Schizophrenia Article

Family Involvement and Schizophrenia: A Developmental Model

Sally G. Mathiesen, PhD

SUMMARY. This paper presents the Family Involvement and Schizo- phrenia model, an adaptation of Rolland’s Family Systems/Illness model (1994). Rolland’s model conceptualized the development of the individ- ual, family, and illness in psychosocial terms using adult developmental theory and family life cycle concepts. The Family Involvement and Schizophrenia Model builds on this prior work, and consists of (1) a psychosocial typology of illness based on characteristics often associ- ated with a diagnosis of schizophrenia, and which are hypothesized to impact individual development and family relationships and (2) the changing psychosocial demands and family relationships at different phases of the illness, which represent an integration of the age-linked stages of individual development with the fluctuations in family cohesion over the life cycle. The Family Involvement and Schizophrenia model will enable clinicians, researchers, and families to conceptualize changing family relationships, and to target individuals and families at greatest stress points in order to provide more individualized treatment over the life cycle. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2001 by The Haworth Press, Inc. All rights reserved.]

Sally G. Mathiesen is affiliated with Florida State University, School of Social Work. This research was supported by the National Institute of Mental Health, (NIMH)

Grant # RO3-MH 56298-01.

[Haworth co-indexing entry note]: “Family Involvement and Schizophrenia: A Developmental Model.” Mathiesen, Sally G. Co-published simultaneously in Journal of Family Social Work (The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1, 2001, pp. 35-52; and: Families and Health: Cross-Cultural Perspectives (ed: Jorge Delva) The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc., 2001, pp. 35-52. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-342-9678, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

 2001 by The Haworth Press, Inc. All rights reserved. 35

KEYWORDS. Schizophrenia, family involvement, psychosocial typology, developmental model

INTRODUCTION

The increasingly important role of the family in the treatment of schizophrenia has a long and varied history. The family has been seen as a causal factor in the illness (Fromm-Reichman, 1950; Lidz & Lidz, 1949), a source of stress capable of affecting the course of the illness (Brown, Birley, & Wing, 1972; Vaughn & Leff, 1976), a resource and advocate for policy change (Bernheim, 1990), and in need of support due to the burdens of caregiving (National Institute of Mental Health [NIMH], 1991; Lefley, 1989; Falloon, Boyd, & McGill, 1984; Group for the Advancement of Psychiatry [GAP], 1992; Bulger, Wandersman, & Goldman, 1993). In 1992 the Clinical Research Services Panel of NIMH recommended that the various kinds and degree of family in- volvement should be “an important variable in rehabilitation effective- ness research” (Attkisson, Cook, Karno, Lehman, McGlashan, Meltzer, O’Connor, Richardson, Rosenblatt, Wells, & Williams, 1992, p. 601).

In a review of the literature, Yank and colleagues (1993) described vulnerability-stress models of schizophrenia as incorporating a variety of etiological components (biological, developmental, learning, ge- netic, and environmental) which interact to produce a degree of vulner- ability (Zubin & Spring, 1977; Goldstein, 1990; Nuechterlein, 1987; Nuechterlein & Dawson, 1984). The vulnerability represents the risk of relapse or acute episode. Environmental stress impacts a vulnerable person, resulting in a schizophrenic episode (Straube & Oades, 1992).

A systems perspective is evident in these conceptualizations, which have considered the mediating factors in schizophrenia (Anthony & Liberman, 1986; Ciompi, 1988; 1989; Nicholson & Neufeld, 1992; Strauss, 1989). The models emphasize “interactions over time, feed- back processes, biological functioning, stressful events, cognitive pro- cesses, coping skills, competence, and symptomatology” (Yank et al., 1993, p. 56).

Most psychosocial treatments for the severely mentally ill are based on the vulnerability-stress theory, with the goal of reducing stress for the vulnerable individual. Psychosocial treatments that intervene at the environmental level to reduce stress, such as family interventions, have been shown to have a positive effect on the subsequent course of schizo- phrenic illness (Anderson et al., 1980; 1986; Leff et al., 1982; 1985;

36 FAMILIES AND HEALTH: CROSS-CULTURAL PERSPECTIVES

Goldstein et al., 1978; Goldstein, 1984; Falloon et al., 1984; Hogarty et al., 1986; 1991; Barrowclough & Tarrier, 1990; McFarlane et al., 1993). In addition, researchers have articulated the need for longitudi- nal studies to determine the changing patterns of the illness (Ciompi, 1987; Wynne, 1988; Carpenter et al., 1990; GAP, 1992; Belitsky & McGlashan, 1993). It is critical to systematically investigate patterns of family involvement across the life cycle and to ultimately use the infor- mation to target treatment more effectively.

But there are several critical issues in regard to our knowledge about schizophrenia and the interaction with family that have important clini- cal and research implications: (1) Family interventions have been con- ducted almost exclusively with individuals who were hospitalized or resided with their family. There is little longitudinal information to characterize patterns of family involvement for those living in the com- munity; (2) There are no existing comprehensive models to predict how family interaction patterns may change over the course of the illness; (3) Client characteristics, such as gender, ethnicity, and age, have been shown to be related to the course of illness, but little is understood of their relation to family involvement.

The purpose of this paper is to present the Family Involvement and Schizophrenia (FIS) model, a developmental model of the individual, family, and course of schizophrenia in psychosocial terms. Rolland’s Family Systems/Illness Model (1994), developed primarily for chronic physical illness and disability, was adapted to address the demands commonly associated with a diagnosis of schizophrenia. The FIS model provides a comprehensive, longitudinal, developmental view of the ill- ness. It will enable clinicians, researchers, and families to conceptualize changing family relationships, and to target individuals and families at greatest stress points in order to provide more individualized treatment over the life cycle.

FAMILY INVOLVEMENT AND SCHIZOPHRENIA (FIS) MODEL

Building on the work of Rolland (1994), the FIS model consists of (1) a psychosocial typology, based on characteristics often associated with a diagnosis of schizophrenia, and which are hypothesized to im- pact individual development and family relationships; (2) the changing psychosocial demands and family relationships at different phases of the illness, which represent an integration of the age-linked stages of in-

Sally G. Mathiesen 37

dividual development (Levinson, 1978; 1986) with the fluctuations in family cohesion over the life cycle (Combrinck-Graham (1985). The re- sulting FIS model is an integrated conceptual model that depicts the un- dulating course of normative family interaction patterns, and the hypothesized effect of a diagnosed schizophrenic illness.

The psychosocial typology of schizophrenia from the Family In- volvement and Schizophrenia (FIS) model will be presented first, fol- lowed by the phases of illness and the transitions between them. Next, the theoretical relationship between the age-linked stages of individual development, combined with the fluctuations in family cohesion over the phases of illness is presented.

Psychosocial Typology of Schizophrenia

The typology of the FIS model is based on the psychosocial demands that are imposed on the individual and family by variations in onset, course, gender, variation in outcome, level of incapacitation, and phase of illness. The categories are hypothesized to be those most relevant to the psychosocial issues posed by chronic conditions, and also related to the developmental tasks at different phases of the illness.

Onset

The FIS model includes both the timing (early to late) and the trajec- tory (acute to insidious) of onset. Rolland (1994) included only acute or gradual onset in his theoretical model, and distinctions were made in re- lation to the presentation of symptomatology, not necessarily biological development. He posited that illnesses with gradual onset require read- justment of the family structure, roles, and coping styles over a pro- tracted period, while acute onset require the same adaptations in a compressed time period. Similarly, the rate or trajectory of onset (acute or insidious) has been included in the FIS model, as it represents an es- sential parameter in identifying course types in schizophrenia (Maren- go, 1994), and has been used in long-term follow-up studies (Bleuler, 1978; Ciompi, 1980; Krauz et al., 1993).

The FIS model incorporates the additional category of the timing of onset (early or late) as an important modification. “Age of onset is the single most important clue to the etiology of (schizophrenic) illness” (DeLisi, 1992, p. 212), and two distinct times of onset have been identi- fied. The differences in the developmental disruptions between early onset, where brain defects affecting language processing are likely, and

38 FAMILIES AND HEALTH: CROSS-CULTURAL PERSPECTIVES

late onset, where recovery from acute episodes may be easier due to fewer developmental deficits, are important aspects of the illness that need further research (DeLisi, 1992). The DSM-IIIR (American Psy- chiatric Association, 1987) allowed a diagnosis of schizophrenia to be made after age 45, defined as late-onset patients (DeLisi, 1992). Clini- cal research found fewer negative symptoms in persons with late onset schizophrenia than in early onset (Yassa & Suranyll-Cadotte, 1993). In- cluding the age of onset into the typology will facilitate a systematic ap- proach for research designs and interpretation of findings, as well as assist the clinician in targeting intervention approaches.

Course of Illness

The FIS model consists of three aspects of the course of illness: the type of course (progressive, constant, or relapsing/episodic), the level of incapacitation in role functioning (including functioning in the areas of social relationships, work, and self-care), and patterns of psychotic and residual symptoms.

The courses of illness as described by Rolland (1994) were consis- tent with the course variation in schizophrenia. Progressive illnesses are those that are continually symptomatic and increasing in severity. Con- stant courses are those in which there is an initial event, followed by a stabilized condition. The residual effect is a semipermanent deficit pre- dictable over long time periods. Relapsing courses are characterized by relatively symptom-free periods of varying length alternating with peri- ods of exacerbation. The continual uncertainty as to when the next fam- ily crisis will occur, combined with the strains of the crises themselves, make this course of illness uniquely stressful and psychologically chal- lenging, regardless of the degree of biological severity.

In the FIS, the role-functioning dimension was added to the typology. The patterns of role functioning in the domains of social interaction, work, and self-care are included in the diagnosis of schizophrenia, as well as representing important areas for determining treatment efficacy (Heinrichs et al., 1984; Marengo, 1994). Their independence from symptomatology levels is indicative of the heterogeneity and complex- ity of patterns in the course of the illness. The inclusion of a role-func- tioning dimension contributes valuable information to the long-term course of the illness.

Patterns of psychotic and residual symptoms each represent unique stressors and necessary adaptations that affect the objective and subjec-

Sally G. Mathiesen 39

tive experience of the illness. Rolland discussed variables that were im- plicated in the adaptation to illness, but were not included in a separate category, such as the visibility of symptoms (visible symptoms increase social stigma, but allow for more objective interactions with the patient than invisible symptoms, which increase ambiguity for the family). Visibility of symptoms is an area that is so central to the individual and family that it should be included in any typology attempting to chart the course of the illness (Marengo, 1994). By utilizing the constant, pro- gressive, and relapsing categories, in combination with the role-func- tioning and symptom subcategories, course types can be more systematically and sensitively investigated.

Gender

The FIS model added gender to the psychosocial typology outlined by Rolland (1994). This is an important contribution, as there is re- search that suggests that gender has implications for the developmental perspective in schizophrenia. One study found that young men ap- peared to be more at risk for a poor outcome than young women (Leventhal et al., 1984). The authors contend that men tend to have more difficulty in the early developmental stages due to limitations re- lated to schooling, socialization, or independent living. In a summary of gender-specific data, Bardenstein and McGlashan (1990) noted that women, in general, required lower doses of medication, had fewer re- lapses, and were less prone to suicide and comorbidity of psychiatric ill- nesses than men with schizophrenia.

There is evidence that women may not display the same type of ill- ness plateau as men (Group for the Advancement of Psychiatry [GAP], 1992). Women may require more adjustment in the later stage, such as during parenthood or menopause. Better outcomes for women in the past may have been related to their increased tendency to be married and to have a spouse and/or children to assist them in their illness. Other evidence suggests that young women with schizophrenia are not as likely to be married, but they may still be a parent. Loss of parental rights due to illness, or remaining childless may increase the stress in later developmental stages of schizophrenia (Salonkongas, 1983; Seeman, 1986). Viewing the limited gender-specific data in a develop- mental perspective highlights the need for a comprehensive model that incorporates critical psychosocial variables over the life cycle so that relationships may be tested.

40 FAMILIES AND HEALTH: CROSS-CULTURAL PERSPECTIVES

Variation in Outcome

In the FIS model, a useful description of the heterogeneity in schizo- phrenia is the variation in outcome over time, ranging from deteriora- tion to improvement. While Rolland’s model included the categories of Fatal, Possibly fatal/Shortened lifespan, and Nonfatal, it is important to make distinctions between physical illness and outcomes associated with a diagnosis of schizophrenia. Schizophrenia is not in itself a fatal illness, but it does result in “an increased risk of suicide, physical ill- ness, and early death” in comparison to the general population (GAP, 1992, p. 5). Estimates of 5 percent to 10 percent suicide rates, and a life- span shortened by up to 10 years have been reported (GAP, 1992). The results are in part due to the lack of optimal care for the population, and the growing numbers of homeless chronically mentally ill in major ur- ban centers (Talbott, 1990).

For the family, their initial expectation of the degree of loss may have the most impact, and yet these perceptions may be based on inaccurate information (Rolland, 1994). The primary difference among outcome types was the degree to which the family anticipated loss and its effect on the family. Illnesses that are known to be fatal result in less ambigu- ity than those that may shorten life. Using existing long-term studies of schizophrenia as a basis for hypotheses, and the onset and course cate- gories in the typology as variables, a psychosocial picture of the course of illness will begin to emerge that may be used to provide more accu- rate prognostic information to the individual and family.

The FIS model considers the degree of uncertainty/predictability in the nature of the illness or the rate of change as a metacharacteristic that influences all the other factors. The greater the degree of uncertainty of outcome, the greater the need for flexible problem-solving styles and contingency plans (Rolland, 1994). The overarching quality of the de- gree of uncertainty or predictability in schizophrenia is particularly a function of the state of knowledge that is possessed currently. There are many aspects of the long-term course of schizophrenia that are undis- covered, increasing the level of stress and anxiety for all those affected by the illness. Knowledge of both the rate of change and the nature of the illness are incomplete. But recognition of the limitations in these ar- eas enables a clinician to alert the individual and family to possible changes in the illness, and the changing psychosocial demands and ex- pectations as the illness moves from one phase to another. As described in the introduction to the model, the following section will address the

Sally G. Mathiesen 41

second part of the FIS model: the phases of illness, and the transitions between the phases.

Phases of Illness

Each phase of illness demands “significantly different strengths, atti- tudes, or changes from a family” (Rolland, 1994, p. 43). The phases are very compatible with researchers’ descriptions of the eras or “epochs” of schizophrenia over time (Carpenter & Kirkpatrick, 1988). The FIS model modified the phases for the demands of schizophrenia, and are described below.

Early Phase

The crisis (early) phase includes both the beginning of psychotic symptoms and early treatment, and the prodromal period that precedes symptomatology. The main tasks for the individual and family are to engage in short term crisis reorganization, grieve for the loss of prior family image, and understand the developmental aspects of the illness.

Mid Phase

The mid phase (chronic course) includes periods of active psychosis and nonpsychotic periods between episodes. Family and individual psychosocial tasks include developing a normal family life in face of the uncertainty and limits of illness, and preserve maximum autonomy for all members.

Late Phase

The terminal phase is re-labeled the “late phase” in the FIS model. The late phase (third epoch) refers to late course and outcome, when some pa- tients improve and others stabilize or deteriorate (Carpenter & Kirkpatrick, 1988). Contrary to earlier conceptions, many patients with schizo- phrenia show sustained and substantial improvement in psychopathology late in the course of illness (Lin & Kleinman, 1988; GAP, 1992). Acceptance of changing generational roles, physiological changes and losses, and learn- ing to define a new balance between youth and age are the primary devel- opmental tasks.

The changing needs of the family over the life span must be consid- ered in a developmental context, as family interaction patterns may dif-

42 FAMILIES AND HEALTH: CROSS-CULTURAL PERSPECTIVES

ferentially affect the individual with schizophrenia at different stages. Due in part to the failure to achieve or maintain adult roles, the impact on self-esteem, and the disruption in family relationships, many young adults diagnosed with schizophrenia engage in self-destructive behav- iors, contributing to the perception that treatment is resisted or refused (Pepper & Ryglewicz, 1984). The focus on the early years, when safety and support are critical, may have contributed to the dearth of informa- tion about other stages of life. Little is known about the life of the indi- vidual and family affected by schizophrenia in mid-life, and some writers have posited that it may be the most opportune period for inter- vention, rather than a time for less intensive efforts (GAP, 1992). The mid-adulthood years may represent a time for re-examination of strengths and limitations, and an openness to change.

The results of a review of long term follow-up studies indicate that the virulent effects of the illness subside to a great degree in middle-age, and reach a plateau or even gradual improvement with time (McGlashan & Carpenter, 1988). Research attention should be focused on the middle and late phases, as little is known about the years beyond early adulthood, which comprise the majority of a person’s life with schizophrenia. Pro- gressive, or episodic in nature, as the individual and family adapt to the realities of daily life with chronic illness.

Transition Periods

The time periods between the three phases described are important in themselves, and represent critical points of leverage in adaptation. When issues remain unresolved from previous phases, the next transi- tion can become very difficult.

According to Rolland’s conceptualization, the move from crisis to chronic is the most difficult transition to negotiate and the most signifi- cant in terms of the ability of the family to reevaluate their coping and adaptation. A family that became competent at marshalling resources and drawing together as a family in a crisis phase may find the same be- haviors maladaptive in the chronic phase (Rolland, 1994). The transi- tion from mid to late phase involves evolving from day-to-day coping to expression of affect, and reevaluation of changing roles.

Integration of Individual Development and Family Spiral Theories

Rolland’s model drew on the adult developmental perspective as ex- plicated by Levinson (1978; 1986), as well as the fluctuating levels of

Sally G. Mathiesen 43

family cohesion described by Combrinck-Graham (1985) to combine the three paths of individual, family, and illness development. As adapted to schizophrenia, these theoretical constructs must be inte- grated to provide a baseline for further theory development and testing.

Figure 1 represents the Family Involvement and Schizophrenia model. The following sections will further describe the theoretical foundations for the model.

Age-Linked Stages of Adult Development

Rolland (1994) applied Levinson’s (1978; 1986) individual adult theory of life structure to the family. Levinson’s model provides dis- tinct, age-linked developmental eras for the entire life cycle, and em- phasizes the importance of transitions from one era to the next. His hypothesis for the underlying order of the human life cycle was based on empirical studies he conducted with men and women, and was meant to provide a starting point for individual variation in life course as a re- sult of the influences of biology, personality, culture, social roles, and life events. The following section closely follows Levinson’s descrip- tion of the four eras of his theory (Levinson, 1986).

Levinson delineated four periods in life structure development, each lasting approximately twenty years, and each era is preceded by a criti- cal transition stage. The goal of the transition period is to carefully

44 FAMILIES AND HEALTH: CROSS-CULTURAL PERSPECTIVES

FIGURE 1

weigh different options for the individual and the family, which will serve as a plan for the next life cycle phase. Transitions from one phase to the next are the points at which individuals and families are the most vulnerable, due to the task of reevaluation of previous life structures.

Preadulthood Era (birth through age 22). The primary task in child- hood and adolescence is to establish the distinction between “me” and “not me” as the individual separates from family and other aspects of the preadult world. Although this era represents great and rapid biopsychosocial growth, in the context of the life cycle it is a basis from which to begin further development.

Early Adulthood Era (age 17-45). This era is preceded by the Early Adult Transition (17-22), which requires that the newly merging adult modify fam- ily, peer, and other social relationships, and begin to create a niche in the adult world. Early adulthood can be the time of greatest reward and also of greatest stress. The individual must pursue early goals, define a distinct place in society, raise a family, and assume a more “senior” position as an adult. A transition period around age 30 is a time for reappraisal of the life structure, and preparation for the final segment of early adulthood.

Middle Adulthood Era (ages 40-65). The Midlife Transition (40-45) results in an appreciable change in lifestyle as early adulthood is left be- hind. Successful resolution of conflicts regarding the growing aware- ness of one’s mortality and limitations can lead to increased compassion, empathy, and inner peace, while an unsuccessful transition may result in an increasingly stagnant and unproductive life (Levinson, 1986). In the middle adulthood era, taking responsibility for one’s own work and maintaining “senior member” status of that self-created world is the paramount task. A transition around age 50 allows for mid-era modification of middle adulthood.

Late Adulthood Era (ages 60-80+). The Late Adult Transition (60-65) precedes the Late Adulthood Era, and is the result of the gradual recognition and experience of physical decline and the culturally-de- fined change of generation in the 60s to “old age.” The developmental task of this era is to end an earlier life structure and find an appropriate balance between the energy, interests and inner resources of youth and age. The loss of “center stage” must give way to a new involvement with society and the self.

Family Spiral Model

The Family Spiral Model (Combrinck-Graham, 1985) depicts three generations of a family alternating through the life cycle between eras

Sally G. Mathiesen 45

of high cohesion (centripetal) and lower family cohesion (centrifugal). Ideally, the periods coincide with family developmental tasks that re- quire similar levels of cohesion (Rolland, 1994). The concept of centrif- ugal (pushing away from center) and centripetal (moving toward the center) forces operating at different points in the family life cycle is use- ful in combining the individual, family, and illness developmental pro- cess (Beavers & Voeller, 1983; Combrinck-Graham, 1985).

The concept describes the “goodness of fit” between developmental tasks and the relative need for internal and group cohesive energy to ac- complish the tasks. For example, during the family life cycle period of child rearing, the individual and the family have a life structure that em- phasizes the solidarity of family life. The “pull” is inward, and centripetal forces allow outside boundaries to be strengthened, while boundaries be- tween family members become more diffuse, as the family operates as a unit. As the family transitions to a centrifugal period such as adolescence, individual and family developmental tasks require a loosening of the ex- ternal boundaries. An outward “push” away from center occurs, and indi- vidual boundaries between family members become more defined in response to developmental tasks (Rolland, 1994).

Rolland theorized that illness and disability exert an inward pull or centripetal force upon individual and family members, and will vary ac- cording to the illness type and phase. The onset of a chronic illness is seen as the addition of a new member of the family, setting the stage for a period of high cohesion. “Symptoms, loss of function, the demands of shifting or new illness-related roles, and the fear of loss through death all serve to make a family turn inward” (Rolland, 1994, p. 109). If the onset of a chronic illness occurs at a centrifugal point in the family life, the family may be derailed. The individual and family members’ auton- omy is placed at great risk due to the new demands for cohesion due to illness coinciding with naturally lower demands of a centrifugal phase. If the onset of a chronic illness occurs at a point in the life cycle which requires greater cohesion (centripetal), there is a risk that the pull of the illness and the pull of the life cycle phase will amplify each other (Rolland, 1994). At best, the centripetal period will be prolonged; at worst, the family may become frozen at this stage and become en- meshed. Other families may survive the initial stage, but when faced with the developmental changes of adolescence, for example, the long-standing and rigid patterns of cohesion clash with the need for au- tonomy, and the family system may break down.

46 FAMILIES AND HEALTH: CROSS-CULTURAL PERSPECTIVES

FIS MODEL AS A FRAMEWORK FOR ASSESSMENT AND INTERVENTION

The combination of the typology of schizophrenia in psychosocial terms, combined with the phases of the illness and the developmental processes of the individual and family provides a basis for assessment and guide to intervention. The model emphasizes the changing “good- ness of fit” between individual, family, and illness development over the course of the illness.

For example, a course of illness categorized by the FIS typology as relapsing would require multiple adjustments for the individual and the family. Relapsing illnesses alternate between requirements for greater family cohesion, and periods of release from the demands of the illness (Rolland, 1994). The degree of uncertainty as to when the individual and family may need to shift to another mode tends to keep some mem- bers of the family in a centripetal mode, even when the ill member is asymptomatic.

The time of onset is critical to a developmental concept, as the illness will force a family into a transition period that is characterized by the family task of adapting to possible loss or deterioration. If the onset oc- curs when a family is already in a transitional period, the intensity of previously unresolved issues will be magnified. There is an increased risk of the illness being inappropriately ignored or becoming the sole focus of the next developmental stage.

The phases of the illness will have an impact on the fluctuating levels of cohesion with family. The early phase, requiring high cohesion, is analogous to the childhood era. The mid phase, whose primary task is to establish autonomy within the restrictions of the illness, is much like ad- olescence and adulthood, with less cohesion required. The late phase corresponds to that of later life, during which a return to family occurs as a result of physical decline and increased caregiving tasks (Rolland, 1994).

The categories of the typology and the changing demands of the ill- ness can help to focus the clinician’s approach with the family in the early phase, clarifying treatment planning and goal-setting. The struc- ture also is valuable to the individual and family who may be unfamiliar with the mental health system, and may be overwhelmed by the poten- tial impact on all their lives. Describing the normative developmental landmarks and tasks of the individual and family, combined with the ad- ditional psychosocial tasks that may be required over time allows for preparation for future transitions. The process also helps the family to

Sally G. Mathiesen 47

develop a relationship with the clinician based on mutual understanding and cooperation.

In addition to the early stage, the typology and model of fluctuating family relationships are useful in the middle and late phases. Under- standing the illness trajectory retrospectively will permit individualized case plans to be formulated, based on the individual characteristics and family experiences.

An example of potential clinical use of the FIS model would be in terms of the concept of expressed emotion (EE). Highly critical and hostile statements of family members have been shown to be predictive of relapse. Some authors have been critical of the concept of EE, hy- pothesizing that it is a bi-directional process, i.e., living with a person diagnosed with schizophrenia may result in family attitudes that are critical and hostile, and that in return, the attitudes affect the course of illness in a negative way. Application of the FIS model would pose an interesting set of questions that have not previously been addressed: What was the developmental phase of the high EE families? Was the onset of illness at a particularly out-of-phase point for the individual and the family? Which family members were required to alter their de- velopmental course to the greatest degree? Are there other chronic con- ditions in the family that compound the effects of the new onset?

Identification of family cycles and individual developmental phases would help to pinpoint those families at greatest risk. An intervention goal of remaining at a distance from family may not be appropriate for patients at different developmental phases, and may need to be adapted. The intensity of the high EE interactions may be correlated with an out-of-cycle illness interacting with family and individual developmen- tal stages.

Another clinical application of the comprehensive, developmental approach of the FIS model would be with psychoeducational interven- tions, noted by Rolland (1994). The developmental aspects of the indi- vidual and family should be incorporated into a psychoeducational treatment model to provide for the most effective and individualized care. The psychosocial improvement seen in later stages of schizophre- nia by long-term follow-up studies may be related to a family and indi- vidual phase coinciding with the natural course of illness, which tends to plateau after the first five to ten years. Psychoeducational modules could be targeted toward specific time phases in the illness and focus on the family skills needed to confront particular psychosocial demands.

48 FAMILIES AND HEALTH: CROSS-CULTURAL PERSPECTIVES

CONCLUSION

Clinical and research needs indicate the necessity of more accurate descriptions of the heterogeneous nature of the course of schizophrenia, in addition to developing and testing an integrated theoretical model that acknowledges the importance of the family. A longitudinal per- spective will help to identify biological, social, and psychological changes that may influence intervention strategies.

The Family Involvement and Schizophrenia (FIS) model offers a method for the conceptualization and testing of the complex interaction of the individual, family, and illness developmental paths over the life cycle. The typology of illness includes the categories that are hypothe- sized to be most relevant to understanding the psychosocial aspects of schizophrenia, as well as providing a basis for cross-study comparisons. The time phases represent the changing developmental tasks and psychosocial demands for the individual and family.

Life cycle concepts of the individual and family developmental pro- cesses as integrated in the FIS highlight the periods of increased vulner- ability to stress. Little is known about the interaction patterns between the family and the individual diagnosed with schizophrenia beyond early adulthood, and use of the typology, combined with continued gathering of family data as to their developmental stage, would facili- tate the inclusion of the family in treatment planning in middle and late phases. Exploration of the changing developmental needs and demands of the illness, combined with those of the individual and family, may lead to an increase in interventions beyond the crisis stage. Periodic re- evaluations to assess strengths, weaknesses, and approaching transi- tions would facilitate an ongoing therapeutic connection, and would enable the clinician to address the life-long coping process.

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