By Dorothy A. Kaplan, Ph.D.
May 25, 2023

U.S. Navy photo by Nicholas Tenorio

Schizophrenia can rob a person of the life they and their family envisioned. There is typically a prodromal period in adolescence and young adulthood of months to years in which function declines and subthreshold psychotic symptoms emerge.¹ The peak age of onset for schizophrenia is the early to mid-20s for males and late-20s for females.² A first episode of psychosis, or FEP, often occurs in the context of a life change or stressor. In addition to their age, specific risk factors for the emergence of FEP in active duty service members are separation from family and other support systems and exposure to the stressors associated with training and military service.³

Families play a critical role in the patient’s recovery from schizophrenia

Support for the caregivers can strengthen the family and enable the recovery of the individual with schizophrenia. Treatment for schizophrenia encompasses more than reducing symptoms and enabling emotional well-being, it is a return to a full life. A full life includes maintaining relationships, having a safe place to live, and living life with a purpose⁴. While antipsychotic medication treatment can result in symptom management, it is the family’s ability to provide love, hope, and stability that contributes to recovery and a meaningful life for the individual with schizophrenia.⁴

What do the 2023 VA/DOD Clinical Practice Guidelines for Management of First-Episode Psychosis and Schizophrenia recommend?

The newly released VA/DOD Clinical Practice Guideline for Management of First-Episode Psychosis and Schizophrenia contain two recommendations for psychosocial interventions with families. For individuals with FEP, the CPG recommends the use of family interventions including problem solving based on self-learning, education, and mutual family support. The use of family interventions is also recommended for individuals with a chronic course of schizophrenia to improve treatment adherence and decrease the risk of relapse and hospitalization.² 

Prove it – show me some good evidence!

Family interventions integrate family members, caregivers, and friends into treatment and are either delivered to a single family or to a group of several families. A recent systematic review and meta-analysis of 12 studies concluded that family interventions for psychosis reduce relapse rates, duration of hospitalization, and psychotic symptoms in FEP patients as well as increasing their functionality for up to two years.⁵ Family-based interventions have also been shown to decrease hospitalization and relapse rates for more chronic schizophrenia although these effects diminish over time. The overall well-being of individuals with schizophrenia improves with family interventions. These interventions also decrease caregiver burden and stress while increasing caregiver quality of life.⁶

Family interventions are family-based therapies^5,6,7,8,9

Family interventions are designed to:

• Help family members understand the disorder and its impact on functioning
• Increase awareness of the importance of treatment adherence
• Identify what exacerbates symptoms
• Learn strategies to manage acute episodes
• Maintain a positive family environment
• Strengthen the relationships with the individual with schizophrenia
• Improve the family’s problem solving and communication to support the patient’s recovery

While these interventions may differ in content and format, these approaches are family-based therapies and not “family therapy.” That is, rather than trying to restructure unhealthy family dynamics, families are seen as integral to the patient’s recovery and empowered to help the patient recover.^7,9

Multi-family group therapy is a family intervention consisting of four components:

• Rapport and alliance building interactions among the patients and families
• A psychoeducational workshop for families to build an understanding of schizophrenia and its management
• Problem solving groups focused on relapse prevention attended by both patients and families, and vocational and social skills rehabilitation.

MFGT is delivered by two clinicians to a group of five to eight families over a two-year period². Studies have shown that family interventions, such as mutual support groups, are effective in reducing emergency department visits, hospitalizations, relapse, and psychotic symptoms. ^{6, 8}

The problem solving based self-learning program is a five month facilitated program based on self-paced learning in which families read about and then practice caregiving and problem-solving in five modules: self-care, seeking services/supports, psychosis care, and managing illness impacts on patient and family (Part I: communication and motivation; Part II: suicidal behaviors and self-harm). The process includes the family exploring their specific problems and obstacles while monitoring the effectiveness of their solutions. In addition, a trained peer facilitator conducts four group sessions (1st, 6th, 13th, and 22nd weeks of intervention) using a set of standardized questions to review family progress. Family members are encouraged to openly discuss their family’s needs and emotions and the facilitator shares their specific caregiving experiences and problem-solving strategies.⁹

A randomized controlled trial of PBSP showed improvement in caregiver burden and problem-solving ability as well as a patient’s psychotic symptoms, recovery, and re-hospitalizations during a six-month follow-up. The high completion and moderately low treatment attrition rates (10.5%) in the PSBP program suggests that PSBP is an intervention with high acceptability and feasibility for many families.⁹

What are the facilitators and barriers to implementation of family interventions in clinical practice?

The acceptability of family interventions is affected by both patient and family readiness as well as preferences. Involving the family of a young adult (age 18+) with a serious mental illness in family-based therapy requires the patient’s consent. Young adults may be reluctant to involve their family in their care, as they may have recently transitioned from living with their family to independence. Engaging with the patient using a shared-decision making framework is important for involving the family in treatment and conveying their supporting role in recovery.³  Motivational interviewing and other strategies can increase the acceptability of family involvement in treatment.¹⁰ More information on engaging families in treatment is available here.

Evidence-based guidelines for the treatment of schizophrenia recommend family interventions for schizophrenia, and research studies confirm their effectiveness; however, numerous barriers at the organizational level have deterred implementation of family and caregiver involvement in clinical interventions.^7,11 Implementation of family-based interventions requires a shift in organizational culture such as changes in work routines, approaches, guiding beliefs, and practices.¹¹ In 2021, the VA established the Early Psychosis Intervention Program, a comprehensive coordinated specialty care program. This program provides evidence-based treatment including family support and psychoeducation for veterans and their families.¹²

Currently, the Department of Defense does not provide an Early Psychosis Intervention Program for service members with psychosis. Research suggests that the lives of our service members, veterans, and their families would benefit if evidence-based family interventions and early intervention programs for schizophrenia were widely implemented and accessible in our health care delivery systems. Availability of these interventions increases patient compliance with medication and reduces the need for hospitalization.^5,13 These health care outcomes could alter the entire trajectory of a patient’s illness, preventing prodromal symptoms associated with a FEP from becoming a relapsing, chronic course of schizophrenia and thus significantly reducing the lifelong impact on the service member and their family.

Resource

Veterans Affairs and Department of Defense Clinical Practice Guideline for Management of First-Episode Psychosis and Schizophrenia

References

1. Albin, K., Albin, C., Jeffries, C. D., & Perkins, D. O. (2021). Clinician recognition of first episodepsychosis. The Journal of Adolescent Health, 69(3), 457–464. https://doi.org/10.1016/j.jadohealth.2020.12.138
2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
3. Veterans Affairs and Department of Defense. (2023). VA/DOD clinical practice guideline for the management of first-episode psychosis and schizophrenia (Version 1.0). https://www.healthquality.va.gov/guidelines/MH/scz/
4. Insel, T.(2022). Healing:Our path from mental illness to mental health. Penguin Press.  
5. Camacho-Gomez, M., & Castellvi, P. (2020). Effectiveness of family intervention for preventing relapse in first-episode psychosis until 24 months of follow-up: A systematic review with meta-analysis of randomized controlled trials. Schizophrenia Bulletin, 46(1), 98–109. https://doi.org/10.1093/schbul/sbz038
6. Ashcroft, K., Kim, E., Elefant, E., Benson, C., & Carter, J. A. (2018). Meta-analysis of caregiver directed psychosocial Interventions for schizophrenia. Community Mental Health Journal, 54(7), 983–991. https://doi.org/10.1007/s10597-018-0289-x
7. Ventriglio, A., Ricci, F., Magnifico, G., Chumakov, E., Torales, J., Watson, C., Castaldelli-Maia, J. M., Petito, A., & Bellomo, A. (2020). Psychosocial interventions in schizophrenia: Focus on guidelines. The International Journal of Social Psychiatry, 66(8), 735–747. https://doi.org/10.1177/0020764020934827
8. Muhić, M., Janković, S., Sikira, H., Slatina Murga, S., McGrath, M., Fung, C., Priebe, S., & Džubur Kulenović, A. (2022). Multifamily groups for patients with schizophrenia: an exploratory randomised controlled trial in Bosnia and Herzegovina. Social Psychiatry and Psychiatric Epidemiology, 57(7), 1357–1364. https://doi.org/10.1007/s00127-022-02227-9
9. Chien, W. T., Bressington, D., Lubman, D. I., & Karatzias, T. (2020). A randomised controlled trial of a caregiver-facilitated problem-solving based self-learning program for family carers of people with early psychosis. International Journal of Environmental Research and Public Health, 17(24), 9343. https://doi.org/10.3390/ijerph17249343
10. Department of Veterans Affairs Mental Illness Research, Education, and Clinical Center. Veteran engagement handout. https://www.mirecc.va.gov/visn22/familyconsultation_veteran_engagement.pdf
11. Eckardt, J. P. (2022). Barriers to WHO mental health action plan updates to expand family and caregiver involvement in mental healthcare. General Psychiatry, 35(2), e100784. https://doi.org/10.1136/gpsych-2022-100784
12. Department of Veterans Affairs, Veterans’ Health Administration. Directive 1163.07 (2020). Services for Veterans Experiencing Early Psychosis. https://www.va.gov
13. Correll, C. U., Galling, B., Pawar, A., Krivko, A., Bonetto, C., Ruggeri, M., Craig, T. J., Nordentoft, M., Srihari, V. H., Guloksuz, S., Hui, C. L. M., Chen, E. Y. H., Valencia, M., Juarez, F., Robinson, D. G., Schooler, N. R., Brunette, M. F., Mueser, K. T., Rosenheck, R. A., Marcy, P., … Kane, J. M. (2018). Comparison of early intervention services vs treatment as usual for early-phase psychosis: A systematic review, meta-analysis, and meta-regression. JAMA Psychiatry, 75(6), 555–565. https://doi.org/10.1001/jamapsychiatry.2018.0623

Dr. Kaplan is a clinical psychologist at the Psychological Health Center of Excellence providing subject matter expert support to the Research Adoption branch and has been involved in developing Clinical Support Tools for the VA/DOD Clinical Practice Guidelines. Over the past ten years, Dr. Kaplan has supported PHCoE and the Traumatic Brain Injury Center of Excellence in disseminating and implementing evidence-based care in the Military Health System.