Schizophrenia and Family Therapy

Schizophrenia doesn't just affect the individual who suffers from it; it tends to have a significant impact on friends and family as well. Today, we'll learn about the dynamics of schizophrenia and family therapy.

The importance of family involvement in the treatment of patients with schizophrenia gained traction in the 1950s. In his studies, Brown observed that patients who returned to their families after treatment had a much higher relapse rate than patients who lived alone or with people who weren’t related to them (i.e. in a home or institution). He concluded that family could be a source of stress that might cause new imbalances. Therefore, interventions were needed to control said stress, which is why the interest in the relationship between schizophrenia and family therapy was born.

Brown, along with two other researchers, Birley and Wing, created the Camberwell Family Interview (CFI). The interview is four hours long and tries to predict patient relapse.

The researchers proposed the novel concept of expressed emotion (EE) that operated on five scales: criticism, hostility, dissatisfaction, warmth, and emotional over-involvement. The EE index is a function of criticism, hostility, and involvement.

Expressed emotion

• Criticism refers to the constant criticism the family expresses about the patient’s behavior.
• Hostility is more general and refers to a total rejection of the patient as a person and not just their behavior.
• Lastly, over-involvement refers to the overprotectiveness that the family displays towards the patient and the dramatization of unimportant situations, and becoming overly upset about things.

This kind of therapy usually lasts several years, a minimum of two if they’re to be effective, and require periodical contact with family members. Below, we’ll talk about the psychological principles of treatment for schizophrenia and family therapy.

These are intervention models that focus primarily on providing information about the illness, modifying certain emotional responses, reducing patient-family contact, improving communication, and providing families with appropriate coping and problem-solving strategies.

The Anderson model

This model is based on the vulnerability theory and its main goal is psychoeducation. The model consists of five highly structured stages, the goal of which is to promote an appropriate family dynamic, encourage the patient to stick to the treatment, avoid social isolation, and avoid stressful situations. The five stages are:

• Family connection. During this stage, the patient can be present. The therapist works with the family on establishing a therapeutic alliance, processing feelings of guilt, how to express emotions, and past and present problem-solving strategies.
• Psychoeducational workshop or survival skills seminary. These can be done with multiple families but no patients are present. During the workshop, the facilitator provides the families with information about the illness, schizophrenia medication, and the importance of self-care.
• Community reintegration. The family and patient are together in these sessions. They’ll work on putting everything they’ve learned so far into practice. These can be routine, scheduled sessions but sometimes require telephone consultations or one-off sessions during times when the patient is experiencing imbalances.
• Social and professional rehabilitation.
• End of treatment. Once the patient and family reach their goals, the sessions become less common. Health professionals and families make plans for long-term follow-up.

The Leff model

This approach offers a set of social-familiar interventions designed to change high expressed emotion (EE). The main goals are to reduce EE and contact with the patient, increase the family’s social networks, reduce unrealistic expectations, and improve communication. The process is organized into three stages:

• Psychoeducation program. The purpose of this first stage is to increase awareness of the disease. The mental health professional usually visits the family at home and gives them a series of lectures. The culmination of this stage is a discussion.
• Multi-family groups. These sessions bring together families with high EE and low EE so they can learn from each other. The key technique of this stage is problem-solving. The families are presented with different situations and together come up with the most realistic and effective coping strategy.
• Single-family groups. The goal here is to reduce EE and social contact. Sessions are with the family and the patient.

The Fallon model

This model is a type of behavioral therapy based on the stress-vulnerability-coping-competence model. It’s highly structured and guided and is based on social learning and behaviorism. This model argues that coping skills make people able to overcome life’s challenges. This therapy is organized into five stages:

• Behavioral evaluation of the family unit. The goal here is to do a functional analysis of how the family communicates and solves problems. The therapist will also evaluate the possibilities, needs, and areas for improvement of each family member.
• Education about the illness. These sessions happen in the home with the patient and the family present. The therapist provides information about the illness using a combination of content, discussion, and sharing of personal experiences. The therapist needs to have an open style and avoid criticism and blame.
• Communication skills training. This stage also happens in the home with the family and the patient present. Social skills and communications training is designed to reduce tension at home and support adaptation.
• Training in problem-solving.
• Specific behavioral strategies. There are some problems that can’t be addressed in the previous stage, so this is a chance for families to learn about other behavioral strategies that might seem useful. These include setting boundaries, social skills, contingency plans, sexual and couples therapy, relaxation, time outs, modeling, etc.

The Tarrier model

This is a cognitive-behavioral model that seeks to provide solutions to family problems and needs and reduce EE. It trains the family members or “rehabilitation officers” in the skills they need to be able to relate to the patient. Reduction of family stress is important, as is the way that the family reacts to stressful events. The stages are:

• Educational program. In one of the sessions, the therapist shares educational material with the family about schizophrenia myths. The patient joins the family for the second session.
• Stress management and coping skills.
• Goal-setting program. The therapist teaches families to face problems in the most constructive way possible. They also equip them to change old patterns and adopt new ones that benefit all family members.

Conclusions about schizophrenia and family therapy

Schizophrenia has traditionally been considered a psychiatric illness for which medication is the only treatment option. This makes patients and their families feel pretty helpless. A schizophrenia diagnosis often triggers a sense that “all is lost” and neither the patient nor the family has any control over the illness.

Thanks to a number of studies in the field of expressed emotion (EE), we now know that medication isn’t the only option. Family therapy can also help patients manage their problems in a more positive way, participate in society, and communicate more effectively. Family can be a significant source of stress for schizophrenia patients, but they can also benefit from therapy and be helpful instead of a hindrance.

Therefore, once the patient is stable, starting psychological therapy and evidence-based treatments is crucial to improve patient quality of life.

In conclusion, these interventions are positive and hopeful, reminding those suffering from schizophrenia that they can play a role in their treatment and well-being.