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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Family Psychoeducation

Workbook
Chapter 2: Overview of Family Psychoeducation

Background

An introduction for practitioners beginning to provide services and support for family members

The nature of professional-family relationships has varied over time according to the assumed etiology or causation of mental illness. When deinstitutionalized consumers went home to their unprepared families and supporters (and inadequate community resources), many consumers suffered relapses. In keeping with the prevailing assumptions about families at that time, these relapses were taken as evidence that the home environment was counter-therapeutic. Families and supporters found themselves in painful situations in that that they not only had to experience their loved one’s suffering from mental illness, they were also blamed for its occurrence.

For most families, the guilt and confusion of being blamed by professionals, and sometimes relatives or neighbors, induced conflict within the family and usually demoralized the members. That result was particularly destructive, because it often led to breaches in family relationships and to the consumer severing ties with the family, or vice versa. Some of the homelessness that has had so many destructive effects on consumers can be traced to the rejection of the family by professionals, many of whom still expected families to provide social and economic support, housing, guidance and control. Families in many ways were the victims of a double bind, rather than the source of the problem.

As the 1990’s became the decade of the brain, professional attention turned away from the family pathology models of mental illness toward the neurodevelopmental models of mental illness. With this advent of advanced research into the brain, the onus for causing mental illness began to be removed from families. From what we now know about the brain and mental illness, we can stop blaming family interactions for precipitating mental illnesses.

Concurrently, the largest national mental illness advocacy organization, the National Alliance for the Mentally Ill (NAMI) promulgated the message that families who had long been viewed as “part of the problem” should now be considered as “part of the solution” as partners in supporting recovery. Collaborative treatment planning with family and other supportive caregivers has since been incorporated under many professionals’ standards of practice, i.e., Standards of Psychiatric Mental Health Clinical Nursing, Standard VI, Collaboration (ANA, 1994).

The Family Psychoeducation model emphasizes basic communication skills and problem solving skills to accommodate the needs of the individuals who have a core information-processing deficit that is often associated with serious mental illness. It is not a model of blame or family pathology. This is a treatment for a disorder, much as is medication, not a method of treating the family or even the consumer. The family and the consumer are recruited and asked to participate and be included as partners in that treatment process. In other words, they help to carry out the treatment, rather than participate as the object of treatment. This may appear to be a matter of semantics to some, but the differences are at the core of this approach. It intends that practitioners work with, not on, the family and the consumer. The model recognizes the vast knowledge and resources that families and supporters play in the recovery of their loved ones. This collaborative approach to sharing knowledge and “joining” together to manage the symptoms of an illness are core foundations of this model. This partnership is essential for success and recovery.

Family Responses

Mental illness brings about such significant changes in people’s lives that many families think in terms of life before and after the onset of the illness. There is much written in the psychology literature on this topic. The literature often addresses two basic concepts: family stress and family strengths. Family stress (“burden”, as it is referenced in the literature) is the overall level of distress experienced by the family in response to an illness. Further distinction can be made between objective stress, which refers to practical problems such as paying medical bills, obtaining services, and enduring daily management of the illness; and subjective stress, which refers to the family’s emotional responses to the illness. Participants in Family Psychoeducation often find relief to discuss openly or problem solve with others “who have been there” about things others might find incredible for example, difficulties accessing treatment, bizarre behaviors, legal compliance issues, medical coverage, etc.

Family strengths have often been overlooked and unrecognized by the professional community. Families and supportive others often have had the potential to respond to the catastrophe of mental illness with great resolve and resilience. Our experience has been that families will rebound from great disappointments within the system and over the course of an illness. They can provide tremendous support and resources to their loved one and knowledge to the clinical team. In this model, families are seen as consultants to help manage an illness. The clinical team and supportive loved ones “join” in sharing their vast array of resources and expertise to assist in dealing with the illness.

As shown in Table 1, a NAMI survey of over 3,000 families confirmed that the educational interventions of lectures, books, classes, workshops and multifamily support groups were rated as of the most value to families.

Table 1: Family Evaluation of Sources of Help

Surveys of NAMI and non-NAMI families and of mental health professionals who have a family member with a mental illness produce similar results. Mental health professionals who have a relative with a mental illness rated education about the illness and specific suggestions for coping with the person’s behavior as the two most helpful family interventions. Even though almost all of these therapists provided dynamic and family systems therapy in their own practices, they rated individual or family therapy as not very helpful for coping with mental illness.

Through NAMI, families have eloquently stated their needs. Their direct statements of need correspond to the skills that research has demonstrated to improve outcome for schizophrenia. The expressed needs of families are also consistent with the findings on adaptive coping by families with a relative who has schizophrenia. Families demonstrate more adaptive coping when they:

• have large social support systems;
• have self-efficacy (i.e., the belief that they can be effective) in dealing with their loved ones’ illness;
• belong to a chapter of NAMI; and
• feel affirmed, respected, and valued for the information and skills that they possess.

Professionals should provide the information and skills that families (and research) say that they need. Families can also instruct professionals in the educational methods that they need. Families state that they prefer education that:

• provides clear, concrete information;
• is directly related to the problems that their relatives have;
• provides specific instructions and skills for coping; and
• increases their ability to access services for their relatives.

Goals for Working with Families

The field of Family Psychoeducation has advanced to the point that there is a common set of principles that guide this work. They were developed as a consensus by the world’s leading researchers, treatment developers, and practitioners. The World Schizophrenia Fellowship published these principles as part of that organization’s efforts to have these approaches made available in mental health services throughout the world. They are included here to make clear the general values of this new form of clinical work, as well as describing what families need from practitioners who are working with their loved one.

The goal of Family Psychoeducation for people with severe mental illness and their families is to achieve full participation in the community by the consumer and to facilitate full and lasting recovery from mental illness.

The objectives of Family Psychoeducation for the consumer are:

• to reduce symptoms of mental illness,
• to prevent relapses and rehospitalizations,
• to provide rehabilitation so that consumers can achieve the maximum possible level of functioning and the best possible outcome,
• to provide the foundation for recovery, through collaborative treatment and rehabilitation, and
• to maximize the ability of the members of the family to foster their loved one's recovery and to alleviate their suffering and stress.

The objectives of Family Psychoeducation for family members are:

• to engage their assistance in supporting treatment and rehabilitation,
• to assure that they can provide knowledgeable support, and
• to alleviate suffering among the members of the family by validating their pain and grief and then supporting them in their efforts to foster their loved one’s recovery.

Principles for Working with Families

Practitioners who work with consumers with severe mental illness achieve best outcomes and the greatest satisfaction if they routinely involve family members in the ongoing treatment and recovery effort. Practitioners, who accept that best practices include work with families, strive to meet the needs of families as they have been described in the literature and as has been validated in many research studies.

That means that practitioners will work to:

• Coordinate all elements of treatment and rehabilitation to ensure that everyone is working towards the same goals in a collaborative, supportive relationship, and to include the family as part of the treatment team when appropriate.
• Pay attention to the social as well as the clinical needs of the consumer.
• Provide optimum medication management.
• Listen to families and consumers and treat them as equal partners.
• Explore family members’ expectations of the treatment program and their hopes for the consumer.
• Assess the family’s strengths and difficulties.
• Help resolve family conflict through sensitive response to emotional distress.
• Address feelings of loss.
• Provide relevant information for consumer and family at appropriate times.
• Provide an explicit crisis plan and professional response.
• Encourage clear communication among family members.
• Provide training for the family in structured problem-solving techniques.
• Encourage the family to expand their social support networks.
• Be flexible in meeting the needs of the family.
• Provide the family with easy access to a professional in case of need if the work with the family ceases.

Core Components of family psychoeducation

All evidence-based Family Psychoeducation models share similar core components. They include:

1. Joining

The practitioner establishes a respectful, trusting, and helpful relationship with family members and consumer and works to build hope for a better future. He or she understands the possible variaton in the meaning of socializing across cultural groups and tailor the socializing aspect of the joining sessions to the specific cultural contexts of the participants.

2. Education

The practitioner helps family members better understand their loved one’s illness and what they can do about it.

3. Problem-solving

The practitioner works with the family and consumer to identify strategies for handling difficult situations by making use of effective behavioral, cognitive and communication techniques to address issues caused by the illness.

4. Structural change in the treatment

The practitioner works with the family and consumer to establish a strengths-based environment where all members are respectful of one another, creating an optimal environment for recovery from mental illness.

5. Multifamily contact

The practitioner creates multi-family groups in the multifamily model. In both multifamily and single family models, the practitioner recommends participation in local family support groups, such as those available through NAMI, to reduce social isolation and sense of stigma.

Research and Practice Background

Family members and significant others involved in the lives of adults with serious mental illnesses often provide emotional and instrumental support, case management functions, financial assistance, advocacy, and housing to their relative with mental illness. Doing so can be rewarding but imposes considerable stress. Family members often find that access to needed resources and information is lacking. Research developed over the last two decades supports the development of evidence-based practice guidelines for addressing family-members’ needs for information, clinical guidance, and support. This research has demonstrated conclusively that meeting the needs of family members also improves consumer outcomes and relationships within the family. Research references can be found in the research review included in this Implementation Resource Kit and in Multifamily Groups in the Treatment of Severe Psychiatric Disorders.

Family Psychoeducation approaches have been remarkably effective in reducing rates of illness relapse when rigorously evaluated in experimental outcome studies. The results of these studies are unusually consistent and point to a valid, reliable and quite robust effect: relapse and rehospitalization rates have been reduced by 40-70% over two years, compared to those who received standard individual services. Programs longer than three months and especially those greater than nine months had better outcomes. In addition, family member well being improved and medical illnesses decreased, negative symptoms decreased, consumer participation in vocational rehabilitation and employment rates increased and costs of care were reduced.

As a result of recently conclusive evidence and several meta-analyses showing overall effects on outcome, the Schizophrenia Patient Outcomes Research Team (PORT) project included family psychoeducation in its set of treatment recommendations. The PORT recommended that all families in contact with their consumer/relative be offered a family psychosocial intervention spanning at least nine months and including education about mental illness, family support, crisis intervention, and problem solving skills training. Practice guidelines established by the American Psychiatric Association and the Expert Consensus Panel reached the same conclusion: families should receive education and support programs. In addition, an expert panel that included practitioners from various disciplines, families, consumers and researchers emphasized the importance of engaging families in the treatment and rehabilitation process. For a fuller discussion of outcomes and research, please see Dixon, et al., 2001, which is included in this Implementation Resource Kit.

What are the Various Approaches that Have Been Shown to be Effective?

A variety of Family Psychoeducation models have been developed over the past two decades. They are all professionally created and led, offered as part of an overall clinical treatment plan for the consumer, last nine months to over five years, are usually diagnosis-specific, and focus first on consumer outcomes, although family understanding and well-being are essential as an intermediary outcome. Models differ in their format (multiple-family vs. single-family sessions vs. mixed), duration of treatment, type of participation by the consumer, location (hospital- and/or clinic-based, home, family practice or other community settings), and variable emphasis on didactic, emotional, cognitive-behavioral and systemic techniques. Several models have evolved to address the needs of family-members: individual consultation, professionally-led family psychoeducation, various forms of more traditional family therapies and a range of professionally led models of short-term family education (sometimes referred to as therapeutic education). There are also family-led information and support classes or groups such as those of NAMI.

Of these models, Family Psychoeducation in the form of multifamily groups and single family therapy has a deep enough research and dissemination base to be considered an evidenced based practice. The descriptor “psychoeducation” can be misleading; family psychoeducation includes many therapeutic elements, often utilizes a consultative framework, and shares characteristics with other types of family interventions.

Family Psychoeducation can be effective in a single-family therapy format or in a multifamily group format, depending on the desires and needs of the family. We describe here the major types of intervention, divided into single- and multifamily formats. The approaches described in this workbook are derived from methods developed by Michael Goldstein, Carol Anderson and Ian Falloon and their colleagues. The practitioner applying the single-family approach may want to refer to Schizophrenia and the Family, by Anderson, Hogarty and Reiss, and Family Care of Schizophrenia, by Falloon, Boyd and McGill. The multifamily group approach has been developed by McFarlane and colleagues, and is described in detail in Multifamily Groups in the Treatment of Severe Psychiatric Disorders.

Another approach, the relatives’ group model, developed by Julian Leff and others in the U.K., involves helping families with high expressed emotion (a term referring to unsupportive, critical interactions) to reduce their exasperation by learning from other families who have more fully understood and mastered the illness and how to cope with it. That approach has also been shown to be effective. That general approach has been incorporated within the multifamily group approach described here, but cannot be implemented in a single-family format. For that reason, it is not described separately here.

The family consultation approach has also been shown to be effective for some types of conditions and families, developed by Lyman Wynne and colleagues. In this approach, families sometimes with the participation of the consumer member, meet in single-family format periodically with a professional consultant, often the psychiatrist or the consumer’s primary practitioner. There is no set agenda, but rather the goal is to provide information and guidance on an individual basis to address the specific concerns and problems identified by the family. Often, these sessions take the form of those in Anderson’s Family Psychoeducation model, but are not scheduled on a regular bi-weekly or monthly basis. Again, this model is not described in detail here, because the material here can be readily adapted to the episodic consultation model. This approach appears to be especially useful when scheduling meetings involves great inconvenience, or in cases in which there are few ongoing problems and acute crises and the family is coping well with the situation. It may also be useful because it offers flexibility and so may be better in locations where the mental health system is not highly professionalized. It is often the de facto approach for long-term follow-up after the family has successfully completed the more intensive approaches described here.

Fitting Family Psychoeducation to the Culture of the Consumer and Family

Working with families requires that the practitioner adapt the approach to the cultural characteristics of the consumer and his or her family. In a sense, each family is a micro-culture that needs to be understood and addressed respectfully and with empathy. Failing to understand and assess the cultural perspective of a family may create a significant barrier to effective treatment. On one hand, there are many ways to offend family members when one does not know the proper and acceptable ways of interacting are within a given culture. On the other hand, clinical experience, now on a global basis, has shown unequivocally that mental illness usually overrides cultural factors in determining families’ perceived need for help, guidance and support. Mental illness, in an important sense, creates its own culture, which Family Psychoeducation is designed to address for consumer and family alike. The result is a general rule that families will almost always accept the offer of help and the opportunity to participate actively in the treatment and recovery of their ill member, if the practitioner can adapt his or her approach to the culture of the family. One can do so by either being a member of that culture or actively seeking assistance and guidance in learning the key ways of respecting that culture’s social norms and mores.

Family Psychoeducation has been applied in the United States, and in many countries successfully, following this very general guideline. For instance, in Falloon’s study in Los Angeles, CA, and the majority of the families were African-American living in Watts. In McFarlane’s large multi-site study in New York, about 40% of the sample was African-American, most living in Harlem. Later implementation throughout New York State showed that sensitive application of the multifamily group version of Family Psychoeducation was not only acceptable but also valued by a wide range of consumers and families with varied cultural and ethnic backgrounds. The key was to assure that either the practitioners themselves or supervisors and/or consultants were familiar with the expectations of members of that given cultural group for professionals and advisors. In particular, practitioners need to understand the possible variation in the meaning of socializing across groups. Practitioners need to tailor the socializing aspect of the joining sessions to the specific cultural contexts of the participants.

Further, practitioners need to take the opportunity (starting with the socializing) to use their observation skills to begin to identify roles, values and norms within the family that could later be used to enhance communication and maximize the impact of the intervention. Linked to the need to understand the cultural context of the participants is the need to acknowledge variation in communication styles. For example, effective communication is implicit in the tasks to be accomplished within each of the three joining sessions. Most non-European cultures do not understand the reserved, “blank-slate” style of interaction that has become the expected norm for professional psychotherapists. Additionally, most families from non-European backgrounds expect their advisors, counselors and healers to be friendly, out-going and fairly direct. This directness may appear to some practitioners as unnecessary and to others as a given in good clinical practice. Nevertheless, communication is so much influenced by cultural and social circumstances that clinicians need to assess the latter in order to engage caregivers and obtain valid information. For example, in the Family Psychoeducation approach described here, the intent of socializing among practitioners, family members and even consumers is to build trust and emphasize the strengths and value of the family. It is expected that practitioners will model normal social conversation. However, there are variations in power hierarchies and turn-taking behaviors during conversation that may not appear to be `normal’ to the practitioner, but are ”normal” for the specific cultural context of the family. Acknowledging these variations and tailoring interventions to these realities is one of the tasks requiring creativity and flexibility of practitioners. Obviously the issue of language preferences will have to be addressed.

Lopez, Kopelowicz, and Canive have recently adapted the multifamily group approach described here to a sizeable population of Mexican-Americans in Los Angeles and have found that it required little change, simply because it includes a variety of methods for including the family’s and consumer’s input into the process throughout the course of treatment. They found that many of its design features matched the needs of people of Hispanic origin living in southern California. This is not as surprising as might be thought: the method itself was developed in the South Bronx of New York City, where the population was entirely composed of Hispanic-, Caribbean- and African-Americans. Likewise, there have been large-scale and very successful applications of these methods in China, Norway and Denmark, Spain, Hungary and Romania, Italy, Netherlands, Germany, Japan, England, Australia and New Zealand and among immigrant groups (for instance, Vietnamese refugees in Melbourne, Australia). There seems to be no cultural group for which an adaptation done with creativity and flexibility and in the spirit of collaboration, understanding and respect has not been successful.

Single Family Psychoeducation

Details of the single-family clinical models are to be found in Anderson’s and Falloon’s books and are summarized here and in the sections to follow. These useful references for family practitioners are detailed and filled with excellent clinical techniques for, and information about, schizophrenia. Both the single- and multifamily approaches described here are based on these works and the outcome research conducted by their groups. Another reference source is Bipolar Disorder: A Family-focused Treatment Approach, by David Miklowitz and Michael Goldstein, which describes the family behavioral management approach for that disorder. These resource books are all referenced in Chapter 12.

Clinical Methods

The basic psychoeducational model consists of four stages that roughly correspond to the phases of an episode of schizophrenia, from the acute phase through the recuperative, rehabilitation and recovery phases.

Joining

Joining refers to a way of working with families and consumers that is characterized by collaboration in attempting to understand and relate to the family. During this phase, a partnership is developed between the consumer, family, and practitioner. The joining phase typically extends from three to five sessions and is the same in both single- and multifamily formats. The goals of this phase are to:

• establish a working alliance with both the family members and the consumer,
• acquaint oneself with any family issues and problems which might contribute to stress either for the consumer or for the family,
• learn about the family's and consumer’s strengths and resources in dealing with the illness,
• instill hope and an orientation toward recovery, and
• create a contract with mutual and attainable goals.

Joining, in its most general sense, continues throughout the treatment, since it is always the responsibility of the practitioner to remain an available resource for the family as well as their advocate in dealing with any other clinical or rehabilitation service necessitated by the illness of their relative. To foster this relationship, the practitioner

• demonstrates genuine concern for the consumer,
• acknowledges the sense of loss of hopes and dreams for their family member and grants them sufficient time to mourn,
• is available to the family and consumer outside of the formal sessions,
• avoids treating the family or consumer as patients or blaming them in any way,
• helps to focus on the present crisis, and
• serves as a source of information about the illness.

Educational and Training Workshop

The family is invited to attend workshop sessions conducted in a formal, classroom-like atmosphere. Typically eight hours in length, several families attend the workshop at a time. The opportunity to interact with other families in similar situations greatly enhances the power of this portion of the intervention, although in some situations, the education is done in single-family format and can be done in the family’s home. Biological, psychological, and social information about schizophrenia (or other disorders, as the case may be) and its management are presented through a variety of formats, such as videotapes, slide presentations, lectures, discussion and question and answer periods. Information about the way in which the practitioner and the family will continue to work together is also presented. The families are also introduced to the “guidelines” for management of the illness. These consist of a set of behavioral instructions for family members that integrate the biological, psychological and social aspects of the disorder with recommended responses, those that help maintain a home environment that minimizes relapse inducing stress.

Community Re-entry

Regularly biweekly scheduled meetings focus on planning and implementing strategies to cope with the changes of a person recovering from an acute episode. Major content areas include the effects and side effects of medication, common issues about taking medication as prescribed, helping the consumer avoid the use of street drugs and/or alcohol, the general lowering of expectations during the period of negative symptoms and an increase in tolerance for these symptoms. Two special techniques are introduced to participating members as supports to the efforts to follow family guidelines: (1) formal problem solving and (2) communications skills training. The application of either one of these techniques characterizes each session. Further, each session follows a prescribed, task-oriented format or paradigm, designed to enhance family coping effectiveness and to strengthen the alliance among family member, consumer and the practitioner. The re-entry and rehabilitation phases are addressed using formal problem-solving methods and communication skills training. The problem solving method is described more fully in the section on multifamily groups. The principal difference is that in single-family sessions, the participants and the recipients of ideas are the same, so that family members most commonly develop new approaches to their problems by brainstorming among themselves.

Communication skills training is developed to address the cognitive difficulties often experienced by consumers with severe mental illness, especially those with psychotic symptoms. The core goal is to teach family members and the consumer new methods of interacting that acknowledge and hopefully counteract the effects of mental illness on the consumer’s information-processing abilities and their marked sensitivity to negative emotion and stimulation.

The key skills include:

• communication of positive feelings for specific positive behavior,
• communication of negative feelings for specific negative behavior, and
• attentive listening behavior when discussing problems or other important family issues.

The approach involves:

• rehearsing communication skills in the session,
• modeling by the practitioner,
• repeated rehearsal, often at home, and
• homework to assist generalizing the skills learned to other contexts, with social reinforcement used throughout the process of training.

These skills are especially useful for families who are markedly exasperated, manifesting criticism or hostility toward the consumer and/or severe anxiety, preoccupation and intrusiveness as a consequence of disability and symptoms caused by the illness. Often, such reactions by family members are a result of poor treatment response, substance abuse, or treatment complications as a result of the severity of the illness.. Please see Chapters 9 and 11 of Fallon’s Family Care of Schizophrenia for further information regarding how to implement these important skills.

Social and Vocational Rehabilitation

Approximately nine to eighteen months following an acute episode, most consumers begin to demonstrate signs of a return to spontaneity and active engagement with those around them. This is usually the sign that the negative symptoms are lifting and the consumer can now be offered more challenges toward achieving his or her own goals. The focus of social and vocational rehabilitation deals specifically with the rehabilitative goals and needs of the consumer, addressing the two areas of functioning in which there are the most common deficits: social skills, and the ability to get and maintain employment. The family sessions are used to role-play situations that are likely to cause stress for the consumer if entered into unprepared. Family members are actively used to assist in various aspects of this training endeavor. Additionally, the family is assisted in rebuilding its own network of family and friends, which has usually been weakened as a consequence of the illness. Regular sessions are conducted on a once- or twice-monthly basis, although more contact may be necessary at particularly stressful times.

Multifamily Group Psychoeducation

The psychoeducational multiple family group is a treatment approach which brings together aspects of Family Psychoeducation, family behavioral and multifamily approaches. As such, it is a second-generation treatment model that incorporates the advantages of each of its sources, diminishes their negative features and leads to a number of synergistic effects that appear to enhance efficacy. Building on the psychoeducational family approach of Anderson, Hogarty and Reiss and the family behavioral management approach of Falloon and his colleagues, the model has attempted to reflect contemporary understanding of schizophrenia and other severe mental illnesses from biological, psychological and social perspectives. The assumption is that an effective treatment should address as many known aspects of the illness as possible, at all relevant system levels.

Unlike the recent origins of psychoeducation, however, multifamily group work arose nearly three decades ago in attempts by Laqueur, Detre and others (1961) to develop psychosocial treatments for hospitalized consumers. The emphasis was more pragmatic than theoretical. Indeed, the first reported successful experience with the modality emerged serendipitously from a need to solve ward management problems. In the process, Laqueur noted improved ward social functioning in inpatients that insisted on attending a group organized for visiting relatives. Detre and his colleagues started a multiple family group in order to encourage cooperation between resident psychiatrists and social workers on an acute inpatient service. They found a high level of interest in the group among consumers and family members alike, as well as improvements in social functioning among consumers and in family communication and morale. From these beginnings, the modality has grown steadily; most of the focus of the practice has continued to be the major psychiatric disorders.

Families attempting to cope with a relative who has schizophrenia, bipolar disorder or another severe mental illness, are likely to experience a variety of stressors, which can impact their ability to offer help to their ill family member. These stressors include social isolation, stigmatization, and increased financial and psychological stress. Multifamily groups address these issues directly by increasing the size and richness of the social support network, by connecting the family to other families like themselves, by providing a forum for mutual aid, and by providing an opportunity to hear the experiences of others who have had similar experiences and have found workable solutions.

Many practitioners have observed that specific characteristics of the multiple family group have remarkable effects on a number of social and clinical management problems commonly encountered in schizophrenia and other severe mental illnesses. A critical goal of all Family Psychoeducation and behavioral models is to reduce family expressed emotion (which is defined as perceived criticism, lack of support, and unrealistic expectations) and thereby reduce the risk of psychotic relapse. The psychoeducational multifamily group approach goes beyond this focus on expressed emotion to address social isolation, stress and stigma as experienced by families and consumers alike. That appears to be key to better overall outcomes, because families attempting to cope with mental illness inevitably experience a variety of stresses which secondarily put them at risk of manifesting exasperation and discouragement as natural reactions.

With respect to the issue of stigma, research has shown (1) that family members do not automatically feel stigmatized but often withdraw as if they have been stigmatized and (2) that friends and more distant relatives do tend to avoid them because of stigma. Thus, like many consumers, many families may be isolated and stigmatized, and may feel so as well. These problems produce strains that are likely to lead to exasperation, a sense of abandonment and eventually demoralization. These effects on the family are likely to interfere with their capacity to support their family member and to assist in their recovery process.

Multifamily groups address these issues directly by:

• increasing the size and complexity of the social network,
• bringing a given family into regular contact with other families like themselves,
• providing a forum for mutual aid,
• providing an opportunity to hear the experiences of others who have had similar experiences and found workable solutions, and
• building hope through mutual example and experience.

In addition, psychoeducational multifamily groups or single-family sessions reiterate and reinforce the information learned in educational and skills training workshops. Coupled with formal problem solving, the group experience serves to enhance the family’s available coping skills for the many problems encountered in the course of the consumer’s recovery.

Clinical Methods

The general character of the approach can be summarized as consisting of three components, roughly corresponding to the phases of the group. In the first phase, the model emphasizes joining with each family and consumer, conducting an educational workshop and focusing on preventing relapse for a year or so. Unlike the Single-Family Psychoeducation approach, the format for treatment after the workshop is a multifamily group. The second phase involves moving beyond stability to support gradual increases in consumers’ community functioning, a process that uses psychoeducational multifamily group-based problem-solving as the primary means for accomplishing social and vocational rehabilitation. This occurs, roughly, during the second year of the multifamily group. The third phase consists of deliberate efforts to mold the group into a social network that can persist for an extended period and satisfy family and consumer needs for social contact, support and ongoing clinical monitoring. This format is also an efficient context in which to continue psychopharmacologic treatment and routine case management. Expansion of the families’ social networks occurs through problem solving, direct emotional support and out-of-group social­izing, all involving members of different families in the group.

Engagement and Family Education

The intervention begins with a minimum of three single-family engagement sessions, in which the consumer’s primary practitioner meets with the individual family, often without the consumer present. Separate meetings accompany these sessions with the consumer. The choice of including the consumer is determined based on consumer and family choices. For both philosophical and practical reasons, we establish treatment plans based on the consumer’s and family’s stated goals and desires. When 5-8 families have completed the engagement process, the practitioners, usually including the consumers’ psychiatrist, conduct an extensive educational workshop, again usually without consumers. The biomedical aspects of the disorder are discussed, after which the practitioners present and discuss guidelines for the family management of both clinical and everyday problems in managing the illness in the family context.

The Ongoing Psychoeducational Multiple-Family Group

The first meeting of the ongoing psychoeducational multifamily group follows the workshop by one or two weeks; its format includes a bi-weekly meeting schedule, 1 1/2 hour session length, leadership by two practitioners and participation by 5-8 consumers and their families. In most instances, the decision to have a given consumer attend is based upon his or her mental status and susceptibility to the stimulation such a group may engender. If the consumer wants to attend, that weights the decision in favor of inclusion. The practitioner, following a standard paradigm closely controls the format of these sessions. From this point forward, consumers are strongly encouraged to attend and actively participate. The task of the practitioners, particularly at the beginning, is to adopt a business-like tone and approach that promotes a calm group climate, oriented towards learning new coping skills and engendering hope.

The multifamily group’s primary working method is to help each family and consumer to apply the family guidelines to their specific problems and circumstances. This work proceeds in phases whose timing is linked to the clinical condition of the consumers. The actual procedure uses a multifamily, group-based, problem-solving method adapted from the single-family version by Falloon and Liberman. Families are taught to use this method in the multifamily group, as a group function. It is the core of the multifamily group approach, one which is acceptable to families, remarkably effective and nicely tuned to the low-intensity and deliberate style that is essential to working with the specific sensitivities of people with schizophrenia. The same principle applies to other mental illnesses that are sensitive to interpersonal and environmental stress, like major depression and bipolar disorder.

The multifamily group maintains stability by systematically applying the group problem-solving method, case-by-case, to difficulties in implementing the family guidelines and supporting recovery. The subsequent rehabilitation phase should be initiated when appropriate for the consumer. The multifamily group functions in a role unique among psychosocial rehabilitation models: it operates as an auxiliary to the services being provided by the mental health treatment team. The central emphasis during this phase is the involvement of both group and family member in helping each consumer to begin a gradual, step-by-step resumption of responsibility and socializing. Practitioners continue to use problem solving and brainstorming in the multifamily group to identify and find support jobs and social contacts with the consumers, as they find new ways to enrich their social lives. This process helps the consumer as they work on their recovery process, which is addressed in the third phase.

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