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Psychosocial interventions offered to families of persons with schizophrenia have been developed and studied over the past 20 years with increasing sophistication and methodological rigor. Although these family interventions differ in their characteristics and methods, they tend to share a common set of assumptions: (1) schizophrenia is regarded as an illness; (2) the family environment is not implicated in the etiology of the illness; (3) support is provided and families are enlisted as therapeutic agents; and (4) the interventions are part of a treatment package used in conjunction with routine drug treatment and outpatient clinical management (Lam 1991). It is imperative to note that these family interventions do not include those traditional family therapies (variously labeled as contextual, symbolic-experiential, structural, strategic, and integrative) derived from the theoretical proposition that behavior and/or communication within the family plays a key etiological role in the development of schizophrenia. The elements of family interventions most frequently used in differing combinations are psycho-education, behavioral problem solving, family support, and crisis management. Interventions differ in whether they are conducted with individual families or groups of families and whether they are in vivo, in the home, or out of the home. They also differ in whether the patient is included or excluded, the length of the intervention, and the phase of illness of the patient at the time of the intervention. The construct of expressed emotion (EE) has played a significant role in the evolution of professional interventions directed at families. During a structured interview, families are assigned an EE rating based on observations of critical comments, hostility, and overinvolvement. A body of literature suggests that patients living with families characterized by high levels of EE are more vulnerable to relapse (Koenigsberg and Handley 1986). Thus, many interventions have targeted high EE families because those families are most likely to benefit from the intervention. However, the utility of this construct has been criticized (Lefley 1992). Determining the validity of the EE construct and whether high EE causes relapse is not the purpose of this review and will not be directly addressed. However, EE will be discussed in the context of patient heterogeneity, because many studies reviewed here include only those patients from families with high EE. The self-help family education movement has had a significant influence on the development of family psycho-education interventions. Pioneers in the family education movement distinguish family education from the professionally driven psychoeducational approaches in that (1) family education is centrally directed at helping the family, not the patient; (2) family education does not assume a medical therapy model, in which a presumption of pathology in the family being treated is implicit; and (3) family education stresses the competencies, not the deficits, of families (Hatfield 1994). Hatfield (1994) and Lefley (1994) acknowledge many overlapping goals and strategies in the family education and professional psychoeducational approaches. Professionally driven psychoeducational interventions have incorporated principles of family education. However, because little controlled research has been conducted on family education protocols (Hatfield 1994), these programs will not be examined in this review. The review will address the following questions: 1. When added to pharmacotherapy, is there evidence that family interventions are effective for reducing patient relapse and improving functional status and family well-being? 2. Is there evidence that a particular kind of family intervention is superior to others? 3. Is there evidence that patient heterogeneity factors, such as family characteristics, age, gender, race, and phase of illness, influence the effectiveness of these interventions? Methods Searches of the PSYCLIT and MEDLINE data bases were conducted covering the years from 1966 to 1993 and using the key words schizophrenia and family intervention or family therapy. All references related to the key words were requested with the "explode" command. These searches yielded 467 citations. In addition, relevant references from articles selected for review were obtained, and unpublished material was gathered through consultation with a selection of experts in the field. Our overall strategy used both existing reviews of the literature and primary studies. All review articles or book chapters identified in searches from 1983 to 1993 were evaluated according to criteria for assessment of reviews derived from Beaman (1991). Reviews by Strachan (1986), Halford and Hayes (1991), and Lam (1991) were the most highly rated and serve as references for this article. These reviews discuss the results of eight randomized controlled trials of a family intervention for the treatment of persons with schizophrenia. We have also included a recently published high-quality meta-analysis by Mari and Streiner (1994). All primary studies cited in these reviews of the literature were retrieved to clarify ambiguities in published reviews. In addition, we identified and retrieved other primary studies that were not cited in the selected review articles. These studies had the following characteristics: (1) randomized controlled trial of an intervention involving family members of persons with schizophrenia; (2) patient group is primarily persons with schizophrenia diagnosed in a systematic fashion; and (3) outcome measures are systematically described and applied. We obtained results of the New York State Family Psychoeducation in Schizophrenia Project, which is in press, and preliminary results from the Treatment Strategies for Schizophrenia study. Given the limited number of primary studies and their relevance to several review questions, each primary study is briefly summarized in the text and in table 1. The summaries of the primary studies are followed by descriptions of the findings of the review by Mari and Streiner (1994), which is the only review to conduct secondary data analysis.
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