California Institute for Mental Health
Page 1
IMPLEMENTING SAMHSA EVIDENCE-BASED PRACTICE TOOLKITS
Family Education and Support1
Brief description of the practice
Target group:
Families of persons with severe and persistent mental illness, particularly schizophrenia although there
have been studies with other diagnostic groups. ”Family” refers to anyone who cares about patient, not
necessarily actual relatives.
Practice components:
Family education and support is a “method of working with families in partnership with families to
impart current information about the illness and help them to develop coping skills for handling problems
posed by mental illness in one member of the family.” (Toolkit)
The family education and support approach arose in the late 1970s. It grew from the recognition that (a)
conventional family therapy not only ineffective but potentially damaging, (b) families need information
about mental illness and (c) families need to learn coping skills which may be counterintuitive and (d)
families can make a difference (either positive or negative) in a client’s recovery.
The approach was conceived and developed by three different investigators, Falloon, Anderson, and
McFarlane, who each had a somewhat different emphasis and format for the intervention, so that the term
has become broader and covers multiple cognitive, behavioral, and supportive interventions delivered in
multiple formats.
The suggested minimum time for the intervention is 9 months. The Toolkit suggests that additional time
for the intervention up to two years will improve outcomes.
The Toolkit is designed to be used by professionals but has been used successfully by paraprofessionals.
The Toolkit can be used in a multifamily or a single family format.
The core components of the model as presented in the Toolkit include the following:

Joining—developing a respectful, trusting, helpful relationship with family

Education about the nature of mental illness

Problem-solving

Structural change in treatment—focus on family strengths, as well as stress/burden

Multifamily contact in order to develop support. This can be accomplished through the use of a
multifamily intervention or if used with a single family will encourage the family to join NAMI.
California Institute for Mental Health
Page 2
Evidence supporting family education and support practices
A.
Narrative reviews
The three review articles in this category include as co-authors the two co-authors of the Toolkit:
William McFarlane and Lisa Dixon. The reviews present an overview of the basic elements of the
intervention along with the supporting evidence for the practice. While the reviews present a
large number of studies they do not purport to be thorough analyses of the literature. There is
minimal description of the methodology of the studies which are cited in the reviews but the
summaries of findings refer almost exclusively to randomized control studies.
McFarlane, Dixon, et.al. (2003)2 summarizes early studies as follows: “Overall, the relapse rate
for patients provided family education and support has hovered around 15% per compared to a
consistent 30-40% for individual therapy and medication or medication alone.” A table of 11
“major outcome” studies shows lower relapse rates in seven studies which compared family
education and support with standard treatment. Differences in relapse rates in these studies ranged
from 17% vs. 83% to 44% vs. 64%.The authors explain the four studies with nonconforming
results as not having adequate interventions (either too short or not culturally sensitive) or as
resulting from comparison against an enriched standard care. “The nonconforming studies tend to
validate the effectiveness of the studies in which an effect was found—by suggesting that the core
elements in fact make a difference.” The authors conclude: “Family education and support has a
solid research base and a consensus among the leaders of the field regarding its marked
efficiency, essential components and techniques; it should continue to be recommended for
application in routine clinical practice. However, there continue to be important gaps in the
knowledge needed to make comprehensive evidence-based practice recommendations and to
implement them with a variety of families.”
B.
Systematic reviews (with meta-analysis)
There are two systematic reviews focused on family interventions which use meta-analysis. Study
selection criteria limited the review to higher quality studies.
Pitschel-Walz, et.al.(2001)3 selected 25 studies from 1977 to 1997 which contained 40 different
comparisons. All studies in the review had consumer rehospitalization or relapse as the major
outcome. Only RCTs were included. All but four of the studies were limited to clients with
schizophrenia and schizo-affective diagnoses.
1. Family intervention vs. standard care. There were 12 studies with 14 different
comparisons. “Effect size” is a standardized measure of difference between experimental
and control groups. The effect size in these studies was what is conventionally viewed as
small. The authors conclude: “A treatment which includes family intervention is clearly
superior to the usual care of schizophrenia patients.”

Stability of impact. There appeared to be no decrement in effect as there was
no difference between the results at different follow-up periods up to 24 months.

Length of intervention. There were 7 studies of short term interventions
(<3 months) and 7 with long-term interventions (>9 months). Both groups of studies
were more effective than standard care, but long-term was more effective than shortterm.

Type of family intervention. The interventions were classified into those with
more of a education and support focus and those with more of a therapeutic
California Institute for Mental Health
Page 3
orientation. Both types of interventions were more effective than standard care. There
was no significant difference between the two types of interventions.
2. Combination of family and individual intervention vs. individual intervention. This
comparison included two studies in which all the clients received a comprehensive
psychosocial program with some receiving in addition a family intervention. These
showed no difference between the groups suggesting “no additional effect of a family
intervention could be found, on condition that the patients received a comprehensive
treatment.”
The other high quality review is Pharoach, et al (2003).4 The authors utilized the Cochrane
Collaboration Guidelines for assessing quality of studies. All the family interventions included an
educational component; other components included in some but not all studies were cognitive
behavioral interventions, role playing, relaxation, motivational interviewing, and home exercises.
A total of 28 studies were included in the review. Studies were conducted in Australia, Canada,
China, and the U. S. The major comparisons were between family intervention and standard
treatment.

Hospital use. Results from 7 studies comparing intervention to standard care are
equivocal. The authors conclude “The reviewers do recognize the enormous difficulty of
conducting randomized trials in this area, but, nevertheless if family intervention is to be
widely used, it could be expected that its implementation should be based on more
convincing data than these.”

Relapse. Family intervention reduced the rate of the variety of 'relapse events' compared
to standard care in 14 studies at 12 months and in 6 studies at 24 months. Results remain
statistically significant at 12 months when heterogeneity is resolved, but authors caution
there may be a small study bias.

Mental status. “The overall impression [regarding mental status] is mixed with findings
both favorable for family intervention and equivocal.”

Treatment compliance. “About 15% of participants left the study before completion of
one year. Compared with other trials of the care of people with schizophrenia, this level
of follow up is excellent. Family intervention did not seem to promote or hinder this
attrition. The experimental intervention did, however, promote compliance with
medication.”5

Social functioning. “There is an impression that family intervention does improve general
functioning in this domain” but there was no impact on more objective outcomes such as
employment, independent living, prison use. “This may be an example of rating scales
being sensitive to slight changes that may not have repercussions for routine life.”

Cost savings. Three studies indicated significant savings in direct or indirect costs.
C. Individual Studies Since Reviews

Randomized studies since the publication of the two major review articles add information to a
few of the items of interested including comparisons of different modalities, application to
different cultural groups, and applicability of the models to community settings.
California Institute for Mental Health
Page 4

Dyck et.al. (2002)6 compared service usage of a group of outpatients with multi-family psychoeducation vs. standard care. Clients were diagnosed with schizo or schizo-affective disorders;
most clients had chronic conditions with mean illness duration of 10 years. The intervention
consisted of weekly sessions for two years conducted by two clinicians using a standardized
protocol based on McFarlane. They were trained and supervised to strict adherence to the manual.
Results showed a significant reduction in hospitalization at one year (9% vs. 22%) controlling for
prior year usage.

Chien et.al (2004)7 compared two types of family intervention in Hong Kong—mutual support
and psychoeducation - to standard care in 96 families with a schizophrenia family member.
Special attention was paid to cultural aspects such as importance of extended family and sense of
filial responsibility. The mutual support intervention which was led by peers who were well
trained and supervised outperformed the other two interventions on specific measures of
functioning and re-hospitalizations with the family education and support outcomes in the middle.

Bradley, et.al (2006)8 studied multiple family psycho-education in Australia for a newly arrived
non-English speaking (Vietnamese) and an English-speaking group. Relapse rates were lower for
the family intervention group at the end of the one year of intervention (12% vs. 36%) and after
18 months (25% vs. 63%).

A 2006 German multicenter study found rehospitalization rates were reduced from 58% to 41%
and hospital days from 78 to 39 days using an 8 session family and client intervention.9
D. Consensus Panel Recommendations Regarding Integrated Treatment of Co-Occurring Disorders
Family education and support is included in a number of consensus panel recommendations and
practice guidelines.

The SAMHSA ACT Toolkit is a result of the consensus panel convened by Robert Wood
Johnson.10

The Schizophrenia Patient Outcomes Research Team (PORT) project recommends that all
families in contact with their consumer/relative be offered a family education and support
intervention of at least nine months duration which includes education about mental illness,
family support, crisis intervention, and problem solving skills. (As reported in Dixon et al,
200311)

The World Schizophrenia Fellowship produced a set of principles which include a number of
items related to the provision of services to families including helping to improve communication
within the family, providing training for family in structured- problem solving, encourage family
to expand its social network including NAMI, being flexible in meeting needs of the family,
listening to families, treating families as partners in planning and delivering Tx, exploring the
family’s expectations for Tx and for the consumer, assessing strengths and limitation of family’s
ability to support consumer, and helping resolve family conflict by responding sensitively to
emotional distress. (As reported in Dixon et al, 2003)

The American Psychiatric Association Guidelines say “On the basis of the evidence, persons with
schizophrenia and their families should be offered a family intervention, the key elements of
which include a duration of at least 9 months, illness education, crisis intervention, emotional
support, and training in how to cope with illness symptoms and related problems.”
California Institute for Mental Health
Page 5
E. Evidence regarding adaptability to cultural and other subpopulations

There is a sizable body of literature about the applicability of the family education and support
intervention to different cultural groups and in different cultural environments. All of the studies
which have dealt with the issue have stressed the importance of adapting the intervention to
account for cultural variations in the understanding of mental illness, the role of the family, and
the ways in which the mental health services are and are not conducive to the culture in question
(e.g. help seeking behavior, role o authority, medical model), variations in the meaning of
socializing, and variations in communication styles..

The Cochrane Review notes the diversity of countries within which the research has been
conducted and concludes “The provision of health care for mentally ill people in the countries in
which the trials were undertaken is diverse but the relative consistency of results suggests that
their outcomes may be generalized to other health service traditions.”

The Toolkit cites the use of the intervention in multiple settings including African-American
clients in Los Angeles and New York, a Mexican-American population in Los Angeles. It also
cites the use of the intervention in numerous European countries, New Zealand and Australia,
Japan and China.

The one negative finding is from a study by Telles et al which compared 40 Hispanic-American
non-English speaking families randomly assigned to family intervention or control (meds and
case management). There was no difference between the groups for those families who were
judged to be more acculturated and the family intervention resulted in exacerbated symptoms for
those who were less acculturated. The authors suggest that some of the messages in the family
intervention may be dystonic with culture of Spanish speaking immigrant families.
Capsule Summary of Evidence: Effective, Efficacious, Promising, or Emerging, Not
Effective, or Harmful
Family education and support can be considered to be Effective as regards the single outcome of
relapse prevention. It meets the criteria of having no substantial harm, having manuals, being
replicated in at least two rigorous randomized controlled trials, having positive impacts for at least
one year, having a reliable outcome measure, and having the overall weight of the evidence in its
favor.
There are, however, a number of limitations and cautions to this rating which will be critical in
counties’ decisions about whether and/or how extensively to implement this practice. These are
briefly discussed below.
1. The rating of an effective practice is limited to the one outcome of relapse. The results for
other outcomes are far less certain. What seemed like early positive findings on reductions in
hospital use have not been supported by more recent studies done by other than the
intervention’s innovators. The findings on improvements in medication compliance are
equivocal. Findings on mental health status and a variety of social functioning outcomes
remain equivocal. In a mental health system moving increasingly toward s a recovery
orientation practices may need to demonstrate effectiveness against a broad range of
outcomes.
California Institute for Mental Health
Page 6
2. The magnitude of the effect on reducing relapse is only small to moderate. A number of
reasons have been cited for a lower level of impact than originally reported. One is that
innovators of interventions often have more success than later implementers. “It is feasible
that family intervention is less potent in the hands of those who have learnt from past work
rather than those who have formulated the approach” (Pharoah). The second is that to show a
significant difference over a standard treatment the latter must have relatively high relapse
rates either as a function of the characteristics of the sample and/or the inadequacy of
standard care.
3. The incremental effectiveness of the model has not been demonstrated. Studies have not
demonstrated that family education and support is more effective when either compared to or
added as a supplement to a comprehensive package of psychosocial interventions for the
consumer. As more of the potentially high relapsing clients receive such services the
incremental impact of family education and support needs to be demonstrated.
4. The intervention is of necessity relevant to only a subset of the population served. Since this
is a family intervention it is by its nature relevant only to those situations in which both the
consumer and the family member(s) are willing to participate. The relevant group is limited
initially to those situations in which the consumer has sufficient contact with the consumer to
make the intervention worthwhile. This number is further reduced by needing the agreement
of both consumer and family member(s) to participate, a rate which was about half the
families in two of the recent studies. As will be discussed in the implementation section, there
are multiple barriers to families choosing to participate in such a time-intensive intervention.
There are two additional issues which have not been resolved by the research which are relevant to
the potential adoption of the practice.

There is no clear indication on the minimal length of time for an intervention to be successful.
The guidelines generally recommend a program of at least nine months duration, but the
support for this is less clear than originally thought. Comparisons by length of treatment in
the Pitschel-Walz review indicated that while longer interventions were more effective than
shorter the shorter ones were still better than standard treatment.

The “minimal ingredients of an effective intervention” (McFarlane) have not been identified.
For the most part the comparisons between different type of interventions have not yielded
reliable findings upon which to judge what elements of the intervention are critical to success.
The importance of these two issues highlights a critical question about the relative impact of the more
intensive professionally directed family education and support intervention and the peer-run NAMI
Family Education Program. This program is available in at least 41 states often with a long waiting
list (McFarlane). The program is based on a family trauma and recovery model and merges education
with specific supports. Unlike the family education and support intervention its primary focus is on
family outcomes and well being although benefits to consumer are also considered important. The
program is largely focuses on schizophrenia and bipolar disorder but is general enough to be used
with other diagnoses.
The most accurate overall summary is found in the Pharoah review: “Packages of care for families
with a member who suffers from schizophrenia that involve education, support and management of
the expression of emotion are prevalent. This review suggests that these approaches may decrease
relapse and increase compliance with medication, but the effect is not strong, and leaves sufferers,
California Institute for Mental Health
Page 7
their families, clinicians and managers/policy makers with difficult decisions as to whether resources
would be better focused elsewhere.”
Information regarding implementation
Fidelity
There was no existing Fidelity Scale for family education and support prior to the National EBP Project.
A scale was developed specifically for that Project. Thus there are no reliability or validity studies on the
Scale in the literature.
Extent of implementation
National surveys have found little implementation of family psychoeducation but more extensive
implementation of NAMI education for families.12 New York State is implementing multiple family
groups in 41 teams around the state and has 3 SAMHSA sites studying adaptation of the family
psychoeducation toolkit to diverse cultures.13
Barriers to implementation
There is substantial discussion of the barriers to implementation in the articles by the promoters of the
intervention. The following summarizes their views on barriers at three levels in the system



Patient/Family—time commitment, transportation, another thing that have to do, stigma, prior
negative experiences with service system, feelings of hopelessness, client fears of losing
confidentiality and autonomy
Clinicians/family administrators—lack of knowledge about effectiveness, lingering blaming of
family reinforced by early emphasis on expressed emotion, job and organizational factors
(conflicts between methodology and usual agency practices, lack of leadership, insufficient
resources, concerns about cost and length of intervention, no reimbursement for sessions with
families without patient, already high caseloads so an added burden, view that long-term benefits
outweighed by short-term costs
Mental health authorities - lack of knowledge about intervention, focus on short-term costs and
benefits, inadequate resources
Implementation success

By Year 2 of the National EBP Project three of six projects achieved an average fidelity score of
4 on a 5 point scale, which is considered “good implementation.” However, of the other three one
program was unsuccessful and two dropped out. The family education and support intervention
started with the lowest fidelity at baseline and was the slowest to show improvement. Most of the
EBPs achieved the bulk of whatever improvement they were going to show within the first six
months while the family education and support was at only 2.3 at 6 months, then 3.4 at 12
months, and 3.9 at 18 months.

McFarlane reported a 2001 study of implementation of multifamily psychoeducation in 15 mental
health agencies in Maine and 51 in Illinois. Nearly all the Maine sites (14, or 93 percent)
implemented multifamily psychoeducation services, whereas only five of the Illinois sites (10
percent) implemented this form of treatment.14
California Institute for Mental Health

Page 8
Magliano et.al (2006)15 tested the feasibility of doing family education and support in 22 Italian
mental health centers. Of the 46 professionals enrolled in the training, 38 completed. Of these,
91% reported difficulty in integrating this with their other work although 96% acknowledged a
positive effect on their relationships with patients and their families.
Costs

One of the important findings from one Phaoroah review is that there were demonstrated cost
savings in the three studies which included an economic analysis. Targeting the intervention on
those most likely to benefit is another way to potentially increase the attractiveness of the
intervention. A possible subset of clients would be those high cost clients who live with
families.16
Assistance available for implementing integrated recovery

The American Psychological Association has put together a resource guide for persons seeking
training in family education and support as well as other recovery-oriented practices. Developers
names and contact information are listed along with brief descriptions of available training.17

In addition to the resources actually in the Toolkit, the Toolkit provides references for further
information. See: http://www.mentalhealthpractices.org/fam_resources.html
California Institute for Mental Health
Page 9
Endnotes
The Toolkit is called “Family Psychoeducation.” The “psycho” is gratuitous since it is descriptive neither of the
content nor the process. We have substituted “Family education and support” in this review.
2
McFarlane, W.R., et al., Family psychoeducation and schizophrenia: a review of the literature. Journal of Marital
Family Therapy, 2003. 29(2): p. 223-45.
3
Pitschel-Walz, et al., The effect of family interventions on relapse and rehospitalization in schizophrenia: A meta
analysis. Schizophrenia Bulletin. 2001. 27: p. 73-92.
4
Pharoah FM, Rathbone J, Mari JJ, Streiner D. Review Group: Cochrane Schizophrenia Group. Family intervention
for schizophrenia. 2003. Cochrane Database of Systematic Reviews (CDSR)
5
Another review which uses medication adherence as the primary outcome concludes that family interventions
based largely on psychoeducation are generally not effective. The review cites 9 of 12 studies showing no difference
with only three having positive effects. Zygmunt, A. et al. Interventions to improve medication adherence in
schizophrenia. American Journal of Psychiatry. 2002. 159(10): p. 1653-64.
6
2.Dyck, D.G., et al., Service use among patients with schizophrenia in psychoeducational multiple-family group
treatment. Psychiatric Services, 2002. 53(6): p. 749-54.
7
Chien, WT, et al. One-year follow-up of a multiple-family-group intervention for Chinese families with patients
with schizophrenia. Psychiatric Services. 2004. 55(11): p. 1276-84.
8
Bradley, G.M., et al. Multiple family group treatment for English- and Vietnamese speaking families living with
schizophrenia. Psychiatric Services. 2006. 57: p. 521-30.
9
Bauml, J., Frobose, T., Kraemer, S., Rentrop, M., & Pitschel-Walz, G. (2006). Psychoeducation: a basic
psychotherapeutic intervention for patients with schizophrenia and their families. Schizophrenia Bulletin, 32(1
Suppl), S1-9.
10
Members were Gary Bond, Deborah Becker, Morris Bell, Charles Rapp, Will Torrey and Earnest Quimby.
11
Dixon, l., et al. Evidence-based practices for services to families of people with psychiatric disabilities.
Psychiatric Services. 2002. 52(7): p. 903-10.
12
Dixon, L., Goldman, H., & Hirad, A. (1999). State policy and funding of services to families of adults with
serious and persistent mental illness. Psychiatric Services, 50(4), 551-553; Dixon, L., Lyles, A., Scott, J., Lehman,
A., Postrado, L., Goldman, H., et al. (1999). Services to families of adults with schizophrenia: from treatment
recommendations to dissemination. Psychiatric Services, 50(2), 233-238; McFarlane, W. R., McNary, S., Dixon, L.,
Hornby, H., & Cimett, E. (2001). Predictors of dissemination of family psychoeducation in community mental
health centers in Maine and Illinois. Psychiatric Services, 52(7), 935-942; Amenson, C. S., & Liberman, R. P.
(2001). Dissemination of educational classes for families of adults with schizophrenia. Psychiatric Services, 52(5),
589-592.
13
Myers, Robert. “Implementing Evidence-Based Practices in New York.” Available at:
http://www.nimh.nih.gov/outreach/partners/myers2005.cfm
14
McFarlane, W. R., McNary, S., Dixon, L., Hornby, H., & Cimett, E. (2001). Predictors of dissemination of family
psychoeducation in community mental health centers in Maine and Illinois. Psychiatric Services, 52(7), 935-942.
15
Magliano, L. et al., Implementing psychoeducational interventions in Italy for patients with schizophrenia and
their families. Psychiatric Service. 2006. 57(2): p. 266-69.
16
A recent IMD study showed that roughly 20% of the clients who were admitted to an IMD in six case study
counties lived with family prior to the episode which resulted in their admission and roughly the same percentage
were discharged to family. This could be a potential target for family psychoeducation intervention.
17
APA/CAPP Task Force on Serious Mental Illness and Severe Emotional Disturbance. “Training Grid Outlining
Best Practices for Recovery and Improved Outcomes for People with Serious Mental Illness.” Available at:
www.apa.org/practice/grid.html
1