What Do Relatives of People With Schizophrenia
Find Helpful About Family Intervention?
by Richard J. Budd and Ian C.T. Hughes
Considerable evidence shows that family intervention
can reduce relapse rates at 1 and 2 years' followup (see
Lam 1991 for a review), and recent evidence suggests that
reduced but clinically significant gains can be maintained
even at 8 years' followup (Tarrier et al. 1994). It is, however, difficult to draw conclusions from this research literature that can usefully guide clinical practice, which in
part reflects the nature of the controlled outcome studies
that have been conducted to date. As Lam (1991) notes,
the focus of these studies has been to address the question
of whether family intervention is effective in reducing
relapse rates, rather than addressing why these interventions are effective. Thus, most outcome studies have used
treatment programs with a diverse range of interventions
that cannot be easily contrasted with each other. The
research literature thus provides few clear guidelines to
shape effective clinical practice. To address this question,
Lam (1991) has argued that future outcome studies should
employ dismantling research designs to identify which
aspects of the interventions are effective.
An alternative methodology that may be capable of
addressing the question of why family intervention is
effective can be found in the psychotherapy research literature. A series of meta-analyses demonstrated that after
20 years of psychotherapy outcome research, the literature
provided little clear evidence of the superiority of one
intervention over another (see Stiles et al. 1986 for a
review). As a result, the focus of research shifted to
emphasize therapeutic process in addition to outcome
(Greenburg 1986; Stiles et al. 1986). The aim of this
research has been to identify the therapeutic processes
that account for successful outcomes (e.g., Hawton et al.
1982; Murphy et al. 1984; Lange and van Woudenberg
1994), and the results of this process research may be particularly applicable to clinical practice (Parry et al. 1986).
Abstract
While research indicates that family intervention is of
benefit to schizophrenia patients and their relatives, it
remains unclear why it is beneficial. Methodologies
developed in psychotherapy process research may be
of use in answering this question. The present study
examines the applicability of one such methodology to
a clinically based family intervention program.
Relatives' (n = 20) reports of what they found helpful
and unhelpful about the program were examined and
the perceived therapeutic impacts of the program are
reported. The implications of these results for future
research are discussed.
Schizophrenia Bulletin, 23{2):341-347,1997.
Family intervention has developed as a result of a confluence of theory and need. The theoretical rationale for family intervention comes from studies showing that schizophrenia patients who live in families that have high levels
of expressed emotion (EE) have relapse rates two to three
times higher than those who live in low EE families (see
Bebbington and Kuipers 1994 for a review). As a result of
this research, behavioral interventions have been developed to reduce EE, and hence relapse rates, by facilitating
problem solving and communication within the family
(e.g., Goldstein et al. 1978; Falloon et al. 1982). In addition, demand for family intervention has developed as a
result of changes in the organization of mental health services, which over the past 20 years have allowed people
with schizophrenia to spend much less time in the hospital
and much more time at home (Weidermann et al. 1994).
Against this background there has been a growing recognition of the considerable degree of burden on some relatives (e.g., MacCarthy et al. 1989), prompting the development of mental health services that meet the needs of
both patients and their relatives (Smith and Birchwood
1990).
Reprint requests should be sent to Dr. RJ. Budd, Deptf. of Clinical
Psychology, Whitchurch Hospital, Whitchurch, Cardiff CF4 7XB,
United Kingdom.
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Schizophrenia Bulletin, Vol. 23, No. 2, 1997
R.J. Budd and I.C.T. Hughes
One tentative conclusion from this research is that the
apparent equivalence of ostensibly different psychological
interventions may be due to their sharing common therapeutic components (Stiles et al. 1986). Thus, the emphasis
in psychotherapy research has shifted from simply contrasting different interventions to including a focus on the
processes that underlie them. One methodology developed
to address therapeutic process is to examine clients'
reports of what they find helpful and unhelpful about different therapeutic interventions (Stiles and Snow 1984;
Elliott 1985; Llewellyn et al. 1988). This methodology
has aided our understanding of both cognitive-behavioral
and psychodynamic/interpersonal therapies and has led to
the development of models that integrate these different
therapeutic interventions into one consistent treatment
approach (e.g., Shapiro et al. 1992). Given the contribution of this approach to our understanding of the
processes of successful psychotherapy, the present study
explores whether this methodology may also be applicable to family intervention, shedding light on some of its
underlying therapeutic processes.
members to become actively involved in local services
and to set goals to promote the patient's active rehabilitation. Work toward these goals may include encouraging
patients to increase the range of daily activities and household chores they undertake, encouraging them to engage
in activities independent of the family, and focusing on
specific problems such as the use of public transportation,
self-care, and getting up in the morning.
Data Collection and Coding. Following the completion
of the family intervention program, respondents were contacted by a research assistant, who introduced herself as
being independent from the clinical team, to arrange time
to interview the principal relative privately in the home.
The semistructured interview was designed to provide
sufficient opportunity for relatives to recall everything
they had found helpful and unhelpful about the family
intervention program. To facilitate this recall, the research
assistant provided open-ended prompts (e.g., "Can you
tell me more about that?") following the initial response
to each structured question. The interview schedule was
split into three sections. (A copy of the interview schedule
is available from the first author on request.) The first section involved a review of relatives' memories and experiences of their relative's first hospital admission. (This section was intended as an introduction to prompt relatives to
begin speaking freely.) The second section focused on
what the relatives had found helpful and unhelpful about
the educational intervention; data are reported elsewhere
(Budd and Hughes, in press). The third section of the
interview focused on what the caregivers reported to be
helpful and unhelpful about the family intervention program. These data are reported below.
The relatives' responses were recorded, and each
helpful or unhelpful aspect of the family intervention was
transcribed onto a separate card. The transcriptions were
edited, removing repetitions, speech errors, and redundancies to facilitate subsequent coding. Categories for coding
the data were then derived from an initial analysis of all
the participants' responses. Each coder was provided with
a list of written definitions for each category. (Examples
of items that were coded into each category are presented
in the appendix.)
Methods
Subjects. The respondents were the primary relatives of
20 people with a DSM-III-R diagnosis of schizophrenia
or schizoaffective disorder (American Psychiatric Association 1987). The mean age of the respondents was 50
years (range 28-65). Fifteen respondents were parents of
the patient (12 mothers, 3 fathers), 3 were wives, 1 was a
husband, and 1 a sister. Patient mean age was 29 years
(range 18-54). The mean length of illness was 5 years
(range 1-28).
Intervention. The intervention was provided as part of
a routine clinical service offered to families in South
Wales, United Kingdom. The family intervention program, which has been described in detail elsewhere
(Hughes et al. 1996), was provided by a specialist therapeutic team that has been providing this service for over
10 years. Therapists are drawn from a variety of professions, including clinical psychology, psychiatry, occupational therapy, and social work. Two therapists visit each
patient and family at home on a regular basis. After completion of an educational package (Birchwood and Smith
1991), the therapists jointly complete an assessment of the
family's needs and identify specific behavioral goals to be
the focus of the family intervention. This intervention
focuses on improving the family's problem-solving and
communication skills through the therapists' modeling of
appropriate behavior and setting of behavioral goals for
the family members. The therapists encourage family
Data Analysis. Two methods of data analysis were
used. First, each statement was independently coded by
three judges (experienced members of the family intervention team) into the predefined categories in order to
examine the adequacy of the coding system. Three criteria
need to be met to demonstrate that the categories adequately represent the data. First, each category should
contain sufficient items to indicate that it does not repre-
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Relatives of People With Schizophrenia
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
sent a rare or idiosyncratic response. Second, few items
should be coded in the "other," nonspecified category,
thus demonstrating that the coding system accounts for
most of the data. Third, there should be a high level of
interrater reliability, demonstrating that the categories
have been reliably defined.
Once the adequacy of the coding system had been
established, the data were reanalyzed using a rating, rather
than the categorical, coding system. The data were reanalyzed in this way for the following reasons. First, as
Llewellyn et al. (1988) note, individual statements can
imply the presence of more than one therapeutic impact.
Thus, while a categorical coding system is unable to represent such data, a rating system enables each statement to
be coded as indicating the presence or absence of each
impact. Moreover, as these authors note, respondents'
comments on what they found helpful and unhelpful in
therapy can imply a particular therapeutic impact without
this impact being unambiguously stated. To account for
this, five coders (experienced members of the family intervention team) rated the presence or absence of each therapeutic impact (category) on a 4-point scale (definitely not
present, possibly present, probably present, definitely
present). This scale was scored 0, 0.33, 0.66, and 1,
respectively, so that mean scores for each impact represent the frequency with which that impact is cited (i.e., a
mean score of 0.5 indicates that the impact was cited by
50% of respondents). Relatives were chosen as the unit of
data analysis, with coders providing a global rating of the
presence or absence of each impact for each relative on
the basis of all the statements provided by that relative.
Following Llewellyn et al. (1988), the alpha coefficient
(Cronbach 1951) was calculated to estimate the interrater
reliability of these ratings.
Of the eight items in the miscellaneous positive category, four concerned unspecified helpful advice the therapists had offered (e.g., "they [the therapists] offered
advice and answered our questions"), making it impossible to classify these items into the more specific categories listed in table 1. The remaining four items in the
miscellaneous positive category all concerned idiosyncratic responses. Of the 13 items classified into the miscellaneous negative (unhelpful) category, 3 implied the
intervention had presented a pessimistic and negative
view of schizophrenia. The remaining items included negative reactions to the therapists (e.g., "We did not feel supported by the therapists") and to specific aspects of the
intervention (e.g., "Suggestions for activities over-stressed
him [the patient]").
Table 1 also presents the alpha coefficient and the
average rating across relatives for each impact, with the
impacts ranked by the frequency with which they were
cited by the relatives. The alpha coefficients are all above
0.8, indicating a high degree of interrater reliability.
The most commonly cited impact was that the intervention had increased the relatives' knowledge about, and
understanding of, the illness, with just over 70 percent of
the sample reporting this impact. The next four most frequently cited impacts all relate to issues of social and
emotional support. Specifically, the second most frequently cited impact was that relatives felt supported by
the intervention, which helped them feel they were not
alone in facing the challenges presented by the illness.
The third most frequently cited impact was that the relatives had found it helpful to know they could contact the
family intervention therapists for help and advice should
any particular difficulties or problems arise. (Surprisingly,
the relatives rarely initiated contact with the family intervention team members, despite this perception.) The next
two most frequently cited impacts were, respectively, that
the relatives had felt reassured and encouraged by the
intervention and had found the therapeutic alliance helpful. With regard to the former impact, they noted that they
had felt reassured to know that they were doing the right
things to manage their relative's difficulties and had been
encouraged to continue their efforts in this regard. Reports
of the helpful nature of the therapeutic alliance focused on
the perceived empathy and warmth of the therapists and
the genuine concern the therapists had expressed.
The last six therapeutic impacts listed in table 1 relate
to specific features of the family intervention program.
First, just over 50 percent of the sample indicated that the
program had helped increase their relative's level of activity. This specific feature of the present family intervention
program encourages patients to increase their activities
around the house and make active use of local resources,
Results
The total number of comments classified into each of the
listed categories (impacts) and the number of relatives
who cited each impact are presented in table 1. Comments
were classified only if at least two of the three judges
agreed to that item's coding. In this way, 86.6 percent of
the items were coded, with the judges failing to reach
agreement on the categorization of the remaining items.
The kappa coefficient (Fleiss et al. 1979) was calculated
for the whole data set (including data on which the judges
disagreed) to estimate the degree of interrater reliability. A
high level of reliability was found among the three coders
(K = 0.83; p < 0.001). Furthermore, table 1 indicates that
the categories appear to represent the data adequately,
with only a small number of items being classified into
the two miscellaneous categories.
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Schizophrenia Bulletin, Vol. 23, No. 2, 1997
R.J. Budd and I.C.T. Hughes
Table 1. Impacts of family intervention
Impact description
Number of
comments
Number of
relatives
14
18
11
12
14
17
9
14
13
7
7
8
13
10
9
7
7
8
8
8
8
7
4
5
5
7
Increased knowledge/understanding of schizophrenia
Relatives felt supported
Useful to have a contact point in case of emergencies
Relatives felt reassured/encouraged
Relatives found the therapeutic alliance helpful
Patient encouraged to increase activity levels
Advice on managing symptoms
Increased caregivers' tolerance of problem behavior
Improved communication between family members
Increased relatives' acceptance of illness
Increased understanding about medication
Miscellaneous positive
Miscellaneous negative
Alpha
Mean
0.864
0.942
0.919
0.935
0.961
0.970
0.899
0.927
0.917
0.908
0.945
0.71
0.68
0.63
0.60
0.58
0.54
0.53
0.51
0.47
0.44
0.35
support and reassurance to be at least as helpful as, if not
more helpful than, the more specific therapeutic factors.
Similar findings have emerged from patient evaluations of
the therapeutic impacts of cognitive-behavioral group
therapy for anxiety disorders (Powell 1987) and obsessive-compulsive disorder (Enright 1991) and of individual
cognitive-behavior therapy sessions (Llewellyn et al.
1988). However, when interpreting the significance of this
result, it is important to bare in mind the following
caveats. This result may, at least in part, reflect either a
lack of sensitivity in the current design or specific characteristics of the present sample. It is therefore important to
replicate this result on different samples to examine
whether the relative perceived importance of different
aspects of family intervention varies between samples.
The apparent outcome equivalence of ostensibly different psychological therapies (Smith et al. 1980; Shapiro
and Shapiro 1982; Robinson et al. 1990) suggests that
there may be common ingredients in these therapies that
account for their successful outcomes (Stiles et al. 1986).
These common ingredients usually include therapistclient relationship factors such as alliance, personal qualities of the therapist such as warmth and empathy, and
therapy elements such as remoralization, universalization,
goal-setting, and informing/understanding (Russell 1994).
Many of the impacts listed in table 1 bear a close resemblance to these common ingredients of therapy. For example, the most frequently cited positive impact was an
increase in relatives' knowledge or understanding of
schizophrenia. Furthermore, the relatives reported feeling
supported by the family intervention therapists, with 58
percent of the sample noting that they had found the therapeutic alliance helpful, and 60 percent of the sample
reporting that they been reassured and encouraged by the
intervention.
including day centers, voluntary support groups, local college courses, and other social activities. Similarly, just
over 50 percent of the sample indicated that they had
found it useful to be given advice on managing symptoms.
In addition to specific advice on managing hallucinations
and delusions, this support also included advice on monitoring early signs and on relapse prevention. Fifty percent
of the sample noted that the intervention had helped them
to become more understanding and tolerant of their relative's difficulties and to reattribute some of their relative's
problem behavior to the illness. In a similar vein, the next
most frequently cited impact was that the intervention had
helped improve communication within the family, with
just under 50 percent of the sample citing this impact. In
this regard, relatives specifically noted that the intervention had not only helped them discuss the illness more
freely, but had also helped them learn how to discuss a
broad range of other issues without arguing. Finally, just
over 40 percent of the relatives indicated that the intervention had helped them come to terms with, and accept, the
illness, with 35 percent of the sample also indicating that
the intervention had helped increase their understanding
about medication.
Discussion
The results suggest that, for the current sample at least,
the relatively nonspecific positive impacts of emotional
support, backup, and reassurance were more commonly
reported as helpful by relatives than were the more specific impacts concerning behavior change and skills acquisition. Even though the family intervention program contained a large and explicit skills-training component, the
relatives in the present sample reported finding emotional
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Relatives of People With Schizophrenia
impacts to therapists' reports of the focus and aims of
each session. This methodology is likely to be more powerful than the present one in isolating the specific impacts
of family intervention, and may help us chart the changing process of therapy across sessions. Second, it would
be useful to examine the relationship between the reported
therapeutic impacts of family intervention and measures
of the family emotional climate, such as EE (Leff and
Vaughn 1985), family coping style (Birchwood and
Cochrane 1990), and patient rejection (Kreisman et al.
1979; Lebell et al. 1993). In particular, it would not be
surprising if certain aspects of family intervention were
more relevant and helpful in some family environments
than others. (For example, families that are high in criticism and hostility may find communication training more
helpful than low EE families do.) Third, studies should
relate therapeutic impacts to measures of outcome to further elucidate the therapeutic mechanisms that may underlie family intervention. Finally, it would be interesting to
consider patients', as well as relatives', reports of what
they find useful about family intervention, although they
may have difficulty articulating such views.
Despite the apparent importance of these common
therapeutic elements, the relatives nonetheless cited a
number of impacts that are specific to family intervention
programs. Most notably, they reported that the intervention had helped them become more tolerant of their relative's behavior by helping them reattribute some problem
behaviors to the illness. In addition, they noted that the
intervention had improved communication between family members, in relation to both the illness and other
issues. Given that the rationale for family intervention
developed from attempts to reduce high EE through
improved communication and problem solving within the
family, it is encouraging that relatives found this aspect of
the intervention helpful. It is similarly encouraging that
more than 50 percent of the sample reported finding both
information on managing symptoms and the rehabilitative
component of the program helpful.
Schooler et al. (1995) noted that, just as in the psychotherapy outcome literature, family intervention outcome studies have not demonstrated any significant differences in outcome between different family intervention
programs, which may suggest that common therapeutic
ingredients account for the efficacy of family intervention
programs but involve ostensibly different therapeutic
interventions. If such common therapeutic processes do
exist, however, calling them "nonspecific factors" may be
misleading. For example, the quality of the therapeutic
alliance and the perceived empathy of the therapists may
be dependent on the therapists demonstrating an accurate
understanding of schizophrenia and its problems and
accurately acknowledging and attending to family members' needs. In this way, nonspecific therapeutic impacts
may result from specific interventions with a clear structure and goal.
Clearly, these observations are highly speculative, but
the present results do, nonetheless, indicate that methodologies developed in the psychotherapy process research
may be profitably applied to family intervention. Clients'
reports that particular aspects of therapy are helpful do not
necessarily imply that these specific mechanisms account
for therapeutic change. Such reports do, however, contribute to our understanding of family intervention. The
examination of clients' reports of what they found helpful
about therapy has significantly contributed to our understanding of the processes that account for successful psychotherapy (Shapiro et al. 1992), and the present results
suggest that this methodology may also be capable of furthering our understanding of family intervention.
Future studies should explore a number of issues.
First, such studies should examine the reported helpful
and unhelpful impacts of family intervention on a session
by session basis, relating clients' reports of therapeutic
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Acknowledgments
The Authors
The authors acknowledge the helpful comments provided
by the anonymous reviewers on an earlier version of this
manuscript. We are grateful for the help of Maria Grazia
Cocchiara with data collection and of Othniel Smith with
data analysis.
Richard J. Budd, Ph.D., M.Sc, B.Sc, and Ian C.T.
Hughes, M.A., M.Sc, are Clinical Psychologists, Department of Clinical Psychology, Whitchurch Hospital,
Cardiff, United Kingdom.
Appendix, Examples of Relatives' Responses
That Were Coded Into Each of the Following
Categories
Increased knowledge/understanding of schizophrenia: The
Schizophrenia Therapeutic Educational Project (S.T.E.P.)
therapists explained what the illness was. They [the therapists] explained the illness and symptoms. They helped me
understand the "voices" are part of his [the patient's] illness.
Relatives felt supported: We [the relatives] felt supported
and helped. It helped to know we weren't alone. I appreciated the support. The support was comforting.
Useful to have a contact point in case of emergencies: It
helps to know I [the relative] can contact the S.T.E.P. team
if I need to. It's nice to know the S.T.E.P. team are there if I
[the relative] need them.
Relatives felt reassured/encouraged: The meetings reassured me I was doing a good job [of caring]. They [the therapists] provided reassurance and stopped me worrying.
Relatives found the therapeutic alliance helpful: The
S.T.E.P. therapists made us feel at ease. They [the therapists] were very accommodating and friendly. They were
very understanding.
Patient encouraged to increase activity levels: They discussed things he [the patient] could do to help around the
house. They encouraged him [the patient] to attend day-
347
time activities. They encouraged him to attend Tegfan [the
day hospital].
Advice on managing symptoms: They [the therapists]
explained the early signs of relapse. It helped to realize
that arguing about the "voices" was pointless. We discussed ways of distracting him from the "voices."
Increased relatives'tolerance of problem behavior: The visits helped us be more patient with him [the patient]. The
S.T.E.P. visitors explained that [the patient] was not lazy,
but sleeping a lot is a common symptom.
Improved communication between family members: The
meetings helped us [relative and patient] talk about the illness. I'm now more able to discuss things with him [the
patient] without upsetting him.
Increased relatives' acceptance of illness: Talking about it
helped us feel more at ease with the illness. It helped my
wife accept the illness. It helped me [the relative] feel less
embarrassed about the illness.
Increased understanding about medication: The S.T.E.P.
visitors provided useful information about medication. They
explained the medication helps prevent relapses. [The
patient] found it helpful to talk about the pros and cons of
the medication.