Family psychoeducation for people living with schizophrenia and their families

Probably not a substantial claim: may not pass S3 (load-bearing).

Staff who work with people with severe mental illnesses may also show high expressed emotion.

“It can also be a feature of staff working with people with severe mental illnesses (Tattan 2000).”

• cites Tattan 2000Not checked yet

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May combine two claims.

Controlled trials indicate FPE benefits other conditions, particularly bipolar disorder and major depression, and schizophrenia with co-occurring substance use.

“Although the evidence for benefit is most extensive for individuals with schizophrenia, controlled studies show positive effects for other disorders, especially bipolar disorder and major depression, as well as for schizophrenia co-occurring with substance use (Dixon 2001;McFarlane 2003;Lucksted 2012).”

• cites Dixon 2001Not checked yet

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• cites McFarlane 2003Not checked yet

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• cites Lucksted 2012Not checked yet

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Family carers frequently say mental health staff do not engage them enough and give insufficient information and support, causing distress and frustration.

“Unfortunately, family carers often report a lack of engagement by mental health practitioners, as well as inadequate provision of information and support, which leads to distress and frustration (Dixon 2001;Wynaden 2005;Harvey 2013).”

• cites Dixon 2001Not checked yet

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• cites Wynaden 2005Not checked yet

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• cites Harvey 2013Not checked yet

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May combine two claims.

FPE has a substantial research base showing it improves outcomes for people with schizophrenia and, increasingly, for their relatives.

“In this article I focus on FPE since it is very well researched and has a strong evidence base for efficacy in delivering improved outcomes for people with schizophrenia and, increasingly, for their families.”

May combine two claims.

Well-known FPE approaches include behavioural family therapy and family work, both single-family models, and multiple-family groups of five to seven families.

“Recognised FPE approaches include behavioural family therapy (Falloon 2004) and family work (Kuipers 2002), both of which are single-family models, and multiple family groups involving five to seven families (McFarlane 2003).”

• cites Falloon 2004Not checked yet

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• cites Kuipers 2002Not checked yet

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• cites McFarlane 2003Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

High expressed emotion can also occur in families of people with conditions other than schizophrenia, such as bipolar disorder.

“Indeed, it has been shown that high EE may be evident in families living with people with other conditions, such as bipolar disorder (Kim 2004).”

• cites Kim 2004Not checked yet

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May combine two claims.

FPE studies have reported successful outcomes in families with mixed high and low expressed emotion, and in those whose expressed emotion status was unspecified.

“However, this is not definitive, since there is evidence for successful outcomes from studies with families of mixed EE status (high and low) as well as unspecified EE status, presumably also mixed (e.g.Barrowclough 1999;Gleeson 2010;Hayes 2014).”

• cites Barrowclough 1999Not checked yet

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• cites Gleeson 2010Not checked yet

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• cites Hayes 2014Not checked yet

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May combine two claims.

An Australian study found carers were almost ten times as likely to be socially isolated as a matched community sample, and more than 40% screened positive for probable anxiety or depression.

“For example, a study in Australia found that carers were nearly ten times more likely to be socially isolated than a matched community group, and over 40% met criteria for probable anxiety or depression (Hayes 2015).”

• cites Hayes 2015Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

FPE has three main forms: brief FPE, single-family work, and multiple-family groups.

“There are three major types of FPE: brief FPE; single-family format; and multiple family groups (Hayes 2013).”

• cites Hayes 2013Not checked yet

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May combine two claims.

Relatives of people with psychotic illnesses have more depression, anxiety, social isolation and lower quality of life than the general community.

“Families of people with psychotic illnesses experience higher rates of depression and anxiety, greater social isolation and decreased quality of life compared with the rest of the community (Hayes 2015).”

• cites Hayes 2015Not checked yet

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May combine two claims.

Family psychoeducation is linked to a 20% reduction in relapse compared with usual care, and the effect is larger when the intervention lasts more than 3 months.

“Reduced relapse rates of 20% compared with usual care have been reported, with greater effects for interventions lasting more than 3 months (Pitschel-Walz 2001).”

• cites Pitschel-Walz 2001Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

It is generally accepted that family psychoeducation approaches have several domains of effect, including improved problem solving and enhanced social support.

“It is generally accepted that FPE approaches have several different domains of effect, ranging from improved problem solving by family members to enhanced social support (McFarlane 2003).”

• cites McFarlane 2003Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Some guidelines also recommend family psychoeducation for persisting symptoms.

“Some also recommend FPE for persisting symptoms (NICE 2014).”

• cites NICE 2014Not checked yet

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May combine two claims.

Talking about negative feelings without blame, together with action to address the problem, helps a family resolve issues and become closer.

“This involves talking about negative feelings such as unhappiness, frustration, anxiety or anger, without blaming, and is combined with doing something to try to resolve the problem, for example making a positive requestit helps the family resolve problems and also increases intimacy (Falloon 2004;Fadden, 2006a)”

• cites Falloon 2004Not checked yet

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• cites Fadden, 2006aNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Expressing pleasant feelings helps a family attend to positive aspects and notice each member's helpful actions.

“Expressing pleasant feelings This is direct verbal communication that informs a person that the speaker is pleased with something that the person has doneit helps the family to focus on positive things and notice helpful things that each of them does”

• cites Falloon 2004Not checked yet

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• cites Fadden, 2006aNot checked yet

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May combine two claims.

Family outcomes of family psychoeducation are studied less often, so the evidence for them is weaker.

“Family outcomes from FPE are less commonly studied, so the evidence is weaker (Barbato 2000).”

• cites Barbato 2000Not checked yet

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May combine two claims.

For people with schizophrenia, family psychoeducation may improve mental state, social functioning and employment.

“For people with schizophrenia, these include improved mental state and important recovery outcomes such as better social functioning and increased employment (e.g.McFarlane 2003; Pharoah 2010).”

• cites McFarlane 2003Not checked yet

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• cites Pharoah 2010Not checked yet

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May combine two claims.

FPE primarily targets outcomes for the person with schizophrenia, while family well-being is considered an important intermediate outcome.

“Family psychoeducation approaches focus primarily on outcomes for the person with schizophrenia, although the well-being of the family is thought to be an essential intermediate outcome (Dixon 2001).”

• cites Dixon 2001Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The Cochrane review noted that family psychoeducation treatment effects may be overestimated because small negative studies may be missing.

“although the Cochrane review noted that treatment effects may be overestimated owing to the possibility that small negative studies are missing (Pharoah 2010).”

• cites Pharoah 2010Not checked yet

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May combine two claims.

Culturally adapted multiple family groups are effective for Vietnamese-speaking Australians and Spanish-speaking Mexican Americans.

“culturally adapted multiple family groups have been shown to be effective for Vietnamese-speaking Australians and Spanishspeaking Mexican Americans (Bradley 2006;Kopelowicz 2012).”

• cites Bradley 2006Not checked yet

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• cites Kopelowicz 2012Not checked yet

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May combine two claims.

More than 50 randomised controlled trials of family psychoeducation have been carried out and synthesised over the past 40 years, including in a Cochrane review.

“More than 50 randomised controlled trials have been conducted in the past 40 years and synthesised, including in a Cochrane review (Pharoah 2010).”

• cites Pharoah 2010Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Active listening lets speakers clarify their thoughts and feelings, helps listeners understand the speaker's concerns, and assists the family in solving problems and reaching goals.

“This is the skill of consciously listening to someone, discussing their concerns and clarifying problem areas and ideasit provides an opportunity for the speaker to clarify their thoughts and feelings and for the listener to better understand the speaker's problems and concerns, and it helps the family to solve problems and achieve goals”

• cites Falloon 2004Not checked yet

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• cites Fadden, 2006aNot checked yet

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May combine two claims.

Family psychoeducation reduces relapse and admission rates for people with schizophrenia, and the evidence for this is strong.

“The most commonly researched effects of FPE concern reduced relapse and admission rates for the person with schizophrenia, for which there is strong evidence.”

• cites Pharoah 2010Not checked yet

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• AssumptionRests on an assumption: Most people living with schizophrenia are supported by their families.

Probably not a substantial claim: may not pass S3 (load-bearing).

There is uncertainty about how family psychoeducation works.

“There is uncertainty about how FPE works (Lobban 2013).”

• cites Lobban 2013Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Making a positive request helps a family resolve problems and reach goals more efficiently.

“This involves using assertive language to make a constructive request for behaviour changeit helps the family to increase their efficiency at resolving problems and achieving goals”

• cites Falloon 2004Not checked yet

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• cites Fadden, 2006aNot checked yet

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May combine two claims.

Guidelines generally include families in assessment and treatment, and for schizophrenia recommend family psychoeducation for individuals at risk of relapse who live with or frequently contact family.

“These guidelines generally propose that families are included in the assessment and treatment process and, in the case of schizophrenia, stipulate that individuals who are at risk of relapse and who are living with, or in frequent contact with, their family should be offered FPE.”

Probably not a substantial claim: may not pass S2 (checkable).

A systemic and multilevel approach to practice change is necessary to promote widespread availability of family psychoeducation.

“Linked to these understandings, it is clear that it is necessary to adopt a systemic and multilevel approach to practice change, as recommended in the field of implementation science, to promote widespread availability of FPE (Damschroder 2009;Lucksted 2012;Eassom 2014).”

• cites Damschroder 2009Not checked yet

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• cites Lucksted 2012Not checked yet

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• cites Eassom 2014Not checked yet

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May combine two claims.

In a meta-analysis of 16 studies, family psychoeducation had considerable positive effects on relatives' burden, psychological distress, the relative-patient relationship, and family functioning.

“In the only meta-analysis of 16 studies of family outcomes, FPE had considerable positive effects on relatives' burden and psychological distress, the relationship between relatives and the person with schizophrenia, and family functioning (Cuijpers 1999).”

• cites Cuijpers 1999 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Peer-to-peer approaches hold potential for reaching more families as the peer workforce develops and expands.

“They also hold potential for reaching more families as the peer workforce develops and expands.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Stepped or tiered approaches acknowledge the value of including family peer-to-peer approaches among available services.

“These stepped or tiered approaches acknowledge the value of including family peer-to-peer approaches in the suite of available services.”

• AssumptionRests on an assumption: Family psychoeducation is not acceptable to all families.
• AssumptionRests on an assumption: Family psychoeducation may not be necessary for all families.

May combine two claims.

Various family consultation models are brief, lasting 1-3 sessions, and may be provided by practitioners or family peers.

“There are various family consultation models, all of which are brief (1-3 sessions) and may be provided by practitioners or family peers (Farhall 2012;Harvey 2013;Killackey 2015).”

• cites Farhall 2012Not checked yet

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• cites Harvey 2013Not checked yet

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• cites Killackey 2015 sourceNot checked yet

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Involving the family as partners in care has the potential to better support the individual's recovery and to address the family's needs for information, support and skills.

“The involvement of the family as partners in care has the potential to better support the individual's recovery as well as address the family's needs for information, support and enhanced skills for their caring role.”

• AssumptionRests on an assumption: Most people living with schizophrenia are supported by their families.

Probably not a substantial claim: may not pass S2 (checkable).

Systemic and multilevel approaches to practice change, with strong emphasis on organisational support, are required.

“It is increasingly clear that systemic and multilevel approaches to practice change, with a strong emphasis on organisational support, are required.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

There is emerging consensus that family psychoeducation should be offered as one of a number of services, and stepped or tiered approaches have been recommended.

“There is emerging consensus that FPE needs to be offered to families as one of a number of services, and various stepped or tiered approaches to providing the full range of services have been recommended (Dausch 2012;Farhall 2012;Harvey 2013).”

• cites Dausch 2012Not checked yet

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• cites Farhall 2012Not checked yet

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• cites Harvey 2013Not checked yet

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• AssumptionRests on an assumption: Family psychoeducation is not acceptable to all families.
• AssumptionRests on an assumption: Family psychoeducation may not be necessary for all families.

May combine two claims.

There is robust evidence for benefits of family psychoeducation participation for individuals and families, and this is reflected in clinical practice guidelines.

“In this regard, there is robust evidence for the benefits of participation in FPE for individuals and their families, which is reflected in recommendations in clinical practice guidelines.”

• AssumptionRests on an assumption: Most people living with schizophrenia are supported by their families.

Probably not a substantial claim: may not pass S2 (checkable).

Practitioners trained in another evidence-based intervention may apply skills in a particular practice element to their work with families, which is a promising approach to practice development.

“Thus, a promising approach to practice development is that practitioners already trained in another evidence-based intervention may apply their skills in a particular practice element to their work with families.”

May combine two claims.

Problem solving and goal setting are common to family psychoeducation and social skills training, and family psychoeducation and cognitive-behavioural therapy both focus on enhancing coping strategies.

“For example, problem solving and goal setting are common to FPE and social skills training, while FPE and cognitive-behavioural therapy both include a focus on enhancing coping strategies.”

May combine two claims.

Family psychoeducation is not widely available, and training practitioners is necessary but not sufficient to address this.

“Despite this, FPE is not widely available, and training practitioners in this intervention is a necessary but not sufficient step to address this.”

May combine two claims.

A Cochrane review of brief family intervention of five sessions or less or no more than 3 months concluded that meta-analysis was not possible and the evidence was of low or very low quality.

“A Cochrane review that examined brief family intervention (delivered over five sessions or less, or of no more than 3 months' duration) concluded that meta-analysis was not possible, and the evidence was of low or very low quality (Okpokoro 2014).”

• cites Okpokoro 2014Not checked yet

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May combine two claims.

Peer-to-peer approaches have promising but limited evidence of benefit and require further research.

“Peer-to-peer approaches have promising, but limited, evidence of benefit and so require further research (Killackey 2015).”

• cites Killackey 2015 sourceNot checked yet

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May combine two claims.

Family consultation models increase overall contact between practitioners and families, which may increase uptake of family psychoeducation where required.

“Beyond the value of offering an opportunity for all families to be in contact with mental health services and to find a doorway to other services, family consultation models also increase the overall contact between practitioners and families, which may in turn increase uptake of FPE where required.”