Principles and Results of Family Therapy in Schizophrenia

  • Kurt Hahlweg
  • Georg Wiedemann


Long-term neuroleptic treatment has been shown to be effective in preventing relapse, but even with continuous medication, about 40% of patients relapse during the first year of discharge from the hospital compared with about 70% of patients taking placebo (Hogarty, 1984). The high rate of relapse has stimulated research on contributing factors: apart from medication non-compliance (Kissling, 1992), social stressors, in particular life events and/or a family environment high on “Expressed Emotion” (EE, Leff and Vaughn, 1985) seem to be important. High EE (HEE) relatives emit more than six critical comments during the semistructured Camberwell Family Interview (CFI) and/or receive a rating of three or more in the “Emotional Overinvolvement” (EOI) scale. Otherwise, relatives are categorized as low on EE (LEE). The predictive validity of the EE rating has been investigated in about 27 studies worldwide resulting in a relapse rate nine months after discharge of 52% for patients living with a HEE relative in contrast to 22 % for patients living in a LEE family (Butzlaff and Hooley, 1998).


Relapse Rate Schizophrenic Patient Family Therapy Brief Psychiatric Rate Scale Communication Skill Training 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Buchkremer, G., Schulze-Mönking, H., Lewandowski, L., and Wittgen, C. (1986): Emotional atmosphere in families of schizophrenic outpatients: relevance of a practice-oriented assessment instrument. In: Treatment of schizophrenia. Family assessment and intervention (Goldstein, M.J., Hand, I., Hahlweg, K., eds.). pp. 79–84. Heidelberg: SpringerGoogle Scholar
  2. Butzlaff, R.L. and Hooley, J.M. (1998): Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry 55: 547–552PubMedCrossRefGoogle Scholar
  3. Cardin, V.A., McGill, C.W., and Falloon, I.R.H. (1985): An economic analysis: Costs, benefits, and effectiveness. In: Family management of schizophrenia (Falloon, I.R.H. et al., eds.), pp. 115–123. Baltimore: John Hopkins University PressGoogle Scholar
  4. Carpenter, W.T., Jr., Hanlon, T.E., Heinrichs, D.W., Kirkpatrick, B., Levine, J., and Buchanan, R.W. (1990): Continuous vs. targeted medication in schizophrenic outpatients: Outcome results. American Journal of Psychiatry 147: 1138–1148PubMedGoogle Scholar
  5. Doane, J.A., Goldstein, M.J., Miklowitz, D.J., and Falloon, I.R. (1986): The impact of individual and family treatment on the affective climate of families of schizophrenics. British Journal of Psychiatry 148: 279–289PubMedCrossRefGoogle Scholar
  6. Endicott, J., Spitzer, R.L., Fleiss, J.L., and Cohen, J. (1976): The Global Assessment Scale. A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry 33: 766–771PubMedCrossRefGoogle Scholar
  7. Falloon, I.R.H., Boyd, J.L., and McGill, C.W. (1984): Family care of schizophrenia. New York: GuilfordGoogle Scholar
  8. Falloon, I.R.H., Coverdale, J.N., Roncone, R., Held, T., Laidlaw, T.M., and Barbaro, A. (1998): Meta-analysis of psychoeducational family treatments for schizophrenia. Unpublished manuscript, paper at the 6th World Congress for Psychosocial Rehabilitation, HamburgGoogle Scholar
  9. Goldstein, M.J., Rodnick, E.H., Evans, J.R, May, P.R.A., and Steinberg, M.R. (1978): Drug and family therapy in the aftercare of acute schizophrenics. Archives of General Psychiatry 35: 1169–1177PubMedCrossRefGoogle Scholar
  10. Hahlweg, K., Dürr, H., and Muller, U. (1995): Familienbetreuung schizophrener Patienten. Ein verhaltenstherapeutischer Ansatz zur Rückfallprophylaxe. Weinheim: Beltz Psychologie Verlags UnionGoogle Scholar
  11. Hahlweg, K, Goldstein, M.J., Nuechterlein, K.H., Magana, A.B., Mintz, J., Doane, J.A., Miklowitz, D.J., and Snyder, K.S. (1989): Expressed emotion and patient-relative interaction in families of recent onset schizophrenics. Journal of Consulting and Clinical Psychology 57: 11–18PubMedCrossRefGoogle Scholar
  12. Hatfield, A.B., Spaniol, L., and Zipple, A.M. (1987): Expressed emotion: A family perspective. Schizophrenia Bulletin 13: 221–226PubMedGoogle Scholar
  13. Herz, M.I., Glazer, W.M., Moster, M.A., Sheard, M.H., Szymanski, H.V., Hafez, M., Mirza, M., and Vaha, J. (1991): Intermittent vs. maintenance medication in schizophrenia. Two year results. Archives of General Psychiatry 48: 333–339PubMedCrossRefGoogle Scholar
  14. Herz, M.I. and Melville, C. (1980): Relapse in schizophrnia. American Journal of Psychiatry 137: 801–805PubMedGoogle Scholar
  15. Hogarty, G.E. (1984): Depot neuroleptics: The relevance of psycho-social factors. Journal of Clinical Psychiatry 45: 36–42PubMedGoogle Scholar
  16. Hogarty, G.E., Anderson, C.M., Reiss, D.J., Kornblith, S.J., Greenwald, D.P., Javna, C.D., Madonia, M.J., and the EPICS Schizophrenia Research Group (1986): Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia: I. One year effects of a controlled study on relapse and expressed emotion. Archives of General Psychiatry 43: 633–642PubMedCrossRefGoogle Scholar
  17. Hogarty, G.E., Anderson, C.M., Reiss, D.J., Kornblith, S.J., Greenwald, D.P., Ulrich, R.F., Carter, M., and the environmental-personal indicators in the course of schizophrenia (EPICS) (1991): Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia. II. Two-year effects of a controlled study on relapse and adjustment. Archives of General Psychiatry 48: 340–347PubMedCrossRefGoogle Scholar
  18. Hogarty, G.E., Goldberg, S.C., Schooler, N.R., and Ulrich, R.F. (1974): The collaborative study group: Drug and sociotherapy in the aftercare of schizophrenic patients: II. Two year relapse rates. Archives of General Psychiatry 31: 603–608PubMedCrossRefGoogle Scholar
  19. Hogarty, G.E., McEvoy, J.P., Munetz, M., DiBarry, A.L., Bartone, P., Cather, R., Cooley, S.J., Ulrich, R.J., Carter, M., Madonia, M.J., and Environmental/Personal Indicators in the Course of Schizophrenia Research Group (1988): Dose of fluphenazine, familial expressed emotion, and outcome in schizophrenia. Results of a two-year controlled study. Archives of General Psychiatry 45: 797–805PubMedCrossRefGoogle Scholar
  20. Jolley, A.G., Hirsch, S.R., McRink, A., and Manchanda, R. (1989): Trial of brief intermittent prophylaxis for selected schizophrenic outpatients: Clinical outcome at one year. British Medical Journal 298: 985–990PubMedCrossRefGoogle Scholar
  21. Jolley, A.G., Hirsch, S.R., Morrison, E. et al. (1990): Trial of brief intermittend neuroleptic prophylaxis for selected schizophrenic outpatients: clinical and social outcome at two years. British Medical Journal 301: 837–842PubMedCrossRefGoogle Scholar
  22. Johnson, D. (1998): The major barriers to implement the findings. Paper at the 6th World Congress for Psychosocial Rehabilitation, HamburgGoogle Scholar
  23. Johnson, D.A.W., Ludlow, J.M., Street, K., and Taylor, R.D.W. (1987): Doubleblind comparison of half-dose and standard-dose Flupenthixol Decanoate in the maintenance treatment of stabilised out-patients with schizophrenia. British Journal of Psychiatry 151: 634–638PubMedCrossRefGoogle Scholar
  24. Kane, J.M., Rifkin, A., Woerner, M., Reardon, G., Sarantakos, S., Schiebel, D., and Ramos-Lorenzi, J. (1983): Low-dose neuroleptic treatment of outpatient schizophrenics. Archives of General Psychiatry 40: 893–896PubMedCrossRefGoogle Scholar
  25. Kane, J.M., Riftkin, A., Woerner, M., Kreisman, D., Blumenthal, R., and Borenstein, M. (1985): High - dose versus low-dose strategies in the treatment of schizophrenia. Pharmacological Bulletin 21: 533–537Google Scholar
  26. Kavanagh, D.J. (1992): Recent developments in expressed emotion and schizophrenia. British Journal of Psychiatry 160: 601–620PubMedCrossRefGoogle Scholar
  27. Kissling, W. (1992): Ideal and reality of neuroleptic relapse prevention. British Journal of Psychiatry 161 (Suppl. 18): 133–139Google Scholar
  28. Laessle, R, Pfister, H., and Wittchen, H.-U. (1987): Risk of rehospitalization of psychotic patients. A 6-year follow-up investigation using the survival approach. Psychopathology 20: 48–60PubMedCrossRefGoogle Scholar
  29. Leff, J., Kuipers, L., Berkowitz, R, Eberlein-Fries, R., and Sturgeon, D. (1982): A controlled trial of intervention in the families of schizophrenic patients. British Journal of Psychiatry 141: 121–134PubMedCrossRefGoogle Scholar
  30. Leff, J.P., Kuipers, L., Berkowitz, R., and Sturgeon, D. (1985): A controlled trial of social intervention in the families of schizophrenic patients: two year follow-up. British Journal of Psychiatry 146: 594–600PubMedCrossRefGoogle Scholar
  31. Leff, J.P. and Vaughn, C.E. (1985): Expressed emotion in families. New York: GuilfordGoogle Scholar
  32. Lukoff, D., Nuechterlein, K.H., and Ventura, J. (1986): Manual for the Expanded Brief Psychiatric Rating Scale (BPRS): Schizophrenia Bulletin 12: 594–602Google Scholar
  33. Marder, S.R., Van Putten, T., Mintz, J., Lebell, M., McKenzie, J., and May, P.R.A. (1987): Low and conventional dose maintenance therapy with fluphenazine decanoate: Two year outcome. Archives of General Psychiatry 44: 510–517CrossRefGoogle Scholar
  34. McFarlane, W.R, Link, B., Dushay, R., Marchal, J., and Crilly, J. (1995): Psychoeducational multiple family groups: Four-year relapse outcome in schizophrenia. Family Process 34: 127–144PubMedCrossRefGoogle Scholar
  35. Mintz, L.I., Liberman, R.P., Miklowitz, D.J., and Mintz, J. (1987): Expressed Emotion: A call for partnership among relatives, patients, and professionals. Schizophrenia Bulletin 13: 227–235PubMedGoogle Scholar
  36. Müller, P., Bandelow, B., Gaebel, W., Köpke, W., Linden, M., Müller-Spahn, F., Pietzcker, A., Schaefer, E., and Tegeler, J. (1992a): Intermittend medication, coping and psychotherapy. Interactions in relapse prevention and course modification. British Journal of Psychiatry 116 (Suppl. 18): 140–144Google Scholar
  37. Müller, U., Hahlweg, K, Feinstein, E., Hank, G., Wiedemann, G., and Dose, M. (1992b): Familienklima (Expressed Emotion) und Interaktionsprozesse in Familien mit einem schizophrenen Mitglied. Zeitschrift für Klinische Psychologie 21: 332–351Google Scholar
  38. Nuechterlein, K.H. and Dawson, M.E. (1984): A heuristic vulnerability/stress model of schizophrenic episodes. Schizophrenia Bulletin 10: 300–312PubMedGoogle Scholar
  39. Nuechterlein, K.H., Ventura, J., Snyder, K.S., Gitlin, M., Subotnik, K.L., Dawson, M.E., and Mintz, J. (1998): The role of stressors in schizophrenic relapse: Longitudinal evidence and implications for psychosocial interventions. Unpublished manuscript, University of California, LAGoogle Scholar
  40. Overall, J.E. and Gorham, D.R. (1962): The Brief Psychiatric Rating Scale. Psychological Reports 10: 799–812CrossRefGoogle Scholar
  41. Pietzcker, A., Gaebel, W., Kopcke, W., Linden, M., Muller, P., Müller-Spohn, F., Schussler, G., and Tegeler, J. (1986): A German multi-center study on the neuroleptic long-term therapy of schizophrenic patients’ preliminary report. Pharmacopsychiatry 19: 161–166CrossRefGoogle Scholar
  42. Rieg, C., Müller, U., Hahlweg, K., Wiedemann, G., Hank, G., and Feinstein, E. (1991): Psychoedukative Rückfallprophylaxe bei schizophrenen Patienten: Ändern sich die familiären Kommunikationsmuster? Verhaltenstherapie 1: 283–292CrossRefGoogle Scholar
  43. Schooler, N.R., Keith, S.J., Severe, J.B., Matthews, S.M., Bellack, A.S. et al. (1997): Relapse and rehospitalization during maintenance treatment of schizophrenia. The effects of dose reduction and family treatment. Archives of General Psychiatry 54: 453–463PubMedCrossRefGoogle Scholar
  44. Spitzer, R.L., Endicott, J., and Robins, E. (1978): Research Diagnostic Criteria: Rationale and reliability. Archives of General Psychiatry 35: 773–782PubMedCrossRefGoogle Scholar
  45. Strachan, A.M., Goldstein, M.J., and Miklowitz, D.J. (1986): Do relatives express expressed emotion? In: Treatment of schizophrenia. Family assessment and intervention (Goldstein, M.J., Hand, I., Hahlweg, K., eds.). pp. 51–58: Heidelberg: SpringerGoogle Scholar
  46. Tarrier, N., Barrowclough, C., Vaughn, C., Bamrah, J.S., Porceddu, K, Watts, S., and Freeman, H. (1988): The community management of schizophrenia. A controlled trial of a behavioural intervention with families to reduce relapse. British Journal of Psychiatry 153: 532–542PubMedCrossRefGoogle Scholar
  47. Tarrier, N., Barrowclough, C., Vaughn, C., Bamrah, J.S., Porceddu, K, Watts, S., and Freeman, H. (1989): Community management of schizophrenia. A two-year follow-up of a behavioral intervention with families. British Journal of Psychiatry 154: 625–628PubMedCrossRefGoogle Scholar
  48. Tarrier, N., Lowson, K, and Barrowclough, C. (1991): Some aspects of family interventions in schizophrenia. II: Financial considerations. British Journal of Psychiatry 159: 481–484PubMedCrossRefGoogle Scholar
  49. Wiedemann, G., Hahlweg, K, Hank, G., Feinstein, E., Müller, U., and Dose, M. (1994): Deliverability of psychoeducational family management for schizophrenia. Schizophrenia Bulletin 20: 547–556PubMedGoogle Scholar
  50. Xiong, W., Phillips, M.R., Hu, X. et al. (1994): Family based intervention for schizophrenia patients in China: A randomised controlled trial. British Journal of Psychiatry 165: 239–247PubMedCrossRefGoogle Scholar
  51. Zubin, J. and Spring, B. (1977): Vulnerability - a new view of schizophrenia. Journal of Abnormal Psychology 86: 103–126PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Wien 2002

Authors and Affiliations

  • Kurt Hahlweg
  • Georg Wiedemann

There are no affiliations available

Personalised recommendations