Family Therapy

Question 1

What is family therapy?

Answer 1

The name given to a range of interventions aimed at the family (e.g. parents, siblings, partners) of someone with a mental disorder.

Question 2

When should family therapy be used?

Answer 2

Should be offered to all, and especially to those who have persistent symptoms or are a high relapse risk.

Question 3

What has research shown?

Answer 3

Schizophrenics in families that expressed high levels of criticism, hostility or over-involvement had more frequent relapses than people with the same problems who lived in families that were less expressive in their emotions.

Question 4

How does family therapy work?

Answer 4

By reducing levels of EE and stress, and by increasing the capacity of relatives to solve related problems, family therapy attempts to reduce the incidence of relapse for the person with schizophrenia.

Question 5

What are the strategies of family therapy?

Answer 5

Psychoeducation - helping develop an understanding and being able to deal with the illness.
Forming an alliance with relatives who care for the person.
Reducing the emotional climate within the family and the burden of care for family members.
Enhancing relatives ability to anticipate and solve problems.
Reducing expressions of anger and guilt by family members.
Maintaining reasonable expectations among family members for patient performance.
Encouraging relatives to set appropriate limits whilst maintaining some degree of separation when needed.

Question 6

What is family therapy commonly used with?

Answer 6

Drug treatment and outpatient clinical case.

Question 7

What is the patient encouraged to do?

Answer 7

To talk to their family and explain what sort of support they find helpful - and what makes things worse for them.

Question 8

How long is family therapy?

Answer 8

Often offered between a period of 3 and 12 months, and at least 10 sessions.

Question 9

What is the main aim of family therapy?

Answer 9

Reducing the level of EE within the family, as EE has been demonstrated to increase the likelihood of relapse.

Garety (2008) estimated the relapse rate for individuals who receive family therapy as 25% compared to 50% for those who receive standard care alone.

Question 10

What does family therapy do?

Answer 10

Provides family with information
Finds ways to support an individual
Finds ways to resolve practical problems
Helps reduce suspicions the patient may have about treatment
Improves relationships - encourages listening, discussion, and negotiation of problems.

Question 11

Who conducted the key study?

Answer 11

Pharoah (2010)

Question 12

What was the procedure of Pharoah’s study?

Answer 12

Reviewed 53 studies published between 2002 and 2010 to investigate the effectiveness of family intervention.
Studies chosen were conducted in Europe, Asia and North America.

The studies compared outcomes from family therapy to ‘standard’ care (i.e. antipsychotic medication) alone.

The researcher concentrated on studies that were randomised controlled trials (RCTs).

Question 13

What were the findings of Pharoah’s study?

Answer 13

Mental state - the overall impression was mixed. Some studies reported an improvement in the overall mental state of patients compared to those receiving standard care. Others didn’t.

Compliance with medication - the use of family intervention increased patients’ compliance with medication.

Social functioning - although appearing to show some improvement on general functioning, family intervention didn’t appear to have much of an effect on more concrete outcomes such as living independently or employment.

Reduction in relapse and readmission - there was a reduction in the risk of relapse and a reduction in hospital admission during treatment and in the 24 months after.

Question 14

What are the evaluative points?

Answer 14

Why is family therapy effective?
A methodological limitation: lack of blinding 
Economic benefits of family therapy 
Impact on family members
Is family therapy worthwhile?

Question 15

What is meant by why is family therapy effective?

Answer 15

The improvements in mental state and social functioning found in the Pharoah study may not be a direct result of family therapy.

The authors suggest that the main reason for its effectiveness may have less to do with any improvements in these clinical markers and more to do with the fact that it increases medication compliance.

This suggests the main benefit of this therapy is that it makes people more likely to comply with their medication regime, which then leads to improvements in their mental state and social functioning.

Question 16

What is meant by a methodological limitation: lack of blinding?

Answer 16

In the Pharoah meta-analysis, methodological quality compromised in those studies where raters were not ‘blinded’ to the condition to which participants had been allocated.

Ten of the 53 studies reported in this meta-analysis didn’t use any form of blinding. A further 16 didn’t mention whether blinding had been used.

The lack of blinding is particularly problematic in studies with longer follow-ups where participants tend to unintentionally reveal the type of therapy they had received.

Question 17

What is blinding?

Answer 17

Raters were unaware of the type of treatment received (family therapy or standard care) by the participants they were rating.

Question 18

What is meant by economic benefit of family therapy?

Answer 18

An additional advantage of family therapy is that it has a considerable economic benefits associated with the treatment of schizophrenia.

The NICE review of family therapy studies (2009) demonstrated that it is associated with significant cost savings when offered to people with schizophrenia in addition to standard care.
The extra cost of family therapy is offset by a reduction in costs of hospitalisation because of the lower relapse rates associated with this form of intervention.
There is also evidence that family therapy reduces relapse rates for a significant period after completion of the intervention.

This means that the cost savings associated with family therapy would be even higher.

Question 19

What is meant by impact on family members?

Answer 19

It has been shown to improve outcomes for the individual with schizophrenia, but there may be an additional advantage in that they can have a positive impact on family members as well.

Lobban (2013) analysed the results of 50 family therapy studies that had included an intervention to support relatives.
60% of these studies reported a significant positive impact of the intervention on at least one outcome category for relatives (coping and problem solving skills, etc).

However, the researchers also concluded that the methodological quality of the studies was generally poor, making it difficult to distinguish effective from ineffective interventions.

Question 20

What is meant by is family therapy worthwhile?

Answer 20

A study by Garety (2008) failed to show any better outcomes for patients given sessions of family therapy compared to those who simply had carers but no family therapy.

Individuals in both groups were found to have unexpectedly low rates of relapse, contrasting markedly with the rates found in the ‘no carer’ group.

The researchers found that most of the carers in this study displayed relatively low rates of EE, which may reflect widespread cultural changes in carers knowledge and attitudes towards schizophrenia.

Garety concluded that, for many people, family intervention may not improve outcomes further than a good standard of treatment as usual.