Since the introduction of psychoanalysis, theorists and practitioners have attempted to use its principles to understand the etiology of schizophrenia and to treat the sufferers. The 1950s and 1960s were a time of great activity. Fromm-Reichmann1 coined the term "schizophrenogenic mother" in a paper on the psychoanalytic treatment of schizophrenic patients, and Alanen2 carried out a series of studies of the mothers of schizophrenic patients in an attempt to substantiate the etiological role of the family. During the same period, Lidz and his colleagues3 intensively studied a small group of families of schizophrenic patients to test their concept of atypical dominance patterns in the parents. Bateson et al4 developed a communication theory about the origin of schizophrenia and introduced the term "doublebind," which won instant popularity, while Wynne and Singer5 proposed their own theory, combining deviant communication with distorted emotions. The British contribution to this body of theory was made by Laing and Esterson6 who viewed the family as scapegoating one member, who would later develop schizophrenia, and hence carry the burden of disturbed relationships for the whole family.
This exciting flurry of theoretical developments stimulated numerous research studies, over 200 of which were reviewed by Hirsch and Leff7. They concluded that none of the abnormalities in parents that were postulated to cause schizophrenia were specific to relatives of schizophrenic patients, but were found in the relatives of patients with other psychiatric conditions. Furthermore, any abnormalities detected in the parents of schizophrenic patients could be the expression of an inherited vulnerability to the disease and of no direct etiological significance.
By the end of the 1970s, most researchers had abandoned the search for features in the parents that might cause schizophrenia. However, an unforeseen effect of the theories and the popularization of concepts such as "schizophrenogenic mother," "double-bind," and "scapegoating" was the rising of anger among relatives. Psychiatric professionals attempting to offer help to the families of schizophrenic patients need to be aware of the justified resentment of relatives at the blame that has been attached to them in the past. Professional attitudes were undoubtedly not only antagonistic to relatives but also contradictory and can be summed up as "You are to blame for the illness for your son/daughter and therefore we want nothing to do with you." This statement is illogical, but many relatives were subjected to this baffling dismissal.
Against this background a new therapeutic approach to the families of schizophrenic patients began to emerge in the mid-1970s.
A NEW APPROACH TO FAMILIES
The impetus to the new approach was partly through the failure of research to provide evidence for a causal role of the family in schizophrenia and partly through a series of studies emanating from the Medical Research Council (MRC) Social Psychiatry Unit in London. Instead of attempting to investigate the etiology of schizophrenia, with its host of attendant problems, the members of this Unit focused on the influence of family factors on the course of the illness once it was manifested. The central plank of this research has been a measure of a relative's emotional attitudes toward the patient. These are elicited by an interview that addresses the patient's recent symptoms and behavior known as the Camberwell Family Interview (CFI). The interview is audiotaped, and ratings on a number of scales are made later from the recording. The key scales are:
* critical comments,
* overinvolvement, and
In the early British studies, high levels of criticism and overinvolvement and the presence of hostility each predicted a relapse of schizophrenia over a nine-month period after the patient's discharge.8-9 These attitudes of a relative also were associated with relapse over a 2-year follow-up period. Ratings of these negative emotions were combined into a global scale termed Expressed Emotion (EE). A household was categorized as high EE if one or more relatives scored high on the index. Relapse rates over 9 months were approximately 50% in high EE homes and 15% in low EE homes.
The emphasis on negative emotions in compiling the EE index has tended to obscure an equally important aspect of the home environment of schizophrenic patients. If a relative was categorized as low EE and also scored high on warmth, the patient had a significantly lower relapse rate than if the relative scored low on warmth. It appeared from this early work that relatives could not only influence the course of schizophrenia for the worse, but also could play a significant role in keeping the patient well. This raised the exciting possibility of a therapeutic alliance with family members that might strengthen their role in maintaining the patient's good health.
The findings on the association between relatives' EE and the outcome of schizophrenia have been replicated in a number of studies, four of which were conducted in the United States. These included samples of English-speaking MexicanAmericans in California,10,11 Spanish-speaking Mexican-Americans in the same locality,12 and relatives in Chicago, including a number of blacks.13
Out of the range of cultures studied, the most strikingly different one from urban populations in the West is in Chandigarh, North India. This sample included both city-dwellers and peasant farmers living a traditional way of life. The CFI was conducted in Hindi, after a pilot study demonstrated that the research techniques could be transposed into this language from English. It was found that high EE attitudes were much rarer in this group of relatives than in those studied in the West, particularly among the peasant farmers, who demonstrated a remarkable tolerance and acceptance of the behaviors associated with both acute and chronic schizophrenia. Nevertheless, dividing relatives into high and low EE based on the same criteria used in Western studies also separated patients into bad and good outcome groups.14
Strong evidence from the international studies of schizophrenia conducted by the World Health Organization15,16 indicates the outcome of this illness is considerably better in non-Western countries. The Chandigarh study suggests that the tolerant attitudes of relatives may well be one explanation for this intriguing finding. It also indicates that Western methods of working with families of schizophrenic patients are unlikely to be applicable in other parts of the world without substantial modification.
NEW METHODS OF WORKING WITH FAMILIES
During the last 11 years, seven trials of family treatment approaches for schizophrenia have beeen published. The premises on which they are based differ in a number of crucial ways from the earlier studies of parental abnormalities. These differences are summarized in Table 1.
An underlying assumption of the earlier work was that abnormalities in the family's manner of communicating ideas or expressing emotions determined the origin and form of schizophrenia in their offspring. The current family treatments reject that assumption and instead are built around a concept of schizophrenia as a disease of the brain. Schizophrenia is viewed as a structural or functional abnormality of the brain that renders the sufferer particularly vulnerable to emotional stress. The family, representing the most intense emotional relationships in the patient's social milieu, has the capacity to augment stress or to alleviate it. Emotional stress as measured by relatives' EE does not in itself determine the form of the schizophrenic illness. There can be no doubt about this, as research on non-schizophrenic conditions has shown that elements of EE also are associated with their relapse. For example, two studies have found that patients with neurotic depression are even more vulnerable to relatives' critical attitudes than are schizophrenic patients. Thus, high EE attitudes constitute a nonspecific stress, and the characteristic form of schizophrenia must be determined by a specific biological abnormality yet to be discovered.
Comparison of Old and New Approaches to Families of Schizophrenic Patients
Another important fact that has emerged from research on relatives' EE is that a considerable proportion of families with a schizophrenic member are functioning in a healthy way in regard to their emotional relationships. Increasing familiarity with low EE relatives has confirmed their resilience and resourcefulness in coping with the formidable problems of daily life with a schizophrenic sufferer. Even in Western cities, a minimum of one third of households are categorized as low EE, while the proportion among Chandigarh villagers is over 90%. How may these observations be reconciled with the earlier work which suggested that all families with a schizophrenic member were dysfunctional in one way or another? The answer probably lies in selective referral. The patients in the EE studies were unselected attenders at state hospitals or clinics, whereas the early research was conducted on families specially referred to centers with a national reputation for work with particular family problems, emotional or communicational.
The recognition that low EE families are coping effectively with the daily problems of schizophrenia offers the opportunity of using their expertise to instruct families that are struggling with similar problems.
The traditional view of family therapists is that the person who is presented as a problem is a messenger for the whole family. The problem is not seen to reside in the "identified patient" but in the family of which he or she is a member. The family, then, constitutes the clientele of the therapist and needs to be treated to restore them to a state of healthy functioning. In the new approach, the patient with schizophrenia is firmly viewed as an ill person, to assist whom the family have organized their resources with greater or lesser success. It is the task of the therapists to maximize the success of the family in coping with the illness in their midst.
CONTENTS OF THERAPEUTIC PROGRAMS
Since each of these programs is based on the view that schizophrenia is an illness with a biological substrate, they all incorporate maintenance treatment with neuroleptic drugs. This is seen as an essential ingrethent since it undoubtedly reduces the patient's risk of relapse. However, it is far from being completely effective as prophylaxis; about 40% of patients on long-acting medication experience at least one schizophrenic relapse in the course of one to two years. Consequently, it is viewed as an adjunct to work with families, and not as a replacement for it.
Education About Schizophrenia
Another consequence of the therapists' acceptance of schizophrenia as an illness is that the family needs to know as much as possible about its nature, treatment, and management. Each program contains an educational element, though this may be delivered in a variety of ways. In one program that I was involved with,17 my colleagues and I wrote four sections on the etiology, symptoms, course, and treatment and management of schizophrenia. The aim was to use basic English and avoid jargon because many of our clients are immigrants. The information was delivered in two sessions held in the patient's home, usually while the patient was still in the hospital receiving treatment. Initially we read out the information as it was written, allowing relatives to interrupt and freely ask questions. As we gained experience we tailored the information to the individual patient's symptoms and behavior. For example we would say, "Some patients find it difficult to put up with visitors and go to their room when anyone calls. I think that's been happening with John."
In the program run by Hogarty and colleagues,18 families initially were educated together in a day-long workshop, while Falloon et al19 and Tarrier et al20 dealt separately with each family. It needs to be recognized that the presentation of factual information is just the start of a process of education of the family. Relatives find it very difficult to absorb certain information, such as the fact that their husband, wife, son, or daughter has an illness called schizophrenia, that is highly charged emotionally. They will need to hear the same facts reiterated many times over the course of months or even years before they can accept them. Thus education is a continuing process throughout the period of working with the family.
In providing facts about the illness, it is extremely important to emphasize that there is no evidence that relatives cause schizophrenia. This immediately reassures the family that they are not going to be blamed for the condition and helps alleviate their sense of guilt. Another issue to be highlighted is that the negative symptoms are as much a part of the illness as the positive symptoms. This is because a content analysis of relatives' critical remarks revealed that the majority of them were focused on negative symptoms - apathy, inertia, lack of participation in household activities, and absence of an emotional response. Relatives viewed these deficits as under the patient's control, rather than stemming from the illness, and consequently blamed the individual for being lazy and selfish.21 The prolonged period needed to recover from negative symptoms also needs to be stressed. In the program that I am associated with, my colleagues and I tell relatives that episodes of florid symptoms are followed by a convalescent period of 1 to 2 years and that it may take that long for the patient to return to a more normal way of life.
Problem-solving features strongly in virtually all programs, but is given particular prominence by Falloon et al19 and Tarrier et al20 whose theoretical orientation is behaviorist. Families are taught to break down problems into small components, to suggest a variety of solutions for each component, and to select one solution to try. It is vital that family members agree on the solution to be attempted and that they take joint responsibility for carrying it out. The therapists tell the family that they will ask for feedback about the solution tried at the next meeting. If the family has failed to carry out the task, a less demanding task is set for the next time.
I have already referred to the theories concerning disturbed communication in the families of schizophrenic patients. In practice many of these families communicate very well, but in some, pressure of emotional arousal in one or more members makes it difficult for the therapist to get a word in edgewise. Relatives interrupt each other, talk at the same time, and address remarks to the therapist about the patient as though he or she were not present. It is the task of the therapist to regulate communication so that everyone has an equal opportunity, including the patient, and to ensure that remarks made about a person present are addressed directly to him or her.
Dealing with Expressed Emotion
Not all the programs specifically have this on their agenda but they all use strategies that would be expected to achieve this effect. Criticism is reduced partly by lowering the family's expectations for the patient. They are taught that progress is slow and that they should greet even small steps forward with praise and sometimes with more tangible rewards. Confrontation is to be avoided, and both relatives and patients are encouraged to develop ways of defusing arguments.
Overinvolvement is more difficult to alter, as it tends to have a longer history than criticism. The issues of developing independence and separating from parents are much more fraught than with a healthy young adult; delicate and protracted negotiation is required. It is rare to encounter overinvolvement in relatives other than parents but when a spouse is overinvolved he or she needs to learn that it is safe to hand over more responsibility to the patient, with the aim of achieving a more balanced relationship.
In the London studies8,9 it was found that patients with low social contact with high EE relatives had a better outcome than those with high contact. Social distance appeared to confer some protection against the emotional stress of a high EE relationship. This finding was replicated in the Los Angeles study10 but not in any other study of EE. Nevertheless, the reduction of contact constitutes an aim of most of the intervention programs. It is achieved in the case of unemployed patients by offering them places in day hospitals, day centers, or other facilities with shelter available. Leisure activities also need to be encouraged, particularly those that bring the young adult patient into contact with his or her healthy peer group.
Independent living can sometimes be achieved, but only if the emotional issues surrounding separation can be negotiated successfully.
Outcome of Family Treatment Trials for Schizophrenia
Expanding Social Networks
This is equally as important for the relatives as for the patient. Although the family often has an adequate social network at the beginning of the illness, this network tends to shrink the longer the illness continues. The family withdraws from their friends and relatives, partly due to shame and embarrassment about the patient and partly as a result of the demands on time and energy that unrelieved care of the patient places on them. Therapists encourage family members to reestablish contact with their social networks and to spend some time away from the patient, enjoying their leisure.
Outcome of Therapeutic Programs for Families
Of the seven trials published, six demonstrated an advantage for work with families in conjunction with maintenance neuroleptics for the patients.18,20,23-25 The outcome of these trials is shown in Table 2.
A seventh trial conducted in Hamburg22 failed to find a significant advantage for the treatment program. TTiis single discrepant study used a form of psychoanalytic group therapy for families that differs in intention and practice from the approach in the other six studies; these studies incorporated the therapeutic elements listed above, with a greater or lesser emphasis. Despite differences in the names given to the programs, eg, behavioral family treatment and family psycho-education, the contents of the six studies share many similarities. All six achieved low relapse rates over 6 to 12 months in groups of high risk patients. Four of the trials have generated two year follow-up data, which show generally a decreased but still significant advantage for the experimental patients.
Modes of Program Delivery
Some programs have involved groups of relatives as well as individual family sessions, and meetings in patients' homes as well as meetings in a psychiatric facility. The most recent study I was involved with23 attempted to determine the comparative effectiveness of these different modes of delivering the programs. Families were assigned randomly either to sessions in their home or to attendance at a group for relatives. Both forms of care were effective in reducing the patients' relapse rates if relatives attended the group. Home visits by the therapists were readily accepted by relatives (although one out of the 12 patients objected) but nearly half the relatives who were invited to participate in the group failed to attend even once.
In my first study,24 my colleagues and I had used a combination of family sessions in the home and a relatives group and found that attendance at the group was much more satisfactory. Therefore, our current recommendation is that relatives groups should be established in conjunction with an initial home session for the family. This probably will ensure attendance at the group for the great majority of relatives, although booster family sessions may be required from time to time. However, even with this combination a small number of families will shun the group. It is essential to reach out to them with home visits because the patients in these families have a particularly bad outcome.
It has become clear that in the past decade effective methods of working with the families of schizophrenic patients have been developed. These not only ease the burden on relatives, but also reduce the relapse rate of schizophrenia over and above the prophylactic effect of neuroleptic drugs. The issue now is how to facilitate their uptake into routine clinical practice.
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19. Falloon IRH, Boyd JL, McGill CW, Razani J, Moss HB, Gilderman AM. Family management in the prevention of exacerbations of schizophrenia. A controlled study. N Engl J Med. 1982; 306: 1437-1440.
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Comparison of Old and New Approaches to Families of Schizophrenic Patients
Outcome of Family Treatment Trials for Schizophrenia