, the clinician’s goal
is to instill motivation for change, as indicated by reduction in substance use or abstinence.
During the active treatment stage, the client has made progress towards reducing substance
use or achieving abstinence and the clinician’s goal is to eliminate the client’s harmful use of
substances. During the relapse prevention stage, harmful use of substances has been eliminated
and the clinician’s goal is to help prevent relapses. Conceptualizing treatment according to the
client’s stage of change helps clinicians optimize their therapeutic interventions by ensuring that
they are consistent with the client’s motivational stage.
Although the term persuasion is used to describe the clinician’s goal when the client has not
identified working on substance abuse as a goal, this does not mean the therapist cajoles or
prompts the person to change his or her behavior. In contrast to some traditional substance
abuse therapies in which the clinician takes an active, directive stance against substance use,
in FIDD the clinician adopts a more exploratory, collaborative approach to understanding the
client’s experiences, including how substance use may have interfered with important goals or
values, to instill motivation for change. If a client comes to treatment with a desire to reduce or
stop substance use, then this is adopted as a therapeutic goal. However, if the client does not
initially articulate this goal, then the clinician helps the person set and work towards alternative
goals, and highlights obstacles to achieving them caused by substance use as they occur over the
course of treatment. This process helps clients see the negative effect of substances in their lives,
leading many to choose to address the issue directly.
The stages of treatment model are also used to inform the organization and pacing of the
FIDD program. Sessions focus initially on establishing a therapeutic relationship with the family,
followed by providing information (and other motivational enhancement strategies, as needed)
to motivate them to work on the client’s substance abuse. When there is evidence of sufficient
motivation, attention shifts to further reduction and abstinence, followed by helping the family
develop relapse prevention strategies when harmful use has ceased.

Family Sessions
Family sessions include the client and any involved family members. Sessions last for about an
hour, are conducted at a location convenient for the family (e.g., home or clinic), and are usually
provided on a declining contact basis (e.g., weekly, biweekly, monthly) for 9 to 18 months.
FIDD is organized into a series of phases: engagement and assessment, psychoedu-
cation, goal-setting, communication skills training, problem-solving training, and relapse-
prevention/termination. Communication and problem-solving training are conducted using
social learning methods such as role-plays, in-session practice, and regular out-of-session prac-
tice assignments, typically scheduled during ongoing weekly home family meetings. These treat-
ment components are discussed in more detail in the case example below. The number of sessions
spent on each phase is flexible, with all aspects of the program individualized to address the
unique needs of each family. Table 1.

Case Illustration
Presenting Problem and Client Description
We present here the case of “Robert,” who participated in the FIDD program for approximately
1.5 years with his girlfriend, “Jessica.” Robert was a 33-year-old unmarried African-American
man with a diagnosis of schizophrenia, paranoid type, who was referred to the FIDD program
 Family Therapy for Schizophrenia 493

Table 1
Phases of FIDD, Corresponding Client Stages of Substance Abuse Treatment, and Number of
Sessions

Phase of FIDD Client stage of treatment No. of sessions

1. Engagement/assessment Engagement or persuasion 1-3

2. Psychoeducation/goal-setting Persuasion or active treatment 4-8
3. Communication skills training Persuasion, active treatment, or relapse prevention 4-8
4. Problem solving training Persuasion, active treatment, or relapse prevention 5-15
5. Relapse prevention/termination Active treatment or relapse prevention 1-3

Note. FIDD = Family Intervention for Dual Diagnosis.

by his psychiatrist. Robert, who had recently started pharmacological treatment at a specialty
psychosis program in a major metropolitan area, eventually disclosed (at the urging of his
girlfriend) that he had a history of alcohol abuse and was using marijuana daily. His initial
complaints also included low motivation, depression, boredom, distractibility, sleep difficulties,
and beliefs that his coworkers were trying to poison him at the factory where he worked.
Robert came from a large, somewhat neglectful family with a history of substance use, mood
disturbance, and psychosis. Robert’s parents were divorced and he described his relationship
with his father as distant. From a previous relationship, Robert had one young daughter with
whom he had frequent contact. He was currently in a 3-year relationship with Jessica, who held
a full-time job that involved long hours and early morning shift work. Soon after they began
dating they moved in together, because Robert lacked money and was in danger of becoming
homeless.
Robert had experienced multiple problems for several years, including difficulty maintaining
employment due to the combined effects of substance use and psychotic symptoms, bouts of
homelessness, and financial problems supporting himself and providing support for his daughter,
whose mother had full custody. As a result, Jessica supported them almost entirely, including
paying rent, buying food, and also giving Robert weekly spending money. Robert’s psychotic
symptoms and paranoia also made it difficult for him to develop and maintain friendships, and
so he had little social contact apart from outings with Jessica and family get-togethers. At the
outset of treatment, Robert’s daily activities included sleeping for several hours after Jessica
had left for work, smoking marijuana, looking for permanent work, playing video games, and
going to his temporary job in the evening for his 3-hour shift. Despite Robert’s social avoidance,
he was affable and friendly in psychotherapy, and demonstrated a good sense of humor in his
interactions with Jessica.
Although Jessica often expressed frustration with “having to do everything around here,”
she tended to become emotionally withdrawn when upset with Robert. She often channeled
her distress into increased cigarette smoking and unhealthy eating, and frequently went out
with her girlfriends to “blow off steam,” which often involved binge drinking. In the initial
sessions, Jessica was sometimes affable like Robert, but at other times became affectively flat and
withdrawn, particularly when she was upset with Robert.

Case Formulation
A close examination of Robert’s problems, including his low motivation for productive activity,
and his substance use, paranoia, and social isolation, suggested that they stemmed from several
sources. Given his family history of substance abuse and psychiatric problems, his biological
vulnerability to developing a substance use disorder or a psychiatric condition was quite high.
These vulnerabilities may have been fueled by the stress of a chaotic upbringing. Robert reported
that he had not received much positive attention as a child and adolescent, in part because of
his large family, his parents’ marital discord, and their own psychiatric problems. Robert had
become socially withdrawn and apathetic about pursuing further education and a career, despite
494 Journal of Clinical Psychology: In Session, May 2012

some interest in becoming a woodworker. In addition, the neighborhood in which Robert grew
up was impoverished and prone to street violence and he felt that he was “always watching [his]
back” during his adolescent years, a degree of hypervigilance that may have contributed to some
of his paranoid ideation.
Further contributing to the development of psychotic symptoms was Robert’s substance use.
In his early 20s, Robert spent a lot of time in bars and drinking with friends. His drinking became
problematic around his mid-20s. When his family grew concerned, he decided to quit. At the
beginning of FIDD, Robert reported that he had not used alcohol for approximately 5 years.
However, after he stopped drinking, he began to smoke marijuana on a more frequent basis so
he would have something to do when friends were drinking around him. He then began to use
marijuana on his own as well, to wake up in the morning and to reduce his anxiety throughout
the day. Robert admitted that although he smoked marijuana to relax, he often ended up feeling
more paranoid, thus creating a vicious cycle whereby the marijuana exacerbated his vulnerability
to psychosis and associated anxiety.
Robert’s drug use and paranoia interfered with his ability to hold a job, which affected many
other areas of functioning, including his relationship with Jessica and his financial situation,
which therefore affected his relationship with his daughter. Although clearly bright with a sharp
wit, Robert did not have a high school diploma and was unable to find meaningful or interesting
work that paid well. As a result, he often was only eligible for temporary unskilled work, which
meant a sporadic schedule and the graveyard shift with unfamiliar people, all of which worsened
his psychiatric symptoms. In addition, because he was often bored at work, he smoked marijuana
before going to work, which decreased his job performance and increased his paranoia, resulting
in avoidance of coworkers and managers and sometimes calling in sick on days when his paranoia
was acute.
Jessica, although clearly very much in love with Robert and fairly tolerant of many of his
problems, was at her wit’s end with some of his behaviors and was desperate to get help. She
reported feeling confused by his paranoid beliefs and was unsure about how to respond to them.
However, Jessica also played an indirect role in maintaining his problem behaviors. Although
she often became angry about Robert’s spending money on marijuana and at his odd beliefs
and behaviors, she supplied him with money on a weekly basis to spend on “necessities, like his
lunch, and stuff for the house,” which, in turn, he often spent on marijuana instead. Despite
working full-time, Jessica took on the majority of the household tasks and paying bills. She
reported feeling anger about Robert’s lack of contribution to the household, and often took on
tasks herself once it became apparent that he was not going to complete them, further increasing
tension in their relationship. She frequently threatened to “kick him out if he doesn’t change,”
but had never followed through on her threats. Jessica’s tendency to adopt a caregiving role with
Robert appeared to perpetuate some of his reluctance to seek more stable employment and to
contribute more to the household.

Course of Treatment
Both Robert and Jessica were initially reluctant to participate in FIDD because they had no past
experience with individual or family therapy and were uncomfortable with the intrusive nature
of therapy as they conceived of it. However, once they learned more about FIDD, particularly
its emphasis on education and skill building, they became interested. They agreed to participate
to address Robert’s substance abuse and to learn more about his psychiatric disorder and how
to deal with it.
Before education and improving communication and problem-solving skills can commence
in FIDD, the clinician may need to evaluate the couple’s commitment to their partnership and
address any uncertainty or disparity about the commitment, as well as endeavor to increase
positive experiences in the relationship. Despite Jessica’s upset at Robert’s substance use and her
threats to leave him, both of them wanted to make their relationship work, which was a primary
motivation for participating in FIDD. Throughout the course of FIDD the therapist looked
for opportunities to draw attention to positive aspects of the couple’s relationship, to bolster
engagement in mutually rewarding activities, and to establish positive expectation for mutually
 Family Therapy for Schizophrenia 495

desired changes. For example, the clinician prompted the couple to make an inventory of their
partner’s strengths, which were periodically reviewed. At the end of particularly challenging
sessions, each member was asked to describe one thing that occurred during the week for which
they were grateful to their partner. These strategies helped strengthen the couple’s resilience and
keep them engaged in both the relationship and the FIDD program.

Engagement and psychoeducation. The initial sessions involved building rapport with
the couple and gathering information to develop a case conceptualization and a treatment
plan. A good deal of time was spent understanding Robert’s substance use habits, triggers, and
perceived benefits to assess both his stage of change as well as Jessica’s willingness to make
changes. Although Robert acknowledged that he wanted to do more with his life, and that it
was hard when Jessica became upset with him, he did not think that his marijuana use was
problematic. Although this revelation upset Jessica, the clinician responded to his perspective in
a nonjudgmental way, and Robert was asked if he would be willing to revisit these beliefs and
experiences at a later point in the program, to which he agreed.
Following engagement, several weeks were spent on psychoeducation. Robert and Jessica
initially took a light approach to the handouts and worksheets, which involved a lot of joking,
suggesting that they were uncomfortable discussing some of the topics, such as the nature of
psychotic symptoms, and the effect of substance use on work and intimate relationships. Upon
further discussion, Jessica admitted that they had never openly talked about any of these topics
and that she often pretended that the psychotic symptoms were not as prominent as they actually
were. Once their avoidance and reluctance were normalized, the couple began to delve into the
educational materials more conscientiously, and many serious and fruitful discussions ensued.
Although Robert felt validated after learning that other people had the same experiences as
he had, he initially seemed embarrassed about his psychotic symptoms, often asking, “Am I
nuts?” Jessica showed a newfound empathy for Robert based on these discussions. The educa-
tional sessions, particularly the stress-vulnerability model and the discussion of how biological
vulnerability can make people more sensitive to the effects of substances, helped the couple.
This increased understanding of the relationship between psychosis and substance use opened
a door for Robert by providing new insight into his difficulties, and increased his motivation to
re-consider his drug use.

Goal setting and treatment planning. The next phase of FIDD involved helping Robert
to develop treatment goals and encouraging Jessica to establish personal goals as well. Having
relatives or significant others work towards personal goals in FIDD, in addition to the client
himself/herself, can both improve their well-being and serve as a positive role model to the
client. Robert’s treatment goals were as follows: (a) to look into my GED and take the test; (b)
to look into trade schools; (c) to have more structure to my day; (d) to think more about my pot
use; and (e) to get along with Jessica better. Jessica, although initially reluctant to set her own
goals, decided to work on looking into smoking cessation programs and starting to exercise and
lose weight.

Communication training. An often crucial component of FIDD is communication train-

ing and practice. Many families struggle with effective communication, which can become more
pronounced with a relative with a dual disorder. Clients may become withdrawn, anxious, and
ashamed and their negative symptoms/depression may reduce their desire and ability to inter-
act meaningfully. Family often become unsure about what to say to their relatives about their
symptoms and may feel resentful or critical about functional difficulties or ongoing substance
use.
Communication training in FIDD is based on social skills training methods. These methods
include establishing the rationale for a specific skill, breaking the skill down into component
steps, modeling the skill, engaging family members in practicing the skill in role-plays, providing
positive and corrective feedback followed by additional practice, and collaboratively developing
home assignments for family members to practice the skill on their own. Some of the skills
496 Journal of Clinical Psychology: In Session, May 2012

taught in FIDD include expressing positive feelings, making a request, and expressing negative
feelings.
Although Robert and Jessica initially scoffed at the idea of role-playing communication skills,
they both readily admitted that they had difficulty communicating about sensitive topics and that
they had tended to avoid these discussions altogether, such as talking about Robert’s symptoms
or marijuana use. Instead, they tended to use humor to deflect their uncomfortable feelings
when communicating, or they argued and yelled at each other. As a result, approximately 10
sessions were spent on communication training. The initial in-session training involved having
the couple use these specific skills to work on less emotionally charged topics, such as the division
of household chores and TV-watching schedules. For example:
Therapist : How about we try a role-play to practice this “Making a Request” skill?
Robert : (laughs) Yeah, I don’t think so. I’m no actor really.
Jessica : Right, that’s not really our thing. We know how to do it; we don’t need to.
Therapist : I completely understand your reluctance, and I do know that you two have a lot
of good skills under your belt as a couple. I also know that some things have been
tough, and this is really common for couples going through the kinds of things that
you are going through. I wonder if we might just give it a try, just to see if this new
way helps, even a little bit.
Robert : I don’t know, I feel stupid.
Therapist : I know it feels uncomfortable initially. When I first started doing role-plays in front
of people, I felt a little funny too. That’s totally normal. But it can make a big
difference to try things out here first; that way when a conflict comes up in real life,
you’ll feel more relaxed about it and know how to handle it. How about I play you,
Robert, first? Beforehand, I can suggest some things for Jessica to say. That way
everyone might feel a little more prepared. Then we can switch off later, if we want
to. What do you think?
Robert : Okay, I can see how you do it. Make sure you talk in a deep voice though (laughs).
Jessica : Yeah, that sounds easier than both of us trying to do this together right now.
As the couple became more skillful at communicating, more challenging topics were initiated,
such as Jessica’s telling Robert, “When you are high when I come home from work, it makes
me feel sad about our relationship” and “I would appreciate it if you didn’t make a joke when I
mention something that upsets me and I want to talk with you about it.” Gradually over time,
at the beginning of sessions, Robert and Jessica began to bring up difficult arguments that they
had during the week, and requested to role-play their communication in session. They began to
integrate improved communication into their lives and found that these skills helped them talk
about and solve problems, both as individuals and as a couple.

Problem-solving strategies. Clients with dual disorders often have difficulty knowing
how to approach and solve daily problems, which can lead to continued avoidance of these
problems, increased substance use as a coping strategy, and eventually an exacerbation of the
original problem. As a result, a substantial part of FIDD is devoted to teaching practical, step-
by-step problem-solving skills that can be done together by the family, or by the individual client
with the help of relatives. Initially, the clinician teaches the steps of problem solving to the family,
demonstrating each step by leading them through an example. As the family learns the skill, the
clinician shifts the responsibility for problem solving to the family, while continuing to provide
prompting, coaching, and feedback. The time spent in sessions focused on practicing problem-
solving steps, with home assignments developed to practice the skills outside of sessions. Robert
had a relatively long problem/goal list, which had become a source of frustration to both him
and Jessica after years of little progress. The steps of problem solving were first introduced in
session while working on a nonemotionally charged problem: Robert’s not knowing where to
look into getting his GED. As Robert and Jessica became more adept at problem solving, more
challenging problems were addressed, such as Robert’s lack of daily structure.
 Family Therapy for Schizophrenia 497

The therapist had to occasionally encourage Robert to stick to the steps of problem solving,
so that he did not become frustrated and give up in the middle of the process. For example,
creating increased daily structure was a big challenge for Robert and involved multiple steps
(buying his own alarm clock, finding out the cost of a gym membership, carving out a time for
chores and GED preparation), many of which necessitated overcoming obstacles (e.g., turning
off the alarm when it beeped after Jessica left for work, getting drawn into several hours of
playing video games, having his daughter’s mother cancel their visit) and developing methods
for rewarding himself for progress towards his goal (e.g., playing 30 minutes of video games for
every hour of GED study).
During this problem-solving training component, although Robert initially had articulated
working on marijuana use as a treatment goal, he remained ambivalent about cutting down.
Robert was in the persuasion stage of treatment, so the family work focused on increasing
motivation through the use of motivational interviewing techniques. For example, a payoff matrix
was used in session to help Robert explore the pros and cons of continuing to use marijuana
versus cutting down or stopping. Robert tended to withdraw and not show up for FIDD
sessions when he felt pressured, and so session time was a balance between working on his other
treatment goals (such as improved daily structure and increased fun activities for the couple)
and motivational enhancement strategies. To keep Robert engaged in FIDD, the clinician also
conveyed empathy about his ambivalence about his drug use and normalized his experience of
finding some beneficial effects of marijuana on anxiety and psychotic symptoms. The clinician’s
validation, normalization, and nonjudgmental stance appeared to increase Robert’s willingness
to stick with the FIDD program and to discuss his thoughts and feelings about his drug use.
Approximately 4 months into the FIDD program, Robert reported a frightening experience
with marijuana while Jessica was at work. He had smoked a larger amount than was usual for
him and suffered severe paranoia and a panic attack involving the belief that he was about to
die. As a result, he went to the emergency room, where he was examined and released. After that
event, and the clinician’s explanation that marijuana use can sometimes cause panic attacks,
Robert decided that he was ready to start reducing his marijuana use and that he wanted to stop
altogether.
Problem-solving work focused on Robert’s developing strategies to deal with cravings, bore-
dom, and triggers (playing video games, loneliness, etc.). Figure 1 presents one of Robert’s
problem-solving exercises. Robert began to reduce his marijuana use, and as he began the action
stage of treatment, it also became possible to address Jessica’s indirect role in reinforcing his use
and his lack of contribution to the household.
The couple decided how to modify their daily activities and time spent together without
contributing to Robert’s substance dependence. For example, they were uncertain how Robert
would assume household responsibilities (i.e., grocery shopping) without spending the money
on marijuana instead. The couple developed a creative set of solutions that involved purchasing
grocery store gift certificates for Robert to use each week. In addition, a variety of related
strategies were developed: (a) Robert would call Jessica right after he spent money on something
healthy and worthwhile so she could praise him and thank him and (b) a reward for the couple
was planned (e.g., going to the movies) if a week went by without Robert’s spending extra money
on drugs. These exercises built a robust skill foundation for the couple, which allowed them to
move toward their individual and shared goals. Robert’s marijuana use decreased in frequency
and quantity. Feeling under less pressure, Jessica began a weekly exercise regimen, and accepted
a referral for a local quit smoking program.
Robert used his communication skills as the problem solving progressed, particularly on this
drug abuse. As Robert began marijuana abstinence, he learned about his personal cues and
triggers and identified cigarette smoke as a trigger for craving. Jessica, who was a heavy smoker
and had initially expressed interest in quitting but had not moved into the action stage yet,
frequently smoked at home and when they were out together. Robert finally chose to tell her in
session, “It is really hard for me when you smoke in front of me. It is a trigger for me for pot. I
know you want to help me quit, but it makes it worse when you smoke. I’d appreciate it if you
would work on quitting smoking for my sake, or at least not smoke when I am around.” This
interaction went well and, as a result, Jessica changed her behavior and followed up on the quit
498 Journal of Clinical Psychology: In Session, May 2012

Figure 1. FIDD problem-solving worksheet completed by Robert in session

smoking program referral. Robert also used his improved communication skills (e.g., refusal
skills) with coworkers who invited him to smoke marijuana during their shift breaks, and also
with his manager to ask him for more stable shift hours. The integration of communication skills
and problem-solving skills allowed Robert to make greater progress on his goal of marijuana
abstinence.

Relapse prevention planning and treatment termination. Approximately 1 year and 25

sessions through the FIDD program, Robert had made substantial progress toward many of his
goals. He had first reduced his frequency of marijuana use and then stopped using completely
and maintained his abstinence even in difficult situations, such as when coworkers invited him to
use while he was bored at work. He also completed the paperwork for the GED test registration
and started studying for the test. Although he still had some paranoid beliefs, he managed them
 Family Therapy for Schizophrenia 499

better without the exacerbating effects of the marijuana. In addition, he and Jessica reported
that they were arguing less, talking more, and having more fun together.
Given these improvements, relapse prevention plans for both psychosis and substance use
were developed over the course of several sessions. These written plans were a collaborative
effort among the clinician, Robert, and Jessica, and included several components: a list of
warning signs of impending psychosis, triggers to use marijuana, effective coping strategies, and
actions for Robert and Jessica to follow should a marijuana lapse occur or a symptom increase.
In addition, protective factors that kept Robert healthy were also highlighted. These included
maintaining psychiatry appointments, not running out of medications or missing doses, keeping
up with daily structure, using drug refusal skills, and communicating honestly with Jessica when
his symptoms were bothering him.
Once the relapse prevention plans were developed and approved by the couple, the session
frequency decreased from weekly to every other week. Robert and Jessica continued to practice
problem solving as a homework assignment. As a result, the final sessions were spent planning
to help them continue to use the problem-solving and communication skills learned throughout
FIDD, now that treatment was coming to a close.

Outcome and Prognosis

Robert and Jessica completed the FIDD program in approximately 18 months and 32 sessions.
By the end of treatment, many new behaviors had been implemented. Robert had moved from
expressing no desire to stop marijuana use to a 3-month period of abstinence, and he reported
reduced paranoia and depression and increased energy. He had learned how to deal with cravings
and noted a reduction in them as well. Robert had also signed up for the GED and had been
given a test date. His studying was sporadic, but he continued to use the study guides. Although
Robert was anxious about the upcoming test, he was proud of taking steps toward his goal.
He also increased his work hours and was more assertive with his managers about scheduling.
Robert and Jessica reported that his parenting skills had improved. His daughter’s mother was
supportive of his recovery and became more willing to allow Robert and his child to spend time
together. Robert noted that when he visited with his daughter, he felt more motivated to plan
and follow through with fun, child-friendly activities, rather than staying home and watching
TV together.
The couple reported that their relationship had improved as well and included more meaning-
ful time together, less tension and arguing, and less avoidance of talking about upsetting feelings.
Jessica reported that she was no longer thinking of ending their relationship and the couple had
made an overt decision to stay together and even began to contemplate marriage. Both Robert
and Jessica had learned much more about schizophrenia, substance use and its consequences,
and dual disorders, which increased their motivation to work on other problems and created a
shared empathy.
Despite these positive outcomes, there were some challenges with this case. Although Robert
had stopped using alcohol prior to FIDD, toward the end of treatment he began drinking socially
again. This behavior change was attributed to his reduction in paranoia and social isolation and
his increased camaraderie with coworkers, who now invited him to join them for drinks after
work. Given Robert’s history of alcohol abuse and newfound abstinence from marijuana, even
this social drinking was of concern to the clinician and Jessica. However, Robert perceived the
social benefits of drinking as outweighing the risks. Further, because Jessica also drank on a
regular basis with her girlfriends and was unwilling to change this behavior, there was little
deterrent for him to avoid alcohol completely. As a result, time was spent in the final FIDD
sessions on how to monitor Robert’s social drinking and develop a plan for responding to any
increases in drinking.
Jessica did not progress on her personal goals in FIDD (i.e., smoking cessation, exercise,
weight loss), although she had enlisted a friend to join her for occasional walks. Toward the
end of FIDD, Jessica decided to begin individual psychotherapy at another mental health clinic
to address upsetting experiences from her childhood. The clinician reinforced this positive step.
One hope was that her behavior would also highlight the benefits of therapy for Robert, who had
500 Journal of Clinical Psychology: In Session, May 2012

declined a referral for therapy to address distress he still experienced related to his symptoms. By
the end of FIDD, Robert had still not elected to follow through on a referral, but had agreed to
continue to see his psychiatrist on a consistent basis and take antipsychotic medications. Given
his history of treatment nonadherence, the fact that he completed 18 months of FIDD with
full medication adherence and agreed to ongoing contact with a psychiatrist was an important
achievement.

Clinical Practices and Summary

This case highlights the multitude of difficulties that schizophrenia can cause: the functional
debilitation for the individual with the disorder; the stress experienced by the partner in under-
standing, empathizing, and coping effectively with the consequences of the disorder; and the
strain on the relationship as a whole. The addition of a substance use disorder, particularly when
left unaddressed by the couple over a long period, puts further strain on the relationship.
Directly addressing substance abuse was particularly helpful in this case, because both Robert
and Jessica had been minimizing its consequences and effects on their relationship. As mini-
mization or avoidance of addressing substance use in families is a common problem, this case
emphasizes the benefits of drawing out the problematic drug and alcohol use as the family
becomes ready to address it. In addition to the positive outcomes that accrued as a result of the
FIDD program, this case also highlights the challenges of effectively treating dual disorders—
within the individual, the family, and particularly a couple.
There were at least three lessons learned with this couple that apply to working with this
population as a whole. First, the lessons of the chronic and relapsing nature of dual disorders.
Robert made significant reductions in his marijuana use but his resumption of drinking was a risk
for relapse. This case illustrates the need to maintain close monitoring of the client’s functioning
and provide booster sessions and family meetings to address continued addiction. Second, the
case demonstrates the need to instill and cultivate motivation to address substance abuse. It is
difficult to motivate clients to change substance abuse when the negative consequences of their
use are not apparent or are compensated for by someone else. Talking openly about Robert’s
marijuana use and helping Jessica to express her resentment towards Robert for “not pulling his
weight” around the house enabled the couple to overcome their minimization of Robert’s drug
use, eventually leading to cessation. Teaching effective communication and problem-solving
skills facilitates the family’s ability to talk honestly while maintaining a low-stress environment
to avoid triggering relapses. Third, the case illustrates the role of goal setting in addressing
substance abuse. In session, motivational interviewing methods such as identifying the client’s
personal values and helping him see the discrepancy between those values and his substance
abuse, were used to move the client toward reducing his drug use. For instance, Robert wanted
to be a better father to his daughter and wanted to improve his relationship with Jessica.
Articulating these goals and exploring how Robert’s marijuana use interfered with them were
central to Robert’s developing motivation to get control over his substance use and eventually
his choice to become abstinent.
Research has demonstrated that the comorbidity of schizophrenia and substance abuse causes
a host of problems for clients in terms of heightened psychotic symptoms, increased difficulty
with daily functioning, and relationship dysfunction. The FIDD program can help clients and
their relatives to become more effective in coping with stressors that exacerbate both disorders,
as well as to reduce substance use and improve their relationships.

Selected References and Recommended Readings

Barrowclough, C., Haddock, G., Wykes, W., Beardmore, R., Conrod, P., Craig, T., . . . Tarrier, N.
(2010). Integrated motivational interviewing and cognitive behavioural therapy for people with psy-
chosis and comorbid substance misuse: Randomised controlled trial. British Medical Journal, 341.
doi:10.1136/bmj.c6325
Dixon, L.B., Dickerson, F., Bellack, A.S., Bennett, M.E., Dickinson, D., Goldberg, R.W., . . . Kreyen-
buhl, J. (2010). The 2009 PORT psychosocial treatment recommendations and summary statements.
Schizophrenia Bulletin, 36, 48–70. doi:10.1093/schbul/sbp115
 Family Therapy for Schizophrenia 501

Drake, R.E., O’Neal, E., & Wallach, M.A. (2008). A systematic review of psychosocial interventions for peo-
ple with co-occurring severe mental and substance use disorders. Journal of Substance Abuse Treatment,
34, 123–138. doi:10.0101/j.jsat.2007.01.011
Mueser, K.T., & Glynn, S.M. (1999). Behavioral family therapy for psychiatric disorders (2nd ed.). Oakland,
CA: New Harbinger.
Mueser, K.T., Glynn, S.M., Cather, C., Xie, H., Zarate, R., Smith, M.F., . . . Feldman, J. (2012). A
randomized controlled trial of family intervention for co-occurring substance use and severe psychiatric
disorders. Manuscript submitted for publication.
Mueser, K.T., Noordsy, D.L., Drake, R.E., & Fox, L. (2003). Integrated treatment for dual disorders: A
guide to effective practice. New York, NY: Guilford Press.
Pourmand, D., Kavanagh, D.J., & Vaughan, K. (2005). Expressed emotion as predictor of relapse in patients
with comorbid psychosis and substance use disorder. Australian and New Zealand Journal of Psychiatry,
39, 473–478. doi:10.1080/j.1440-1614.2005.01606.x
Stanton, M.D., & Shadish, W.R. (1997). Outcome, attrition, and family-couples treatment for drug abuse:
A meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 122, 170–191.
doi:10.1037/0033-2909.122.2.170