Family intervention in the treatment of schizophrenia

Mental Health Nursing,  Jul 1999  by Tredget, John

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The perception of families as playing a central role in the 'cause' of schizophrenia has shifted gradually, and involving the family in treatment of the person with schizophrenia is now commonplace. JOHN TREDGET considers the background to family interventions and concludes that although they can reduce relapse rates in schizophrenia, the mechanism by which they do so remains unclear.

Two government papers in the early 1990s1,2 directed that more emphasis be placed on the care of those with mental illness and that mental health nurses should be encouraged, with appropriate training, to develop their role as specialists with specific clinical skills, acknowledging the changing context of health-care delivery. One area where mental health nurses were encouraged to further their skills was through family intervention in the treatment of schizophrenia.

Historical perspective

Historically, the families of the seriously and persistently mentally ill have been implicitly or explicitly blamed for the mental illness of their loved ones.3 As far back as the I92os, a family role in the cause of mental illness was suggested, and later research turned to interactions within the family, with terms such as the `schizophrenogenic mother' and dysfunctional families',4 'family scapegoats', 'overdominant parenting with skew and schism' and `double-bind' interactions.

Yet none of these studies was able to show that schizophrenic families differed from the rest of the community5 and it is now accepted that families are an extremely valuable positive resource for the client - arguably, more so than the combined efforts of the best mental health professionals.6 They provide a natural resource for coping with stressors through support% and save the government some 25 billion through informal care.8

Yet these unsubstantiated theories that families cause schizophrenia were once widely held among professionals.9 This resulted in considerable harm to the relationship between mental health professionals and the families of those suffering from a mental illness. It is recognised that families that take on the burden of caring for someone with a severe or chronic mental illness experience high levels of stress% and they feel burdened by the serious and persistent nature of the illness of the family member.3 Untold distress was caused in those families who were having to cope with a mentally ill family member and who were also being blamed for the cause of that illness. Thankfully, with the passage of time, such beliefs of family causation of schizophrenia have diminished, having not withstood thorough investigation, although proponents of the theory can still be found, often fuelled by media hype.

While it is recognised that families can play a positive part in the illness, it is possible that incorrect family dynamics can cause an illness episode to be triggered or to increase the severity of an episode. In order to improve family interaction, innovative family interventions have been developed over a number of years, originally built on the research into expressed emotion.8

The interest in expressed emotion began in the IgS when medical sociologist George Brown and his colleagues in London found that patients with schizophrenia discharged from hospital had higher relapse rates if they lived with their families than if they lived alone in some other residential setting.9

The Camberwell Family Interview

From this discovery, the Camberwell Family Interview was developed. This assesses the feelings of the patient's relatives and their experiences surrounding the patient's admission to hospital, with special emphasis placed on the occurrence of arguments or irritability in the family. As a consequence of the development of this interview three measures were used to rate the expressed emotion of a particular family - criticism, hostility and emotional overinvolvement.

The Camberwell Family Interview was updated by Leff and Vaughn in the mid-seventies,9 with two important additional factors given recognition: faceto-face contact between the patient and relatives (more than 35 hours per week was considered to be high contact) and whether the patient took neuroleptic medication. Patients who did not take continuous medication and who lived with high expressed emotion relatives, with whom they had high contact, were shown to have relapse rates of up to go per cent.

The research undertaken on expressed emotion has stimulated a number of family intervention studies and although these differ in detail, they are all based on the premise that if living with a high expressed emotion relative, there is an increased probability of schizophrenic relapse in patients who have had at least one previous illness episode. The studies tested the hypothesis that interventions with the families would reduce this risk factor, resulting in decreased relapse rates.9

Seventeen predictive studies of the relationship between expressed emotion and relapse in patients with a diagnosis of schizophrenia have now been undertaken in nine different countries around the world. Only two of these studies have failed to show higher relapse rates in patients living with high expressed emotion relatives.I0