Psychological Society of South Africa. All rights reserved. South African Journal of Psychology, 41(2), 2011, pp.

140-146
ISSN 0081-2463
Family therapy for schizophrenia in the South African context:
challenges and pathways to implementation
Janis Kritzinger
Department of Psychology, Stellenbosch University, South Africa
Leslie Swartz
Department of Psychology, Stellenbosch University
Sumaya Mall
Department of Psychology, Stellenbosch University,
Department of Psychiatry and Mental Health, University of Cape Town
sumaya.mall@gmail.com
Laila Asmal
Department of Psychiatry, Stellenbosch University
Schizophrenia is a chronic psychiatric disorder that affects 1% of the worlds population. Family in-
terventions whereby the patients and their relatives can attend psychiatric therapy sessions are
effective at preventing relapse of symptoms. In a country such as South Africa where there has been
a shift from institutionalisation to community care, family therapy treatment models are an important
option to explore. Although there is a paucity of research on family therapy for schizophrenia in the
South African context, we found a number of studies conducted in both developed and developing
countries. Problems with adherence to medication, lack of psychoeducation and low expressed
emotion (EE) were identified as challenges to effective family therapy models. A country such as
South Africa has additional challenges of stigmatisation of mental illness as well as cultural per-
ceptions of illness that may influence barriers to mental health care. These should be considered
when designing family therapy interventions. We suggest further research endeavour to explore the
applicability of family therapy models for people living with schizophrenia in South Africa. EE in
relation to different cultural groups in South Africa should be considered.
Keywords: expressed emotion; family therapy; schizophrenia; South Africa
INTRODUCTION
Schizophrenia is a chronic psychiatric disorder that affects approximately 1% of the worlds popula-
tion (Kazadi, Moosa, & Jeenah, 2008; Schultz, North, & Shields, 2007). The symptoms of schizo-
phrenia are serious and can influence mental and social functioning of both the patient and their
caregivers. Relapse (the re-emergence or aggravation of psychotic symptoms for at least seven days)
presents a crisis for not only the patient and family but also the family system itself (Almond, Knapp,
Francois, Toumi, & Brugha, 2004; Glynn, Cohen, Dixon, & Niv, 2006).
As South Africa has followed the worldwide move from institutionalisation to community care
(Awad & Vorunganti, 2008; Botha, Koen, & Niehaus, 2006), it is important to consider the impli-
cations of schizophrenia on caregivers or relatives. It is also important to provide appropriate
interventions in this regard (Kleinman, 2009). Evidence-based practices are preferable, as they have
been rigorously researched with respect to their effectiveness and efficiency (Bond & Campbell,
2008). The question is also whether the intervention must be offered to the family, patient or both.
This literature review will examine appropriate evidence-based models of family intervention
suitable for the South African context.
Expressed emotion (EE)
A central concept in the field of family intervention for schizophrenia is that of expressed emotion
(EE), a measure of the observation of families involvement in the lives of people with schizo-
phrenia. An understanding of the relationship between EE and schizophrenia has been fundamental
to the development of family interventions for schizophrenia and it is crucial to these sorts of treat-
South African Journal of Psychology, Volume 41(2), June 2011 141
ment approaches (Asmal, Mall, Kritzinger, Chiliza, Emsley, & Swartz, 2010). People with schizo-
phrenia from families that express high levels of criticism, hostility, or over involvement, have more
frequent relapses than people with schizophrenia from families that tend to be less expressive of
emotions (Pharoah, Mari, Rathbone, & Wong, 2010; Aguilera, Lopez, Breitborde, Kopelcizw, &
Zarate, 2010). A relapse rate of over 50% is evident when patients return to high-EE families com-
pared to only a 20% relapse rate when patients return to a low-EE family setting (Kuipers, 2006).
Although EE is a robust predictor of the course of the illness especially when a patient lives with
relatives (Askey, Gamble, & Gray, 2007), one has to consider its applicability in a resource-poor
setting like South Africa.
There are limitations with regard to measurement tools for EE. While the Camberwell Family
Interview (CFI) has been found to be both valid and reliable, measuring five sub-scales of EE
(criticism, hostility, emotional over-involvement, warmth, and positive regard), administrators need
to have over 40 hours of formal training. It is also expensive and time-consuming to use. Each CFI
takes between two to four hours to administer and between two to three hours to code (Hooley &
Parker, 2006). Several alternatives are available (Hooley & Parker, 2006): The Five Minute Speech
Sample (FMSS), Level of Expressed Emotion Scale (LEE), Family Attitude Scale (FAS), and
Perceived Criticism (PC). While each instrument has some advantages, they all also have several
limitations, which can be further researched in Hooley and Parker (2006).
In a country such as South Africa, which is culturally diverse, a number of potential limitations
of EE need to be considered. EE has been found to be a predictor of relapse in a range of cultural
settings (Karno, Jenkins, de la Selva, Santana, Telles, Lopez, & Mintz, 1987; Kopelowicz, Zarate,
Gonzalez, Lopez, Ortega, Obregon, & Mintz, 2002 in Asmal, Mall, Kritzinger, Chiliza, Emsley, &
Swartz, 2010). However, amongst indigenous cultural groups in South Africa, psychotic symptoms
could be attributed to spiritual forces. This may lead to further complexities. Relatives may be more
accepting of psychotic behaviour since it is believed that the patient is not fully in control of their
actions (Mzimkulu & Simbayi, 2006) creating a natural low-EE environment.
Adherence to medication
Non-adherence to medication has very often been found to lead to relapse in patients suffering from
schizophrenia (Schultz et al., 2007) and lack of adherence to medication has been shown to be a
problem in many instances in the South African health sector. In two reviews of non-adherence with
regard to schizophrenia, the mean rates were calculated at 40.5% (all-inclusive) (Lacro, Dunn,
Dolder, Leckband, & Jeste, 2002) and 55% (Fenton, Blyler, & Heinssen, 1997). Hudson et al. (2004)
investigated the reasons for non-adherence. The most common reasons were the stigma attached to
taking anti-psychotic medication, lack of a social support network, adverse side effects of the medi-
cation and forgetting. Family interventions have been developed to address these needs of the patient
in two principal ways: firstly, by showing the relatives how they can provide support to the patients
and help them remember to take their medication and secondly, by disseminating information about
the illness to lessen the stigma. Reduced levels of stigma could contribute to decreased relapse rates
in patients (Pharoah et al., 2010).
PSYCHOEDUCATION
Family psychoeducation when combined with pharmacotherapy has proven to be the most popular,
effective choice of treatment for schizophrenia as it supplements medication and improves social and
family functioning (Huxley, Rendall, & Sederer, 2000). In a meta-analysis Mojtabai, Nicholson, and
Carpenter (1998) found that on average a patient receiving both psychoeducation and medication
performed better than 65% of patients treated only with medication. From an evidence-based point
of view these interventions have met the criteria of being clearly defined for a designated target
group (schizophrenia patients and relatives). They have also proved effective through randomised
controlled trials with convincing results of which replication has been found by many other groups.
Meaningful outcomes have been proven and these interventions have demonstrated a capacity to be
South African Journal of Psychology, Volume 41(2), June 2011 142
effective across different groups (although more research is needed in this area) (Bond & Campbell,
2008). Psychoeducation has proven to have a significant effect in reducing relapse rates of patients,
improving recovery and improving family well-being and dynamics (McFarlane, Dixon, Lukens, &
Lucksted, 2003). This provides scientific evidence as to why family interventions should be included
in treatment protocols of patients suffering from schizophrenia (Montero et al., 2005). Similar to
findings in western cultures, research in China showed improvement in family interactions and
burden of care, with decreasing number and length of rehospitalisation over a follow-up period of
12 months (Chien & Wong, 2007).
Dixon, Adams and Lucksted (2000) remind us that although family psychoeducation is intended
for not only high-EE families, the needs and understanding of methods used and goals attained may
be different for low-EE families. Certain questions need to be answered before the appropriateness
of an intervention for a particular family can be assessed: whether the family and patient will be
interested in attending family therapy, how much contact the patient has with family members and
the quality of their interactions, whether there are clear goals that can be identified and whether the
family and patient would choose family therapy instead of other alternatives that could potentially
achieve the same goals (Dixon et al., 2000).

Effectiveness of different evidence-based family interventions
As early as 1982, Leff, Kuipers, Berkowitz, Eberlein-Vries, and Sturgeon found significant dif-
ferences in relapse rates of 50% and 9% between their control group and experimental group. The
experimental group was offered an intervention package consisting of an educational programme,
four lectures in the patients home, covering aetiology, symptoms, the course and treatment of schi-
zophrenia, with unlimited time to ask questions. This was followed by attendance of a relatives group
(excluding patients) consisting of maximum seven members, every two weeks for nine months, ex-
posing high-EE and low-EE relatives to each other in order for them to learn different coping
strategies, gain information and anothers perspective (Velligan & Gonzalez, 2007) while reducing
any feelings of isolation. These sessions were subsequently complemented with family sessions
including the patient (1 to max 25 sessions), in their own home in a sensitive manner that was ad-
justed to meet the objectives and needs of the family. What is positive to note is that although Leff
et al. (1982) managed to successfully lower EE and/or social contact in three quarter of the families,
there were no patients who relapsed in this group.
A non-western study by Chien and Wong (2007) concluded that a family psychoeducation
group intervention was superior to the standard care provided to patients in Hong Kong. The family
group took place for two hours, every second week, for a total of 18 sessions spanning nine months.
There were four stages to the intervention, three sessions on orientation and engagement followed
by a six session educational workshop that the patients also attended. This was followed by seven
sessions on the therapeutic role of the family and strength rebuilding. After this the intervention was
terminated over two sessions. The content of the intervention was culture sensitive, including tenets
taught by Confucius, and was based on the results of a needs assessment of 180 relatives of schizo-
phrenic patients (Chien & Wong, 2007).
In Italy, it has been reported that a multi-group family treatment (that comprises 89 relatives
meeting weekly for 48 sessions over 2 years) has positive results. If this type of intervention comple-
ments an informational group (consisting of 16 to 18 relatives meeting for 24 sessions using an
informational approach) it reduces the level of EE better than an informational group run on its own.
Other outcomes, such as reduction in relapse rate and hospitalisation, did not differ between groups.
The effect diminished by the two year follow-up period. After family interventions have been
completed, relatives should be further supported with regular booster sessions (Carr, Montomoli,
Clerici, & Cazzullo, 2007).
Montero et al. (2005) completed a study to assist with the question of which model is best. They
attempted to determine baseline characteristics that could potentially determine which type of inter-
vention would provide the best results for a certain subgroup of patients. Although further research
South African Journal of Psychology, Volume 41(2), June 2011 143
is needed in this field, preliminary results indicated that short-term illness (more recent cases) require
more intensive, personal intervention (behavioural family therapy), while long-term illness requires
a more continuous type of support model (relatives group) (Montero et al., 2005).
Despite evidence for the effectiveness of family psychoeducation in all its many forms, Pharoah
et al. (2010) found inconsistent results to those of many previous studies. They conducted a Coch-
rane review of randomised/quasi-randomised trials (RCT) and concluded that they were not con-
fident about the effects reported on family psychoeducation. They felt that many of the studies were
inadequately reported and, as this intervention is widely used, additional investigations are needed
to clarify the short and long term outcomes. It must be noted further that the studies reviewed were
European, Asian and North American; no adequate RCT has been conducted in Africa. However,
they did mention that even though the provision of health care across the studies was diverse, relative
consistency in the results existed, proposing the possibility of generalisation to other populations.
Considering all of the above, a potentially good option within the South African context, with
limited resources, is a one-day psychoeducation workshop aimed at relatives of patients with schi-
zophrenia and other affective disorders (Pollio, North, Reid, Miletic, & McClendon, 2006). This
workshop would start with three sessions about the illnesses, medication and other treatments, en-
couraging informal discussion during the breaks with a further two sessions in the afternoon. Pollio
et al. (2006) found that relatives benefited from this type of workshop by gaining knowledge and
advice and, in addition to that, it is also an excellent platform to encourage and introduce family psy-
choeducation. Another option would be family-to-family interventions, in the form of educational
programmes that support the families with the stages of apprehension following the diagnosis. As
it has been determined family well-being inevitably has a positive effect on the patient despite the
patients treatment status, these interventions are mainly focused on family outcomes, are led by
volunteer families from within the community, and tend to be short (12 weeks), mixing relatives of
patients who have various diagnoses (McFarlane et al., 2003).

Barriers experienced with implementation of psychoeducation interventions
Probably the greatest barrier to implementation lies within the health system itself. Magliano, Fio-
rillo, Malangone, de Rosa, and Maj (2006) report that after attending training courses in family
interventions only 7% to 27% of trained staff actually applied these principles and interventions.
Magliano et al. (2006) found that 91% of trained participants found it difficult to integrate family
interventions with their other work.
Besides the barriers found within health care settings, relatives are not always receptive to these
interventions: Leff et al. (1989) found that only five out of 11 families accepted the invitation to
attend a relatives group and, of those who accepted, most only attended 4.5 sessions. However, when
at least one individual family session was given in the patients home most relatives attended 10.8
sessions (Leff et al., 1989). The reality is that the patients at most risk of relapse are those patients
whose relatives refuse interventions and contact with professionals, therefore careful consideration
and patience is needed to engage these relatives for the sake of the patient (Leff et al., 1989).
Similarly, a survey conducted of all psychiatric institutions in Germany, Austria and Switzerland
revealed that relatives often reject family interventions (Rummel-Kluge, Pitschel-Walz, Buml, &
Kissling, 2006). Psychoeducation, while not offered in all institutions, was offered in 84% of the
respondent institutions as part of the treatment protocol for schizophrenia and, within these institu-
tions, only an average of 13% of family members actually attended. Reasons provided for drop out
from family therapy were lack of interest and time, non-acceptance of the diagnosis and patient
discharge (Rummel-Kluge, Pitschel-Walz, and the other two authors, first reference of the source,
2006).
Additional barriers to consider within a South African context
In South Africa, stigma of mental disorder is an important barrier that needs consideration (Botha
et al., 2006). Hugo, Boshoff, Traut, Zungu-Dirwayi and Stein (2003) reported that within a Western
South African Journal of Psychology, Volume 41(2), June 2011 144
Cape sample, stigma and misunderstanding around severe mental illnesses exist. Misunderstanding,
in the form of considering schizophrenia as a result of stress or lack of willpower, in particular in-
fluences the treatment, if any, which is sought. Hugo et al. (2003) postulate that increasing the
understanding of mental illness within the communities will lessen stigmatization and also increase
the use of appropriate services available.
With their limited resources South African institutions can take heart from two studies demon-
strating the effectiveness of family work when facilitated by non-psychiatrists. In a non-randomised
pilot study, Brooker, Tarrier, Barrowclough, Butterworth, and Goldberg (1992) found that patients
and family members who received behavioural family therapy facilitated by a psychiatric nurse had
several better outcomes than those patients receiving standard care. Randolph et al. (1994) found
similar results with a behavioural family management programme facilitated by two psychologists
and a nurse within a clinic setting (not a research setting) achieving a similar reduction in relapse
rates as normally recorded in research settings. In a more recent study Leff, Sharpley, Chisholm,
Bell, and Gamble (2001) reported that community mental health workers who were third-generation
trainees were as successful as professional mental health workers in reducing levels EE through
family work.
While it would seem that more training is needed to work with individual families as opposed
to facilitating a relatives group, Leff et al. (1982) mention that they succeeded with what was initially
little experience in working with schizophrenia, by setting clear aims at the beginning of the inter-
vention and having as their main aim the reduction of social contact between patients and high-EE
relatives. From a South African point of view, it is interesting to consider that Kazadi et al. (2008)
found no significant association between poor relationships with providers or living distance from
local clinics and relapse. This is encouraging to note as both distance from service and poor provider/
family relationships are real problems in South Africa.
CONCLUSION
As EE and relapse rates are so intricately linked, an attempt should be made to investigate whether
EE is predictive of the course of schizophrenia and how it relates to the prognosis of the illness
within the different cultures of South Africa. While it is evident that culture does play a part in EE
and indirectly plays a part in relapse rates and family interactions, it has been largely ignored
(Kymalainen & Weisman de Mamani, 2008; Rosenfarb, Bellack, & Aziz, 2006) even in a culturally
diverse country like South Africa. As with the Chinese population (Chien & Wong, 2007), little is
known about whether the existing models of family intervention will actually be successful within
the diverse South African cultures.
There are many evidence-based programmes that can be used within the South African context,
but what needs to be considered first is the effect that traditional definitions of EE have on a South
African patient. Leff (2000) mentions a study by Linszen et al. (1996) which considered a group of
participants that included both those living with high-EE and low-EE relatives. They found that
patients in low-EE families had higher rates of relapse when they received a family intervention
compared to when they received individual attention. This serves as a warning to not interfere with
families that are coping well. Trying to improve communication in these families was seen as in-
dicating that they were not coping and actually created more stress. Commonly, the main aim of a
family intervention is to try to reduce EE within family relationships; unfortunately, it is not always
possible to assess relatives before an intervention starts. Lowering EE within the African ethnic
groups may actually have detrimental outcomes on the patient, as what is considered as critical com-
ments in the literature is perceived in the traditional home as a sign of care and concern. In addition
to this it has been noted that acculturation and attribution may already have reduced EE levels in
African relatives. Low-EE families are however not problem free and, if they do not receive any
intervention, they may present with more critical and hostile comments over time (Tarrier et al.,
1988).
The ultimate achievement would be that all patients and their families have the possibility of
South African Journal of Psychology, Volume 41(2), June 2011 145
being offered a form of family psychoeducation in order to be educated about the illness so they can
understand what is transpiring, enabling them to receive the necessary advice on coping strategies
and gain confidence in making the correct decisions about relapse prevention and medication, while
supporting them in overcoming and managing their emotional response of grief and loss (Kuipers,
2006; Rummel-Kluge et al., 2006).
Although reviews on family psychoeducation have provided evidence of its superiority over
standard care with regards to relapse, symptoms, social and vocational functioning, compliance and
hospitalisation there is still no clear indication whether single family or multiple family treatment is
more effective (Huxley et al., 2000). Furthermore, when interventions are matched in duration and
intensity there is no significant evidence toward a certain orientation (McFarlane et al., 2003).
We urgently need South African studies that explore logistical and cultural issues and the
question of cost-effectiveness of family-based interventions in our context. Given the welter of evi-
dence showing that such approaches have benefits in other countries, it would be irresponsible to
ignore the potential of this approach to patient care.
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