Family intervention

What it is

Family intervention is a series of meetings between a person with psychosis or schizophrenia, the relatives they live with or see often, and a trained professional. Together they learn about the condition, look at what causes stress at home, and work out how to solve problems and handle a crisis. It is given alongside medicine and other care. NICE recommends offering it to every such family.¹

How it works

The idea grew out of research on the atmosphere at home. In 1972, researchers reported that people with schizophrenia relapsed more often when the relatives they lived with were highly critical, hostile or emotionally over-involved.² This is called high expressed emotion. Across 27 studies, it reliably predicted relapse.³ Warmth at home, by contrast, goes with a lower risk of relapse.⁴

High expressed emotion is often a response to how hard caring is. In 50 families followed from a first episode of psychosis, relatives who felt they had lost something of the person they loved were more likely to become over-involved.⁵

Family intervention aims to lower the stress on everyone. The family learns about the condition, and practises solving everyday problems step by step.⁶ In one early trial, it also included groups where relatives could meet one another.⁷

History

Two early trials were published in 1982. In one, 24 families with high expressed emotion had education about schizophrenia, a relatives’ group and family sessions, or routine care. Over 9 months, 9 in 100 people in the treated families relapsed, against 50 in 100 in routine care.⁷ In the other, 36 people had family therapy at home or individual support at a clinic. Over 9 months, 1 of 18 relapsed with family therapy, against 8 of 18 with individual support.⁶

Dozens of trials have followed.⁸ NICE has recommended offering family intervention since 2009.¹

How well it works

Across 32 trials with 2,981 people, family intervention almost halved the risk of relapse. For every 7 families who had it, one relapse was prevented. It also reduced hospital admissions and helped people keep taking their medicine. Many of the trials were of poor quality, so the benefit may be overestimated.⁸

A 2021 comparison of 20 talking and social therapies, across 72 trials with 10,364 people, found family intervention among the most effective at preventing relapse in the first year, together with relapse prevention programmes and CBT.⁹

In the 1982 trial with 24 families, the benefit lasted two years for people who kept taking their medicine.¹⁰

Possible downsides

The sessions mean talking openly about tensions at home, which can be hard for everyone. The whole family needs to set aside time, for at least 10 sessions.¹

Few families are offered it. In one NHS trust in north-west England, 3 of 187 people with schizophrenia had family intervention offered over a year, and 2 had it.¹¹

Format

NICE recommends at least 10 planned sessions over 3 months to a year. The person with psychosis takes part if possible. The family can choose between sessions on its own or a group with other families. The professional takes account of the relationship between the person and the relative who cares for them most, and the sessions include working through problems together or planning for a crisis.¹ In one early trial, the sessions took place at home.⁶

Contraindications and cautions

Family intervention is given alongside medicine. In the 1982 trial with 24 families, the lower relapse rate at two years held for people who stayed on their medicine.¹⁰ It can start during an acute episode or later, including during a hospital stay.¹

Alternatives

NICE also recommends an education and support programme for all carers, which can be part of family intervention.¹ Such programmes improve relatives’ understanding of the condition and their ability to cope.¹² CBT for psychosis (opens in a new tab) also lowers the risk of relapse.⁹ For relatives’ own wellbeing, see Caring without burning out (opens in a new tab).

What we don’t know yet

• Which parts of family intervention matter most.
• How large the benefit is in well-run, blinded trials.⁸
• How to make it available to every family who could use it.