Advanced Family Work for Schizophrenia: An Evidence-Based Approach

This slim book of 19 case studies details how clinicians deal with special problems that arise in family psychoeducation for schizophrenia. The supervisor of these clinicians is Julian Leff, professor emeritus at the Institute of Psychiatry, King's College London. Leff is internationally recognized as a leading pioneer of family psychoeducation and the expressed emotion research that played a role in the creation of family psychoeducation.

Evidence-based family psychoeducation focuses on information about schizophrenia, support for caregivers, illness management, communication techniques, and problem-solving strategies. This intervention helps family members interact in a beneficial way and alleviates burdens engendered by the enormous stressors of living with schizophrenia. Yet Leff notes that additional work might be needed for special situations, such as culture clashes with ethnically diverse families, patients with dual diagnoses of psychosis and physical problems, and psychiatric illness of more than one family member. Special interventions might also be needed for families in conflictual or dysfunctional relationships, people with past traumas, and even exploitive caregivers.

Chapters addressing each of these categories add family therapy interpretations and techniques to the basic psychoeducational armature. However, Leff hastens to say, "I do not refer to family work as therapy since the family members are not considered to be in need of treatment. Rather they need to be seen as allies in the struggle to help the ill person recover from schizophrenia and fulfill their potential." Family work is clearly distinguished from the old family therapy paradigm of schizophrenia as a functional product of disturbed family dynamics. Interventions are viewed as shoring up the family as a supportive resource for recovery.

Each case is presented with history, presenting problems, formulation, supervisor's suggestions, follow-up, and commentary. Major issues involve control and independence, family roles, emotional overinvolvement of caregivers, and appropriate behavioral expectations. Different cultural assumptions and diverse feelings about medications are acknowledged. Illness behaviors and strategies for coping with voices and other hallucinations are discussed. Referrals are made for cognitive therapy to deal with delusions, a child guidance team, or dual therapists for a husband and wife.

Yet Leff is primarily a social environmentalist, both in research interests and in clinical supervision. What is clear from these interventions is the importance of the cultural context and referrals to external resources, particularly social networks. Day treatment programs, survivor clubs, religious societies, and support groups are avenues to new lifestyles and improved role identities. For a Jamaican patient, a culturally appropriate day program replaces a cannabis-smoking Rastafarian brotherhood that impedes therapeutic progress. A sexually abused woman thrives in a survivor group. A frazzled mother is referred to a caregiver's support group. McFarlane's findings of the superiority of multifamily psychoeducation reinforce the value of adding to the individual family intervention the dimension of shared experience ( 1 ).

This small but thoughtful volume offers potentially valuable materials for clinicians. Leff feels that a therapist support group is essential for emotionally taxing family work. Some situations are extremely difficult, and a family's hopelessness can make a therapist pessimistic. A therapist group can brainstorm solutions or at least help a colleague contest a family's feelings of helplessness. Leff points out that interventions that fail at one point may succeed at another, and the most valuable contribution a therapist can give a family is hope.