strategies involving reduced medication exposure in interaction with ap- plied and supportive family management for the long-term treatment of schizophrenia.
Family The
Treatment
Design
and
of Therapist I.N II
R I
S
t
S
S
.
N
S
II.
C
t1
I
N
Ni
The NIMH phrenia
S
Treatment
I
C
II
0
0
Strategies
collaborative
vestigated the efficacy maintenance strategies
I
II
I
G
c
i
Ni
.
C
in Schizo-
study
group
in-
of ant zsychotic drug involving reduced
medication exposure in interaction with applied and supportive family management for the long-term treatment of schizophrenia. Therapy was provided at five centers by 25 clinicians who did not particzate in the development of the therapies. They were trained by two of the authors, I.R.H.F and C. WM, in applied family management, a homebased family cians’
treatment derived from the behavioral therapy developed by them. Clinicharacteristics, selection, and training
methods,
as well
as patient
rehospitalization
rates, are reported for the two family management conditions. The TSS study represents a bridge between the development of a novel therapy and calpractice. (The and
its dissemination
Journal
Research
of 1996;
in general
Psychotherapy
B .
P
R
cliniPractice
5:45-56)
P
i.
.
s
i-:
K I-. I 1 II
.
.
(TSS)
Models 1\/i.I).
NI
.
NI
.
j
I.
R
:
NV
Schizophrenia
Application
I\I.I0ON,
-r I N C
N
Research
Training
R.
C
for
ii
I)
.
A
.
D II
.
I)
T
he
past
decade
has
growth increased
in schizophrenia focus on the
evaluation
of a wide
schizophrenia. to ameliorate
seen
unprecedented
research, development
range
with
of treatments
These treatments the personal and
den on patients, their families, and others during acute exacerbations ness, and they aim at providing
significant of the illlong-term
relief from Medication
decompensation strategies have
relapse. refined to
relieve
prominent
the
often
associated
and been
positive
with
relapse
symptoms
in schizophrenia;
psychosocial
strategies
may lapse
additional protection stress reduction and
provide through
often enduring impairments functioning
are
negative in social in the
developing
general
that
from address
symptoms, functioning,
In the psychosocial
rethe
including work, and
community. domain,
several
stud-
ies’’3 have examined the efficacy of family participation in the treatment of schizophrenia. Although the specifics of the family treatment interventions vary, the following principles
Received
Room
OF PSYCHOTHERAPY
for
are designed economic bur-
are
common
November
23,
among
1993;
revised
them:
February
accepted February 14, 1995. Study sites are listed acknowledgments at the end of the article. Address respondence to Susan Matthews, 5600 Fishers
JOURNAL
an and
18C26,
PRACTICE
Rockville,
AND
MD
RESEARCH
20857.
7, 1995; in the corLane,
46
FRE\I\1ENI
1.Engagement
of the family
therapeutic 2. 3.
4.
in a positive
Provision of psychoeducationai about schizophrenia. Introduction of social learning ples
of problem-solving
sonal
communication
material
interperto the
was 56%
drug
to enhance management of everyday stresses and major life events. Enhancement of family social networks,
findings
often
family Patients within
through
These
mutual
investigations
cation improves fore, the National (NIMH), five sites,
have the
with
maintenance
that were of medication
designed patients
acknowledgments followed
family
a psychoeducationai
of the treatments, (AFM),
was
based
cians
family
on earlier who
(11%
vs.
reported
psychopathology tion, whereas
6
in TSS One
exacerbation
of
work
daily Such
was
pro-
to provide
treatments
settings by clinicians in the development who were not under
in a range who did not of the treatthe immediate
of the treatment provide a link
clini-
episodes
condition.3 not had
of condireported Only 3 a major
whereas
15
clinical
settings.
innovators. between the
this study
two viable intensities (home
NUMBER
#{149}
versus
clinic). often
Research fails
that
to provide
differing delivery is outsufficient
the quality article, in
of the treatment conjunction with
provided. This reports that ad-
dress
detailed
the
methods
5
stud-
of psychosocial readers to judge
rate
VOLUME
earlier
detail regarding the methods treatment delivery to allow
phrenia.
24
upon
family treatments with and locales of treatment
come-oriented
designed of study
at
built
and the clinical by the
ies of family treatment that compared family therapy to routine treatment and found demonstrably reduced rehospitalization and relapse rates for the family-treated groups, we did not include such a routine-treatment comparison group. Rather, this study examined
not experiof schizo-
rehospitalization
study
family
Because
family-treated patients (83%) had enced a substantial clinical episode The
of the TSS
defined
supervision studies can
by Falloon behavioral
schizophrenia,
goal
of clinical participate ment and
new
management
At 24 months,
had
medication
close collaboration of the treatment innovators (I.R.H.F., C.WM.) with the study staff responsible for the delivery of treatment in five
in the family-treated 31 major episodes were
in the individual-treatment individual cases (17%)
double-blind
used
developed
major
patients the two
development of the treatment model transfer of such treatments to general care. In TSS, this linkage was achieved
the end of 9 months, the approach was superior in symptomatic exacerbations subsequent patient rehospi50%).
Initially, one of
to
Strategies in Agreement below in the
therapy (BFT).’ They had reported of a randomized study comparing BFT and clinic-based individual sup-
portive care. At family-treatment preventing major (6% vs. 44%) and talization
at
the The
approach.
applied
his colleagues,
family findings at-home
One
medication
treatments
have
strategies described below. stabilized symptomatically were then further random-
to a 2-year
carefully
section.
two
preliminary
stabilization
elsewhere.’720 assigned
treatment who 6 months
recovery rate especially neuroleptic
and
early
patients findings
tocol.
ThereHealth
to reduce received.
design
regarding reported randomly
ized
of family medi-
with investigators of family treatment
study is called the Treatment Schizophrenia (TSS) Cooperative Program;’’ study sites are listed The
provided
addition antipsychotic
in collaboration initiated a study
been were
groups.
patient outcome.’4’ Institute of Mental
in combination strategies amount
support
22% for family-treated for control subjects. These
maintenance. The TSS study
family
IRENI\
1 IIZOPI
suggest that BFT enhanced the for patients with schizophrenia, when combined with optimal
princi-
and skills
strong evidence that treatment to maintenance
and
months versus
alliance.
S(
FOR
I
WINTER
#{149}
outcome
to fill that gap and results to evaluate employed
1996
in the
of
the
will enable the integrity family
study,
is
readers of the
treatments.
F.\IJA)ON
The in TSS,
47
IT-iL.
two
psychosocial
applied
treatments
family
and supportive are based on
family
studied
as medications
management
(AFM)
resources,
management
(SFM),
sequent
A psychoeducation
2.
ment of schizophrenia. A recognition of the
model
3.
the family in supporting the community. The explicit expectation
of the treat-
important
role
patient that
many
in in-
herent problems in the illness are responsive to aspects of the environment. Principles
common
cial treatments
two
psychoso-
schizophrenia
illness
2. 3.
ment. The fact
that
with
components. of stress interpersonal
be uniquely
as a
biologic and
and
its manage-
relationships
stressful
modeled
loon,
Boyd,
provision
5.
The
importance
of general
of case of
and
in schizophre-
management.
early
patient-specific
for AFM, the has a behavioral viding specific
identification
indicators
SFM in intensity and in of treatment (the home
clinic for SFM). Further, focus, with the intent training in communication
and
SFM were
purposes,
the
BFT
McGill.2
family home in
and AFM conducted two
and
everyday
stresses.
All
evaluated
initially
with
sessions
of Falassigned
to
all components in addition, they
of re-
sessions sessions
in on
conducted focused
included
personal
problem
solving
family
members
functional
to identify the specific nesses of each individual.
for were
assessments
strengths and Subsequent
the
are
McGill,
approach
communication,
attainment,
sub-
meeting
the
Patients
received above;
improvement
and
of relapse. AFM differs from the site of the delivery
after
this treatment SFM described
feelings,
The
the
patient,
weakfamily
parents,
and
others. In these sessions, presentation of educational materials and training in communication skills (expressing positive and negative
nia. 4.
problem
was
goal
regarding mental
psychosocial The importance
may
the
to
and
among
for research
ceived individual the home. These
include
Education major
discussion
Although the group sessions
separately
community
management)
parallel in design and implementation. AFM, designed by Falloon and
of
gains
stress
open
participants. multifamily
1.
1.
for schizophrenia, or
AFM of proand
solving.
active
practice
listening) of
led
Sessions
were
months months
(13 sessions), (13 sessions),
conducted
patient
reached
double-blind
to the
problem-solving weekly
teaching strategies.
for the
first 3
biweekly for the next 6 and monthly until the
the
end
medication
of the
first
year
of
treatment.
Clearly, the therapeutic skills of trained therapists responsible for the delivery of treatment are essential to the potential success of any the
treatment approach. Further, because of varied clinical settings employed in this
SFM was designed to provide families with a framework for a shared and supportive experience through an initial psychoeducational workshop (designed after the survival
study, the assurance delivery of the family across five study sites
skills workshop model developed by Anderson et al.21) and monthly multifamily supportive group meetings conducted by a family
treatments follow the same treatment principles and differ primarily in intensity and location of treatment delivery, the same therapists
management clinician (FMC). These monthly meetings included joint participation by patients, family members, and significant others and were structured to include a brief educa-
were responsible for delivering treatments. In this article we describe
tional
presentation
on a topic
JOURNAL
of interest
(such
OF PSYCHOTHERAPY
the
conduct
of the
models, subsequent competency, and
PRACTICE
AND
of comparability in the treatment components was a critical element in
study.
Because
both
both the
family
of these training
monitoring of therapist adherence to the TSS treat-
RESEARCH
48
TI*:-VIMI:NI’
F-NiIIv
ment nents
protocol, of AFM.
sibilities
emphasizing We detail the
and
family
coordination,
management
the
and
roles
selec-
tocol
home
and
monitoring
of the process,
0
H
1)
I
N
NIMH
staff
-r
A
collaboration at the five of the (I.R.H.F., protocol
(Sj.K.,
0
I
S.M.M.),
in
investigators the expertise
family management consultants C.WM.), developed the operational for the two family management treat-
A restriction
for
ticipation-that is, problem solving-were
dur-
and
ing the second year of double-blind treatment. The initial psychoeducation workshop for
were tions.
conducted All FMCs
conditions. The
staff
“Medication Role of the
tored
comparability
pared
the
initial
psy-
for Schizophrenia,” Family.” They also workshops
staff
and
review
of schizophrenia ment, and the
symptoms, role of the
etiology, treatfamily. Structural
elements,
as evening
versus
shops group
such
or the order presentations,
and content were not
The veloped group ment 1.
day
VOLUME
5
NUMBER
#{149}
A N
\
(;
I A
I-.
in conjunction consultants:
1
experience characterized
(such
as schizophrenia
A clear
desire
the family
N
therapeutic Willingness the family’s
1996
de-
manage-
of professional
working with a popuby severe disability or mental
retar-
of schizophrenia. to work
with
families
patients with schizophrenia sider the family as a potential
WINTER
1-.
paractive
S
N
of 6 months
clinical lation
#{149}
and
StIettion
with
3.
1
family
following selection criteria were by the NIMH central coordination
2.
4.
both
compothe home
active
I. I N I C
dation). Some knowledge
work-
of monthly standardized
the in-
in
role-playing not used. N-i
V
A minimum
across
the essential
on
meetings
required
(:III1RILI1
and moni-
identifying elements that had to be such as the introductory video pre-
by NIMH
I I.
C
manual, modeled et al.,2’ and a series “What Is Schizophre-
of the
A M
conditions, but group meetings
prepared
workshop of Anderson handouts,
gen-
monthly meetan initial brief
that the two principal that were used in
that
randomization
separately for the two condiwere assigned cases in both
nia?”, “The
the sites, included,
before treatment family
NIMH
choeducational on the work of educational
same
management,
monthly
sessions
to the two family thereafter monthly
the
cluding crisis intervention, problem-solving, and psychoeducational material (such as information about schizophrenia, treatment, and the role of the family in managing the illness).
of double-blind
the first year
treatment; no were regularly
completed
monthly
minutes)
clinical
AFM-protocol scheduled
was
that
(15-20
of good
zation
families
in AFM
parallel
principles were adgeneral conduct of the
component
principles
conditions was nents of AFM
and
monithat of pro-
conducted
of the
to ensure
ments. The distinctiveness of AFM and SFM was maintained only during the initial stabiliperiod
staff
determining frequency
the two family treatments. The ings were structured to include
N
N.R.S.,
with the principal study sites and using
medication home sessions
NIMH
were
tapes
meetings
didactic The
sessions
IRENI-\
IIZOPI
support group sessions was defined by the study protocol so as to ensure the comparability of the monthly meetings conducted within NI)
0
group
addition,
Sd
adherence, number and
eral psychoeducational hered to in both. The
of rehospitalizaof maintenance
RCSI0NSIIIILIrICs
C
In
of the
I Ni II
N
sites.
tored protocol the prescribed
the
characteristics monitoring
outcome in terms over the 2 years
across
comporespon-
consultants,
tion and descriptive FM Cs, the training and basic tion rates treatment.
the NIMH
bR
resource. to work home.
with
the
of
and to conpositive family
in
5.
An
49
El-IL.
FALIA)ON
appreciation
straints
of the
of treatments
search context. Commitment
6.
tion
of the
potential offered
to the
approach
con-
project
used
lished,
in a re-
in the
modifications
date the specific included standardizing
for the dura-
study.
rials
and
adding
study were
was
made
study the
well
estab-
to accommo-
needs. Changes educational mate-
an educational
module
on the
role The
principal
final
decision
investigator on
advice of the if requested.
start,
FMC
site retained
selection,
with
management each
to participate One clinician
alternate fied” mum
staff
family
At the study clinicians process.
at each
the
site
selected
was
trained
ioral techniques that require experience behavioral psychotherapy and extensive
three
in the initial was designated
who
the
consultants
training as an
and
and
was ready
to assume
Each
additional
cases if required. Each site also identified an onsite supervisor. Trainees were encouraged to build on their existing skills in psychosocial treatment; in parallel fashion, they were expected
to assist
building
patients
on their
munication,
and
Training
was
Irainlrig
designed
consultants in central coordination
sive workshop
their
families
understanding,
problem-solving
FNi(:
agement NIMH
and
existing
model
in com-
skills.
man-
An
with inten-
for initial
at a distance” model neither of the consultants
was required was part of
the TSS
study
However,
sites.
the
FMCs who joined the study in progress (n = 10) were trained by use of a more familiar apprenticeship model in conjunction with the
Intensive
WorkshopModel: in the application
theoretical
earlier. Therapists were of BET, the principal
attended
by FMCs
from
was
followed
by
constructive
coachgeneral
OF PSYCHOTHERAPY
text
for
study
video
feedback
and
and
sites.
didactic comporole-play
and extensive clinicians, with
coaching,
until
cli-
nicians showed mastery in the performance of each skill. Initial training required treatment of three training families. video taped and
Sessions reviewed
agement written
feedback.
tocol
was
oral
were either audio or by the family manwho
consultants,
and
established.
provided specific A certification pro-
Each
clinician
submit-
ted taped sessions conducted with three families over a 3- to 4-month period to the consultants, who evaluated the sessions for were
least
mastery of specific required to demonstrate 30 taped sessions to
delivery of the elements all sessions had specific
JOURNAL
all of the
by the trainers rehearsal by the
going ing.
supportive for the
the
consultants (I.R.H.F., C.WM.). Three workshops were held within the first 9 months of study funding. Each lasted 3 to 5 days and was
I.R.H.F. providing
and basis
Fam-
training. A series of intensive training was led by the family management
component of AFM, by use of a competencybased model of skill training that included intensive training workshops followed by oncase supervision Although the
handbook, basic
supple-
clinician workshops
therapist trained
more
(now
which
of Schizophrenia,2
by the family
“training because
developed
the
a workbook
form22),
ily Care
demonstration behavioral
was developed
methods
mented
nent
staff.
received
in published
Models
collaboration
at the
clinician
available
with clini-
training emphasized the of negative symptoms
A skill training approach was used: presentation of the rationale of each
training (14 clinicians were originally trained; one clinician did not complete training). A
team
cian training; rather, characteristic features and their management.
“certi-
(see description below), carried a miniof one case assigned to each treatment
condition,
of the family and a medication module specific to the TSS dosing strategies. Less emphasis was placed on specific cognitive-behav-
model,
PRACTICE
Therapists mastery on at be “certified” by skills.
or C.WM. From the standpoint of the treatment according to the BET sessions
AND
needed
RESEARCH
to show of the model. goals, sessions
competent Because that did
F-NIII
50
not meet these goals meeting the 30-session cians
received
were
not
target,
feedback
counted in and the clini-
from
I.R.H.F.
or
C.W.M.
on strategies and techniques to achieve the session goals. Skills mastery was not achieved without substantial effort. For many of the FMCs, the shift from therapist to teacher, coach, ner was difficult. They had a wide prior clinical experience, but they desire context came
to approach with novel to the
enthusiasm, and some
first
schizophrenia treatment workshop
willingness apprehension.
and partrange of shared a
in being
assessed.
followed techniques
by
with
a mixture
to learn new The method
later
phase
was
a period of mastery (giving positive feedback,
were
the
qualified
families withdrew
in the TSS study. The did so after attending
shop; she found with her clinical
Apprenticeship
to begin
the model style and
1.
ticeship”
These
training
model
signed
to work
in tandem
with
NUMBER
#{149}
11 10
Proficieriry
of therapist
training mastery
was of the
advanced
workshop
workshops
were
and
courses.
typically
conducted consultants
supervisors.
3 to 5 by the for all
Annual
work-
particular clinical by clinicians, super(such as family com-
pliance with homework, setting realistic goals, and substance abuse) and reviews of specific behavioral skills (such as active listening, management). shops provided
contracting, In addition, the format
and stress the workfor further
training on educational topics (for example, one workshop included a seminar on substance abuse among the chroni-
using
5
one they
a cotherapist.
of therapists’
ing that addressed problems identified visors, and trainers
cally mentally ill.) Onsite supervision. FMCs with the onsite supervisor
2.
an experienced
VOLUME
New
at least whom
gan to decline. (The distinctive components of AFM were delivered only during the first year of double-blind treatment.) These workshops were partially structured to divide clinicians into more and less experienced groups. The workshops incorporated advanced train-
of the into FMCs were An “apprento train was as-
sessions.
shops were held through the sixth year of the study, when patient intake was completed and clinician workload be-
with
adopted,
and
criterion continued 1986 and 1989, training; of these,
l N1(
of
aspect
clinicians
both incompatible stressful.
was
specific
without
days long and were family management
generally
the original FMCs as peer supervisors new clinicians. Each new clinician
as an observer
skills of BET and integrated case manThis was achieved through several
Regular
one trainee who the first work-
additional study sites.
IRINI.
mechanisms:
Training Model: Because length of patient recruitment
extended the study (6 years), trained at four of five
Iltenallee
maintenance
specific agement.
of specific express-
working
IIZOPI
certified.
A critical
of
successfully completed and were certified by the
as
for
5:I
required to treat family with
all sessions
Niai
things, of su-
first
The initial 30-tape training to be required. Between additional FMCs started
standing of the contribution of individual elements (techniques) to the approach and the integration of the model into each clinician’s personal therapeutic style. All but one of the
trainers
as a therapist
conducted
ing negative feelings, identifying pros and cons for particular problem solutions). The final stage of training involved the under-
original 15 clinicians the training process
1 or 2 cases,
clinicians were non-TSS-protocol
initial discomfort in learna novel treatment and This
on
in a family methods. They
pervision that included review of video or audio tapes and detailed feedback on the content of these tapes was also novel for many of the clinicians in that the trainers/supervisors had direct access to their performance. Clinicians often reported ing and implementing
FMC
l:oI
N TREVl’MIN’I’
1
WINTER
#{149}
1996
met weekly to review
F.IiA)ON
51
IT-iL.
cases, discuss clinical feedback, consistent
issues, and receive with the methods
used in the study. Over course, with the adoption ticeship
model,
the
study of the appren-
the designated
were generally replaced model of supervision
ing more
senior
provided
and
to newer
experienced feedback FMCs
techniques
employed
development can be applied
FMCs
during
of the BET skill training in facilitating
3.
ment
consultant
specific
4.
tionale and ing, feedback
the
over,
a be-
are
and
cian
always
during Monthly
review of cases
B
one
case
under
the entire study duration. conference calls with
management
clinicians,
and
management
a family
of
NIMH
selected for clini-
review
management
staff,
consultant
consultants
and NIMH staff were held to monitor progress and resolve problems. All treatment session tapes for 2 cases
by an independent
JOURNAL
rater
using
initial
above viously
I
S
I.
I
S
the
characteristics
who
participated
(n
cohort
=
of
clinicians staff were
(n
=
trained
15) was
selected
trained according training model
at the
to the indescribed preThe
10) who later joined the by use of the modified
work
discipline
(72%),
years rience
old, and only using behavior
they
were
28% had therapy
two
in the study.
(includes 1 clinician who had been fully trained in BET at the outset).
The from
study apFMCs
a social
a mean
of 37
any prior methods.
expe-
FMC competency ratings are also shown in Table 1. The overall mean level of clinician competence was similar during treatment of early cases (3.3 ± 0.95 ± 0.85). A nonsignificant competence Whereas
levels 27%
(n
=
[SD]) and late cases trend was noted
(3.6 for
to rise in later cases. 17) of all sessions with early
cases were considered less competent than the criterion set for certification by I.R.H.F. and
for each FMC (1 representing an early case in the clinician’s experience in TSS, 1 representing a later case) were rated
completion
prenticeship supervision model. tended to be female (92%) and
family
(C.W.M.) were designed to discuss treatment concerns, review study cases, and monitor overall adherence to the study’s clinical management protocol. Regular conference calls and meetings of the family
coachhanding
relationship,
following
I-.
study outset and tensive workshop
required
to I.R.H.F. monthly and feedback. Each
had
ra-
of case
The
tapes
of
review, and
session,
C.WM.
BET. Ongoing
to send
and
of training.
of FMCs
sessions
thera-
components
rehearsal reinforcement, of
1 presents
treatment
to assess
key
assessment
structuring
provided
assurance
used to assess in the AFM
and dealing with therapeutic difficulty. This instrument was applied by one of its originators (M. Laporta) to sessions conducted by the FMCs who had been certified by
groups
quality
scales
teaching, and
Table
by NIMH staff quality control
7.
They
I.R.H.F.
on all aspects
Cornpeterice
in eight
management as well as specific resolution of problems associated with the
clinicians
6.
It includes
competence
ap-
the transisupervisor
(C.W.M.)
FN1(
of
Skills below.
BETS assessment was ongoing competence
BET.23
case discussion a family manage-
guidance
audiotaped
5.
pist
of competence in families in the supervision of pro-
natural progression. Monthly individual tween FMCs and
The therapists’ condition.
another
the weekly
fessional therapists, making tion between therapist and
Therapy described
su-
with a involv-
to one
meetings. An advantage proach is that the same
-ssessuient
onsite
pervisors peer-review who
Behavioral Family (BETS) assessment
the
OF PSYCHOTHERAPY
C.WM., this (n =6) when independent
PRACTICE
AND
proportion was reduced later cases were rated assessor. Similarly, the
RESEARCH
to lO% by the propor-
52
FANiII
tion
of therapists
who
averaged
less
than
the
V lRFINIINF
ble-blind
I’OR
medication
S( 1 IIZOPI
protocol.
As
II{ENl\
described
criterion of 3.00 in three sessions with early cases was 38% (n = 8), compared with 10% (n =2) for later cases. There was no difference
by Keith et al.” for a partial sample, there were no differences between the two family treatments in attendance at the initial psychoedu-
between the overall tence of FMCs trained
mean with
cation
learning
model
those
intensive
workshop
and
tions
with
the
to the
successful
medication
in
Table 2, there were no differences between two family treatments in the likelihood of bilization: 157 (58%) of the 272 patients domized to AFM and 156 (61%) of the
the staran256
randomized
TABLE!.
to SFM
entered
characteristics
Background
They
n
attendance
to 29%
and
among
the
2 also
pre-
Table
assessments
of TSS
family
Clinicians at Distance”
11alned
by
(n
=
35%
by the
management
Apprenticeship
15)
end
of the
clinicians
‘framing
(n
Model
n
=
10)
0
13 (87%)
(0/u)
10 (100%)
years 36.2
37.7
Range
28-45
25-53
Education,
M.S.W,
n (0/u)
M.S.S.
Psy.D.,
Ph.D.
Other Postgraduate
clinical
8 (80%)
10 (67%)
M.S.N.
experience,
2 (13%)
0
3 (20%)
0
0
2 (20%)
years
Mean
7.6
7.2
Range
0-17
0-22
Experience
treating
families,
n (0/u)
Yes
13 (87%)
No
2 (l3%)
Experience therapy
using methods,
9 (90%) 1(10#{176}!)
behavior n
(0/u)
Yes
6 (40%)
1 (10%)
No
9 (60%)
9 (90%)
Competency
Late
the as-
in Table 2, there the two family
cohort.
Mean
Early
the
given that to treatment
year.
2 (13%)
(0/u)
Female,
.G
finding prior
that of
information
Male,
Age,
group
phase
as shown between
stabilized
rose
second
Model Background
total
sents cumulative rehospitalization rates for AFMand SFM-treated subjects. Rates at one year were 25% for AFM and 26% for SFM.
competency
“‘framing
the
in workshop
successfully
the douand
Further, differences
treatments
condi-
within stabilization
anticipated was offered
signment. were no
As shown
patients
stabilization.
the
study-an workshop
patients were randomized Of this cohort, 313 were
randomized after
trained
workshop
entered
model.
A total of 528 to AFM and SFM. further
levels of compethe apprenticeship
Ratings,a
mean
± SD 3.2±
cases
alncludes late study
1.1
3.4±0.9
3.6 ± 1.0
cases only those clinicians who cases (11 in the “training
3.6 ± 0.8
remained in the study for a sufficient time at a distance” model, 10 in the apprenticeship
VOLUME
5
NUMBER
#{149}
I
WINTER
#{149}
1996
to conduct training
sessions model).
with
early
and
F1uooN
53
ETAL.
I)
S
I
I
(;
S S I 0
psychometric
N
the task. Experience above has
This
finding
training
levels
prior knowledge methods, can be levels of compe-
tency in delivering a family management col to patients and their families struggling with the daily management phrenia. described
ity precludes ments, and
with the training methods described shown that clinicians in a variety of
clinical settings, with limited and experience in behavioral trained to maintain acceptable
is confirmed models. Data
We
had
two
methods
assessment
in the
behavioral may have promote of BET
of
first was the deterof BET that the
from
constraints research
TSS
is quite
to tradi-
ation
training
complicate quire more
and egy
This
clinical
method methods
close
of therapist
supervision. The innovations were “training at a distance”
of video
and
The going
second
review
pendent documenting time. Use has
audio
both
tapes
in the
study
are specific to the reported by Laporta
on-
2.
of applied
ComparIson
family
basic techniques with therapists
background.
Similarly,
need
of treatment the required research
and
of this
training
design
study
models
are
members
who imposed
(AF M)
and
are
dealing by
suggest
that
effective
with
the significant Further,
a bridge between the in a research environ-
m anagement
SFM %
%
Entered
stabilization
272
52
Entered
double-blind
157
58
156
61
117
75
124
79
psychoeducation
Rehospitalization
workshopa
rate
256
48
(cumulative)”
Atlyear
25
26
At 2 years
29
35
313
subjects
who
entered
double-blind.
JOURNAL
OF PSYCHOTHERAPY
PRACTICE
AND
RESEARCH
two
a behavioral their family
schizophrenia.
f amily
su pportlve
AFM
Attended
a
may
equally
clinicians to deliver for patients and
burdens
ent
the
within reconcili-
ment and its application to more general cal practice. FMCs at four of the five
as
,Z
judged
in the be required
the study represents delivery of a treatment
its
m anagem
of sessions
the delivery of treatment and reintensive training than would othresults
in training intervention
by inde-
approach and, his colleagues,
study
be needed.
clinician
with the goal of of competence over for the latter purpose
AFM and
in our
methods, their training process required more intensive followup to
of delivery context and
The the
proportion
of clinical
erwise
strengths and weaknesses. The include the fact that it rates skills that
strengths
TABLE
involved
of sessions assessors the level of the BETS
to this stratand the use
of sessions.
innovation
achieved
a behavioral
the skills sufficiently in the context of the
study.
other treatto compare
achieved in other psystudies. Although the dif-
competency than might
clinicians had mastered well to implement them tional
to
its specific-
competent in our study did not change significantly over time, the direction of the scores toward improvement suggests the value of ongoing supervision. Because therapists were primarily from a social work background with limited experience and expertise in cognitive-
in both of the show that thera-
for
performance. The by the developers
adequate
is that
its application to therefore it is difficult
competency treatment
ference
protowho are of schizo-
appear
weakness
of competence
with the chosocial
pist competency does not decline over time and suggest that the ongoing training contacts contributed to the maintenance of therapist competency in this study. therapist mination
properties Its major
clinistudy (SFM)
FNIIIx
54
sites
have
those
initiated
described
training in this
models
report
at their sites. Preliminary encouraging and positive training study volved
and
on
experience
are being in clinical
similar
to
for clinical
staff
reports are two fronts:
both first,
gained
by staff
disseminated care; second,
participate
in treatment
instaff
psychoeducational finding given families prior ment.
Although the FMCs specific treatment model
lies did not. Further, have found comparable receiving AFM and
the
study
itself
conducted
in aca-
who reads and immediately
TABLE
3.
Rehospitallzatlon
rates
In studies
significantly
patients
whose
the initial workshop double-blind than
other
studies
that
the
nonfamily
treatment
more whose
reported
results
the to
of family
treatment Rate
lYear
2Year
18
Il
22
18
50
56
(%)
approaches
case management
Kottgen’3
Family
15
treatment
Usual
care
Randolph
33
NA
34
53
NA
21
38
NA
20
50
NA
II
Family
treatment
Customary Comparison
care between
two family
treatments
McFarIane10 Psychoeducational
family
groups
16
12
23
Psychoeducational
single
family
18
22
44
13
47
NA
17
54
Zastowny12 Family
treatment
Supportive .
Note:
Falloon
family and
treatment Kottgen
reported
9-month
VOLUME
rates;
5
Zastowny
NUMBER
#{149}
from
(11%-38%) at 1 year than for the nontreatment (50%-53%). The two studies that compared two forms of family treatments reported 1-year rehospitalization rates ranging from 12% to 54%. For the two studies providing rehospitalization rates at 2 years, the rehos-
family
treatment
Individual
atlikely fami-
rehospitalization.
Falloon3 Family
pre-
as shown in Table 2, we outcomes for patients SFM for a measure of
Rehospitalizatlon
with
families
were those
ments
N Comparison
IRENI.\
For studies comparing a family treatment with a nonfamily treatment, the rehospitalization rate is consistently lower for the family treat-
incorporate these methods into his or her treatment for schizophrenia. Our study represented a necessary step in the process, but it is certainly not a sufficient condition. Results of the study also suggest that willingness of patients and family members
may
IIZOPI
relapse (defined by rehospitalization). Table 3 presents comparable
demic clinical settings with distinct research interests, arguably far from the “average” clinician’s circumstances. Thus, successful implementation of the method in our study does not mean that any clinician manual can master the skills
However,
tended to enter
were novices to the employed in the TSS was
S(:I
workshop, an anticipated that the workshop was offered to to their family treatment assign-
appear to be ready to accept these new strategies for interacting with patients, their families, and significant others.
study,
lOR
dict patient outcome.’8 As shown in Table 2, there were no differences between the two family treatments in attendance at the initial
in this
to others clinical
i’IU:INiI:NI
reported
I
WINTER
#{149}
16-month
1996
rates.
NA NA
=
not
available.
F-IiooN
pitalization family
rate
ranges
treatment
nonfamily pitalization those
55
El-iL.
and
treatment.
reported
22%
to 44%
for the only
for
reported
The AFM andSFM rehosconsistently lower than
are
rates
from 56%
for nonfamily
treatments
in prior
studies. The 29% rehospitalization rate at 2 years for AFM is very similar to the rate reported by Falloon for BET (22% at 2 years), the study that provided the model for AFM. The rehospitalization rate for AFM is also relatively low compared with prior studies. These findings suggest that the engagement of families in both family treatment conditions may contribute to improved outcome, at least in terms of relapse (rehospitalization). Future reports a wide
range
from
the TSS
of variables
that
ence outcome. These variables impact of therapist competency
will examine
potentially
influ-
include on both
the the
delivery of treatment and the patient’s and family’s response to treatment; the impact of the family constellation; and individual patient predictors of outcome. That therapist competency
ratings
characteristics work would
of the families with whom they come as no surprise to clinicians.
To researchers, lenge to identify for whom agement
applied are
The information
may
be influenced
by the
this possibility offers the chalthe characteristics of families and
supportive
family
man-
appropriate. contained
in this report
is derived
from the Treatment Strategies in Schizophrenia (TSS) CooperativeAgreement Iogram, a multicenter clinical trial carried out by five research teams in collaboration with the Division of Clinical and Treatment Research of the National Institute of Mental Health (NIMH), Rockville, MD. The NIMH Principal Collaborators are Nina R. Schooler, Ph.D., SamuelJ. Keith, M.D.,Joanne B. Severe, MS., and Susan M Matthews. The NIMH F’rinczpal Collaborators for the Adjunctive Lithium Trial are S. Charles Schulz. MD., and Carol L. Odbert. The following are the Princzal Investigators and Co-Princzal Investigators at the five sites. Albert Einstein School of Medicine and Hillcide Hospital-Long IslandJewish Medical Center, Glen Oaks, NY (UO1 MH39992):John M Kane, MD.,
JOURNAL
OF PSYCHOTHERAPY
Jeffrey A. Lieberman, erner, Ph.D. Medical
MD., and Margaret WoCollege of Pennsylvania and Eastern Pennsylvania Psychiatric Institute, Philadelphia, PA (UO1 MH39998): Alan S. Bellack, Ph.D., and George M Simpson, MD. Cornell University Medical College and Payne Whitney Clinic, New York, NY (UO1 MH40007): Ira D. Glick, MD., andAllenJ. Frances, MD. University of California at San Francisco and San Francisco General Hospital, San Francisco, CA (UO1 MJ-140042): William A. Hargreaves, Ph.D., and Marc Jacobs, MD. Emory University and Grady Memorial Hospital, Atlanta, GA (UO1 MH40597): Philip T Ninan, MD., and Rosalind M Mance, MD. Consultants for Applied Family Treatment are Ian K H. Falloon, MD., University of Auckland, Auckland, New Zealand, and Christine W. McGill, Ph.D., University of Calfornia at San Francisco and San Francisco General Hospital, San Francisco, CA. (Dr. Schooler is now with the Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA; Dr. Keith is now with the Department of Psychiatry, University of New Mexico, Albuquerque, NM; Dr. Bellack is now with the Department of Psychiatry, University
ofMaryland,
Baltimore,
MD;
Dr. Glick
is now with the Department of Psychiatry and Behavioral Science, Stanford University School of Medicine, Stanford, CA; Dr. Frances is now with the Department of Psychiatry, Duke University Medical Center, Durham, NC; Dr. Simpson is now with the Department of Psychiatry and Behavioral Sciences, University of Southern Calfornia, Los Angeles, CA. Dr. McGill is now with the School of Social Work, San Francisco State University, San Francisco, CA.) The authors also acknowledge and thank the family management clinicians and supervisors who particzated in the study, including (in alphabetical order) Julie Agresta, Sara Andrews, Regina Armas, Evelyn Balancio, Susan Balder, Bert Bauer, Alan Bellack, John Clarkin, Sandra Cummings, Eiie Dwyer, Susan Gingerich, Margaret Glover, Michelle Hamilton, Sheila Head, Beverly Hoffman, JanetLavelle, Lisa Mahon, Yvonne McMullen, Kim Mueser, Trudie Pass, Jurella Poole, Susan Rappaport, Susan Scheidt, Sydney Schemer, Vivian Schirn, Robert Surber, Eileen Wade, Marcella Wal-
PRACTICE
AND
RESEARCH
56
F-%MII N i’R:,-vrN1ENT
ters, Pamela Young and Stephanie Zemon. Finally, the authors acknowledge and thank Marc Laporta, MD., Royal Victoria Hospital, Montrea4 Quebec, Canada, for his extensive effort in reviewing
numerous
audio
home
sessions for
TSS
R
i
N
i-.
;
H
F
IRH,
1. Falloon
IRH,
agement nia:
CW,
al:
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1
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#{149}
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M, Fadden
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Routledge,
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G, et al: Managing 1993
