The Family Forum: Directions for the Implementation of Family Psychoeducation for Severe Mental Illness

The Family Forum provided an opportunity to discuss randomized controlled trials that indicated the efficacy of family psychoeducation in reducing symptomatic relapse and hospitalization rates and in improving medication compliance in schizophrenia. Five published meta-analyses have confirmed these benefits ( 8, 9, 10, 11, 12 ). However, forum participants identified serious practical difficulties in implementing family psychoeducation in nonresearch settings as well as unresolved research questions that limit our understanding of how to best structure the intervention to facilitate implementation.

Although family psychoeducation is ostensibly a specific model of family involvement, it may best be thought of as a collection of programs because it has been operationalized and implemented in various ways. A review of the empirically based family psychoeducation manuals reveals that although family psychoeducation interventions share many characteristics, there are considerable differences among them. The various programs share an emphasis on illness education, an empathic stance, formal or informal problem-solving training, and support for treatment adherence. However, they differ with respect to the proportion of time the consumer is present in the family sessions, the location of the intervention (home, clinic, or both), the degree of emphasis on formal skills training, the format (individual, group, or combination), the intensity of contact (weekly, biweekly, or monthly), and the length beyond nine months (up to three years).

With the exception of individual versus group interventions, these variations in family psychoeducation have not been systematically studied, so guidelines for the clinician (and therefore guidelines for implementation and dissemination) are absent. With respect to whether the intervention is conducted individually or in groups, the data suggest that the results of the two are comparable ( 13 ). The slight advantage of multiple-family groups over individual group interventions reported by McFarlane and colleagues ( 1, 14 ) is found only when examining results from people who have completed treatment. Because there are considerable dropouts in multiple-family groups, intention-to-treat analyses are appropriate, and in these analyses the advantage of multiple-family groups is not as robust ( 1, 14 ).

The specific mechanisms by which family psychoeducation generates its benefits are unclear. Because many family psychoeducation trials compare the intervention with customary care or waiting-list control groups ( 2, 15 ), positive findings may result from the intervention or simply more frequent therapist contact. Furthermore, tests of hypothesized mediating variables have yielded contradictory findings. Consider the case of improved family problem solving, which was hypothesized by Falloon and colleagues ( 16 ) to underlie the positive benefits of behavioral family therapy. Although the initial investigators reported significant improvements in problem solving ( 16 ), a more fine-grained analysis ( 17 ) found no significant improvement in communication or problem-solving skills associated with the more intensive, applied family treatment in the Treatment Strategies in Schizophrenia study ( 13 ). In another case, an early study indicated that reduced negative reactions (such as expressed emotion) by family members could underlie the positive benefits of family therapy ( 18 ), yet a later study found no effect of family therapy on relatives' negative reactions ( 19 ). Only one of the recent meta-analyses showed support for family interventions in reducing negative reactions ( 11 ).

Participation in an empirically validated family psychoeducation program clearly seems to confer a number of benefits that were not considered or measured by treatment originators yet may be integral to their positive impact. For example, participation in family psychoeducation typically permits easier access to the treatment team. Although such access is likely to promote better outcomes, it is rarely mentioned in study publications. Similarly, almost all of these programs include helping families to identify prodromes and develop a plan for rapid response. If such plans were implemented, they would probably lead to fewer acute exacerbations, yet use of specific relapse prevention plans has typically not been formally measured or linked with outcomes in family psychoeducation studies. Also, studies have indicated that education alone is not efficacious; instead, education in addition to support, problem-solving training, and crisis intervention are important components of efficacious family therapy ( 20 ). Thus, although meta-analyses clearly indicate that participation in these programs can reduce relapse, we have limited knowledge of the critical elements in the interventions. More data on the mediators, or critical elements, would increase the likelihood of successful implementation of family psychoeducation and increase its acceptability among consumers, families, and providers.

In summary:

• How family psychoeducation programs achieve their effects is not clear.

• Identification of causal therapeutic mechanisms would provide direction for the development of effective, more flexible, modifications of family psychoeducation models.

Theoretical and experiential literature has recently been published on the obstacles to implementation of family psychoeducation in routine practice. Forum participants identified barriers facing each stakeholder group (organization, provider, family, and consumer) and ways to address these barriers in order to serve the broadest population of consumers and their families. The group concluded that for family psychoeducation to be viable, three elements were essential: leadership support, training and ongoing supervision in family psychoeducation models, and adequate access to resources.

A critical issue that emerged from attempts to understand low rates of family psychoeducation use was the failure to consider family psychoeducation interventions in the context of the larger universe of family services for severe mental illness. In much the same manner that assertive community treatment is not appropriate, cost-effective, or acceptable to all consumers with severe mental illness, their families, or both, neither is family psychoeducation appropriate, cost-effective, or acceptable for all consumers and families. Some families may benefit from support but do not necessarily need an intensive intervention. Other families may not be receptive to long-term services but may undertake a briefer intervention.

Family Forum participants felt that, as the field focuses on implementation of family psychoeducation (currently the only evidence-based family involvement practice), we should not neglect the development and evaluation of other family-based strategies to support recovery. Interventions for families and consumers should be tailored to the needs of participants and will vary over time and circumstance. Further, successful development, implementation, and evaluation of an array of family-based services and interactions are very likely to increase and expand the appropriate utilization of family psychoeducation. The goal of adopting a treated-population perspective is to provide family services that are well matched to the consumer's service needs. This will permit the delivery of appropriate services to large numbers of consumers while using relatively fewer resources.

Efforts to advance a treated-population approach must address the needs of each key stakeholder, starting with the consumer. A subset of programs that address both consumer and family needs was discussed. The Family Member Provider Outreach intervention, which is a newly developed, two-phase manualized program, systematically engages the consumer in a discussion about family issues and concerns, encourages the expression of ambivalence, educates about options, and provides consumers with skills to talk with family members. Results from a pilot study of the Family Member Provider Outreach program indicate that this may be a promising approach to increase rates of family involvement in treatment, including but not limited to family psychoeducation.

Consideration of the treated-population approach also requires exploration of the relative's perspective. Family members typically benefit from access to the treatment team, a menu of options for education and support, and skill building. Naturally, they want to meet these needs as easily as possible. E-mail holds promise for connecting relatives with the treatment team efficiently, provided that security of information can be established and that families have access to a computer. Internet-based support and educational programs also address barriers to access often cited by families, especially in rural areas. Programs such as Support and Family Education ( 26 ) provide open educational and support groups for families that allow attendance at the family member's convenience and may provide a bridge to family psychoeducation.

Other options beyond family psychoeducation are community-based services such as the National Alliance on Mental Illness' Family-to-Family education program or the Journey of Hope family education course. These models are not clinical services but are offered by unpaid peer volunteers. They cannot substitute for family psychoeducation or other strategies that mental health providers use to link with families, but their potential to reduce families' subjective illness burden and to increase coping and knowledge of mental illness merits attention.

It is important to identify the expected outcomes of family involvement in care within each of the two broad program categories (less intensive family education and consultation and family psychoeducation). Published studies suggest that participation in general forms of family education, consultation, and involvement in treatment is associated with better adherence to treatment and to medications ( 33, 34 ) and increased feelings of empowerment and hope and greater perceived illness knowledge by consumers ( 35 ). Forum participants hypothesized that involvement in such programs could also be expected to result in greater rates of ongoing contact between family and the consumer's treatment team; increased empowerment for family members; increased knowledge about psychiatric illness, treatment, and resources for family members; increased satisfaction with the mental health services provided for consumers and their family members; an improved subjective recovery trajectory (such as perceived control and well-being) of the consumer participating in family-based services; enhanced perceptions of family support by consumers participating in family services; and improved coping and reduced stress and conflict among all involved family members. It is important to acknowledge that the measurement of many of these constructs (empowerment, knowledge, and recovery, for example) is a developing area of scientific inquiry. Table 1 summarizes the existing measures suggested for assessing the major outcome domains ( 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 ).

With regard to sustained participation in family psychoeducation, the existing literature on outcomes is more extensive, with a large body of randomized trials indicating that participation in family psychoeducation results in improved psychiatric symptoms ( 2 ), reduced frequency of relapses and hospitalizations ( 9 ), enhanced social functioning and quality of life, reduced family burden ( 51 ), and improved family functioning ( 52 ). Table 2 summarizes measures to assess these outcome domains ( 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70 ). Although initial family psychoeducation studies focused on measuring more clinically oriented outcomes (such as symptoms and relapses), forum participants agreed that the evaluation of family psychoeducation and family involvement in care should be broadened to incorporate a range of outcomes more directly relevant to recovery, such as empowerment, recovery orientation, community functioning, and consumer quality of life (see Table 1 ).

Additional work is needed to better understand the impact of family interventions on family members by assessing constructs such as family members' level of burden and family functioning.

In summary:

• Outcomes that may be achieved through general forms of family education, consultation, and involvement in treatment will likely differ from those achievable through family psychoeducation.

• Given the considerable efforts under way to implement and conduct further research on family interventions for consumers with severe mental illness, there is a pressing need for experts in measurement to develop appropriate measures of the impact of family programs.

Providing optimal care to the population of individuals with severe mental illness requires provision of services to families. The failure to achieve even minimal family involvement in care, let alone the more intensive involvement required by family psychoeducation, raises concerns. This article outlines critical issues that must be addressed by the field if we are to expand the proportion of families served. In the simplest terms: we need to offer family psychoeducation to more families, and we need to develop an evidence base for complementary family services.

Implementing family psychoeducation is a challenge, and to maximize its offering we need to know the critical aspects, or mediators, of family psychoeducation models. If research could provide answers to these questions, and if the answers drove the refinement of interventions toward the greatest clinical flexibility, then wider implementation could be achieved. Key unaddressed issues in family psychoeducation implementation include the question of how (and whether) individual and group family interventions should be combined. Also, can groups be open, with rolling admission, or must they be closed to new participants once the group begins?

It is clear that successful implementation requires adequate resources to get the services up and running, to support the providers, and to provide appropriate referrals. Giving family psychoeducation its best chance at affecting a larger population requires considerable front-loading of investment and agencies or institutions that consider family services to be a top priority and a necessity in good clinical care. This is a challenge to agency administrators and clinical supervisors, as well as to funding agencies and institutions to provide this support.

Ideally, future family services research would fully disaggregate family psychoeducation manuals in order to randomly assign and study family psychoeducation elements (for example, group 1 gets family psychoeducation part A, group 2 gets family psychoeducation parts A and B, and group 3 gets family psychoeducation part B). Unfortunately, such studies would require a relatively large sample to be adequately powered and might be prohibitively expensive. However, there are investigations that could be informative. For example, studies that implement family psychoeducation could include a systematic qualitative analysis of the elements via interviews or focus groups with consumers and providers in order to elucidate critical elements of the family psychoeducation program. Future studies could also be hypothesis-driven theoretical studies of mediators in order to identify how family psychoeducation creates its effects. Either methodology could lead to the development of modified family psychoeducation models that incorporate the critical (presumably causative) components and permit flexibility with the remaining program components in order to further the penetration of family psychoeducation in the population.

There is an opportunity to improve family services by adopting a population-based approach that more fully addresses the needs of a range of consumers and families. A treatment heuristic such as the one presented in this article would facilitate the assignment of consumers and families to the least intensive intervention sufficient for their current needs and in doing so may optimize use of family psychoeducation while expanding complementary services. As complementary services to family psychoeducation are expanded and utilized, careful empirical study will be necessary.

Finally, there is a critical need to further develop and validate assessment instruments that will measure the intervention process and consumer and family outcomes. Measure development and validation will be necessary to properly assess the critical aspects of family psychoeducation and thereby optimize the models. Measure development is also critical for efficacy evaluations of complementary family services implemented. Measures will also be needed to access the efficiency and impact of the tiered treatment heuristic proposed.

A considerable list of challenges faces the family services research, academic, and administrative communities, but the time is ripe to expand the involvement of families in the care of individuals with severe mental illness.

The authors report no competing interests.

Dr. Cohen is affiliated with the Greater Los Angeles Veterans Affairs (VA) Healthcare Center, Mental Illness Research, Education and Clinical Center (MIRECC), 11301 Wilshire Blvd., MIRECC (210A), Los Angeles, CA 90073 (e-mail: [email protected]). Dr. Glynn is with the Greater Los Angeles VA Healthcare System at West Los Angeles and the Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles. Dr. Murray-Swank and Dr. Dixon are with the VA Capitol Network MIRECC and the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Barrio is with the School of Social Work, University of Southern California, Los Angeles. Dr. Fischer is with the VA South Central MIRECC and the Central Arkansas Veterans Healthcare System Center for Mental Healthcare and Outcomes Research, North Little Rock. Dr. McCutcheon is with the VA Office of Mental Health Services, Department of Veterans Affairs, Washington, D.C. Dr. Perlick is with Veterans Integrated Service Network 3 MIRECC and the Department of Psychiatry, Mount Sinai School of Medicine, New York City. Dr. Rotondi is with VA Stars and Stripes MIRECC and the Department of Critical Care Medicine, University of Pittsburgh. Dr. Sayers is with VA Stars and Stripes MIRECC and the Department of Psychiatry, University of Pennsylvania, Philadelphia. Dr. Sherman is with the Oklahoma City VA Medical Center and VA South Central MIRECC.