Although efficacy studies indicate positive effects of family interventions when a loved one has schizophrenia, studies examining the implementation and utilization of such programs in routine care are limited. This study includes a random, representative sample of patients in care for schizophrenia and their clinicians across two VA mental health clinics. The patient sample was mostly older, unemployed, and single. Clinicians were a mix of staff psychiatrists, residents, and nurse case managers who each had at least 1/3 of their caseloads comprised of patients with psychosis.
The failed uptake of the family intervention suggests that there were many obstacles to its use. Clinicians reported high levels of contact with family prior to the study, but given the reports of infrequent contact reported by patients, it is likely that this was a very small minority of the pool of possible families. Clinicians’ competency in getting families involved in care was considered to be moderate and higher than that reported in a sample of managed care clinicians from the community,20
but there was little follow-through with families of patients identified as possibly benefitting from family services. This lack of follow-through could be due in part to clinicians’ perceptions that patients did not have supportive and/or available family members.
Contrary to these perceptions, however, many patients reported having supportive families, being in contact with their families, and patients readily provided consent for family contact when asked. It may be, though, that patients did not encourage their families to become involved given the high rate (88%) of patients who reported at the final interview that they did not want their families involved in their care. It is possible that patients distinguished between “providing consent to contact” and “having family involved,” with the latter representing an intensity of involvement that was not desired.
Organizationally, the participating VA clinics lacked the resources and supports necessary to function as family-friendly environments including evening appointments, designated family therapists, protected appointment times for families, and performance measures regarding family involvement.25
There are considerable efforts underway to implement the VHA Uniform Mental Health Services Package,8
which may facilitate a transformation to more family-friendly clinics.
Our program implementation strategies were consistent with much of the existing evidence for successful implementation, including early involvement of opinion leaders, more thorough training and supervision, and personal contact between the intervention developer and adopters. Nevertheless, it is clear that other obstacles needed to be addressed, including staff skepticism about the benefit/risk ratio of family involvement in patient care, limited leadership support, and no reorganization of staff time, as well as few incentives for providing this clinical service. Staff’s low sense of personal accomplishment and to a lesser degree emotional exhaustion and depersonalization on the job seem to be particularly problematic and warrant further attention.
The VA mental health staff in these clinics serves a predominately aging, chronic but stable, low economic resource population. Many staff may have become accustomed to seeing avoidance of crises as the primary treatment goal, and the value of newer, recovery-oriented interventions may be perceived to have little likelihood of payoff. Addressing issues of staff motivation and low levels of personal achievement as well as more rigorously employing the knowledge and tools from implementation science will be needed if a full partnership with patients and families is to be achieved.
Similar to work in schizophrenia, there is now a growing literature on the efficacy of interventions for families of persons with traumatic brain injury,26
While these programs can both reduce caregiver burden and improve patient functioning in controlled research settings, our results suggest that disseminating these family interventions to routine care may require overcoming many obstacles in non-specialized heath care settings where there are few incentives for medical professionals to change practices. Our results also suggest that complementary efforts must be spent both learning new interventions and
developing incentive programs to assure clinicians implement the new techniques.
While implementing intensive family interventions programs may be difficult, even more modest programs aimed at involving families with the care team have been underdeveloped in the literature. For example, in recent studies on collaborative care models of depression, even though mention is made of involving families in care,30
to date no systematic reports have been made of optimal ways to involve families as part of the collaborative care model. Only recently has there been qualitative work examining the needs of families in post-stroke care,31
which grew out of low attendance rates and equivocal efficacy studies in this population.32,33
A recent positive trial of collaborative care in dementia did include caregivers,34
but again it remains to be seen whether such a program can be successfully disseminated to non-research settings.
Interventions for family members of individuals with serious psychiatric or physical illnesses have been found to be efficacious and are included in numerous illness best practices, but without attention to implementation these services are often minimally utilized and not sustained. This can lead to assumptions that the service is not needed or is ineffective, when in reality it was never successfully implemented. Implementation science is a burgeoning field that offers data that can direct plans for roll-out, uptake, and sustaining an intervention, such as family services. Our work indicates that for family services to be utilized, additional attention needs to be paid to reorganization of care practices, clinician competencies, and education to patients and families regarding their role in the patient’s recovery and rehabilitation.