Family treatment, expressed emotion and relapse in recent onset schizophrenia

Psychiatry Research 72 Ž1997. 23]31

Family treatment, expressed emotion and relapse in recent onset schizophrenia Annet Nugter a,U , Peter Dingemans b , Jan Willem Van der Does c , Don Linszen b , Berthold Gersons b a

Psychiatric Centre Willibrord, Department of Psychotherapy ‘De Oosthoek’, P.O. Box 49, 1906 ZG Limmen, The Netherlands b Department of Psychiatry, Academic Medical Centre, Tafelbergweg 25, 1105 BC Amsterdam, The Netherlands c Department of Psychiatry, Leiden Uni®ersity, P.O. Box 1251, 2340 BG Oegsgeest, The Netherlands Received 26 March 1996; accepted 8 November 1996

Abstract A controlled longitudinal treatment study was carried out to investigate the effect of a behavioral family treatment on Expressed Emotion ŽEE. and to examine the correspondence between EE changes and relapse rates. Subjects were 52 patients with recent onset schizophrenia or related disorders and their parents. After completion of inpatient treatment they were randomly allocated to individual treatment or individual treatment plus family treatment. The family treatment consisted of education and training in communication and problem-solving skills. Expressed Emotion was measured with the Five-Minute Speech Sample ŽFMSS.. The findings show that family treatment did not have a significant positive effect on EE level. The dichotomous FMSSrEE did not systematically change and these findings were comparable with the results of prior EE research. A scoring system that included all subscores of the FMSS was somewhat more sensitive to changes. In the individual treatment condition relapse rates tended to co-occur with a change in FMSSrEE level, irrespective of the direction of this change. Q 1997 Elsevier Science Ireland Ltd. Keywords: Five-Minute Speech Sample ŽFMSS.; Stability; Behavioral family treatment

U

Corresponding author. Tel: q31 72 5312322rq31 20 6947400; fax: q31 72 5312371.

0165-1781r97r$17.00 Q 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S0165-1781Ž97. 00086-3

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A. Nugter et al. r Psychiatry Research 72 (1997) 23]31

1. Introduction Family attitudes operationalized as Expressed Emotion ŽEE. ŽBrown et al., 1972. predict the course of schizophrenic disorders ŽKavanagh, 1992; Kuipers, 1992.. Patients returning to critical or emotionally overinvolved families are three to seven times more likely to relapse within 1 year than patients with relatives without such attitudes ŽParker and Hadzi-Pavlovic, 1990.. This finding has led to the development of family intervention programs aimed at reducing EE. Common elements in these programs are psychoeducation and training in communication and problem-solving skills ŽLeff et al., 1982; Falloon et al., 1984; Anderson et al., 1986.. There is substantial evidence that these programs reduce the relapse rates of patients with high EE families ŽDixon and Lehman, 1995; Penn and Mueser, 1996.. Although the family interventions were developed to change high EE levels, few studies have examined whether the reduced relapse rates are related to changes in EE. Three studies found that family treatment reduced the level of EE, although ‘spontaneous’ reductions in EE also occurred ŽLeff et al., 1982; Hogarty et al., 1986; Tarrier et al., 1988.. In two studies ŽLeff et al., 1982; Hogarty et al., 1986. it was shown that no patient relapsed when EE had changed from high to low, irrespective of the treatment condition. Moreover, in one study no relapse occurred even if family treatment did not affect the EE level ŽLeff et al., 1982. and in a second study the risk for relapse in families with a stable high EE was reduced when family treatment was combined with individual social skills training ŽHogarty et al., 1986.. These latter results seem to indicate that EE reductions may not be the only mechanism through which family treatment affects relapse rates ŽLam, 1991.. The instrument that is used to assess EE is the Camberwell Family Interview ŽCFI. ŽVaughn and Leff, 1976.. An important disadvantage of the CFI is that the interview is focused on symptoms and illness-related behavior, which makes it difficult to compare relatives’ EE during hospitalization with their EE during periods of remission. An alternative method without this disadvantage

is the Five-Minute Speech Sample ŽFMSS. ŽMagana ˜ et al., 1986.. Several studies have shown that the FMSS and the CFI are significantly related, although approximately one-third of the family members who score low on the FMSS have a high score on the CFI ŽMagana ˜ et al., 1986; Leeb et al., 1991; Stark and Buchkremer, 1992.. So far only one preliminary study has analyzed the effects of a psychoeducational family treatment on the FMSSrEE ŽHonig et al., 1995.. No significant treatment effects were found, although reductions in the FMSSrEE level were only found in the family treatment group. More than 75% of the relatives in both treatment groups did not change their EE, indicating that the FMSSrEE may be less modifiable than the CFIrEE. The results were not analyzed in relation to relapse rates. The purpose of the present study was to analyze the effects of a behavioral family treatment on parental EE as assessed with the FMSS, and to investigate to what extent changes in EE levels were related to relapse rates. 2. Method 2.1. Subjects Patients with recent onset schizophrenia or related disorders, consecutively admitted to an inpatient unit for adolescents and young adults, participated in the study, after signing an informed consent Žboth patients and parents.. Other inclusion criteria were: need for continuous antipsychotic medication; age between 15 and 26 years; living with parents or other relatives, or in close contact with them. Patients with primary alcohol, hard drug dependence or brief drug-related psychoses and in need of detoxification were excluded. For adequate FMSS assessments the parents and patients had to speak Dutch. Of the 84 eligible families, 52 participated in the family treatment study. Reasons for non-participation are listed in Table 1. The number of patients that dropped out of treatment was equally divided over both treatment conditions. The 52 patients that completed the study had clinical discharge diagnoses ŽDSM-III-R axis 1

A. Nugter et al. r Psychiatry Research 72 (1997) 23]31 Table 1 Reasons for non-participation Number of admissions Refusal of family treatment study Refusal of family assessments Treatment dropout prior to pretest

84 10 6 4

Number of assessments at pretest ŽT 1. Treatment dropout after pretest Refusal at T 2

64 5 7

Number of assessments at post-test ŽT 2.

52

criteria. of schizophrenia Ž n s 25, 48.1% ., schizophreniform disorders Ž n s 9, 17.3% ., schizoaffective disorders Ž n s 12, 23.1%. and other psychotic disorders Že.g. delusional disorder and atypical psychosis Ž n s 6, 11.5%.. Their mean age was 20 years Ž20.5.. They were predominantly male Ž n s 36, 69.2%. and most lived with their parents Ž n s 41, 78.8%.. More than half of the patients Ž n s 29, 55.8%. had their first psychotic episode and their first hospital admission Ž n s 31, 59.6%.. The mean duration of the illness before admission was 8.4 months. The socioeconomic level of approximately three quarters of the families Ž n s 38, 73.1%. was low Žscore 3 to 5 on the Hollingshead Index. ŽHollingshead and Redlich, 1968.. Two thirds of the families Ž n s 35, 68.6%. had a high CFIrEE level during hospitalization. The sample consisted of 14 single parent families and 37 dual parent families; one patient lived with her partner. Of two divorced families, both parents were involved, because the patient had close contact with both of them. In all, the research group consisted of 91 family members. 2.2. Assessments 2.2.1. Assessment of Expressed Emotion During hospitalization, relatives’ EE was assessed with the CFI ŽVaughn and Leff, 1976., a semi-structured interview with a relative concerning the patient’s functioning in the 3 months prior to admission. The interview was audiotaped and scored from tape. Five aspects were scored:

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warmth, positive remarks, criticism, hostility and emotional over-involvement ŽEOI.. The final EE rating was high or low. A high EE was defined as 6 or more critical remarks Žhigh critical . andror score of 1 or more on hostility Žhigh critical . andror score of 4 or 5 on emotional overinvolvement Žhigh EOI.. The CFI tapes were scored by two researchers ŽAN and JVDD.. They were trained by one of the authors ŽPD. who was trained in the administration and scoring of the CFI at Maudsley Hospital in London. The interrater agreement between both raters was 0.82 Ž k . based on 25 randomly selected tapes. The effect of family treatment on EE was assessed with the FMSS ŽMagana ˜ et al., 1986., a procedure developed at the University of California at Los Angeles ŽUCLA. in which the parent is asked to talk about the patient and their relationship for 5 min, without interruptions by the interviewer. Thespeech sample was audiotaped for scoring. The conventional coding system incorporated the two predicting variables of the EE concept: criticism and emotional overinvolvement. In addition two other categories were scored: quality of initial statement and quality of the relationship ŽMagana ˜ et al., 1986.. A parent was considered high critical when scored for a negative initial statement, a negative relationship, or one or more criticisms. High EOI was defined as: emotional display, self-sacrificing and overprotective behavior, or any two of the following: excessive details, a statement of attitude, or excessive praise. Family units were assigned a high EE score if one or both parents scored positive on the criticism andror EOI dimension. Because of the dichotomization of the final EE profiles, information is lost. Therefore a second scoring method was added, in which all subscores were used to define a five-point scale, ranging from very positive to very negative ŽStubbe et al., 1993; McGuire and Earls, 1994.. Score 5 Žvery negative. was assigned to high EE speech samples. Score 4 Žmildly negative. was assigned to borderline EE samples, defined as Žlow EE. speech samples that contained some evidence for but did not qualify as high EE. With scores 1]3 the low EE families were further subdivided.

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A. Nugter et al. r Psychiatry Research 72 (1997) 23]31

Speech samples with a positive initial statement andror a positive relationship were assigned score 1 Žvery positive. when five or more positive remarks were made and score 2 Žmildly positive. with fewer positive remarks. A neutral score Žscore 3. was assigned to speech samples with a neutral initial statement, a neutral relationship and few positive remarks. To compute family scores based on the five-point scale, scores of both parents of a dual parent family were averaged. In single parent families, the family score was determined by the score of the single relative. The FMSS tapes were scored by two researchers ŽAN and JVDD.. Their interrater agreement with criterion ratings UCLA were 0.60 and 0.74 Ž k ., respectively. Their interrater agreement on 24 randomly selected tapes was 0.81 Ž k . on the FMSSrEE profiles. Their average interrater agreement on the subscores of criticism was 0.81 Ž k ., and that on the subscores of emotional overinvolvement was 0.69 Ž k .. Both raters were not blind to the treatment condition of the families. To make recall of the treatment assignment more difficult, all FMSS tapes were scored some time after all families had completed the treatment. 2.2.2. Assessment of relapse The patient’s symptomatic status was rated on a monthly basis with the expanded 24-item version of the Brief Psychiatric Rating Scale ŽBPRSE. ŽLukoff et al., 1986.. The BPRS-E was rated by a trained professional ŽPD., on the basis of a semi-structured interview, covering the period of 1 month prior to the interview. He had an interrater agreement with a UCLA criterion rater of 0.79 Ž k .. Reliability did not decrease over time. The BPRS rater was blind to the family’s EE status and to the treatment assignment. In an earlier publication by our research group it was found that research and clinical criteria represented different perspectives on relapse ŽLinszen et al., 1994.. Therefore two different definitions of relapse were used. The first was based on BPRS-E ratings of hallucinations, conceptual disorganization and unusual thought content. Following Nuechterlein et al. Ž1986., three types of relapse were distinguished: Ža. remission

followed by relapse; Žb. remission followed by significant exacerbation; and Žc. persisting symptoms followed by significant exacerbation. The second definition of relapse was based on clinical records of the treating psychiatrists and the social psychiatric nurse. These data were rated by an independent research assistant. Relapse was defined as: Ža. the recurrence or exacerbation of psychotic symptoms, based on an explicit statement in the psychiatric record; Žb. a significant increase in antipsychotic medication; and Žc. psychotic symptoms persisting at least 1 week. All three criteria had to be present. 2.3. Treatment The treatment of all patients included an inpatient phase of about 3 months and an outpatient phase of 12 months. The inpatient treatment was aimed at remission or stabilization of the psychotic symptoms and involved also two psychoeducational meetings for groups of families. The outpatient treatment consisted of individual contacts with a psychiatrist and with a social psychiatric nurse. In these contacts patients were taught about their illness and trained in recognizing their psychotic and negative symptoms and prodromal signs and symptoms as warning signs of relapse, with which they were helped to cope. The family treatment started after discharge and paralleled the individual contacts of the patient during the outpatient treatment. The family treatment consisted of 18 sessions over a 12-month period. The treatment was based on the behavioral family management approach as developed by Falloon et al. Ž1984.. The main elements were education, communication and problemsolving techniques. The treatment was clinic based, and both the patient and the parents participated. The family sessions turned out to be well attended Žmean: 17 sessions.. Details of the treatment program have been reported elsewhere ŽLinszen et al., 1996.. 2.4. Design and procedure In the first month of hospitalization the CFI

A. Nugter et al. r Psychiatry Research 72 (1997) 23]31

was administered Žmean: 30 days.. This measure was used for a stratified sampling method: the families were first divided into low and high CFIrEE groups and then randomly divided over two treatment conditions: the individual treatment ŽIT. or the individual treatment to which family treatment was added ŽIFT.. In the first month after discharge Žmean: 4.8 weeks. the first FMSS assessment ŽT 1. took place. This measure was used as the pretest of the treatment study. The second FMSS assessment ŽT 2., the post-test, took place after treatment completion, in the 14th month after discharge Žmean: 57.3 weeks.. The time lapse between T 1 and T 2 was 12.1 months. 2.5. Data analyses In order to test whether the FMSSrEE scores of both treatment groups differed at T 1 and T 2, non-parametric Mann]Whitney tests were conducted. Changes in the dichotomous FMSS profiles were analyzed with the non-parametric test of McNemar, for each treatment group separately. Changes in the five-point scale were analyzed with the non-parametric test of Wilcoxon, again for each treatment group separately. Possible differences between both treatment groups with regard to the FMSSrEE change patterns between T 1 and T 2 were analyzed with x 2-tests. In order to analyze the correspondence between EE change patterns between T 1 and T 2 and relapse rates, x 2-tests were performed. Because five FMSS tapes were unintelligible, the analyses were done with 48 families, consisting of 86 family members.

Table 2 Scores on the five-point scale at T 1 and T 2 T1

IFT group IT group

T2

Mean

S.D.

Mean

S.D.

3.76 3.50

0.89 1.27

3.22 3.46

1.04 1.11

Note: IFTs individual treatment q family treatment; IT s individual treatment.

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3. Results Comparisons between the patients who completed the study and the patients who dropped out revealed several differences. The participating patients had a shorter period of illness without treatment before admission Ž z s 2.04, n s 81, P - 0.05., higher scores on the Strauss and Carpenter Ž1974. prognostic scale at admission Ž t s 2.43, d.f.s 82, P- 0.05. and lower scores on the negative symptom factor of the BPRS-E ŽLukoff et al., 1986. at the start of the outpatient treatment Ž t s 2.23, d.f.s 42.25, P- 0.05.. These differences indicated that the research group was a slightly better functioning group. No significant differences were found between the two treatment groups. 3.1. Treatment effects on FMSS r EE At T 1, 25 families Ž52.1%. had a high FMSSrEE. The FMSSrEE profiles of the families of the two treatment groups did not differ significantly at T 1 Ž z s 0.12, n s 48, Ps 0.99.. After treatment completion ŽT 2. also no significant difference was found in the FMSSrEE profiles of the two treatment groups Ž z s 0.31, n s 48, Ps 0.76.. In the family treatment group ŽIFT group. no significant change in proportions was found between T 1 and T 2 Ž Ps 0.75.. In the individual treatment group ŽIT group. likewise no significant change in proportions was found Ž Ps 1.00.. Between T 1 and T 2 four EE change patterns existed, stable low Ž n s 14., low]high Ž n s 9., high]low Ž n s 12. and stable high Ž n s 13.. The EE change patterns of the two treatment groups were almost identical Ž x 2 s 0.10, d.f.s 3, Ps 0.99.. The analyses of the five-point scale revealed an almost significant reduction in the scores between T 1 and T 2 in the IFT group Ž z s 1.89, n s 48, P- 0.10.. In the IT group no such effect was found. Both treatment groups had comparable scores on the five-point scale at T 1 and T 2 ŽTable 2.. Although family treatment did not affect family

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A. Nugter et al. r Psychiatry Research 72 (1997) 23]31

profiles, it could have affected scores of individual parents. Therefore the analyses were repeated with individual scores. Again, no significant differences in treatment effects were found. In both treatment conditions, approximately three quarters of the parents with a low EE at T 1 had the same score at T 2. In the IFT group half of the parents with a high FMSSrEE at T 1 changed into low at T 2, while in the IT group this percentage was only 28.6%. This difference was not statistically significant Ž x 2 s 1.35, d.f.s 1, Ps 0.25.. In an earlier publication by our research group an almost significant family treatment effect was found on relapse rates within the group of low CFIrEE families, with a lower relapse rate in the group of families who were not treated. Among high EE families the relapse rates in both treatment conditions were comparable ŽLinszen et al., 1996.. To find out whether treatment effects on families would also be dependent on their CFIrEE level during hospitalization, all analyses reported above were repeated for families with low and high CFIrEE levels separately. For both high and low CFIrEE families no significant differences in treatment effects were found. 3.2. Treatment effects on le®el of EE and relapse rates. Ten patients Ž20.8%. had a relapse according to the BPRS-E criteria and 11 Ž22.9%. had a relapse according to the clinical criteria. Seven patients Ž14.6%. had a relapse according to both criteria. First we analyzed whether these relapse rates were related to the changes in the level of FMSSrEE between T 1 and T 2. The results were non-significant. In both treatment groups FMSSrEE changes and relapse rates were unrelated. Whenwe divided the FMSSrEE change patterns into stable and unstable, an almost significant correspondence in the IT group was found between level of stability and relapse according to clinical criteria Ž x 2 s 2.97, d.f.s 1, Ps 0.08. and according to both definitions Ž x 2 s 3.29, d.f.s 1, Ps 0.07., indicating slightly higher relapse rates when the FMSSrEE profile changed between T 1 and T 2, irrespective of the direction of this

change. No such results were found in the IFT group. Then we examined whether changes in the five-point scale were related to relapse rates. Following Stubbe et al. Ž1993. and McGuire and Earls Ž1994., the five-point scale was dichotomized into a low score Žscore 1]3. and a high score Žscore 4]5.. Compared to the conventional FMSSrEE criteria, this scoring system resulted in an increase in high FMSSrEE families at both T 1 Žfrom 52.1% to 68.8%. and T 2 Žfrom 45.8% to 58.3%.. With these dichotomous scores four change patterns were defined, stable low Ž n s 5., stable high Ž n s 18., highrlow Ž n s 15. and lowrhigh Ž n s 10.. In the IT group, an almost significant relationship was found between the change patterns and relapse for the seven patients who fulfilled both definitions of relapse Ž x 2 s 7.29, d.f.s 3, Ps 0.06.. All relapses had occurred in families with unstable patterns, irrespective of the direction of change. Moreover, the findings with regard to each of the relapse definitions separately were in the same direction, although not significant. The change patterns were then recoded into stable and unstable. In the IFT group, no significant correspondence was found between level of stability and relapse. In the IT group, on the other hand, the level of stability was significantly related to relapse according to the BPRS-E criteria Ž x 2 s 3.95, d.f.s 1, P0.05., to relapse according to the clinical criteria Ž x 2 s 5.54, d.f.s 1, P- 0.05. and to both relapse definitions Ž x 2 s 6.77, d.f.s 1, P- 0.01. ŽTable 3.. These results indicate that in families who are not involved in family therapy, higher relapse rates co-occur with changes in EE level. However, this becomes most apparent with a more refined FMSS scoring system than is conventionally used. 4. Discussion The present study demonstrated that family treatment did not affect the level of EE as assessed with the FMSS. Additionally, in individually treated patients relapse rates were related to an unstable FMSSrEE, when a more refined scoring procedure was used.

A. Nugter et al. r Psychiatry Research 72 (1997) 23]31

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Table 3 Relapse rates and EE patterns Stable FMSSrEE IFT group n

Unstable FMSSrEE IT group

%

n

IFT group %

IT group

n

%

n

%

Relapse 1

Yes No

2 8

20.0 80.0

1 12

7.7 92.3

2 11

15.4 84.6

5 7

41.7 58.3

Relapse 2

Yes No

1 9

10.0 90.0

1 12

7.7 92.3

3 10

23.1 76.9

6 6

50.0 50.0

Relapse 3

Yes No

0 10

0.0 100.0

0 13

0.0 100.0

2 11

15.4 84.6

5 7

41.7 58.3

Note: IFTs individual treatment q family treatment; IT s individual treatment.

The fact that no family treatment effect was found is in agreement with an earlier finding of our research group, that the addition of a family treatment program to individual treatment did not differentially influence relapse rates ŽLinszen et al., 1996.. Thus, contrary to prior family intervention studies, in the present study the family treatment main goals were not attained. An explanation for these divergent results may be that our sample consisted of relatively young recent onset patients, while prior treatment studies were undertaken with more chronic patient groups. Moreover, the family program started after the symptoms of the patients were remitted or stabilized. It may have been difficult to believe for the parents that the symptoms of the patients could emerge again, since in most instances it had been the first episode. This may have reduced the motivation of parents to change. Indications of this are the difficulties that wereexperienced by the family therapists in implementing the intervention in some families ŽLinszen et al., 1996.. The results of our study are in agreement with those of Honig et al. Ž1995., who also found a somewhat greater reduction in the number of high EE parents in the family treatment than in the individual treatment condition. Since the number of high FMSSrEE parents in both studies was rather small, larger samples of high FMSSrEE parents may show this difference to be statistically significant.

The results of the present study also converge with those of the CFIrEE intervention studies. When high CFIrEE families were involved in family treatment, the reduction in the number of high EE family members varied from 40% ŽHogarty et al., 1986. to 75% ŽTarrier et al., 1988.. Under control conditions the reduction varied from 20% ŽLeff et al., 1982. to 50% ŽTarrier et al., 1988.. These percentages are in agreement with the reduction in the number of high FMSSrEE family members in our study. Two prior studies ŽDulz and Hand, 1986; Tarrier et al., 1988. demonstrated that under control conditions the low CFIrEEs remained rather stable: only 5% ŽTarrier et al., 1988. to 18% ŽDulz and Hand, 1986. of the low EE parents changed their EE from low to high. In the present study likewise 20% of the low EE parents who were not involved in family treatment changed into high. These comparisons between the present FMSSrEE study and prior CFIrEE studies indicate in general that the effects of family treatment on EE levels are similar. Moreover, both instruments show more change in high EE parents than in low EE parents. Analyses of the five-point scale showed a tendency for reduction in the family treatment condition. This change was in agreement with our expectation. Scoring systems in which low FMSSrEE scores are further subdivived by using all subscores and adding a borderline score may

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A. Nugter et al. r Psychiatry Research 72 (1997) 23]31

be more sensitive to changes in families than conventional dichotomous FMSSrEE scores. The correspondence between relapse rates and instability of FMSSrEE scores inthe individual treatment group was a rather unexpected finding. Since the direction of this relationship is unclear, two interpretations may apply. Firstly, it may be that the instability of the EE scores reflected a reaction of the families to the occurrence of relapse. It is possible that parents of young patients do not have a fixed way of reacting when the symptoms emerge again. This would be in agreement with the suggestion of Birchwood and Smith Ž1988. that EE is not a trait characteristic, but the outcome of a process, in which the emerging illness and the behavior of the patient contribute to the development of negative family attitudes. On the other hand, it is also possible that the occurrence of relapse was the result of an unstable EE. Adolescents with recent onset schizophrenic disorders may be relatively sensitive to a change in attitudes of their parents. It may be true that for these patients an unstable EE, even if it decreases, is more stressful than a stable Žhigh. EE level, because the attitudes of their parents are less predictable. Both explanations are not mutually exclusive. To further investigate the direction of the relationship between the course of the FMSSrEE and relapse rates future studies should be undertaken, in which the FMSS is administered repeatedly, in both recent onset and more chronic samples. The findings with regard to the correspondence between relapse rates and level of stability of EE diverge from the findings of the CFIrEE studies, in which no relapse occurred when high EE levels changed to low. Explanations for this divergence may be threefold. Firstly, our sample consisted of young patients. The correspondence between the course of EE and relapse rates may be different in more chronic samples. Secondly, in the CFIrEE studies only high EE families were involved. Different results may be found for low CFIrEE families. And thirdly, EE reductions as assessed with the CFI may be an artifact of the instrument, because it is possible that EE reductions result from the absence of symptoms at follow-up.

Our findings did not confirm the hypothesis that treatment effects depend on the CFIrEE level during hospitalization. Although we reported elsewhere ŽLinszen et al., 1996. that the implementation of behavioral family therapy was somewhat more difficult in low EE families than in high EE families, this did not result in different treatment effects. Both low and high EE families were equally likely to change their attitudes. The dropout analyses have shown that the group of 52 patients who were able to complete the study was a relatively well-functioning group with a history of more treatment compliance. The results might have been different with the original cohort. In general, the findings of the present study suggest that further studies should be undertaken to examine the extent to which families of young patients with schizophrenic disorders require for family-focused interventions and may benefit from such interventions. Acknowledgements The authors thank the late Prof. M.J. Goldstein of the University of California in Los Angeles for review of an earlier version of the manuscript. References Anderson, C.M., Reiss, D.J., Hogarty, G.E, 1986. Schizophrenia in the Family: A Practitioner’s Guide to Psychoeducation and Management. The Guilford Press, New York. Birchwood, M., Smith, J., 1988. Expressed emotion and first episodes of schizophrenia. British Journal of Psychiatry 156, 357]362. Brown, G.W., Birley, J.L., Wing, J.K., 1972. The influence of family life on the course of schizophrenic disorders: a replication. British Journal of Psychiatry 121, 241]258. Dixon, L.B., Lehman, A.F., 1995. Family interventions for schizophrenia. Schizophrenia Bulletin 21, 631]643. Dulz, B., Hand, I., 1986. Short-term-relapse in young schizophrenics: can it be predicted and affected by family ŽCFI., patient and treatment variables? An experimental study. In: Goldstein, M.J., Hand, I., Hahlweg, K. ŽEds.., Treatment of Schizophrenia: Family Assessment and Intervention. Springer-Verlag, Berlin, Heidelberg, pp. 59]75. Falloon, I.R.H., Boyd, J.L., McGill, C.W., 1984. Family Care of Schizophrenia. Guilford Press, New York. Hogarty, G.E., Anderson, C.M., Reiss, D.J., Kornblith, S.J., Greenwald, D.P., Javna, D., Madonia, M.J., 1986. Family

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