Multiple-Family Group Treatment for English- and Vietnamese-Speaking Families Living With Schizophrenia

Comprehensive evidence has established family intervention as a powerful tool in the treatment of schizophrenia. After a correlation was found between family tension and relapse (  1 ), a range of interventions has been developed to improve family atmosphere and reduce relapse. 

Applying stringent methodological criteria, the Cochrane review of family interventions concluded that interventions incorporating an educational component to improve caregivers' understanding of mental illness, along with additional cognitive-behavioral interventions, are effective in reducing relapse at 12 and 24 months posttreatment (  2 ). Family intervention studies have demonstrated reductions in relapse rates well below the expected two-year cumulative relapse rates of 64 percent obtained for standard care (case management and medication) (  3 ). For instance, Leff and colleagues (  4 ) in a small-scale study with 23 participants reported relapse rates of 36 percent for multiple- and single-family psychoeducation and support. In a study sample of 83 families, Tarrier and associates (  5 ) found relapse rates of 33 percent for behavioral family therapy, including stress management and training in goal setting. 

Although the primary focus of outcome studies has been relapse, there is also evidence that family interventions have a positive impact on other measures of client and family functioning, including negative symptoms (  6 ), family burden (  7 ), vocational outcomes (  8 ), knowledge about schizophrenia (  9 ), quality of life (  10 ), and social adjustment (  11 ). 

The relative effectiveness of different types of treatment within family interventions has received little attention. Although all family interventions incorporate psychoeducation, standardized intervention models have focused on a variety of treatments, including behavioral family therapy, incorporating communication training to reduce family conflict and improve problem solving (  12 ); social skills, problem solving, and the development of family support networks (  13 ); and general supportive family therapy (  14 ). Although these models have not been compared, replication studies and studies comparing these treatments with general family support provide some evidence about the consistency of treatment effects. 

Studies of behavioral communication training have yielded mixed results. Earlier studies (  5 ) indicated greater efficacy than a more recent trial, which did not show any benefit of intensive behavioral intervention over general family support on relapse or rehospitalization measures (  15 ). Similarly, mixed results have been reported for supportive family therapy. One study reported no difference in outcomes between family therapy and caregiver support groups (  14 ). 

Consistent positive treatment effects have been associated with McFarlane's (  16 ) multiple-family group intervention, an adaptation of Hogarty's (  11 ) approach. Both are based on psychoeducation, problem solving, and development of social support networks. In a large-scale multisite study of 172 families that compared single- and multiple-family treatment, cumulative two-year relapse rates of 16 percent were reported for the multiple-family groups, compared with 27 percent for single-family therapy (  17 ). Multiple-family treatment also showed superior outcomes in other measures of functioning, such as employment and perceived family burden. The positive effects of multiple-family group interventions that were seen in multisite trials have also been found in natural clinical settings (  6 ,  17 ). In these settings multiple-family groups were shown to be more cost-effective than standard care; savings from reductions in inpatient hospital admissions and from use of the group treatment format were estimated to yield a cost-benefit ratio of 1:17 for multiple-family group treatment compared with standard care (  16 ). 

Some variation is evident in the impact of the multiple-family group intervention on specific symptom profiles, which may be related to the types of patient groups in different studies. For instance, McFarlane and colleagues (  16 ) used the multiple-family group intervention with people in an acute phase of illness and reported significant changes in acute symptoms. In contrast, a study by Dyck and associates (  6 ), which involved 63 people with chronic schizophrenia in an outpatient setting, found that acute symptoms of consumers who received multiple-family group treatment were not affected but that their negative symptoms improved. 

Several cross-cultural applications have identified family interventions as an efficacious treatment in international settings in which the cultural identification of the treatment group is consistent with the dominant culture (  18 ,  19 ). However, very little research has explored the impact of family intervention in migrant groups, even though it could be argued that these groups have the greatest need for family support. Common experiences of stress, isolation, and burden experienced by families dealing with mental illness are likely to be further intensified for newly settled migrant families because of language and communication difficulties, reduced access to extended family supports, and lack of knowledge of mental health services. 

For example, Klimidis and associates (  20 ) found lower rates of use of adult community mental health services among people of non-English-speaking backgrounds in Victoria, Australia, particularly among Asian and South East Asian communities. However, the only study that investigated the effectiveness of family interventions with a migrant population showed an adverse outcome. Telles and colleagues (  21 ) assigned 40 Hispanic-American families of non-English-speaking backgrounds to behavioral family management or a case management control group. Behavioral family management made no significant clinical contribution beyond case management and medication, and compared with individual treatment, behavioral family management actually exacerbated symptoms of individuals who were defined as "less acculturated." The authors suggested that the psychoeducation and support packages developed for English-speaking cultures may contain directives that are culturally dystonic, such as expressing negative emotions in the presence of an authority figure within the family. Such findings have prompted some researchers to recommend caution in using family interventions for individuals from non-English-speaking backgrounds (  22 ). However, very little attention has been directed to modifying family interventions to incorporate culturally sensitive practice, despite suggestions that cultural factors may have a profound influence on the way services are received and their effectiveness (  23 ). 

Our study compared outcomes for participants in a multiple-family group intervention for people with schizophrenia and their caregivers and a case management control group. The study sought to extend the multiple-family-group approach with appropriate cultural modifications to a newly arrived migrant group with a non-English-speaking background—first-generation Vietnamese families.

Click to view the articleView Article
Home of the Culturally Adapted Psychoeducation project for families of patients with first-episode psychosis and The Culture and Psychosis Working Group