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Section 21
Interventions for Schizophrenic Clients

Question 21 | Test | Table of Contents

Psychosocial interventions contribute significantly to the course and outcome of schizophrenia. They effectively lower relapse rate, reduce expressed emotion and improve outcome among individuals with schizophrenia (Penn et al., 1996; Goldstein, 1994; Bums, 1997). A variety of psychosocial interventions have been developed in the last decade and all tend to have a similar goal, i.e. to improve family atmosphere and thus reduce relapse. A popular model of psychosocial interventions is Behavior Family Therapy (BFT) (Anderson et al., 1980; Falloon et al., 1982). The intervention consists of three components: family education about schizophrenia, training in problem-solving skills and communication skills. These interventions were proposed as adjuncts and not alternatives to drug treatment.

Home-based BFT (Falloon et al., 1982)was first introduced for families with high expressed emotion (EE) and aimed to reduce relapse rates by lowering EE. Since then, adaptations of the original protocol have been conducted with some success. These include delivering the therapy in a clinical setting (Randolph et al., 1994), involving multiple families in group settings (McFarlane et al., 1995) and modification of various core components of BFT (McGorry et al., 1997). The need to modify intervention strategies to be culturally sensitive has also been suggested. A study in China (Xiong et al., 1994) and among less acculturated patients in USA (Telles et al., 1994) found that the Western or standard model of BFT was not suitable and too intrusive.

A local study found that poor compliance with medication was the main factor contributing to relapse (Razali & Yahya, 1995) and active psychosis was a major cause of family distress. In order to improve treatment compliance, family atmosphere and acceptance of treatment, Falloon et al.'s (1984) BFT model was modified for this study. This culturally modified model included the sociocultural approach of patient and family education and the addition of a new component to tackle poor drug compliance while retaining an emphasis on problem solving skill training.

Effective patient and family education needs a sociocultural approach because the majority of the Malay patients attribute mental illness to supernatural agents (Razali et al., 1996). They cannot accept explanations based on the Western model. In the absence of our advice they will visit traditional healers and subsequently default from psychiatric follow-up. The problem solving skill training is still maintained because the majority of the families could not handle the crisis which leads to frequent family distress (Salleh, 1994). We omitted communication skills training as this is the least important among the three core components of the standard model. This is supported by the finding that generally the carers of Malay schizophrenic patients could tolerate negative symptoms of schizophrenia (Salleh, 1994). The objective of this study is to assess the efficacy of the Culturally Modified Family Therapy (CMFT) against the Behavioral Family Therapy (BFT) in the management of schizophrenia in a developing country.

Methodology
Recently discharged Malay patients from the University Hospital (USM) Kota Bharu, West Malaysia, with the diagnosis of schizophrenia (DSM-IV) (American Psychiatric Association, 1994) were screened for the study. Subjects were selected for the study if they fulfilled the following criteria.
At least two previous psychiatric admissions (including the latest admission).
Aged between 17 and 55 years.
Staying with a responsible relative who is willing to be involved in the study.
Stabilized at least for 4 weeks (stabilization was defined as rating of 4 or less on the BPRS psychotic items).

Once patients confirmed their willingness to participate in the study, they underwent a semi-structured interview based on a standard pro forma to assess sociodemographic variables, past psychiatric treatment and family support. The Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962) was administered as the primary measure of psychopathology. All the assessments were done independently by two research psychiatrists (SMR and CIH). All patients gave their written consent in a standard form after the study was fully explained to them.

The selected patients were randomly assigned to the study or control group. The study group received the CMFT and the control group was assigned with the BFT. The sessions were conducted in an outpatient setting. The CMFT consists of a sociocultural approach of family education, drug intervention program and problem solving skills. The sociocultural approaches to family education include explanations of the concept of schizophrenia from a cultural perspective and an attempt to correct negative attitudes toward modern treatment. The family education and drug intervention was delivered as a package. The drug intervention program includes drug counseling and close monitoring of compliance by a drug-intake check-list presented in every follow-up visit. The problem solving skill was delivered as in the standard model.

The two research psychiatrists treated the patients separately. The same psychiatrist throughout the study treated each group of patients. They were followed-up on the same schedule; monthly for the first 3 months and then every 6 weeks in the next 9 months. SMR dealt with the study group while CIH treated the control group. The patient and his or her carer attended these 30-45 minutes sessions. Two additional home-visits were planned for each family every 6 months. Both groups of patients received routine prescription of medication.

Discussion
Overall a small difference between the two groups was identified. Although both treatments are effective, the culturally modified technique is superior in the long run. All differences found between the groups can be attributed to the much better compliance with medication achieved in the study group. This could be responsible for the smaller number of exacerbations in these patients and hence the reduced burden on the family. Since the main difference in treatment between the group was that the study group received a module comprising information about medication, close monitoring of compliance and reinforcing carers' role in supervising medication; this is likely to be the intervention responsible for their better outcome. It could be argued that the significantly greater number of drop-outs in the control group would bias the results but the bias would probably be to produce worse outcomes in the study group. The most likely reason for a drop out is a poor outcome.

Since the two treatments were administered by different therapists it could be argued that the improvement observed is a therapist effect and not a treatment effect. This is unlikely since there were major differences between the treatments but no major differences between the therapists. Both were experienced, both had received specialized training and both were warm, empathic therapists. It is difficult to control completely for a therapist effect even if both treatments are delivered by the same therapist. In this situation the problem of fidelity to different models of treatment will arise. Will the therapist be more enthusiastic about the one rather than the other, for example? As with other areas of scientific endeavor an attempt should be made to replicate these results.

Mari & Streiner (1994) emphasized that one of the important ingredients of psychosocial family intervention :is to achieve changes in relatives behavior and belief system. Although we do not specifically measure their changes on attitude, we found that the sociocultural approach to family education changed the carers' attitudes toward their schizophrenic relative after they understood the nature of the illness, which has a spill over effect on compliance and family burden. Left et al. (1989) also found that if the patient's family understood the nature of the illness and were instructed in problem solving techniques, they would gain a new understanding of the patient's abnormal behavior. As a result, the relapse rate and expressed emotion in the family will be reduced; and subsequently, the patient' s social functioning would be partly recovered.

The importance of understanding patients' cultural backgrounds to avoid emotional conflict has long been recognized (Murphy, 1973; Henderson & Primeaux, 1981). Explanations that incorporate local concepts of illness would help patients and carers to accept and understood the illness better. Acceptance of the patient's interpretation of his or her symptoms will strengthen the therapeutic relationship. The modified model, which left out communication skills training, is suitable for eastern culture. The program such as training to communicate assertively and establishing eye contact with the elderly (especially one's parents) are regarded as disrespectful in the Malay culture. Furthermore a highly structured program is experienced as stressful and intrusive in the long run with the result that interest in the program slowly diminishes and finally stops half-way. The success of our program may also be attributed to the extended family system among the Malays (Yusof, 1976).
- Razali, Salleh M.; Hasanah, Che Ismail; Khan, Ali; Subramaniam, Mutusamy; Psychosocial interventions for schizophrenia; Journal of Mental Health; Jun2000; Vol. 9 Issue 3

Personal Reflection Exercise #7
The preceding section contained information about the benefits of psychosocial interventions for schizophrenic clients. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Using Relapse Prevention Interventions to Maintain Remission and Minimize Relapse Rates for Individuals With Schizophrenia: A Scoping Review

Abu Sabra, M. A., & Hamdan-Mansour, A. M. (2022). Using Relapse Prevention Interventions to Maintain Remission and Minimize Relapse Rates for Individuals With Schizophrenia: A Scoping Review. Journal of psychosocial nursing and mental health services, 60(7), 47–54. https://doi.org/10.3928/02793695-20220112-02


Peer-Reviewed Journal Article References:
Barrios, M., Guilera, G., Hidalgo, M. D., Cheung, E. C. F., Chan, R. C. K., & Gómez-Benito, J. (2020). The most commonly used instruments in research on functioning in schizophrenia: What are they measuring? European Psychologist, 25(4), 283–292.

Bechi, M., Bosia, M., Agostoni, G., Spangaro, M., Buonocore, M., Bianchi, L., Cocchi, F., Guglielmino, C., Mastromatteo, A. R., & Cavallaro, R. (2018). Can patients with schizophrenia have good mentalizing skills? Disentangling heterogeneity of theory of mind. Neuropsychology, 32(6), 746–753.

Diamond, D. (2018). Changes in object relations in psychotherapy with schizophrenic patients: Commentary on Carsky and Rand (2018). Psychoanalytic Psychology, 35(4), 410–413.

QUESTION 21
What are the three components of Behavior Family Therapy? To select and enter your answer go to Test.

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