MJP Online Early MJP-02-08-12

REVIEW PAPER

Family Psychoeducation for : A Clinical Review

De Sousa A1, Kurvey A2, Sonavane S3

1Desousa Foundation, Mumbai 2Department of Psychology, LS Raheja College, Mumbai 3Department of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai

Abstract

Family psychoeducation is an integral part of schizophrenia treatment programmes. Recent shifts to briefer hospitalization and an emphasis on community care have emphasized the significance of relative education in this phase of treatment. Psychoeducational family programs designed to increase medication compliance and effectiveness in coping with stressors have been successful in reducing the risk of relapse in the first year following hospital discharge. They are aimed to provide correct information about the illness, treatments available and long term course and prognosis of the disease. Over the last three decades various models and different types of family psychoeducation programmes have been implemented to empower relatives of patients with schizophrenia. In the present paper different models for family intervention are discussed and their strengths and weaknesses evaluated.

Keywords: Family, Psychoeducation, Schizophrenia

Introduction and support.3 A variety of interventions referred to as ‘family psychoeducation’ Family members often play a vital role as programs, have been developed and caregivers in the lives of individuals with practiced all over the world in schizophrenia schizophrenia and other serious mental rehabilitation programmes.4 These programs illnesses. It has been estimated across are carried out along with an overall clinical studies that 30-85% of adults with treatment plan, and while the main focus is schizophrenia have a family member as a on improving the well-being and functioning caregiver.1 Recent trends point towards a of the patient, family members also community-based care for persons with experience significant benefits from such schizophrenia where family members would programs.5 assist with the care of these patients.2 Over the past 2 decades, a body of evidence-based The Use of the Term Psychoeducation practices have emerged to meet family member’s needs for education, guidance, The term ‘psychoeducation’ was first MJP Online Early MJP-02-08-12 employed to describe a behavioural Within the framework of , therapeutic concept consisting of four family psychoeducation refers to the elements viz. briefing the patients about components of treatment where active their illness, problem solving training, communication of information regarding the communication training, and self- illness and treatment methods along with a assertiveness training, whereby relatives treatment of general aspects of the illness were also included.6 are prominent.15 Indications for family psychoeducational groups are wide ranging. Psychoeducation often fulfilled less the There are only few mandatory function of an independent, self-contained contraindications, including relatives with therapeutic method and was viewed more as massive formal thought disorders, manic a combination of several therapeutic elevated mood, schizophrenia or acute elements contained within a complex suicidality with generally reduced stress psychosocial intervention.7-8 Various studies resilience.16 have demonstrated clear superiority of psychoeducational family interventions Family members can be integrated within when used in combination with standard the treatment as soon as they are capable of treatments in schizophrenia compared to taking part in a group for a period of 60 standard treatments being used alone.9-11 min.17 Ideally, only relatives of patients suffering from schizophrenic psychoses There has been an evident decline in should participate in the group, in order not duration of stay in medical institutions of to evoke unnecessary confusion in other patients with schizophrenia since caregivers through the schizophrenia- approximately 1990. The simultaneous specific informational content.18 Group necessity for an economic use of therapeutic sittings last approximately 1 hour, take place resources exists and the demand for compact once to twice a week, and consist of and yet efficient treatment methods exists.12 between 4 and 16 sessions. Group leaders Within this context, an independent are in most cases doctors or ; understanding of psychoeducation began to co-leaders can be recruited from all relevant unfold. The working group and complementary faculties ‘Psychoeducation of patients with or even may be caregivers who have been schizophrenia’ has formulated the following trained to disseminate this information.19 definition13 –“The term psychoeducation The superordinate goal can be seen in the comprises systemic, didactic relatives acquiring basic competency in psychotherapeutic interventions, which are order that they may reach well-informed and adequate for informing patients and their self-competent decisions as to which of the relatives about the illness and its treatment, modern therapeutic options viz. medications, facilitating both an understanding and electroconvulsive therapy, personally responsible handling of the psychotherapeutic and/or psychosocial are illness and supporting those afflicted in recommendable and suitable in their own coping with the disorder.” family member.20

The roots of psychoeducation are to be Therapeutic and Critical Factors in found in , although current Psychoeducation conceptions also include elements of client centered therapy in various degrees.14 In accordance with the psychotherapeutic MJP Online Early MJP-02-08-12 nature of family psychoeducation, comprehensible concept of the illness and its therapeutic alliance, causal and control treatment (causal and control attribution).31 attributions are also of utmost importance In particular, the concrete elaboration of here.21 It is important that emotional, illness- ‘missing links’ which enables lay persons to related topics are deliberately discussed in more fully understand why mental problems family education sessions. Emotions with a can be successfully treated by ‘chemical’ positive overtone, such as pride in one’s interventions, is of great significance for own role as a caregiver or the feeling of increasing functionality.32 In this capacity, having used unique methods to manage the psychoeducation can be seen to serve an patient along with issues such as being out ‘interpreter’ function, pursuing the aim of of one’s depth or struggling with one’s fate, translating complicated ‘technical jargon’ are also addressed.22 Through the into common and everyday language, which employment of techniques such as can be understood by relatives and helps ‘positivation’ of prior experiences, them to become experts of their illness.33 normalization of relapses or systematic Relatives progress with the patient through depathologicalization of the patient, each stage of treatment feeling encouraged participants are to be sent the signal that, and full of hope. The cautious introduction given close cooperation, a viable solution of the topic of handicaps caused by the can be found for all difficulties.23 illness, which are often severely protracted and unpredictable in terms of duration, also The primary goal of family entails a great challenge for simultaneously psychoeducational interventions consists in working on feelings of guilt, and finding a common denominator between the grief that the relatives may harbour.34 objective, textbook medical knowledge with Relatives are to increasingly gain access to regards to background information of the positive thoughts and positive disorder and treatment measures, and the conceptualizations of themselves and their subjective viewpoint of the afflicted patient.35 patient.24 Carrying out this requires an extremely differentiated behavioral Psychoeducation is thus primarily a form of therapeutic approach, supported by a basic therapy conveying reassurance and hope, humanistic orientation.25 with the aim of optimally integrating empowerment of those whose close ones are Each session comprises a module which is affected, with professional therapeutic highly structured, whose informational techniques in a working and therapeutic contents are to be interactively compiled and alliance.36 The take-home-message of relatives are to gain access to information psychoeducational programs must be that concerning appropriate mental health schizophrenic psychoses are induced by behavior.26-28 While individual opinions are biological factors in combination with appreciated and respected, great value is psychosocial stress; therefore, they must be placed on clearly and comprehensibly treated with both medication and presenting current scientifically founded psychotherapeutic interventions.37 expert knowledge in the form of direct information and advice giving.29-30 It is less The Goals of Psychoeducation in about the absolute comprehensiveness of Schizophrenia transmitted textbook knowledge which is important and more the construction of a The formulation of realistic and coherent MJP Online Early MJP-02-08-12 therapeutic goals in family psychoeducation well as structured training in problem- is of particular importance for all involved solving and effective communication in the i.e. relatives, and professional auxiliaries. family. In behavioural family management, Here, the greatest danger within the active phase of intervention typically psychoeducation is that despite the narrow lasts 1–2 years, and sessions are conducted time frame in which the intervention is to be within the home to increase accessibility, carried out, goals are set which are too high treatment adherence, and generalization of and indeed unattainable.38 The very strength skills.45 In a study using this model, 36 of psychoeducation lies in the deliberate patients and their families were assigned to focus upon relatives attaining basic behavioral family management (BFM) or a competence in the area of schizophrenic supportive individual therapy condition. psychoses.39 On the contrary, it is only when After 9 months, 6% of BFM patients had a basic understanding of the illness and its relapsed, compared with 44% who were requisite therapeutic measures have been treated individually.46 The BFM group also established that more continual and specific showed lower relapse rates and lower therapeutic elements can be employed.40 hospitalization days in a two year follow up.46 In a number of research studies, BFM Psychoeducation should ensure a has been found to impact important patient comprehensive introduction into the realm outcomes (reduced relapse rates, improved of psychoses for relatives of patients with a symptoms), as well as improve family first episode of schizophrenia and inform member knowledge and well-being.47-48 recurrent patients of the latest developments in terms of treatment options.41 The Family Psychoeducation conscious limitation of sessions to an average of eight, together with a central The family psychoeducation model focus upon facts, entails that these groups emphasizes connecting with the family, are also suitable for all types of relatives.42 providing illness education, and ongoing In the case of more seriously impaired support and crisis intervention in the reha- patients, these groups can be successful in bilitation process.49 In a two year study motivating and convincing relatives of these involving 106 patients family patients to opt for involvement in long term psychoeducation was proven to reduce rehabilitation and more differential relapse rates when combined with standard therapy.43 Relatives of chronic patients can, treatments. The patients whose families through recurrent integration in the family received psychoeduaction had lower psychoeducation group concept, can be sent expressed emotion scores and did better at a a sign of hope insofar that they have not society level and employment level at the been forsaken or abandoned to their fate end of two years.50 Thus family despite multiple relapses in their patients.44 psychoeducation is effective in reducing patient relapse and enhancing the outcomes Types of Psychoeducation Interventions of vocational rehabilitation for patients with in Schizophrenia schizophrenia.51

Behavioral Family Management Relatives Groups

Researchers have developed a family-based This is a model of family intervention approach that involves illness education, as involving individual family sessions and a MJP Online Early MJP-02-08-12 separate group for patients’ relatives. It was Treatment (FACT).59 and studies done developed in the UK but has been used all demonstrated that this combination has over the world.52 Like other models, there is significant benefits for improving the a strong focus on providing education and clinical and psychosocial functioning of helping the patient and family members patients with schizophrenia. develop skills to cope with the disorder. A unique component of this model is biweekly Specific Educational Programs relatives’ groups (which do not include patients), focusing on support and problem- Alongside these models of family solving for the family.53 psychoeducation, a number of specific family education programs have been Psychoeducational Multi-Family Groups developed. There are noteworthy differences between these family education programs The psychoeducational multi-family group and models of family psychoeducation model was designed to integrate components discussed above. First, family education of each of the approaches discussed above. programs do not involve intervention with As in other models, there is an initial the patient and do not focus on patient emphasis on joining with the family and outcomes as the primary goal. Instead, providing education.54 At the core of the education programs typically focus on model is the multi-family group that the helping family members find support and patient and family members attend, with information to cope with their relative’s group sessions primarily focused on enhanc- illness. Secondly, these programs are briefer ing problem-solving and coping skills. The and provide less-intensive services to family group is also designed to provide a valuable members. Third, the research evidence on support network for the patients and family family education programs is limited, and, in members.55 Controlled research studies have contrast to family psychoeducation, studies indicated that the program significantly have not indicated that family education reduces relapse rates and improves the programs influence patient outcomes functioning of patients with schizo- (though they may provide important benefits phrenia.56-57 In an outpatient patient group to family members).60-61 where this model was used, 63 outpatients with schizophrenia were randomized to Professional Family Education and receive either standard care or multiple- Consultation family group psychoeducation at a large community mental health center. Among the Certain authors have developed and 42 patients who completed 1 year of the evaluated individual and group education study, the multiple-family group treatment programs for family members. In their study was found to significantly reduce levels of both intervention programs significantly negative symptoms, compared with standard improved family members’ self-efficacy in care.58 This study is in contrast to most coping with issues related to their ill psychoeducational studies that are based on relative.62 There is also an educational inpatient relative groups. In a novel intervention, the Support and Family combination of approaches, the above model Education program, for family members of was integrated with assertive community patients in the Veterans Administration treatment (ACT), to create a model called treatment system. This program consists of a Family-Aided Assertive Community series of monthly workshops that family MJP Online Early MJP-02-08-12 members can attend, focusing on a variety of generally supported the cross-cultural challenges faced by family members.63 effectiveness of family psychoeducation Some researchers have proposed a family across various nations. Further work is consultation model in which individual fam- needed to more comprehensively understand ilies meet periodically with a professional the role of cultural factors in working with involved in the patient’s treatment (most families via psychoeducation.69 often the psychiatrist or primary clinician). This flexible model may be particularly well Second, while there is clear evidence that suited for families who would have family psychoeducation improves other difficulty participating in a longer interven- aspects of recovery beyond relapse rates, a tion, for families who are coping relatively more complete understanding of this topic is well, or, alternatively, in times of crisis.64 needed.70 Additionally, studies have documented improvements in family Research Needs in Family member well-being and decreased feelings Psychoeducation for Schizophrenia of subjective burden among family members. More research is needed to Over the past 25 years over 35 randomized examine how family interventions impact clinical trials have indicated that family the lives of patients and families in other psychoeducation is a highly effective important areas of functioning beyond evidence based treatment intervention, relapse and symptomatic improvement. particularly in reducing relapse rates for Such studies will help make family patients with schizophrenia.65 It should be psychoeducation more relevant to the noted that definitions of ‘relapse’ in research concerns of patients and their families.71 vary from study to study moving from symptom worsening to hospitalization. Third, research is needed to identify which Relapse rates have averaged to 10-15% interventions are most likely to be effective when psychoeducation has been added to for particular families. Patients in families standard treatment models compared to an with low levels of expressed emotion and average of 30-50% for those receiving unusually favorable medication response individual therapy and medication or have fared relatively better in single-family medication alone.66 Research indicates that formats than in multi-family groups. More such programs provide support and help research is needed to gain a more family members feel more knowledgeable comprehensive understanding of which and better able to cope with their relatives’ patients and families are most likely to illness.67 benefit from which particular models of intervention.72 While there is compelling evidence in support of implementing family Fourth, research is needed to identify the psychoeducation, there are a number of necessary ingredients for effective important topics for further study to gain a intervention, beyond the general principles more comprehensive base of knowledge for offered by the World Schizophrenia treatment recommendations.68 Fellowship73 and PORT treatment guidelines.74 First, more knowledge is needed regarding the influence of cultural factors in the implementation of programs. Research has MJP Online Early MJP-02-08-12

Family Psychoeducational Interventions Conclusions in Clinical Practice Family psychoeducation is a well- Despite strong research support, the established, efficacious psychosocial implementation of family psychoeducational treatment for schizophrenia. A large body of interventions in clinical practice has been controlled studies indicates that patient very limited. This is due to a number of relapse rates are generally cut in half with factors, including practitioner restraints (eg, the use of family psychoeducation time, expertise, training), systems-level interventions. Programs have also been issues (eg, lack of administrative support for shown to impact other important clinical programs, reimbursement/funding issues), outcomes, such as levels of positive and and barriers related to patients and families negative symptoms, as well as psychosocial (eg, time, reservations about participation).75 outcomes, such as employment rates and Family interventions are a vital service and social functioning. Thus family efforts must be made to make these psychoeducation represents a vital programs more available and accessible. component of comprehensive and evidence- based care for persons with schizophrenia An optimal clinical program would provide and is applicable in both short and long term access to family psychoeducation for all treatment and rehabilitation settings. serious mental illnesses patients in treatment and their families.76 References

In clinical practice, the implementation of 1. Avasthi A. Preserve and strengthen family interventions may vary depending on the family to promote mental health. setting and available resources. In the Indian J Psychiatry 2010;52(2):113- treatment of patients with serious mental 126. illness, the degree of involvement of and role of family members and significant 2. Awad AG, Voruganti LN. The others should be routinely assessed.77 burden of schizophrenia on Psychoeducational interventions are likely to caregivers : a review. have equivalent effects when conducted Pharmacoeconomics 2008;26:149- with other significant support figures, 162. regardless of the degree of biological relation while the term ‘family’ is used in a 3. Srinivasan N. Families as partners in broader connotation.78 care : perspectives from AMEND. Indian J Soc Work 2000;61:352-365. Once the support network of the patient is clearly understood, clinicians can then 4. Murthy RS. Family interventions and assess the preferences of the patient and empowerment as an approach to family regarding intervention and support enhance mental health resources in programs. In many geographical areas, developing countries. World formal resources to involve the family in Psychiatry 2003;2:35-37. treatment are limited or non-existent, highlighting the need for increased 5. Penn DL, Mueser KT. Research dissemination of research-based practices.79 update on the psychosocial treatment

MJP Online Early MJP-02-08-12

of schizophrenia. Am J Psychiatry the field. Curr Opin Psychiatry 2004;153:607-617. 2008;21(2):168-172.

6. Anderson CM, Gerard E, Hogarty 14. Cain DJ. Humanistic GE, Reiss DJ. Family treatment of : handbook of adut schizophrenic patients : a research and practice. Washington psychoeducational approach. DC: American Psychological Schizophr Bull 1980;6:490-505. Association ; 2002.

7. Bauml J, Frobose T, Kraemer S, 15. Chadda RK, Singh TB, Ganguly KK. Rentrop M, Pitschel-Walz G. Caregiver burden and coping : a Psychoeducation : a basic prospective study of the relationship psychotherapeutic intervention for between burden and coping in patients with schizophrenia and their caregivers of patients with families. Schizophr Bull schizophrenia and bipolar affective 2006;32(suppl 1):S1-S9. disorder. Soc Psychiatry Psychiatr Epidemiol 2007;42:923-930. 8. Mueser KT, Bond GR. Psychosocial treatment approaches for 16. Dixon L, Lehman AF. Family schizophrenia. Curr Opin Psychiatry interventions for schizophrenia. 2000;13:27-35. Schizophr Bull 1995;21:631-643.

9. Barbato A, D’Avanzo B. Family 17. Mino Y, Shimodera S, Inoue S, interventions in schizophrenia : a Fujita H, Fukuzawa K. Medical cost critical review of clinical trials. Acta analysis of family psychoeducation Psych Scand 2000;102:81-97. for schizophrenia. Psych Clin Neurosci 2007;61(1):20-24. 10. Fadden G. Research update : psychoeducational family 18. Lucksted A, McFarlane W, Downing interventions. J Fam Ther D, Dixon L. Recent developments in 1998;20:293-310. family psychoeducation as an evidence based practice. J Marit Fam 11. Dixon L, Adams C, Lucksted A. Ther 2012;38(1):101-121. Update on family psychoeducation for schizophrenia. Schizophr Bull 19. Lincoln T. Effectiveness of 2000;26:5-20. psychoeducation for schizophrenia : Is family inclusion necessary. 12. Sovani A. Understanding Schizophr Res 2010;117(2):120-122. schizophrenia : a family psychoeducational approach. Indian 20. Nasr T, Kausar R. Psychoeducation J Psychiatry 1993;35:97-99. and family burden in schizophrenia : a randomized controlled trial. Ann 13. Rummel-Kluge C, Kissling W. Gen Psychiatry 2009;8:17-23. Psychoeducation in schizophrenia : new developments and approaches in 21. J. Working with families of schizophrenic patients. Br J MJP Online Early MJP-02-08-12

Psychiatry 1994;164(suppl 23):71- practices for people with 76. schizophrenia. Schizophr Bull 2009;35(4):704-713. 22. Cohen AN, Glynn SM, Hamilton AB, Young AS. Implementation of a 30. Lehman AF, Buchanan RW, family intervention for individuals Dickerson FB, Dixon LB, Goldberg with schizophrenia. J Gen Intern R, Green-Paden L, Kreyenbuhl J. Med 2010;25(suppl1):32-37. Evidence based treatment for schizophrenia. Psychiatr Clin N Am 23. Kulhara P, Chakrabarti S, Avasthi A, 2003;26(4):939-954. Sharma A, Sharma S. Psychoeducational intervention for 31. Merinder LB. Patient education in caregivers of Indian patients with schizophrenia : a review. Acta Psych schizophrenia : a randomized Scand 2000;108(2):98-106. controlled trial. Acta Psych Scand 2009;119(6):472-483. 32. Bradshaw T, Lovell K, Bee L, Campbell M. The development and 24. Lefley HP. Family psychoeducation evaluation of a complex health for serious mental illness. Oxford: education intervention for adult with Oxford University Press; 2009. diagnosis of schizophrenia. J Psych Ment Health Nurs 2010;17(6):473- 25. Friedman MS, Mueser KT, Giuliano 486. A, Goff DC, Seidman LJ. Family directed cognitive adaptation for 33. Gray R, White J, Schulz M, schizophrenia. J Clin Psychol Abderhalden C. Enhancing 2009;65(8):854-867. medication adherence in people with schizophrenia: An international 26. Chan SW. Global perspective of programme of research. Int J Ment burden of family caregivers of Health Nurs 2010;19(1):36-44. persons with schizophrenia. Arch Psych Nurs 2011;25(5):339-349. 34. McWilliams S, Hill S, Mannion N, Kinsella A, O’Callaghan E. 27. Patterson TL, Leeuwenkamp OR. Caregiver psychoeducation in Adjunctive psychosocial therapies schizophrenia : is gender important. for the treatment of schizophrenia. Eur Psychiatry 2007;22(5):323-327. Schizophr Res 2008;100(1):108-119. 35. Rummel-Kludge C, Kissling W. 28. Glick ID, Stekoll AH, Hays S. The Psychoeducation of patients with role of the family and improvement schizophrenia and their families. Exp in treatment maintenance, adherence Rev Neurother 2008;8(7):1067-1077. and outcome for schizophrenia. J Clin Psychopharmacol 2011;31:82- 36. Smerud PE, Rosenfarb IS. The 85. therapeutic alliance and family psychoeducation in the treatment of 29. Drake RE, Bond GR, Essock SM. schizophrenia: an exploratory Implementing evidence based prospective change process study. J MJP Online Early MJP-02-08-12

Cons Clin Psychol 2008;76(3):505- psychoeducation in a psychosocial 510. rehabilitation setting. Int J Psychosoc Rehabil 2012;16(1):112-119. 37. Hauser M, Juckel G. Psychoeducation in subjects at an 44. Robinson DG. Medication adherence elevated risk for : a critical and relapse in recent-onset review. Curr Pharm Design psychosis. Am J Psychiatry 2012;18(4):566-569. 2011;168:240-242.

38. Lincoln TM, Wilhelm K, Nestoriuc 45. Liberman RP, Cardin V, McGill Y. Effectiveness of psychoeducation CW, Falloon IR. Behavioral family for relapse, symptoms, knowledge, management of schizophrenia : adherence and functioning in clinical outcome and costs. Psych psychotic disorders: A meta-analysis. Ann 1987;17(9):610-619. Schizophr Res 2007;96(1):232-245. 46. Mueser KT, Glynn SM. Behavioral 39. Lefley HP. Treating difficult cases in for psychiatric a psychoeducational family support disorders. New Harbringer group for serious mental illness. J Publications, Oakland:CA; 1999. Fam Psychother 2010;21(4):253-268. 47. Falloon IR, Boyd JL, McGill CW, 40. Bossema ER, de Haar CAJ, Razani J, Moss HB, Gilderman AM. Westerhuis W, Beenackers BF, Blom Family management in the BCEM, Appels MCM, van Oeveren prevention of exacerbations of CJ. Psychoeducation for patients schizophrenia: a controlled study. N with a psychotic disorder: effects on Engl J Med 1982;306:1437-1440. knowledge and coping. Prim Care Companion CNS Disord 48. Falloon IRH, Penderson J. Family 2011;13(4):213-219. management in the prevention of morbidity of schizophrenia: the 41. Swaminath G. Psychoeducation. adjustment of the family unit. Br J Indian J Psychiatry 2009;51(3):171- Psychiatry 1985;147:156-163. 172. 49. Falloon IRH, Boyd JL, McGill, CW. 42. Dixon LB, Dickerson FB, Bellack Family Care of Schizophrenia: A AS, Bennett M, Dickinson D, Problem-Solving Approach to the Lehman AF, Tenhula WN, Calmes Treatment of Mental Illness. New C, Passilas RM, Peer J, Kreyenbuhl York, NY: Guildford; 1984. J. The 2009 Schizophrenia PORT Psychosocial Treatment 50. Hogarty GE, Anderson CM, Reiss Recommendations and Summary DJ. Family psychoeducation, social Statements. Schizophr Res skills training, and maintenance 2010;36(1):48-70. chemotherapy in the aftercare treatment of schizophrenia II: Two- 43. Phillips LA, Scahde DN. year effects of a controlled study on Implementing empowerment relapse and adjustment. MJP Online Early MJP-02-08-12

Environmental-Personal Indicators in Management of negative symptoms the Course of Schizophrenia (EPICS) among patients with schizophrenia Research Group. Arch Gen attending multiple-family groups Psychiatry 1991;48:340-347. Psychiatr Serv 2000;51:513-519.

51. Glynn SM. Family interventions in 59. Mari JJ, Streiner DL. An overview of schizophrenia: promises and pitfalls family interventions and relapse on over the last 30 years. Curr Psych schizophrenia: meta-analysis of Rep 2012;(Epub ahead of print). research findings. Psychol Med 1999;24: 565-578. 52. Leff J, Berkowitz R, Shavit N, Strachan A, Glass I, Vaughn C. A 60. Malm U, Ivarsson B, Allebeck P, trial of family therapy versus a Falloon IRH. Integrated care in relatives group for schizophrenia. Br schizophrenia: a 2-year randomized J Psychiatry 1989;154:58-66. controlled study of two community- based treatment programs. Acta 53. Leff J, Berkowitz R, Shavit N, Psych Scand 2003;107:415-423. Strachan A, Glass I, Vaughn C. A trial of family therapy versus a 61. Stam H, Cuijpers P. Effects of family relatives’ group for schizophrenia: intervention on burden of relatives of Two-year follow-up. Br J Psychiatry psychiatric patients in the 1990;157:571-577. Netherlands: a pilot study. Comm Ment Health J 2001;37:179-187. 54. Jewell TC, Downing D, McFarlane WR. Partnering With Families: 62. Solomon P. Moving from Multiple Family Group psychoeducation to family education Psychoeducation for Schizophrenia. for families of adults with serious J Clin Psychol 2009;65:868-878. mental illness. Psychiatr Serv 1996;47:1364-1370. 55. McFarlane WR, Link B, Dushay R, Marchal J, Crilly J. 63. Sherman MD. The Support and Psychoeducational multiple family Family Education (SAFE) program: groups: Four-year relapse outcome in mental health facts for families. schizophrenia. Fam Process Psychiatr Serv 2003;54:35-37. 1995;34(2):127–144. 64. Wynne LC. The rationale for 56. McFarlane WR. Multifamily groups consultation with the families of in the treatment of severe psychiatric schizophrenic patients. Acta Psych disorders. New York: Guilford Press; Scand 1994;90(suppl 384):125-132. 2002. 65. Burland JF. Family-to-family: a 57. McFarlane WR. Family Therapy for trauma-and-recovery model of Schizophrenia. New York: Guilford family education. New Dir Ment Press; 1983. Health Serv 1998;77:33-44.

58. Dyck DG, Short RA, Hendryx MS. 66. Murray-Swank AB, Dixon LB. MJP Online Early MJP-02-08-12

Family psychoeducation as an 74. Kreyenbuhl J, Buchanan RW, evidence based practice. CNS Spectr Dickerson FB, Dixon LB. The 2004;9(12):905-912. Schizophrenia Patient Outcomes Research Team (PORT): updated 67. Magliano L, Fiorillo A. treatment recommendations 2009. Psychoeducational family Schizophr Bull 2010;36(1):94-103. interventions for schizophrenia in the last decade: from explanatory to 75. Bebbington P, Kuipers L. The pragmatic trials. Epidemiol Psych predictive utility of expressed Soc 2007;16(1):22-34. emotion in schizophrenia: an aggregate analysis. Psychol Med 68. Paley G, Shapiro DA. Lessons from 1994;24:707-718. psychotherapy research for psychological interventions for 76. Pincus HR. From PORT to policy to people with schizophrenia. Psychol patient outcomes: crossing the Psychother Theory Res Pract quality chasm. Schizophr Bull 2002;75:5-17. 2010;36(1):109-111.

69. Wong V. Cultural influence of 77. Solomon P, Draine J. Subjective psychoeducation in Hongkong. burden among family members of Internat Psychiatry 2010;7(1):20-22. mentally ill adults: relation to stress, coping, and adaptation. Am J 70. Resnick SG, Rosenheck, RA, Orthopsychiatry 1995;65:419-427. Lehman, AF. An exploratory analysis of correlates of recovery. 78. World Schizophrenia Fellowship. Psychiatr Serv 2004;55:540-547. Families as Partners in Care: A Document Developed to Launch a 71. Anderson CM, Reiss DJ, Hogarty Strategy for the Implementation of GE. Schizophrenia and the Family. Programs of Family Training, New York, NY Guildford; 1986. Education, and Support. Toronto, Canada: World Schizophrenia 72. Solomon P, Draine J, Mannion E, Fellowship; 1998. Meisel M. Impact of brief family 79. Pitschel-Walz G, Leucht S, Bauml J, psychoeducation on self-efficacy. Kissling W, Engel RR. The effect of Schizophr Bull 1996;22:41-50. family interventions on relapse and rehospitalization in schizophrenia–a 73. Insel TR. Rethinking schizophrenia. meta-analysis. Schizophr Bull Nature 2010;468:187-193. 2001;27:73-92.

Corresponding Author Dr. Avinash De Sousa, Carmel, 18, St Francis Avenue, Off S.V. Road, Santacruz (West), Mumbai – 400054 Tel: 022-26460002 Email: [email protected]