Multiple studies have shown that family psycho-educational interventions can lead to a change in the level of criticism and (to a more limited extent) over-involvement among relatives of people with schizophrenia and to a reduction in the relapse rate. The benefits of reducing household stress on the relapse rate in schizophrenia appear to be equally as strong as the effect of antipsychotic drug treatment. A person with schizophrenia who is taking antipsychotic medication and living in a high-EE household runs a roughly 50 per cent chance of relapse in the course of a year; if the household environment can be changed to a low-EE level, the relapse rate drops to 10 per cent or less. Effective interventions offer three basic ingredients: (a) detailed information about the illness for the patient and the family; (b) helping the family develop problem-solving mechanisms; and (c) practical and emotional support.
In a British study, for example, the family was given education, usually in the family home, on the diagnosis, causes, course, and management of schizophrenia. The family was also invited to join a relatives’ group in which high-EE relatives learned from low-EE family members how they coped with the day-to-day problems of living with someone with schizophrenia without becoming critical or over-involved. The family member with schizophrenia was not invited to attend the relatives’ group.
A US-based psycho-educational approach consisted of education about schizophrenia, communication training, a structured problem-solving method, and similar strategies. Families were taught about the use of medication, side effects, warning signals of impending relapse and the risks of street drug use. The communication training examined the expression of positive and negative feelings in the home, listening skills, and how to ask others to behave differently.
Another US researcher developed a multiple family group approach that aimed to provide support and education while reducing feelings of blame and creating avenues for changing family interaction patterns.
These family psycho-educational approaches have proven to be very effective in reducing the rate of relapse in schizophrenia. The approach, however, has not disseminated at all broadly in community psychiatric practice anywhere in the world. Only seven per cent or fewer of people with schizophrenia in the US, for example, are involved in a family intervention program. There are several explanations for this. In many parts of the US, few people with schizophrenia are living with their family members. Furthermore, organized attempts to disseminate the model to mental health managers and providers have been virtually nonexistent because, unlike pharmaceuticals, no-one stands to profit from marketing the approach, and those who would benefit most, organizations of families of people with mental illness, have, at times, considered any form of family intervention to be stigmatizing and have not lobbied for dissemination of the approach.
Most of the work cited above was published in the 1980s or 1990s; little development of the model has occurred in the past fifteen to twenty years. The advent of the internet, however, offers new possibilities for disseminating the approach. US researchers recently described a web-based psycho-educational intervention for people with schizophrenia and their families. Internet forums were created for this intervention for family members and for clients. Each forum was led and moderated by a trained therapist/moderator. A library of educational resources and responses to frequently asked questions was also provided online. A study of the approach revealed a large reduction in positive symptoms among the consumers and a growth in knowledge about schizophrenia in both patients and family members.
Colorado Recovery has developed a similar forum for family members of people with mental illness that is moderated by a cohort of trained mental health professionals, family members and people who have themselves experienced mental illness. On-line delivery of family psycho-education may have a promising future.