Key Elements of a Family Intervention for

Schizophrenia: A Qualitative Analysis of an RCT

JAIME GRACIO* ,†

ß ALVES-PEREIRA*
MANUEL GONC
JULIAN LEFF‡,§

Schizophrenia is a complex biopsychosocial condition in which expressed emotion in

family members is a robust predictor of relapse. Not surprisingly, family interventions are
remarkably effective and thus recommended in current treatment guidelines. Their key ele-
ments seem to be common therapeutic factors, followed by education and coping skills
training. However, few studies have explored these key elements and the process of the
intervention itself. We conducted a qualitative and quantitative analysis of the records
from a pioneering family intervention trial addressing expressed emotion, published by
Leff and colleagues four decades ago. Records were analyzed into categories and data
explored using descriptive statistics. This was complemented by a narrative evaluation
using an inductive approach based on emotional markers and markers of change. The most
used strategies in the intervention were addressing needs, followed by coping skills
enhancement, advice, and emotional support. Dealing with overinvolvement and refram-
ing were the next most frequent. Single-family home sessions seemed to augment the thera-
peutic work conducted in family groups. Overall the intervention seemed to promote
cognitive and emotional change in the participants, and therapists were sensitive to the
emotional trajectory of each subject. On the basis of our findings, we developed a longitudi-
nal framework for better understanding the process of this treatment approach.

Keywords: Family Interventions; Psychoeducation; Psychosis; Schizophrenia; Process;

Qualitative Research

Fam Proc 57:100–112, 2018

BACKGROUND

T he debate over the definition of what constitute key elements of family interventions
for psychosis (FIP) is not over. Although there have been contributions outlining their
main components (Kuipers, 2006; Liberman & Liberman, 2003; McFarlane, 1991; World

*Chronic Diseases Research Center (CEDOC), Nova Medical School/Faculdade de Ci^encias M
edicas, Universi-
dade Nova de Lisboa, Lisbon, Portugal.
†
Cl
ınica Psiqui

atrica de S. Jos
e, Sisters Hospitallers, Lisbon, Portugal.
‡
King’s College London, London, UK.
§
University College London, London, UK.
Correspondence concerning this article should be addressed to Jaime Gr
acio, Cl
ınica Psiqui

atrica de S.
Jos
e, Sisters Hospitallers, Azinhaga da Torre do Fato, 8, 1600-774 Lisboa, Portugal. E-mail: jaime.
gracio@nms.unl.pt.
We thank Elizabeth Kuipers and Ruth Berkowitz for describing their approaches to working with the
relatives and helping to identify the EE levels of the relatives. We also thank Carla Nunes, Catarina Mor-
ais, Daniel Mira, Daniela Marques, Maria Jo~ ao Marques, Pedro Aguiar, and S
onia Dias for their valuable
help in data coding and analysis. Finally, we thank Daniel Sampaio and Telmo Baptista for their thought-
ful comments on the methods of this research project.

100
Family Process, Vol. 57, No. 1, 2018 © 2016 Family Process Institute
doi: 10.1111/famp.12271


GRACIO, ß ALVES-PEREIRA, & LEFF
GONC / 101
Fellowship for Schizophrenia and Allied Disorders, 1997), authors still raise the need to
thoroughly describe the process of these interventions (Cohen et al., 2008; Dixon et al.,
2001; Lam, 1991; Leff, 2000; McFarlane, Dixon, Lukens, & Lucksted, 2003). As McFarlane
(2016) recently argued in this journal, the main descriptor “psychoeducation” may be mis-
leading; most FIP include a broad array of cognitive, behavioral, and supportive elements,
using a consultative framework while sharing some characteristics with family therapy
approaches.
Two recent literature reviews attempted to increase the literature about the process of
FIP, one by Sin and Norman (2013) and another from ourselves (Gr
acio, Goncßalves-
Pereira, & Leff, 2016). Sin and Norman (2013) suggested that education and coping skills
training are essential components of FIP, stressing the need for interventions to be flexible
and give the opportunity for relatives to share their experiences. Our review also sup-
ported the importance of these elements, with the so-called “common therapeutic factors”
(e.g., therapeutic alliance, support, sharing) seeming most pervasive and relevant across
FIP. Moreover, we suggested a stepped-model of intervention according to relatives’ needs
(Gr
acio et al., 2016). Both studies emphasized the lack of research on the process of FIP.
To identify the key elements of the process of FIP, it is necessary to provide qualitative
research alongside efficacy studies (Higgins & Green, 2011), namely in what constitutes
the most effective treatment approaches. The first FIP trial conducted by Leff, Kuipers,
Berkowitz, Eberlein-Vries, and Sturgeon (1982) and Leff, Kuipers, Berkowitz, and Stur-
geon (1985) provided one of the best known studies with the firmest evidence found of the
effects of FIP on the course of schizophrenia (Pitschel-Walz et al., 2001). This trial demon-
strated a reduction in relapse rates from 50% in the control group to 8% in the treatment
group over 9 months (Leff et al., 1982), and from 78% (control) to 14% (experimental) at a
two-year follow-up (Leff et al., 1985). The aim of this particular FIP was to regulate rela-
tives’ expressed emotion (EE), that is, emotional overinvolvement, hostility, and criticism
toward the patient, and to reduce face-to-face contact between patients and their high EE
caregivers. The intervention was delivered to each family in a combined format of group
sessions for relatives alone and single-family home sessions that included the patient.
Participants received an array of pragmatic techniques, which had not been manualized
at that time. After initial engagement, task-setting, education, and sharing, the program
moved to more advanced work on EE components. Therapists would promote dialogue
among participants in the group sessions and provide information and advice as needed.
Participants would be encouraged to talk to each other and not to the therapists. Thera-
pists would be expected to create a positive atmosphere within the group by validating
participants, facilitating support, and allowing for information-sharing as well as direct
advice. The accumulated experience of these 1980s trials together with years of subse-
quent interventions and training was later described in a book, first published in 1992
(Kuipers, Lam, & Leff, 1992, 2002). Although the original intervention, now under analy-
sis, took place four decades ago, a direct examination of the intervention records had never
been attempted on account of the heavy labor involved. In this study, we describe the anal-
ysis of this highly relevant material. We believe doing so will provide a golden opportunity
for in-depth understanding of the core processes of a treatment program which remains
current and is still being trained and implemented by many mental health teams (Leff,
2005).

Aims
To identify the most used therapeutic strategies in the intervention program from
Kuipers et al. (2002), Leff et al. (1982, 1985). Second, we expect to provide a basis for
determining the usefulness of different strategies throughout the course of the

Fam. Proc., Vol. 57, March, 2018

102 / FAMILY PROCESS

intervention; to explore the differences between the strategies addressing high and low
EE relatives; and to define variables related to this process that may be manipulated in
future research.

METHODS
Data Collection
Data were recorded during a clinical trial by Leff et al. (1982, 1985) between 1977–
1982. The analyzed material included summary transcripts of 85 relatives’ group sessions
and 25 single-family home sessions, written by the therapists after each session while lis-
tening to the respective audiotape. For each session, therapists recorded the main themes
and interactions, including direct speech sentences and clinical comments. In addition,
they inserted the number and duration of the session, the name of the participants attend-
ing, the name of the therapists that conducted the group, and the aims of that particular
session, together with general observations and relevant comments. The group sessions
were delivered every fortnight at the locus of service, whereas the single-family home ses-
sions did not have a previously defined schedule. Instead the decision to hold such a ses-
sion was based on the therapists’ clinical judgment. Each of the therapists was highly
experienced in their own field.
Subjects included in the clinical trial under analysis were relatives of patients suffering
from schizophrenia. Recruitment had been carried out during psychiatric admissions at
three hospitals in London. To meet inclusion criteria, patients and caregivers had to live
together continuously for 3 months before admission and spend more than 35 hours per
week in face-to-face contact.
Twenty-two relatives of 19 patients participated in the group sessions. Seventeen were
female. Sixteen were parents (of 6 daughters and 10 sons), and the other six were spouses
(two wives and four husbands).
Each participant attended an average of 14 sessions. Only five participants were identi-
fied as low EE, 10% of the total of the attendance in the group. The mean participation
rate for low EE relatives was six sessions and 18 sessions for high EE relatives. All partici-
pants did not attend the groups together. The groups were open to new participants, and
former participants dropped out or were ruled to have received the maximum benefit with
the agreement of the therapists.
In addition, a small proportion of relatives also participated in single-family home ses-
sions. Only eight relatives were included in the single-family home sessions that we ana-
lyzed. These participants were all high EE relatives, and the majority received two
sessions each. However, before entering the group, all participants received at least one
home session dedicated to education about the illness (Leff et al., 1982). These sessions
were not available for analysis.

Data Coding
Before starting the coding process, materials were carefully organized. This process
allowed for a floating reading that aided in identifying the best qualitative approach to
use.
We applied a deductive mechanical approach to analyze and sort data content into pre-
viously defined categories (Bradley, Curry, & Devers, 2007). This decision was based on
the length of the records, and because we had previously established evidence about cate-
gories that it would be possible to identify in the records. We created a comprehensive list
with a provisional set of therapeutic strategies that may have been used in the interven-
tion to begin category definition. The majority of defined categories were based on the

www.FamilyProcess.org


GRACIO, ß ALVES-PEREIRA, & LEFF
GONC / 103
intervention manual (Kuipers et al., 2002). The remaining items of this initial category
set were based on our systematic literature review about the process of FIP (Gr
acio et al.,
2016). Throughout several meetings with two experts in qualitative analysis, we discussed
the meaning of each category and shortened the initial list. We outlined an operational
definition of each category to avoid overlap. The list was eventually adjusted in order to
obtain the final structure, with conceptual codes (i.e., categories) matching therapeutic
strategies. This final code structure was comprised of 18 mutually exclusive categories
that were used in the content analysis (“therapeutic alliance”; “emotional support”; “ad-
dressing needs and sharing”; “group dynamics”; “education”; “coping skills and advice”;
“problem-solving”; “modeling”; “reframing”; “dealing with emotional upset”; “dealing with
anger, conflict and rejection”; “dealing with overinvolvement”; “working with grief”; “work-
ing with the family’s sense of stigma”; “getting absent family members involved”; “coping
with lack of interest in meetings”; “coping with nonattendance”; “involving network for
support”).
The process of coding consisted of two investigators (coders), who read and indepen-
dently analyzed record content (i.e., summary transcripts written by the therapists of
the trial under analysis). Coding was performed using NVivoâ version 10 software
(QSR International, Doncaster, Victoria, Australia). The agreed upon rules for analysis
were: (1) each category was selected on the basis of the closest match to the apparent
strategy used by the therapists in each case in the records and (2) specific therapeutic
strategies were linked with the participant or set of participants that raised that issue
in the group, functioning as receivers of the underlying message and apparently benefit-
ing from it. Records were classified by session and by participant. For each excerpt
demonstrating the occurrence of a specific therapeutic strategy, the coders inserted: the
respective session number; the code number of the participant or set of participants to
whom the strategy was mainly addressed; and the category corresponding to the under-
lying therapeutic strategy. Using this process, we were able to understand which strat-
egy was used, which session it was used in, and with which specific participant. Below
we provide brief examples of the coding process.
P4 was asked about and described his wife’s adult education courses again. [Code: Addressing
needs and sharing; participant 4; session 3]; P6 then replied “Oh, if it happens again, I’m off”,
“I’m bailing out”. P2 again sympathised with this, saying “It nearly caused us to separate”. [Code:
Emotional support; participant 6; session 6]; P6 eventually said to P1 “You can’t dodge the issue,
he needs taking away from you two for a while”. [Code: Dealing with emotional overinvolvement;
participant 1; session 17].
After performing the content analysis and parsing into categories, we also used an induc-
tive approach to conduct a narrative evaluation of the main parts of the intervention.
These parts were identified based on emotional markers and markers of change in the par-
ticipants, which had been secondarily coded by one of the investigators during the content
analysis.

Validity and Reliability

Two investigators independently read all records and coded the emergent therapeutic
strategies. Several meetings were dedicated to the discussion and re-examination of cod-
ing discrepancies. In the event of disagreement, the two independent coding outputs were
compared, and the two coders used a consensus model to reach a mutual decision on the
final code (Bradley et al., 2007). If no agreement was reached, a third researcher was con-
sulted. We achieved a moderate level of inter-rater reliability in the independent coding
based on reference taxonomies (Hruschka et al., 2004). Eventually, complete agreement
was achieved.

Fam. Proc., Vol. 57, March, 2018

104 / FAMILY PROCESS

We adopted qualitative research criteria on reliability (Armstrong, Gosling, Weinman,

& Marteau, 1997; Hruschka et al., 2004) by: (1) providing independent coding in the con-
tent analysis; (2) assessing and controlling consistency between observers; (3) defining the
study operations of the coding process; (4) specifying an operational definition for each
category; (5) conducting line-by-line analysis; and (6) keeping memo writing of the coding
process. Validity was addressed by: (1) guaranteeing that all coders had theoretical and
practical knowledge in the field; (2) addressing the richness and uniqueness of the records;
(3) ensuring supervision from the senior authors, experts in the field; and (4) certifying
the relevance and pertinence of the records.

Data Analysis and Synthesis

We created enumerating rules to quantify the coding process. The frequencies of each
strategy were counted both overall and in detail by participant and session. Afterwards,
visual comparisons were performed using graphs of relationships between categories and
calculated correlations.

RESULTS
Relative Groups
The frequency counts showed that the most used strategies in the relative groups were:
(1) “addressing needs and sharing”—21% of all strategies used in the intervention; (2)
“coping skills and advice”—15%; (3) “emotional support”—12%; (4) “dealing with overin-
volvement”—10%; and (5) “reframing relatives’ views about patients’ behaviors”—10%.
“Education” about the illness, “dealing with emotional upset” “dealing with anger, conflict
and rejection”, and “dealing with the family sense of stigma” were in the mid-range.
Strategies to “work on grief”, “problem-solving”, and “modeling” were negligible. Figure 1
presents the overall frequencies for each strategy in the relative groups.

350

300

250

200

150

100

50

0
n
g

f
ce

a
t
g

ng
n
t

io
ce

en

ie
se
in
or

ic

gm
in

g
tio
an

ct

gr
vi

in
vi

up
pp

em
ar

ca

sti
lli

ad

el
ol

ra
na

ng
sh
su

re
l

lv
u

od
-s
.a

ef

a
dy

ng
nd
Ed

ki
on

vo
nd
l

d
R
M
ap

na

or
an

ki
sa

le

i
up

in
sa

ot
er

io

or
ob

er
t,
ill
ro

em
Th

ot

ed

W
ic

ov
Pr
sk
G
m

ne

f l
l.
E

ith
ng

ea

co
g
in

pi

w
r,
ss

Co

l.
ge
re

ea
an
dd

D
A

l.
ea
D

FIGURE 1. Overall Frequencies of Each Therapeutic Strategy in the Relatives Groups.

www.FamilyProcess.org


GRACIO, ß ALVES-PEREIRA, & LEFF
GONC / 105
Longitudinal analysis by therapeutic strategy and session
The longitudinal analysis performed using visual graph comparisons of each strategy
throughout group sessions showed variations in almost all categories. We focused on
the most used strategies, as they offered more information about what happened in the
intervention. To better understand these data on a longitudinal basis, we divided the
group into two phases due to a change in the set of participants in the middle of the
program. As mentioned, participants did not come to group at the same time. The clini-
cal trial under analysis was conducted over 5 years, and participants were continuously
admitted during this period, following patients’ admissions at the hospital. Therefore,
while newcomers were entering the group, others were ending their participation.
Between sessions 35–36, there was a considerable gap (3 months), coinciding with sum-
mer holidays. Participants who were already attending had been participating in the
group for a long period, whereas newcomers were not admitted for an extended period.
All participants attending session 36 but one were new to the group. Therefore, we ana-
lyzed the results in two phases—from session 1 to session 35 (phase A) and from session
36 to session 86 (phase B).
On a longitudinal basis, “addressing needs and sharing”, “coping skills and advice”,
and “emotional support” were frequently used in almost all sessions, especially during
the first half of both phases. The frequency distributions of these strategies had irregu-
lar patterns following a specific order. When “addressing needs and sharing” had the
highest value, there was a tendency for “coping skills and advice” and “emotional sup-
port” also to increase. “Addressing needs and sharing” was positively correlated with
“coping skills and advice”, r(394) = .35, p < .0001, and “emotional support”, r(394) = .29,
p < .0001.
The remaining therapeutic strategies seemed to occur more often in the middle and at
the end of both phases of the intervention program, namely “dealing with overinvolve-
ment”, “reframing relatives’ views about patients’ behaviors”, and “dealing with anger,
conflict and rejection”. However, “dealing with overinvolvement” seemed to occur slightly
earlier as compared to the others.
Analysis of the strategies specific to each participant
As mentioned above, there was a much higher number of high EE participants, and low
EE participants attended considerably fewer sessions. Therefore, in view of the preponder-
ance of high EE compared to low EE participants, we exercised caution in drawing conclu-
sions. We based our analysis on the overall frequency counts. We found a tendency for
some participants to receive more therapeutic strategies as compared to others. This was
particularly observed with high EE relatives who received more of “emotional support”,
“addressing needs and sharing”, “coping skills and advice”, and “reframing relatives’ views
about patients’ behaviors”. Concerning low EE relatives, they received considerable
amounts of “therapeutic alliance” and “emotional support” oriented strategies.
Analysis of the frequencies of “education” by participant revealed that high EE partici-
pants, who invariably received large amounts of other strategies, had low values on this
category. The analysis also revealed that “dealing with overinvolvement” was mostly used
with parent participants.

Single-Family Home Sessions

The most used therapeutic strategies in the single-family home sessions were: (1) “deal-
ing with overinvolvement”—corresponding to 33% of all strategies used in the single-
family home sessions; (2) “coping skills and advice”—22%; and (3) “reframing relatives’
views about patients’ behaviors” and “dealing with anger, conflict and rejection”—both

Fam. Proc., Vol. 57, March, 2018

106 / FAMILY PROCESS

25

20

15

10

n
g
ce

t
et
n
rt

io
ce

en
g

in
io
po

ps
in
an

ct
vi

em
at
ar

je
lu
up
lli

ad

fra
uc

re
sh

lv
.a

ls

na
nd
Ed

Re

vo
d
nd
ap

na

io

an
sa

in
ot
sa
er

io

er
t,
ill

em
Th

ot

ed

lic

ov
sk
Em

ne

nf
l.

ith
ng

ea

co
g

pi

w
in

r,
Co
ss

l.
ge

ea
re

an

D
dd

l.
A

ea
D

FIGURE 2. Overall Frequencies of Each Therapeutic Strategy in the Single-family Home Sessions.

10%. Figure 2 presents the overall frequencies for each strategy in the single-family home
sessions.
The analysis of strategy use by participants in the single-family home sessions
revealed that almost every participant received “dealing with overinvolvement”. One
participant also received considerable amounts of “education” and “dealing with
emotional upset”, and another received “dealing with anger, conflict and rejection”
substantially.

Additional Information Provided by the Narrative Evaluation

The narrative evaluation revealed that, throughout the therapeutic program, high EE
and low EE relatives experienced different emotions. During the first sessions, high EE
relatives frequently tended to ruminate on past events and expressed feelings of anger.
Therefore, therapists had to help them focus on current problems and interrupt rumina-
tive thoughts and memories. Afterward, participants tended to experience feelings of loss
and anguish. As a consequence, therapists would create conditions in the group that
allowed relatives to receive emotional support. Discussions then focused on coping skills
and advice to improve the relatives’ ability to deal effectively with the illness and to
become less emotionally overinvolved. Finally, they were encouraged to explore the rea-
sons underlying patients’ behaviors. This work allowed participants to reframe their view-
points to reach positive appraisals of stressful situations, eventually achieving positive
attitudes, such as acceptance and positive regard, and improving their sense of control
and security.
The analysis also revealed an interesting phenomenon when new members joined the
group. Those who were receiving the most attention in the group at that moment fre-
quently would change their role and become interested in the problems of newcomers,
assuming a supportive and advisory role.

www.FamilyProcess.org


GRACIO, ß ALVES-PEREIRA, & LEFF
GONC / 107
DISCUSSION
We completed a comprehensive qualitative analysis of one of the most effective clinical
trials of FIPs ever conducted (Leff et al., 1982, 1985; Pitschel-Walz et al., 2001). To our
knowledge, this is the first qualitative study of this kind to produce in-depth data. Despite
the existence of a manual describing the intervention (Kuipers et al., 2002), this study
was uniquely able to identify and enumerate the strategies therapists actually employed.
In fact, we conducted an analysis based on detailed clinical records, combining qualitative
and quantitative approaches.

Which Were the Most Used Therapeutic Strategies in the Intervention?

Throughout the intervention, the most used therapeutic strategy was “addressing
needs and sharing”. In the group sessions, therapists prioritized creating moments in
which relatives could express their needs and share their difficulties about the caregiving
experience. This is consistent with the findings by Bloch, Szmukler, Herrman, Benson,
and Colussa (1995), who highlighted the importance of addressing needs in FIP programs.
From a practical perspective, this involves: (1) asking relatives directly about their diffi-
culties; (2) setting the aims of the intervention based on relatives’ needs; and (3) creating
an atmosphere in the group that allows relatives to share their own difficulties sponta-
neously.
The second most used therapeutic strategy was the “enhancement of relatives’ coping
skills and advice” on how to cope with patients’ behaviors. Our operational definition of
this category considered only problem-focused coping strategies. In practice, this means
that the therapists created opportunities in the group to generate discussions on how to
deal with challenges that the illness may generate in the household. This was achieved
either by peer-to-peer input, sometimes based on relatives’ own experience, or direct
advice from the therapists. This strategy was also prominent in the single-family home
sessions. By increasing coping skills, relatives’ overall stress level may decrease. As a con-
sequence, relatives’ criticism, hostility, and emotional overinvolvement, that is, EE, may
also decrease (Cotton et al., 2013; Kunimatsu & Marsee, 2012). Despite being considered
an advanced strategy in the stepped model we proposed (Gr
acio et al., 2016), coping skills
enhancement was delivered very early in this intervention. This may be explained by the
nature of this treatment program, which was mainly EE targeted. A large proportion of
the relatives in this group were high EE and “coping skills and advice” was almost entirely
directed at these high EE relatives.
“Emotional support” was another frequent therapeutic strategy used in the relatives’
groups. This implies acknowledging relatives’ feelings and offering validation. In this
study, we accumulated evidence showing that emotional support is a key element of FIP,
as has been previously suggested (Budd & Hughes, 1997; Cabral & Chaves, 2010; James,
Cushway, & Fadden, 2006; Levy-Frank et al., 2012; Mannion et al., 1997; Stanbridge,
Burbach, Lucas, & Carter, 2003). FIP should be a “sanctuary” where relatives freely
express their emotions and find validation. FIP becomes a healing process, allowing a
place where relatives receive warmth and their concerns are fully understood by others
(peers and therapists).
“Dealing with overinvolvement” and “reframing relatives’ views about patients’ behav-
iors” were also prominent, both in the relative groups and in the single-family home ses-
sions. “Dealing with overinvolvement” is a key feature of the Leff and colleagues’ program.
This therapeutic strategy is merged with strong emotional variables, such as the “Catch-
22” situation, guilt, and the independence-intrusiveness conflict (Berkowitz, Kuipers, Eber-
lein-Fries, & Leff, 1981). The “Catch-22” situation happens when a relative sees no way of
balancing personal needs combined with the fear that acting on them will have awful

Fam. Proc., Vol. 57, March, 2018

108 / FAMILY PROCESS

consequences on the patient. As a result, whatever the relative may do, he/she will feel that
he/she did it wrong. Feelings of guilt arise when relatives question what they may have
done to contribute to the illness. As a result, they try to go back in time to repair or undo
their actions. Inevitably, this leads to the perception of their loved ones as young people,
leading to feelings of overprotection. In practice, “dealing with overinvolvement” includes:
(1) diminishing relatives’ guilt; (2) repeating that relatives cannot cause schizophrenia; (3)
finding a lever, such as identifying opportunities, to improve the patient’s autonomy; (4)
drawing the relative’s attention to the ‘When I am Gone’ scenario; (5) using the collapsed
time technique; (6) exploring anxieties about separation; (7) getting relatives to face the
impossibility of maintaining constant vigilance; (8) encouraging the parents to go out
together; (9) giving relatives “permission” to relax and enjoy themselves; and (10) encourag-
ing relatives to resuscitate contacts with friends and relations outside the home.
“Reframing of relatives’ views about patients’ behaviors” is also of great importance in
programs aiming to regulate EE. Reframing is a mediating variable in lowering EE
(Barrowclough & Hooley, 2003; Bentsen et al., 1997, 1998; Breitborde et al., 2009). This
strategy is central to cognitive therapy techniques, such as peripheral questioning. It also
may be prompted by information, sometimes provided by other relatives, and reality test-
ing. In addition, in this analysis we identified some role-plays being carried out to give rel-
atives a different point-of-view about their attributions concerning patients’ behaviors.

What Was the Usefulness of the Different Therapeutic Strategies Throughout the
Intervention Program?
“Addressing needs and sharing” is a key element of FIP. This compels effective FIP pro-
grams to be flexible, in contrast with very structured scripts. In the intervention that we
analyzed, therapists created group moments for relatives to express their needs and share
their experiences in almost every session. This was especially true in the beginning of the
program. When therapists dedicated some time to “addressing needs and sharing”, they
immediately after provided “emotional support” and “coping skills and advice”. This work
might have been the basis for participants to start their individual process of change,
which was then promoted in the following sessions by “dealing with overinvolvement” and
“reframing of relatives’ views about patients’ behaviors”.
It must be recognized that by elaborating on the usefulness of each strategy, we found
some unexpected elements in our analysis. We were surprised by the low use of problem-
solving, modeling, and working with grief. Problem-solving is crucial in some FIP
approaches (Falloon, Boyd, & McGill, 1984; McFarlane, 2002), and modeling was a key
element of the intervention by Leff and colleagues (Kuipers et al., 2002). Likewise, many
FIP authors have spotlighted working with grief (Bentsen et al., 1998; Kuipers et al.,
2002; Riley et al., 2011). The nature of these strategies can explain their low frequency in
the sessions we analyzed. Despite being specific, they are linked with other therapeutic
strategies. That is, working with other strategies could also impact them. For example,
when low EE participants were spontaneously sharing their caregiving experience, they
were also modeling for high EE relatives. However, as we defined in our code structure,
modeling would only be coded when therapists intentionally gave voice to low EE partici-
pants to influence others. The same happened with problem-solving, which was coded only
when the structured “six-step” approach was applied. Regarding grief work, we found a
possible overlap between emotional support (or other emotional categories) and this cate-
gory. We only coded working with grief when this was the only or the predominant feeling
involved. However, it was often very difficult for us to isolate only one emotion, as fre-
quently multiple feelings were displayed. For example, a relative might have exhibited
anger, while the underlying emotion could be grief.

www.FamilyProcess.org


GRACIO, ß ALVES-PEREIRA, & LEFF
GONC / 109
A final comment on the education component is worthwhile. Our analysis revealed a
prominence of this strategy in the beginning of groups. However, education was not associ-
ated with any other variables and had a secondary role in the group sessions. This can be
explained by the fact that all relatives who received an individual education session in
their home were given a booklet containing important information about schizophrenia
and its management, which was not available at that period from other sources. Neverthe-
less, if we recall that we are analyzing a FIP based on the “psychoeducation paradigm”, it
is worth noticing the secondary role of education.

Are There Differences Between Strategies Used With High EE Relatives and Those
Used With Low EE Relatives?
The most obvious difference in the use of therapeutic strategies between low and high
EE relatives is the amount of intervention they received. High EE relatives received sub-
stantially more therapeutic strategies as compared with low EE relatives. Again, this
might be related to the level of intervention in this program. In the stepped-model we
speculated that not every relative would need advanced strategies (Gr
acio et al., 2016).
Low EE relatives may not need in-depth interventions, and hence, it might be difficult to
retain them in the group. Another difference in the use of strategies between low and high
EE relatives was the higher use of therapeutic alliance strategies with low EE relatives.
These low EE relatives also received a considerable amount of emotional support. Accord-
ing to our findings, establishing a therapeutic alliance involved the offer of positive experi-
ences of contact and informal contacts outside the sessions. This is another aspect
consistent with the stepped-model of intervention. There is evidence that therapeutic alli-
ance-focused interventions produce positive outcomes in the course of the illness (Levy-
Frank, Hasson-Ohayon, Kravetz, & Roe, 2011). We believe that low EE relatives may ben-
efit from low intensity programs utilizing therapeutic alliance and emotional support.
The variability in relatives in the groups showed that it is possible to have different
levels of intervention in the same group, that is, low intensity “common therapeutic fac-
tors” strategies for one kind of relatives, and high intensity coping skills enhancement and
dealing with EE strategies for another set of relatives. However, it seemed to be difficult
to keep low EE relatives in the group for longer periods.

Which Changes Were Observed in the Participants?

Using the narrative evaluation method, we observed an emotional pathway in high EE
participants showing movement from feelings of anger, to anguish and despair, and later
on to acceptance associated with positive reappraisal. In addition, we found that the role
of high EE relatives in the group shifted from being the focus of attention of the group,
and therefore directly receiving more therapeutic strategies, to becoming a source of sup-
port and advice to newcomers. This interesting phenomenon could be called the “Relay
Effect”. Keeping in mind that low EE relatives probably needed less intensive interven-
tions and stayed in the group for shorter periods, using the contribution of formerly high
EE participants in the group might foster peer-to-peer modeling for newcomers.

Overview of the Research Findings. Clinical Recommendations: Suggesting a

Roadmap for Therapists
The information presented here may provide a framework for the intervention process,
as based on empirical data. We suggest that the following sequence may serve as a road-
map for therapists when delivering this kind of intervention. In the first sessions of rela-
tive groups, therapists should provide an atmosphere that will allow participants to

Fam. Proc., Vol. 57, March, 2018

110 / FAMILY PROCESS

express their needs and share their difficulties. This should be the most highly used strat-
egy throughout the sessions, especially in the beginning of the treatment program,
together with emotional support, coping skills enhancement, and advice. After four to six
sessions, participants may start to benefit from other strategies, namely dealing with
overinvolvement, reframing and (further ahead) dealing with anger, conflict, and rejec-
tion. Education may be offered in a preliminary interview before entering the program
and less frequently in the first third of the program (additionally, information tailored to
participants’ needs will help provide context for the discussions). Each participant, espe-
cially high EE relatives, should attend more than fourteen fortnightly group sessions.
Single-family home sessions including the patient may be provided to potentiate the
effects of group work.

Study Limitations
We acknowledge some limitations in this analysis. The trial records were for therapists
to keep a clear clinical account of their interventions. Because this was not directed by a
standardized protocol, it is possible that there were some inaccuracies and omissions.
However, as we have documented above, there is no doubt that all therapists took extra
care to keep accurate and detailed notes, since at that time this was still a novel form of
therapy for families of people with schizophrenia.
Despite our efforts to develop an operational definition for each category of the coding
structure (with mutually exclusive categories balancing specificity and comprehensive-
ness), we acknowledge the possibility of some coding and statistical overlap because of the
complex nature of the therapeutic strategies under assessment.
This study is actually a post hoc analysis of data recorded a few decades ago, before fur-
ther empirical knowledge about the intervention was gathered and a manual was written.
The investigators that performed the coding process could not be completely na€ıve regard-
ing what they might find in the records. However, this is not unusual when using deduc-
tive approaches, which do not require complete blindness throughout the analysis.

Final Comments
The kind of family work we have analyzed is mainly concerned with family members’
EE, a pathological construct which has been consistently reproduced over decades and
across cultures as a robust predictor of relapse in schizophrenia (Butzlaff & Hooley, 1998).
This type of intervention is still being trained in the specific form that was studied here,
and the same therapeutic techniques are being used by different teams worldwide (Leff,
2005).
Thus, the target of our study was by no means a context-specific, historical-sociological
exploration. We were able to conduct a qualitative analysis that allowed a better under-
standing of this treatment approach, similar to what has been achieved in other fields
(Nichols & Tafuri, 2013). One should bear in mind that the findings we presented were
based on a specific FIP approach, that is, the model from Leff and colleagues. It would be
helpful to replicate this kind of study with other treatment approaches and compare data
to understand the process of FIP more comprehensively.

REFERENCES
Armstrong, D., Gosling, A., Weinman, J., & Marteau, T. (1997). The place of inter-rater reliability in qualitative
research: An empirical study. Sociology, 31(3), 597–606.
Barrowclough, C., & Hooley, J. M. (2003). Attributions and expressed emotion: A review. Clinical Psychology
Review, 23(6), 849–880. doi:10.1016/s0272-7358(03)00075-8.

www.FamilyProcess.org


GRACIO, ß ALVES-PEREIRA, & LEFF
GONC / 111
Bentsen, H., Munkvold, O. G., Notland, T. H., Boye, B., Lersbryggen, A. B., Okarsson, K. H. et al. (1997). Rela-
tives’ locus of control and expressed emotion in schizophrenia and related psychoses. British Journal of Clini-
cal Psychology, 36, 555–567.
Bentsen, H., Notland, T. H., Munkvold, O. G., Boye, B., Ulstein, I., Bjorge, H. et al. (1998). Guilt proneness and
expressed emotion in relatives of patients with schizophrenia or related psychosis. British Journal of Medical
Psychology, 71, 125–138.
Berkowitz, R., Kuipers, L., Eberlein-Fries, R., & Leff, J. (1981). Lowering expressed emotion in relatives of
schizophrenics. In M. S. Goldsterin (Ed.), New directions for mental health services: new developments in
interventions with families of schizophrenics. San Francisco, CA: Jossey-Bass.
Bloch, S., Szmukler, G. I., Herrman, H., Benson, A., & Colussa, S. (1995). Counseling caregivers of relatives with
schizophrenia: Themes, interventions, and caveats. Family Process, 34(4), 413–425.
Bradley, E. H., Curry, L. A., & Devers, K. J. (2007). Qualitative data analysis for health services research: Devel-
oping taxonomy, themes, and theory. Health Services Research, 42(4), 1758–1772. doi:10.1111/j.1475-
6773.2006.00684.x
Breitborde, N. J. K., Lopez, S. R., & Nuechterlein, K. H. (2009). Expressed emotion, human agency, and
schizophrenia: Toward a new model for the ee-relapse association. Culture Medicine and Psychiatry, 33(1),
41–60. doi:10.1007/s11013-008-9119-x.
Budd, R. J., & Hughes, I. C. T. (1997). What do relatives of people with schizophrenia find helpful about family
intervention? Schizophrenia Bulletin, 23(2), 341–347.
Butzlaff, R. L., & Hooley, J. M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of
General Psychiatry, 55(6), 547–552.
Cabral, R. R. F., & Chaves, A. C. (2010). Multi-Family Group Intervention in a programme for patients with first-
episode psychosis: A brazilian experience. International Journal of Social Psychiatry, 56(5), 527–532.
doi:10.1177/0020764009102754.
Cohen, A. N., Glynn, S. M., Murray-Swank, A. B., Barrio, C., Fischer, E. P., McCutcheon, S. J. et al. (2008). The
family forum: Directions for the implementation of family psychoeducation for severe mental illness. Psychi-
atric Services (Washington, D. C.), 59(1), 40–48. doi:10.1176/appi.ps.59.1.40
Cotton, S. M., McCann, T. V., Gleeson, J. F., Crisp, K., Murphy, B. P., & Lubman, D. I. (2013). Coping strategies
in carers of young people with a first episode of psychosis. Schizophrenia Research, 146(1–3), 118–124.
doi:10.1016/j.schres.2013.02.008.
Dixon, L., McFarlane, W. R., Lefley, H., Lucksted, A., Cohen, M., Falloon, I. et al. (2001). Evidence-based prac-
tices for services to families of people with psychiatric disabilities. Psychiatric Services (Washington, D. C.), 52
(7), 903–910.
Falloon, I. R., Boyd, J. L., & McGill, C. W. (1984). Family care of schizophrenia. New York: The Guilford Press.
acio, J., Goncßalves-Pereira, M., & Leff, J. (2016). What do we know about family interventions for psychosis at
Gr

the process level? A systematic review. Family Process, 55(1), 79–90.
Higgins, J., & Green, S. (2011). Cochrane handbook for systematic reviews of interventions version 5.1.0.
Retrieved September, 2013, from http://www.cochrane-handbook.org/
Hruschka, D. J., Schwartz, D., St. John, D. C., Picone-Decaro, E., Jenkins, R. A., & Carey, J. W. (2004). Reliability
in coding open-ended data: Lessons learned from HIV behavioral research. Field Methods, 16(3), 307–331.
James, C., Cushway, D., & Fadden, G. (2006). What works in engagement of families in behavioural family ther-
apy? A positive model from the therapist perspective. Journal of Mental Health, 15(3), 355–368. doi:10.1080/
09638230600700805.
Kuipers, E. (2006). Family interventions in schizophrenia: Evidence for efficacy and proposed mechanisms of
change. Journal of Family Therapy, 28(1), 73–80. doi:10.1111/j.1467-6427.2006.00338.x
Kuipers, E., Lam, D., & Leff, J. (1992). Family work with schizophrenia: A practical guide. London, UK: Gaskell.
Kuipers, E., Lam, D., & Leff, J. (2002). Family work with schizophrenia: A practical guide (2nd ed.). London, UK:
Gaskell.
Kunimatsu, M., & Marsee, M. (2012). Examining the presence of anxiety in aggressive individuals: The illumi-
nating role of fight-or-flight mechanisms. Child & Youth Care Forum, 41(3), 247–258. doi:10.1007/s10566-012-
9178-6.
Lam, D. (1991). Psychosocial family intervention in schizophrenia: A review of empirical studies. Psychological
Medicine, 21(2), 423–441.
Leff, J. (2000). Family work for schizophrenia: Practical application. Acta Psychiatrica Scandinavica, 102(Suppl.
407), 78–82.
Leff, J. (2005). Advanced family work for schizophrenia: An evidence-based approach. London, UK: Gaskell.
Leff, J., Kuipers, L., Berkowitz, R., Eberlein-Vries, R., & Sturgeon, D. (1982). A controlled trial of social interven-
tion in the families of schizophrenic patients. British Journal of Psychiatry, 141, 121–134.
Leff, J., Kuipers, L., Berkowitz, R., & Sturgeon, D. (1985). A controlled trial of social intervention in the families
of schizophrenic patients: Two year follow-up. British Journal of Psychiatry, 146, 594–600.

Fam. Proc., Vol. 57, March, 2018

112 / FAMILY PROCESS

Levy-Frank, I., Hasson-Ohayon, I., Kravetz, S., & Roe, D. (2011). Family psychoeducation and therapeutic alli-
ance focused interventions for parents of a daughter or son with a severe mental illness. Psychiatry Research,
189(2), 173–179. doi:10.1016/j.psychres.2011.02.012
Levy-Frank, I., Hasson-Ohayon, I., Kravetz, S., & Roe, D. (2012). A narrative evaluation of a psychoeducation
and a therapeutic alliance intervention for parents of persons with a severe mental illness. Family Process, 51
(2), 265–280. doi:10.1111/j.1545-5300.2012.01398.x.
Liberman, D. B., & Liberman, R. P. (2003). Involving families in rehabilitation through behavioural family man-
agement. Psychiatric Services, 54(5), 633–635. doi:10.1176/appi.ps.54.5.633
Mannion, E., Draine, J., Solomon, P., & Meisel, M. (1997). Applying research on family education about mental
illness to development of a relatives’ group consultation model. Community Mental Health Journal, 33(6),
555–569. doi:10.1023/a:1025008905304.
McFarlane, W. R. (1991). Schizophrenia and psychoeducation: Model for intervention in family practice. Cana-
dian Family Physician, 37, 2457–2465.
McFarlane, W. R. (2002). Multifamily groups in the treatment of severe psychiatric disorders. New York: The
Guilford Press.
McFarlane, W. R. (2016). Family interventions for schizophrenia and the psychoses: A review. Family Process,
doi:10.1111/famp.12235
McFarlane, W. R., Dixon, L., Lukens, E., & Lucksted, A. (2003). Family psychoeducation and schizophrenia: A
review of the literature. Journal of Marital and Family Therapy, 29(2), 223–245.
Nichols, M., & Tafuri, S. (2013). Techniques of structural family assessment: A qualitative analysis of how
experts promote a systemic perspective. Family Process, 52(2), 207–215. doi:10.1111/famp.12025
Pitschel-Walz, G., Leucht, S., Bauml, J., Kissling, W., & Engel, R. R. (2001). The effect of family interventions on
relapse and rehospitalization in schizophrenia–a meta-analysis. Schizophrenia Bulletin, 27(1), 73–92.
Riley, G., Gregory, N., Bellinger, J., Davies, N., Mabbott, G., & Sabourin, R. (2011). Carer’s education groups for
relatives with a first episode of psychosis: An evaluation of an eight-week education group. Early Intervention
in Psychiatry, 5(1), 57–63. doi:10.1111/j.1751-7893.2010.00195.x
Sin, J., & Norman, I. (2013). Psychoeducational interventions for family members of people with schizophrenia: A
mixed-method systematic review. Journal of Clinical Psychiatry, 74(12), e1145–e1162. doi:10.4088/
JCP.12r08308
Stanbridge, R. I., Burbach, F. R., Lucas, A. S., & Carter, K. (2003). A study of families’ satisfaction with a family
interventions in psychosis service in Somerset. Journal of Family Therapy, 25(2), 181–204. doi:10.1111/1467-
6427.00243.
World Fellowship for Schizophrenia and Allied Disorders (1997). Schizophrenia and Mental Illness: Families as
partners in care, goals and principles. Retrieved August 2013, from http://www.world-schizophrenia.org/activ-
ities/fpc/principles.html

www.FamilyProcess.org