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August 1995, Vol 52, No. 8 >
Article | August 1995

Multiple-Family Groups and Psychoeducation in the Treatment of Schizophrenia

William R. McFarlane, MD; Ellen Lukens, PhD; Bruce Link, PhD; Robert Dushay, PhD; Susan A. Deakins, MD; Margaret Newmark, CSW; Edward J. Dunne, PhD; Bonnie Horen, MA; Joanne Toran, MPA
Arch Gen Psychiatry. 1995;52(8):679-687. doi:10.1001/archpsyc.1995.03950200069016
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Objective:  To compare outcomes in psychoeducational multiple-family group treatment vs psychoeducational single-family treatment.

Method:  A total of 172 acutely psychotic patients, aged 18 to 45 years, with DSM-III-R schizophrenic disorders were randomly assigned to single- or multiple-family psychoeducational treatment at six public hospitals in the state of New York. Psychotic relapse, symptom status, medication compliance, rehospitalization, and employment were assessed independently during 2 years of supervised treatment.

Results:  The multiple-family groups yielded significantly lower 2-year cumulative relapse rates than did the single-family modality (16% vs 27%) and achieved markedly lower rates in patients whose conditions had not remitted at index hospital discharge (13% vs 33%). The relapse hazard ratio between treatments was 1:3. The relapse rate for both modalities was less than half the expected rate (65% to 80% for 2 years) for patients receiving individual treatment and medication. Rehospitalization rates and psychotic symptoms decreased significantly, and medication compliance was high, to an equal degree in both modalities. Psychoeducational multiple-family groups were more effective than single-family treatment in extending remission, especially in patients at higher risk for relapse, with a cost-benefit ratio of up to 1:34.

Conclusion:  Psychoeducational multiple-family groups were more effective than single-family treatment in extending remission, especially in patients at higher risk for relapse, with a cost-benefit ratio of up to 1:34.

REFERENCES

1 +
Goldstein MJ, Rodnick E, Evans J, May P, Steinberg M.  Drug and family therapy in the aftercare of acute schizophrenics . Arch Gen Psychiatry . 1978;;35:1169-1177.
2 +
Leff JP, Kuipers L, Berkowitz R, Sturgeon D.  A controlled trial of social intervention in the families of schizophrenic patients: two year follow-up . Br J Psychiatry . 1984;;146:594-600.
3 +
Falloon I, Boyd J, McGill C, Williamson M, Razani J, Moss HB, Gilderman AM, Simpson GM.  Family management in the prevention of morbidity of schizophrenia . Arch Gen Psychiatry . 1985;;42:887-896.
4 +
Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Javna CD, Madonia MJ.  Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia . Arch Gen Psychiatry . 1986;;43:633-642.
5 +
Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Ulrich RF, Carter M, EPICS Research Group.  Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia, II: two-year effects of a controlled study on relapse and adjustment . Arch Gen Psychiatry . 1991;;48:340-347.
6 +
Tarrier N, Barrowclough C, Vaughn C, Bamrah JS, Porceddu K, Watts S, Freeman H.  Community management of schizophrenia: a two-year follow-up of a behavioral intervention with families . Br J Psychiatry . 1989;;154:625-628.
7 +
Leff J, Berkowitz R, Shavit N, Strachan A, Glass I, Vaughn C.  A trial of family therapy v a relatives group for schizophrenia . Br J Psychiatry . 1989;;154:58-66.
8 +
McFarlane WR.  Multiple family groups in the treatment of schizophrenia . In: Nasrallah HA, ed. Handbook of Schizophrenia . Amsterdam, the Netherlands: Elsevier; 1990;;4:167-189.
9 +
Schooler NR, Keith SJ, Severe JB, Matthews S.  Acute treatment response and short-term outcome in schizophrenia: first results of the NIMH Treatment Strategies in Schizophrenia Study: Treatment Strategies in Schizophrenia Collaborative Study Group . Psychopharmacol Bull . 1989;;25:331-335.
10 +
McFarlane WR, Link B, Dushay R, Marchal J, Crilly J.  The multiple family group and psychoeducation in the treatment of schizophrenia: four year outcome in a small sample . Fam Process . 1995;;34:127-144.
11 +
Laqueur HP.  Mechanisms of change in multiple family therapy . In: Sager CJ, Kaplan HS, eds. Progress in Group and Family Therapy . New York, NY: Brunner/Mazel; 1972;.
12 +
Detre T, Sayer J, Norton A, Lewis H.  An experimental approach to the treatment of the acutely ill psychiatric patient in the general hospital . Conn Med . 1961;;25:613-619.
13 +
Beels CC.  Family and social management of schizophrenia . Schizophr Bull . 1975;;13:97-118.
14 +
Berman KK.  Multiple family therapy: its possibilities in preventing readmission . Ment Hygiene . 1966;;50:367-370.
15 +
Lansky MR, Bley CR, McVey GG, Botram B.  Multiple family groups as aftercare . Int J Group Psychother . 1978;;29:211-224.
16 +
Levin EC.  Therapeutic multiple family groups . Int J Group Psychother . 1966;;19:203-208.
17 +
Lurie A, Ron H.  Socialization program as part of after-care planning . Gen Psychiatr Assoc J . 1972;;17:157-162.
18 +
Braun P.  Deinstitutionalization of psychiatric patients: a critical review of outcome studies . Am J Psychiatry . 1981;;138:736-749.
19 +
Bachrach LL.  Assessment of outcomes in community support systems: results, problems and limitations . Schizophr Bull . 1982;;8:41-60.
20 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;.
21 +
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK.  Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study . JAMA . 1990;;264:2511-2518.
22 +
Leff J, Vaughn C.  The interaction of life events and relatives' expressed emotion in schizophrenia and depressive neurosis . Br J Psychiatry . 1980;;136:146-153.
23 +
Herz M.  Recognizing and preventing relapse in patients with schizophrenia . Hosp Community Psychiatry . 1984;;35:344-349.
24 +
Falloon IRH, Liberman R.  Behavioral family interventions in the management of chronic schizophrenia . In: McFarlane WR, ed. Family Therapy in Schizophrenia . New York, NY: Guilford Press; 1983;:141-172.
25 +
Anderson C, Hogarty G, Reiss D. Schizophrenia and the Family . New York, NY: Guilford Press; 1986;.
26 +
Falloon I, Boyd J, McGill C. Family Care of Schizophrenia . New York, NY: Guilford Press; 1984;.
27 +
Spitzer RL, Williams JBW, Gibbon M, Burke J, Keith SJ, Schooler N.  Structured Clinical Interview for DSM-III , Psychotic Disorders Version (SCID-PD, 3/1/85) . New York, NY: Biometric Research Dept, New York State Psychiatric Institute; 1985;.
28 +
Kane J, Rifkin A, Woerner M.  Low-dose neuroleptic treatment of outpatient schizophrenics . Arch Gen Psychiatry . 1983;;40:893-900.
29 +
Overall J, Gorham D.  The Brief Psychiatric Rating Scale . Psychol Rep . 1962;;10:799-812.
30 +
Andreasen N. Scale for the Assessment of Negative Symptoms (SANS) . Iowa City: University of Iowa; 1981;.
31 +
Cox DR.  Regression models and life tables . J R Stat Soc B . 1972;;34:187-202.
32 +
Allison P. Event History Analysis: Regression for Longitudinal Event Data. Beverly Hills , Calif: Sage Publications; 1984;.
33 +
Young JL, Zonana HV, Shepler L.  Medication noncompliance in schizophrenia: codification and update . Bull Am Acad Psychiatry Law . 1986;;14:105-122.
34 +
Cohen J.  Things I have learned (so far) . Am Psychol . 1990;;45:1304-1312.
35 +
Hammer M.  Social supports, social networks, and schizophrenia . Schizophr Bull . 1981;;7:45-57.
36 +
Garrison V.  Support systems of schizophrenic and non-schizophrenic Puerto Rican women in New York City . Schizophr Bull . 1978;;4:561-596.
37 +
Dozier M, Harris M, Bergman H.  Social network and rehospitalization among young adult patients . Hosp Community Psychiatry . 1987;;38:61-64.
38 +
Anderson C, Hogarty G, Bayer T.  Expressed emotion and social networks of parents of schizophrenic patients . Br J Psychiatry . 1984;;144:247-255.
39 +
Lipton F, Cohen C, Fischer E.  Schizophrenia: a network crisis . Schizophr Bull . 1981;;7:144-151.
40 +
Pattison E, Llama R, Hurd G.  Social network mediation of anxiety . Psychiatr Ann . 1979;;9:56-67.
41 +
Granovetter M.  The strength of weak ties . Am J Sociol . 1973;;78:1360-1380.
42 +
Reiss D, Costell R.  The multiple family group as a small society: family regulation of interaction with nonmembers . Am J Psychiatry . 1977;;134:21-32.
43 +
Falloon IRH. Family Management of Mental Illness: A Study of Clinical Social and Family Benefits . Baltimore, Md: The Johns Hopkins University Press; 1984;.

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1 +
Goldstein MJ, Rodnick E, Evans J, May P, Steinberg M.  Drug and family therapy in the aftercare of acute schizophrenics . Arch Gen Psychiatry . 1978;;35:1169-1177.
2 +
Leff JP, Kuipers L, Berkowitz R, Sturgeon D.  A controlled trial of social intervention in the families of schizophrenic patients: two year follow-up . Br J Psychiatry . 1984;;146:594-600.
3 +
Falloon I, Boyd J, McGill C, Williamson M, Razani J, Moss HB, Gilderman AM, Simpson GM.  Family management in the prevention of morbidity of schizophrenia . Arch Gen Psychiatry . 1985;;42:887-896.
4 +
Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Javna CD, Madonia MJ.  Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia . Arch Gen Psychiatry . 1986;;43:633-642.
5 +
Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Ulrich RF, Carter M, EPICS Research Group.  Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia, II: two-year effects of a controlled study on relapse and adjustment . Arch Gen Psychiatry . 1991;;48:340-347.
6 +
Tarrier N, Barrowclough C, Vaughn C, Bamrah JS, Porceddu K, Watts S, Freeman H.  Community management of schizophrenia: a two-year follow-up of a behavioral intervention with families . Br J Psychiatry . 1989;;154:625-628.
7 +
Leff J, Berkowitz R, Shavit N, Strachan A, Glass I, Vaughn C.  A trial of family therapy v a relatives group for schizophrenia . Br J Psychiatry . 1989;;154:58-66.
8 +
McFarlane WR.  Multiple family groups in the treatment of schizophrenia . In: Nasrallah HA, ed. Handbook of Schizophrenia . Amsterdam, the Netherlands: Elsevier; 1990;;4:167-189.
9 +
Schooler NR, Keith SJ, Severe JB, Matthews S.  Acute treatment response and short-term outcome in schizophrenia: first results of the NIMH Treatment Strategies in Schizophrenia Study: Treatment Strategies in Schizophrenia Collaborative Study Group . Psychopharmacol Bull . 1989;;25:331-335.
10 +
McFarlane WR, Link B, Dushay R, Marchal J, Crilly J.  The multiple family group and psychoeducation in the treatment of schizophrenia: four year outcome in a small sample . Fam Process . 1995;;34:127-144.
11 +
Laqueur HP.  Mechanisms of change in multiple family therapy . In: Sager CJ, Kaplan HS, eds. Progress in Group and Family Therapy . New York, NY: Brunner/Mazel; 1972;.
12 +
Detre T, Sayer J, Norton A, Lewis H.  An experimental approach to the treatment of the acutely ill psychiatric patient in the general hospital . Conn Med . 1961;;25:613-619.
13 +
Beels CC.  Family and social management of schizophrenia . Schizophr Bull . 1975;;13:97-118.
14 +
Berman KK.  Multiple family therapy: its possibilities in preventing readmission . Ment Hygiene . 1966;;50:367-370.
15 +
Lansky MR, Bley CR, McVey GG, Botram B.  Multiple family groups as aftercare . Int J Group Psychother . 1978;;29:211-224.
16 +
Levin EC.  Therapeutic multiple family groups . Int J Group Psychother . 1966;;19:203-208.
17 +
Lurie A, Ron H.  Socialization program as part of after-care planning . Gen Psychiatr Assoc J . 1972;;17:157-162.
18 +
Braun P.  Deinstitutionalization of psychiatric patients: a critical review of outcome studies . Am J Psychiatry . 1981;;138:736-749.
19 +
Bachrach LL.  Assessment of outcomes in community support systems: results, problems and limitations . Schizophr Bull . 1982;;8:41-60.
20 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;.
21 +
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK.  Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study . JAMA . 1990;;264:2511-2518.
22 +
Leff J, Vaughn C.  The interaction of life events and relatives' expressed emotion in schizophrenia and depressive neurosis . Br J Psychiatry . 1980;;136:146-153.
23 +
Herz M.  Recognizing and preventing relapse in patients with schizophrenia . Hosp Community Psychiatry . 1984;;35:344-349.
24 +
Falloon IRH, Liberman R.  Behavioral family interventions in the management of chronic schizophrenia . In: McFarlane WR, ed. Family Therapy in Schizophrenia . New York, NY: Guilford Press; 1983;:141-172.
25 +
Anderson C, Hogarty G, Reiss D. Schizophrenia and the Family . New York, NY: Guilford Press; 1986;.
26 +
Falloon I, Boyd J, McGill C. Family Care of Schizophrenia . New York, NY: Guilford Press; 1984;.
27 +
Spitzer RL, Williams JBW, Gibbon M, Burke J, Keith SJ, Schooler N.  Structured Clinical Interview for DSM-III , Psychotic Disorders Version (SCID-PD, 3/1/85) . New York, NY: Biometric Research Dept, New York State Psychiatric Institute; 1985;.
28 +
Kane J, Rifkin A, Woerner M.  Low-dose neuroleptic treatment of outpatient schizophrenics . Arch Gen Psychiatry . 1983;;40:893-900.
29 +
Overall J, Gorham D.  The Brief Psychiatric Rating Scale . Psychol Rep . 1962;;10:799-812.
30 +
Andreasen N. Scale for the Assessment of Negative Symptoms (SANS) . Iowa City: University of Iowa; 1981;.
31 +
Cox DR.  Regression models and life tables . J R Stat Soc B . 1972;;34:187-202.
32 +
Allison P. Event History Analysis: Regression for Longitudinal Event Data. Beverly Hills , Calif: Sage Publications; 1984;.
33 +
Young JL, Zonana HV, Shepler L.  Medication noncompliance in schizophrenia: codification and update . Bull Am Acad Psychiatry Law . 1986;;14:105-122.
34 +
Cohen J.  Things I have learned (so far) . Am Psychol . 1990;;45:1304-1312.
35 +
Hammer M.  Social supports, social networks, and schizophrenia . Schizophr Bull . 1981;;7:45-57.
36 +
Garrison V.  Support systems of schizophrenic and non-schizophrenic Puerto Rican women in New York City . Schizophr Bull . 1978;;4:561-596.
37 +
Dozier M, Harris M, Bergman H.  Social network and rehospitalization among young adult patients . Hosp Community Psychiatry . 1987;;38:61-64.
38 +
Anderson C, Hogarty G, Bayer T.  Expressed emotion and social networks of parents of schizophrenic patients . Br J Psychiatry . 1984;;144:247-255.
39 +
Lipton F, Cohen C, Fischer E.  Schizophrenia: a network crisis . Schizophr Bull . 1981;;7:144-151.
40 +
Pattison E, Llama R, Hurd G.  Social network mediation of anxiety . Psychiatr Ann . 1979;;9:56-67.
41 +
Granovetter M.  The strength of weak ties . Am J Sociol . 1973;;78:1360-1380.
42 +
Reiss D, Costell R.  The multiple family group as a small society: family regulation of interaction with nonmembers . Am J Psychiatry . 1977;;134:21-32.
43 +
Falloon IRH. Family Management of Mental Illness: A Study of Clinical Social and Family Benefits . Baltimore, Md: The Johns Hopkins University Press; 1984;.

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