Psychiatric Annals

CME Article 

Cross-Cultural Perspective of Family Psychoeducation

Harriet P. Lefley, PhD

Abstract

CME Educational Objectives

  1. Become familiar with studies of family psychoeducation for mental illness in other parts of the world.
  2. Learn of various cultural adaptations, their rationale, and research results.
  3. Recognize that migration, status, and acculturation experiences may transcend cultural boundaries in treating ethnic minority families.

Family psychoeducation for serious mental illness is now conducted throughout the world, but there are a plethora of models and time frames for its administration. In some countries, the models are tailored to cultural norms and expectations. The seminal work of Falloon and colleagues1 on family psychoeducation (FPE) in California was expanded into an integrative service model that was replicated and rigorously studied in many countries. Research on family psychoeducation, initially conducted in the United Kingdom and the United States, has now been reported from countries around the world. The Optimal Treatment Project (OTP) was an international collaborative group to promote evidence-based treatment for schizophrenia and other nonaffective disorders, initially developed in 80 clinical centers in 20 countries. Education of patients and caregivers was an integral part of their package of services. In 2002, a review of 14 OTP centers and almost 600 cases noted significantly lower levels of impairment and disability and less caregiver stress.2

Abstract

CME Educational Objectives

  1. Become familiar with studies of family psychoeducation for mental illness in other parts of the world.
  2. Learn of various cultural adaptations, their rationale, and research results.
  3. Recognize that migration, status, and acculturation experiences may transcend cultural boundaries in treating ethnic minority families.

Family psychoeducation for serious mental illness is now conducted throughout the world, but there are a plethora of models and time frames for its administration. In some countries, the models are tailored to cultural norms and expectations. The seminal work of Falloon and colleagues1 on family psychoeducation (FPE) in California was expanded into an integrative service model that was replicated and rigorously studied in many countries. Research on family psychoeducation, initially conducted in the United Kingdom and the United States, has now been reported from countries around the world. The Optimal Treatment Project (OTP) was an international collaborative group to promote evidence-based treatment for schizophrenia and other nonaffective disorders, initially developed in 80 clinical centers in 20 countries. Education of patients and caregivers was an integral part of their package of services. In 2002, a review of 14 OTP centers and almost 600 cases noted significantly lower levels of impairment and disability and less caregiver stress.2

Family psychoeducation for serious mental illness is now conducted throughout the world, but there are a plethora of models and time frames for its administration. In some countries, the models are tailored to cultural norms and expectations. The seminal work of Falloon and colleagues1 on family psychoeducation (FPE) in California was expanded into an integrative service model that was replicated and rigorously studied in many countries. Research on family psychoeducation, initially conducted in the United Kingdom and the United States, has now been reported from countries around the world. The Optimal Treatment Project (OTP) was an international collaborative group to promote evidence-based treatment for schizophrenia and other nonaffective disorders, initially developed in 80 clinical centers in 20 countries. Education of patients and caregivers was an integral part of their package of services. In 2002, a review of 14 OTP centers and almost 600 cases noted significantly lower levels of impairment and disability and less caregiver stress.2


Cultural adaptations to FPE may accommodate specific cultural beliefs, practices, or value systems or the realities of rural vs. urban life. In most cases, when adaptations are made to FPEs in ethnic minority groups, status issues and cultural changes encountered via immigration must be taken into account. However, in almost all cases, FPE is adapted to the more important role of families and family relationships in traditional cultures. For example, Kopelowicz and colleagues3 evaluated the effectiveness of a skills-training program for illness management in Latino patients with schizophrenia. Their culturally appropriate adaptation was simply to include key family members to facilitate acquisition and generalization of skills, with a focus on medications, symptom management, and problem-solving. In this group, only 5.1% of patients were re-hospitalized, compared with 22.2% in a customary-care control group without family participation.3

FPE in China

The most extensive and rigorous research has been conducted in China. Most family interventions in China seem to have modeled Western educational content, whereas others have developed models deemed more culturally appropriate. For example, a controlled study in three rural townships in China randomly assigned patients’ families to FPE plus medications (n=33). The control group (n=36) was assigned medications only. The investigators specifically “aimed to teach family members basic knowledge of mental diseases and their treatment, also to help family members identify and solve problems to increase their knowledge of mental health rehabilitation.”4

Although this rural Chinese intervention closely resembled the Western model, it was supplemented by family home visits together with general health education transmitted through the village radio network. The results showed highly significant differences from the control group in terms of patients’ full treatment compliance; improvement in clinical status and social functioning; increase in the percentage of patients who could do some farm work or housework; and a decrease in the percentage of families who thought the patients’ disorders were caused by ghosts or evil spirits rather than the symptoms of a disease.4

A psychoeducational program for families of patients with schizophrenia in five cities in China was found to have reduced relapse rates from 35% to 20% per year, and also demonstrated reductions in patients’ disability levels and in family burden.5 A number of controlled studies of the benefits of FPE by this group of investigators (with numbers ranging from less than 100 to more than 1,000) found significantly lower rates of hospital readmissions. Overall, patients who did not receive the family intervention were almost eight times as likely to be readmitted as patients who received the family intervention.6

In a large-sample, 2-year study in two Chinese cities, 682 families received FPE; a control group (n=366) received conventional services only. FPE included coping with psychotic behaviors; understanding psychotropic medications and their side effects; supervision and care of psychotic patients; methods of social and vocational rehabilitation; promoting the mental health of caregivers; and marriage and family plans for psychotic patients. Patients in the FPE program showed a higher rate of recovery and stabilization, a lower rate of exacerbation of symptoms, and a reduction in annual relapse and rehospitalization rates. Among their relatives, knowledge increased, family burden decreased, and psychosomatic health issues decreased compared with controls. Almost all findings were significant at the P ≤ .01 level.7

A project by Xiong and colleagues8 seems to have focused on one culturally appropriate aspect of the previous intervention. The investigators surveyed the Western literature on various models of family interventions for schizophrenia and rejected them as inappropriate for China. They reasoned that Western-style FPE was based on the goals of making the individual an independently functioning member of society and less dependent on family. In Western societies, there was also a mental health care system that would provide ongoing services, something that was not available in China. Xiong et al reasoned that:

“The ultimate social goal of families of mentally ill individuals in China is to develop a sustainable family-based support system for a dysfunctional member. The cultural and legal obligations of parents toward disabled children continue until the child is married, when the responsibility is transferred to the patient’s spouse.”


The authors note that the major goals of these parents are to 1) obtain employment for the patient; 2) find a spouse; 3) encourage the young couple to have a child as soon as possible to care for the patient in his or her old age; and 4) offer financial help to prevent divorce.

“Once the patient’s acute symptoms are under control, these issues become the major focus of the counseling sessions; the therapist assists patients and family members in their dealings with work sites, helps them negotiate the hurdles of marriage, educates them about the potential problems of pregnancy, and trains the patient to adapt to the demands of marriage and parenthood.”8

This type of FPE might pose ethical problems for Western practitioners, including the targeted goal of having children mainly for the purpose of providing care in the patient’s old age. Yet this educational intervention was aimed at attaining a culturally desirable and pragmatically useful goal. In a randomized controlled trial with three follow-up periods, this family intervention had highly significant effects in terms of lowering rates of rehospitalization, shortening duration of rehospitalization, lengthening duration of employment, and reducing family burden.8

Multicultural Communities

Major psychiatric disorders such as schizophrenia and bipolar disorder tend to have long illness histories, with cyclical stressors for both patients and families.9 Many problems arise in life that are not or cannot be dealt with in FPE manuals, such as reduction in social services, difficulties in accessing crisis or inpatient care, problems with federal entitlements, and trouble with police, just to name a few.9 Normative life stressors such as accidents, loss of housing, or unemployment produce periodic crises in lives of people with mental illness and their families. Ongoing supportive resources can help them deal with existential stressors that may trigger symptom recurrence in patients who previously had been functioning well.

Multicultural Family Support Group

About 25 years ago, the University of Miami (UM) started a weekly, no-fee psychoeducational support group for families of persons with serious mental illness and as a training vehicle for psychiatric residents.10 It was continued long after its initial formation as an ongoing, no-fee service for families of patients and for the community at large. Often, FPE is reduced to a rote manual and administered within a specific time frame to accommodate research needs. The UM model is neither didactic nor time-limited, and can be incorporated into standard practice; psychoeducation is administered on an-ad hoc basis in response to specific problems as they arise.9 Despite ethnic and religious differences, immigrant groups in multicultural populations such as Miami’s share a similar set of problems. Ethnic minority groups tend to have overlapping histories of discrimination, the ordeals of migration; adapting to other cultures; and family disruptions. They encounter prejudice from the majority culture and are often economically deprived. When serious mental illness further disrupts their lives, cultural norms may have to be breached to find a solution. However, to do so, the clinician must have some knowledge of such norms, as well as ways of implementing change without destroying cultural or family integrity.

In the program at UM, African-American, European-American, Hispanic, and Haitian families interact and share their experiences dealing with mental illness. Many have also experienced the typical stressors of immigrant families, the most common of which is intergenerational conflict. Children encounter a different culture as soon as they enter school and begin to absorb behavioral norms and value systems that are alien to their more traditional parents. English-speaking children become linguistic interpreters, and other adults communicate with them rather than with their parents. Family therapist Salvador Minuchin11 recognized that one of the primary tasks in keeping immigrant families together is to help maintain parental authority.

Multicultural Interventions

Some clinicians have focused on work with families of one culture, whereas others have formulated approaches to ethnic minority groups in general. Lopez and colleagues12 have suggested that FPE adaptations developed for Hispanic patients with schizophrenia also apply to other traditional cultural groups. They recommend involving the extended family (ie, grandparents, aunts, and uncles) along with siblings and parents; clearly manifesting respect for family elders; and developing a relationship of trust. Lopez and colleagues12 also suggest eliciting “folk concepts” of mental illness and discussing them within the context of current scientific information. Such concepts may view mental illness as the work of the devil, infestation by evil spirits, fulfillment of ancestral curses, or punishment for past sins or unknown crimes.

In conducting psychoeducational interventions with Asian-American, African-American, and Mexican-American families, Jordan and colleagues13 suggested attention to the following issues: extended family and multifamily format; length of treatment; and differential use of authority. In more traditional cultures, the clinician is typically viewed as an authority figure, so an egalitarian relationship with the family may be uncomfortable. Typical clinician questions, such as asking how the patient or family member feels or how an event is perceived (implying equality between patient and healer), may be perceived as weakness or lack of knowledge. A long treatment span, as is necessary in many psychotherapies, may be misinterpreted as ignorance or ineptness on the part of the clinician. It may be important to anticipate such misjudgments and clarify the process at the beginning.

Role of Religion and Spirituality

Many ethnic families in Miami rely on religion for psychological sustenance; in the UM program, this is encouraged. Although most attend various conventional churches, some Cuban families also practice Santeria, while some Haitian families practice Vodou (preferable to the spelling, “Voodoo,” which is considered derogatory). Both are religious belief systems with a pantheon of African gods who are believed to give special strength for coping with distress.

In our community mental health work over the years, we have found that traditional healing systems often have a powerful role in helping patients and their families cope with psychiatric disorders or other life stressors.14 Fulfillment of required rituals often gives a sense of empowerment in overcoming sickness or adversity, since the gods (santos or loas) have been satisfied and are now on the side of the supplicant. In the few cases where mental illness may be viewed as the work of the devil or as payment for past sins, the believer is swiftly enlightened by the other families that these are diseases, not character defects. FPE is a group effort; it is taught not only by the group leader, but by others who have mastered the basic concepts and information and are willing to share their insights with new and less knowledgeable families.9

Collectivist Cultures

McFarlane’s multifamily group (MFG) model15 has been shown in the US to be an effective model for administering FPE, particularly for the first episode of psychosis.16 In most of the international literature, MFG also seems to be the format most widely used.17 This benefits communities by spreading scarce resources and aligning with collectivist or family-oriented cultures. As McFarlane15 notes, there are advantages to other families sharing their mutual experiences, information, and coping strategies. In working with other cultures, a clinician can benefit from the power of other families who understand the language and cultural idiom of their peers. Regardless of cultural differences, families of persons with serious mental illness share a body of experience that is easily recognizable to one another.

Negative Results

There have been only a few negative findings in the cross-cultural literature on FPE. In Madrid, Spain, Canive and colleagues18 found no significant difference in patient relapse rates or family burden between families receiving FPE and control families.

A study by Telles and colleagues19 of Mexican-American immigrant families using the Falloon behavioral model of FPE1,2 and case management found significantly more relapse in FPE patients than in patients with case management alone. However, the data indicated that both patients and families low in acculturation had poorer outcomes than more acculturated patients and families, suggesting this may have been the critical factor in comprehension and acceptance of the training.

A more recent study of schizophrenia patients and their families in Mexico City compared a group receiving FPE and psychosocial skills training with customary treatment using Liberman’s20 integrated behavioral learning principles. Patients’ relatives were randomly assigned to 12 multifamily FPE sessions and five patient-family sessions on communication skills, solving emotional problems, and relapse prevention. The study’s authors described their cultural adaptations as having the therapists begin the patient sessions with “small talk” to build trust. The therapists also offered some minor self-disclosure to generate a sense of personal connection. Otherwise, the structure and material was the same as in the US research.

Results at 1 year showed significant differences in the FPE-social skills group compared with controls in terms of improved adherence to medication, appointment-keeping, social functioning, symptoms, and reduced relapse and re-hospitalization rates.21

On the whole, FPE has been applied with positive effects among ethnic minority groups, traditional cultures, and numerous countries. In India, commenting on their 9-month randomized controlled trial of FPE for caregivers of patients with schizophrenia that showed significant improvement in psychopathology, disability and caregiver satisfaction, the authors concluded, “Structured psychoeducational intervention is a viable option for treatment of schizophrenia even in developing countries.”22

Conclusion

A review of the literature indicates that with appropriate cultural adaptations, the basic psychoeducational model of information about schizophrenia and other serious mental disorders, illness management techniques, behavioral skills training, problem-solving strategies, and family support are effective across and within national boundaries.

References

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Authors

Harriet P. Lefley, PhD, is Professor, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine.

Disclosure: Dr. Lefley has disclosed no relevant financial relationships.

Address correspondence to: Harriet P. Lefley, PhD, Department of Psychiatry & Behavioral Sciences D-29, University of Miami Miller School of Medicine, UM-JMH Mental Health Building, 1695 N.W. 9th Avenue, Miami, FL 33136; fax: 305-355-9187; email: HPLefley@aol.com or H.Lefley@miami.edu

10.3928/00485713-20120606-07

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