LHD

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Family members and other persons involved in the lives and care of adults who have

serious mental illnesses often pro- vide emotional support, case man- agement, financial assistance, advo- cacy, and housing to their mentally ill loved ones. Although serving in this capacity can be rewarding, it impos- es considerable burdens (1–4). Fam- ily members often have limited ac- cess to the resources and informa- tion they need (5–7). Research con- ducted over the past decade has shown that patients’ outcomes im- prove when the needs of family members for information, clinical guidance, and support are met. This research supports the development of evidence-based practice guide- lines for addressing the needs of family members.

Several models have evolved to ad- dress the needs of families of per- sons with mental illness: individual consultation and family psychoedu- cation conducted by a mental health professional (8,9), various forms of more traditional family therapy (10), and a range of professionally led short-term family education pro- grams (11,12), sometimes referred to as therapeutic education. Also available are family-led information

Evidence-Based Practices for Services to Families of People With Psychiatric Disabilities LLiissaa DDiixxoonn,, MM..DD..,, MM..PP..HH.. WWiilllliiaamm RR.. MMccFFaarrllaannee,, MM..DD.. HHaarrrriieett LLeefflleeyy,, PPhh..DD.. AAlliicciiaa LLuucckksstteedd,, PPhh..DD.. MMiicchhaaeell CCoohheenn,, MM..AA.. IIaann FFaalllloooonn,, MM..DD.. KKiimm MMuueesseerr,, PPhh..DD.. DDaavviidd MMiikklloowwiittzz,, PPhh..DD.. PPhhyylllliiss SSoolloommoonn,, PPhh..DD.. DDiiaannee SSoonnddhheeiimmeerr,, MM..SS..,, MM..PP..HH..

Dr. Dixon and Dr. Lucksted are affiliated with the Center for Mental Health Services Research at the University of Maryland School of Medicine in Baltimore and with the De- partment of Veterans Affairs Capitol Health Care Network Mental Illness Research, Ed- ucation, and Clinical Center, 701 West Pratt Street, Room 476, Baltimore, Maryland 21201 (e-mail, [email protected]). Dr. McFarlane is affiliated with the Maine Medical Center in Portland. Dr. Lefley is with the University of Miami School of Medi- cine. Mr. Cohen is with the New Hampshire chapter of the National Alliance for the Mentally Ill in Concord. Dr. Falloon is with the University of Auckland in Auckland, New Zealand. Dr. Mueser is with Dartmouth Medical School in Hanover, New Hamp- shire. Dr. Miklowitz is with the University of Colorado. Dr. Solomon is with the Uni- versity of Pennsylvania School of Social Work in Philadelphia. Ms. Sondheimer is with the Child, Adolescent, and Family Branch of the Center for Mental Health Services in Rockville, Maryland.

Family psychoeducation is an evidence-based practice that has been shown to reduce relapse rates and facilitate recovery of persons who have mental illness. A core set of characteristics of effective family psychoeducation programs has been developed, including the provi- sion of emotional support, education, resources during periods of cri- sis, and problem-solving skills. Unfortunately, the use of family psy- choeducation in routine practice has been limited. Barriers at the lev- el of the consumer and his or her family members, the clinician and the administrator, and the mental health authority reflect the exis- tence of attitudinal, knowledge-based, practical, and systemic obsta- cles to implementation. Family psychoeducation dissemination efforts that have been successful to date have built consensus at all levels, in- cluding among consumers and their family members; have provided ample training, technical assistance, and supervision to clinical staff; and have maintained a long-term perspective. (Psychiatric Services 52:903–910, 2001)

2001 Dedicated to

Evidence- Based

Psychiatry

and support classes or groups, such as those provided by the National Al- liance for the Mentally Ill (NAMI) (13,14). Family psychoeducation has a deep enough research and dissem- ination base to be considered an evi- denced-based practice. However, the term “psychoeducation” can be misleading: family psychoeducation includes many therapeutic elements, often uses a consultative framework, and shares characteristics with other types of family interventions.

In general, evidence-based prac- tices are clinical practices for which scientific evidence of improvement in consumer outcomes has been con- sistent (15). The scientific evidence of the highest standard is the ran- domized clinical trial. Often, several clinical trials are pooled by use of a technique such as meta-analysis to identify evidence-based practices. Quasi-experimental studies, and to a lesser extent open clinical trials, can also be used. However, the research evidence for an evidence-based practice must be consistent and suf- ficiently specific for the quality and outcome of the intervention to be assessed.

The purpose of this article, as part of a larger series on evidenced-based practices for persons with severe mental illnesses (15), is to describe family psychoeducation, the basis for its identification as an evidence-based practice, and barriers to its imple- mentation. We also propose strategies for overcoming these barriers.

What is family psychoeducation? A variety of family psychoeducation programs have been developed by mental health care professionals over the past two decades (8,9). These programs have been offered as part of an overall clinical treat- ment plan for individuals who have mental illness. They last nine months to five years, are usually diagnosis specific, and focus primarily on con- sumer outcomes, although the well- being of the family is an essential in- termediate outcome. Family psy- choeducation models differ in their format—for example, multiple-fami- ly, single-family, or mixed sessions— the duration of treatment, consumer participation, location—for example,

clinic based, home, family practice, or other community settings—and the degree of emphasis on didactic, cognitive-behavioral, and systemic techniques.

Although the existing models of family intervention appear to differ from one another, a strong consen- sus about the critical elements of family intervention emerged in 1999 under the encouragement of the leaders of the World Schizophrenia Fellowship (16).

Goals and principles for working with families The main goals in working with the family of a person who has a mental illness are to achieve the best possible outcome for the patient through col- laborative treatment and manage- ment and to alleviate the suffering of the family members by supporting them in their efforts to aid the recov- ery of their loved one.

Treatment models that have been supported by evidence of effective- ness have required clinicians to ad- here to 15 principles in working with families of persons who have mental illness:

♦ Coordinate all elements of treat- ment and rehabilitation to ensure that everyone is working toward the same goals in a collaborative, supportive re- lationship.

♦ Pay attention to both the social and the clinical needs of the consumer.

♦ Provide optimum medication management.

♦ Listen to families’ concerns and involve them as equal partners in the planning and delivery of treatment.

♦ Explore family members’ expec- tations of the treatment program and expectations for the consumer.

♦ Assess the strengths and limita- tions of the family’s ability to support the consumer.

♦ Help resolve family conflict by responding sensitively to emotional distress.

♦ Address feelings of loss. ♦ Provide relevant information for

the consumer and his or her family at appropriate times.

♦ Provide an explicit crisis plan and professional response.

♦ Help improve communication among family members.

♦ Provide training for the family in structured problem-solving techniques.

♦ Encourage family members to expand their social support net- works—for example, to participate in family support organizations such as NAMI.

♦ Be flexible in meeting the needs of the family.

♦ Provide the family with easy ac- cess to another professional in the event that the current work with the family ceases.

Overview of the research Studies have shown markedly higher reductions in relapse and rehospital- ization rates among consumers whose families received psychoeducation than among those who received stan- dard individual services (17–20), with differences ranging from 20 to 50 percent over two years. For programs of more than three months’ duration, the reductions in relapse rates were at the higher end of this range. In addi- tion, the well-being of family mem- bers improved (21), patients’ partici- pation in vocational rehabilitation in- creased (22), and the costs of care de- creased (4,20,23,24).

As a result of this compelling evi- dence, the Schizophrenia Patient Outcomes Research Team (PORT) included family psychoeducation among its treatment recommenda- tions. The PORT recommended that all families who have contact with a relative who has mental illness be of- fered a family psychosocial interven- tion that spans at least nine months and that includes education about mental illness, family support, crisis intervention, and problem solving (25). Other best-practice standards (26–28) have recommended that fam- ilies participate in education and sup- port programs. In addition, an expert panel that included clinicians from various disciplines as well as families, consumers, and researchers empha- sized the importance of engaging family members in the treatment and rehabilitation of persons who are mentally ill (29,30).

Delivering the appropriate compo- nents of family psychoeducation for patients and their families appears to be an important determinant of out- comes for both consumers and their

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families. It has been demonstrated that programs do not reduce relapse rates if the information presented is not accompanied by skills training, ongoing guidance about management of mental illness, and emotional sup- port for family members (31).

In addition, these interventions that present information in isolation tend to be brief: a meta-analysis of 16 studies found that family interven- tions of fewer than ten sessions had no substantial effects on the burden of family members (32). However, the number of sessions could not completely explain the differences in outcomes. The outcomes may have been influenced by the total duration of treatment rather than the number of sessions, or by the individual ther- apist’s approach to dealing with the emotional reactions of patients and their families. The behaviors and dis- ruptions associated with schizophre- nia, in particular, may require more than education to ameliorate the bur- den on the family and enhance con- sumer outcomes.

Most studies have evaluated family psychoeducation for schizophrenia or schizoaffective disorder only. Howev- er, the results of several controlled studies support the benefits of both single- and multiple-family interven- tions for other psychiatric disorders, including bipolar disorder (33–38), major depression (39–41), obsessive- compulsive disorder (42), anorexia nervosa (43), and borderline person- ality disorder (44). Gonzalez and col- leagues (45) have extended this re- search to deal with the secondary ef- fects of chronic physical illness.

Family psychoeducation thus has a solid research base, and leaders in the field have reached consensus on the essential components and techniques of family psychoeducation. This form of treatment should continue to be recommended for use in routine practice. However, several important gaps remain in the knowledge re- quired to make comprehensive evi- dence-based practice recommenda- tions and to implement them with a wide variety of families.

First, although the members of the World Schizophrenia Fellowship and others have delineated the core com- ponents of a successful family inter-

vention, the minimum ingredients are still not clear. This gap was high- lighted by a study of treatment strate- gies for schizophrenia, which found no significant difference in relapse rates between families who received a relatively intensive program—a sim- plified version of cognitive-behavioral family intervention plus a multiple family group—and those who re- ceived a less intensive psychoeduca- tional, or supportive, multiple-family group program (46). However, both programs provided levels of support and education to families that far sur- passed those provided by usual serv- ices. It will be necessary to conduct studies designed to identify the least intensive and smallest effective “dose” of family psychoeducation.

Second, increasing the sophistica- tion, variety, and scope of indicators that are used to measure “benefit” is essential. Commonly used bench- marks are subject to complicated in- tervening variables and need to be correlated with other results. For ex- ample, a greater number of hospital- izations for a mentally ill person dur- ing the year after family psychoedu- cation could be a positive sign if it in- dicates that a previously neglected consumer is getting care and that the family is getting better at identifying prodromal symptoms that indicate an impending relapse (4). The well-be- ing and health of the family should be routinely measured as well.

A third knowledge gap involves the relationship between family psychoe- ducation and other programs. Since the conception of family psychoedu- cation, other psychosocial programs have developed a substantial eviden- tiary base, including supported em- ployment and assertive community treatment (47,48). For example, as- sertive community treatment com- bined with family psychoeducation has been associated with better non- competitive employment outcomes than assertive community treatment alone (22). The combination of as- sertive community treatment, family psychoeducation, and supported em- ployment has been associated with better competitive employment out- comes than conventional vocational rehabilitation, although the contribu- tions of each component could not be assessed in that study (49). The op- portunities for family psychoeduca- tion to be combined with or com- pared with these new psychosocial models have not been fully explored.

Fourth, research is needed to re- fine the interventions so that they better address different types of fam- ilies, different situations, and differ- ent time points throughout the course of illness. For example, there is some evidence that individualized consulta- tion may be more beneficial than group psychoeducation for families who have existing sources of support or who already belong to a support group (50–52).

Fifth, although family psychoedu- cation has been tested in a wide range of national and global settings, there is still a need to assess modifications in content and outcome among par- ticular U.S. subcultures and in other countries. In the United States the one study involving Latino families had mixed results (53,54). However, studies in China (55–57) as well as studies that are under way among Vietnamese refugees living in Aus- tralia have had results comparable to those of studies conducted in Cau- casian populations.

Finally, what happens after a family has completed a psychoeducation program? Families of consumers with long-term problems and disability may need ongoing support and en- hanced problem-solving skills to deal

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Family

psychoeducation

has a solid research base,

and leaders in the field have

reached consensus on its

essential components

and techniques.

with the vicissitudes of illness. Lefley (58) has described ad hoc psychoedu- cation in informal settings, such as an ongoing family support group con- ducted through a medical center. Mc- Farlane (4,59) has used a usually open-ended multiple-family group structure. NAMI’s Family-to-Family program is limited to 12 sessions of formal education but offers continu- ity in the NAMI support and educa- tional group structure (14).

Barriers to implementation Despite the gaps in the research, the extensive documentation of the basic benefits of family psychoeducation prompts the question of why this service is rarely offered. In general, low levels of contact between clinical staff and family members in public and community-based settings may preclude the more substantial educa- tional or support interventions. Also, the availability of any intervention is limited by the availability of people to provide it and the training necessary to equip those people. The requisite clinicians, resources, time, and reim- bursement have not been forthcom- ing. These deficits imply the exis- tence of larger obstacles related to at- titudes, knowledge, practicality, and systems.

Consumers and family members Implementation of family psychoedu- cation may be hindered by realities in the lives of potential participants. Practical impediments such as trans- portation problems and competing demands for time and energy are common (50). If family members per- ceive that the training provided through family psychoeducation in- volves expectations of additional care- giving responsibilities, they may stay away (16). Sessions must be sched- uled during periods when facilitators are available, but these times may not suit the clients and their families. Family members face significant bur- dens that may pose barriers to attend- ing family psychoeducation sessions, even though attendance could lighten these burdens (60,61).

In addition, stigma is common— family members may not want to be identified with psychiatric facilities. They may feel uncomfortable reveal-

ing that there is psychiatric illness in their family and airing their problems in a public setting. They may have had negative experiences in the past and be hesitant to expose themselves to the possibility of further negative experiences. Most people have not had access to information about the value of family psychoeducation and so may not appreciate the potential utility of these programs (16). They may believe that nothing will help. Consumers may have similar appre- hensions and may worry about losing the confidential relationship with their treatment teams or about losing autonomy.

Clinicians and program administrators The lack of availability of family psy- choeducation may reflect an under- appreciation on the part of mental health care providers of the utility and importance of this treatment ap- proach (16,18,31,50). Providers may choose medication over psychosocial interventions, and family involve- ment may seem superfluous. In addi- tion, some providers may still adhere to theories that blame family dynam- ics for schizophrenia. Bergmark (62) noted the persistence of psychody- namic theories as a potential barrier, because many families perceive these theories as blaming. The findings on expression of emotion—the original basis for family psychoeducation— are often perceived similarly despite researchers’ attempts to avoid imply- ing blame (16,50).

Although the knowledge and un- derlying assumptions of individuals are important, they are only part of the picture. Wright (63) found that job and organizational factors were much better predictors of the fre- quency of mental health profession- als’ involvement with families than were professionals’ attitudes. The clinician’s work schedule and profes- sional discipline were the strongest predictors, but other organizational factors posed barriers as well. Dis- semination of the multiple-family psychoeducation group model devel- oped by McFarlane and colleagues (64,59) has been hindered by a pauci- ty of programmatic leadership, con- flicts between the model’s philosophy

and typical agency practices, insuffi- cient resources, and inadequate at- tention to human dynamics at the system level. For example, reason- able concerns about confidentiality may be seen as roadblocks to family involvement rather than as opportu- nities to create useful innovations (65). Similar barriers to implementa- tion of family treatment approaches have been identified in studies in Italy (66).

Mental health professionals have also expressed concern about the cost and duration of structured family psychoeducation programs (67), even though medication and case manage- ment services for clients usually have to be continued for much longer pe- riods than family programs. The lack of reimbursement for sessions with families that do not involve the men- tally ill relative—a characteristic of many family psychoeducation pro- grams—is a significant disincentive to providing such services. Caseloads are universally high, and staff’s time is stretched thin. Therefore devoting substantial human resources to train- ing, organizing, leading, and sustain- ing family psychoeducation is seen as a luxury (16). In such an atmosphere, horizons tend to be short. The long- term payoff of fewer crises and hos- pitalizations and lower total costs of treatment is overshadowed by imme- diate organizational crises or short- term goals (16).

Mental health authorities At the health-system level, pressures to focus on outcomes, cost-effective- ness, and customer satisfaction seem in principle to favor the widespread adoption of family information and support interventions. However, oth- er tenets of the current health care environment—such as the emphasis on short-term cost savings, technical rather than human-process-oriented remedies, and individual patholo- gy—discourage clinicians from pro- viding such services, which may be viewed as ancillary. At this level, it seems that the evidence for family psychoeducation has not been ac- cepted. Many of the consumer- and program-level impediments we have mentioned are paralleled in the larg- er administrative systems: lack of

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awareness of evidence, ingrained as- sumptions about how care should be structured, and inadequate re- sources.

Overcoming barriers to implementation Research on technology transfer has identified four fundamental condi- tions that must be met for change to occur at the individual or system lev- el: dissemination of knowledge, eval- uation of programmatic impact, availability of resources, and efforts to address the human dynamics of re- sisting change (68). Implementation strategies must include clear, wide- spread communication of the models and of their benefits to all stakehold- ers. This communication must occur through channels that are accessible and acceptable to the various stake- holders (16), including families, con- sumers, providers, administrators, and policy makers. It must be accom- panied by advocacy, training, and su- pervision or consultation initiatives to raise awareness and support at all or- ganizational levels (69).

The consumer and family members At the level of the individual con- sumer and members of his or her family, effective treatment models include strategies for overcoming barriers to participation, such as stigma and a sense of hopelessness. Such strategies include offering to hold sessions in the home of the client or family member; helping family members understand that the intervention is designed to improve the lives of everyone in the family, not just the patient; being flexible about scheduling family meetings; and providing education during the engagement process to destigmatize mental illness and engender hope (70,71).

Recent efforts to disseminate fam- ily psychoeducation in New York State, Los Angeles, Maine, and Illi- nois have illustrated clearly the im- portance of including clients and their families in the planning, adapta- tion, and eventual implementation of family psychoeducation (72). In New York, dissemination was initiated and sponsored by the state NAMI chap- ter (73). Dissemination in Maine and

Illinois had dramatically different outcomes, partly because NAMI’s Maine chapter provided strong for- mal support for the effort in that state, whereas the effort in Illinois did not involve NAMI’s Illinois chap- ters (73).

Experience and now some empiri- cal data illustrate the need to include consumers and their families in ef- forts to disseminate family psychoed- ucation. The tension often encoun- tered between some consumer advo- cacy groups and family advocacy or- ganizations can be bridged by em- phasizing the complementarity of the outcomes in family work: as con- sumers’ symptoms are alleviated and their functioning improves, their families become more engaged in and satisfied with community life, and both the family burden and med- ical illness decrease (22,74,75).

Clinicians and program administrators Among professionals working in community mental health services, awareness and evidence, although necessary, are often not sufficient for adoption of new programs. Although interventions must adhere to param- eters of the family psychoeducation model if good client and family out- comes are to be achieved, they also have to be responsive to local organi- zational and community cultures. Engagement and implementation strategies, as well as the interventions themselves, must be tailored to local and cultural characteristics, workload and other stresses faced by clinicians and agencies, particular diagnoses, relationships, the duration of illness and disability, and whether the client is currently receiving medical treat- ment (50,76,77).

Perhaps even more critical to the adoption of family psychoeducation is the need to match both administra- tive support and expectations for evi- dence-based practice with a rationale and explication of the advantages of this treatment approach that are meaningful to clinicians. Advantages can include avoidance of crises, more efficient case management, gratitude from families and consumers, and a more interesting, invigorating work environment for clinicians. Recent

studies have shown that on the whole, knowledge about empirical advantages of family psychoeduca- tion, such as reductions in relapse and rehospitalization rates, carry al- most no weight in convincing work- ing clinicians to change their atti- tudes toward families and adopt new clinical practices (73).

Consensus building among agency staff and directors—including a wide range of concerned parties—in a process of planning from the bottom up is critical but must be tailored to address local operational barriers and contrary beliefs. In addition, success- ful implementation of family psy- choeducation has required ongoing supervision, operational consulta- tion, and general support. In a sense, these characteristics help to build consensus on an ongoing basis. For example, the PORT found that it was possible to change current practice by providing a high level of technical assistance and a supportive environ- ment that reflected staff agreement with the principles and philosophy of the new program (67). The recent dissemination of a family psychoedu- cation program in Los Angeles Coun- ty succeeded because of the persist- ent advocacy of the local NAMI group, the support of top manage- ment, a nine-month training period, the high aptitude and strong commit- ment of the trainees, and the skill of the trainer (72).

Mental health authorities and government Although it is tempting to assume that implementation of family psy- choeducation could be mandated centrally by state mental health au- thorities, experience suggests that a more complex approach is required. Dissemination of a family psychoed- ucation program in New York State succeeded partly because of a part- nership between the state, the NAMI affiliate, and an academic center. Un- fortunately, the state’s mental health authority abruptly terminated this large dissemination program before a widespread impact could be made. Maine’s recent success was initiated by a state trade association of mental health centers and services, with sup- port from but little involvement by

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the state mental health authority, which recently began exploring a for- mal partnership to continue and deepen this largely successful effort. A simultaneous effort in Illinois, ini- tiated by the state authority but dis- tinctly lacking consensus among cen- ter directors or the state NAMI chap- ter, has been less successful (73). One state that has had some success is New Jersey, which was able to dis- seminate family psychoeducation by setting expectations and require- ments at the state level.

With the exception of the New Jer- sey effort, experience suggests that the most promising strategy is one in which provider organizations take the initiative with support from con- sumer and family organizations, the state mental health authority, and the key insurance payers. Appropriate reimbursement for family psychoed- ucation will follow. Experience also suggests that several years of consis- tent effort and ongoing monitoring are required for success. Fortunately, this process is not necessarily an ex- pensive one: Maine implemented its family psychoeducation program in more than 90 percent of agencies for about 25 cents per capita over four years, including evaluation costs. The principal costs are in human effort, especially the effort required to over- come resistance to change.

Delivery of services to families must be subject to accountability and tracking. Although many states en- courage the delivery of services to families, few monitor such services or make funding contingent on the serv- ices being delivered (78). One sys- tem-level option is for mental health centers to create a position for an adult family intervention coordinator, who would serve as the contact per- son for interventions, facilitate com- munication between staff and fami- lies, supervise clinicians, and monitor fidelity (79).

Family-to-Family Education Program In the absence of family psychoedu- cation programs, voluntary peer-led family education programs have de- veloped, epitomized by NAMI’s Family-to-Family Education Pro- gram (FFEP) (14,80–82). FFEP is

currently available in 41 states, many of which have waiting lists. FFEP and other mutual-assistance family programs are organized and led by trained volunteers from families of persons who have mental illness.

These community programs are of- fered regardless of the mentally ill person’s treatment status. They tend to be brief—for example, 12 weeks for FFEP—and mix families of per- sons with various diagnoses, although they focus on persons with schizo- phrenia or bipolar disorder. On the basis of a trauma-and-recovery mod- el of a family’s experience in coping with mental illness, FFEP merges education with specific support mechanisms to help families through the various stages of comprehending and coping with a family member’s mental illness (14). The program fo- cuses first on outcomes of family members and their well-being, al- though benefits to the patient are also considered to be important (50).

Uncontrolled research on FFEP and its predecessor, Journey of Hope, suggests that the program increases the participants’ knowledge about the causes and treatment of mental illness, their understanding of the mental health system, and their well- being (13). In a prospective, natura- listic study, FFEP participants re- ported that they had significantly less displeasure and concern about mem- bers of their family who had mental illness and significantly more em- powerment at the family, community, and service-system levels after they had completed the program (83). Benefits observed at the end of the program had been sustained six months after the intervention. Pre- liminary results from a second ongo- ing study with a waiting-list control design have revealed similar findings.

Although FFEP currently lacks rigorous scientific evidence of effica- cy in improving clinical or functional outcomes of persons who have men- tal illness, it shows considerable promise for improving the well-being of family members. In recent re- search and practice, attempts have been made to optimize the clinical opportunities provided by family psy- choeducation and peer-based pro- grams such as FFEP by developing

partnerships between the two strate- gies. For example, family psychoedu- cation programs have used FFEP teachers as leaders, and participation in FFEP has facilitated eventual par- ticipation in family psychoeducation.

Conclusions The efficacy and effectiveness of family psychoeducation as an evi- dence-based practice have been es- tablished. To date, the use of family psychoeducation in routine clinical practice is alarmingly limited. Re- search has recently begun to develop dissemination interventions targeted at the programmatic and organiza- tional levels, with some success. On- going research must continue to de- velop practical and low-cost strate- gies to introduce and sustain family psychoeducation in typical practice settings. Basic research that identi- fies the barriers to implementing family psychoeducation in various clinical settings is also needed—for example, the impact of clinicians’ at- titudes, geographic factors, funding, disconnection of patients from family members, and stigma—as well as the extent to which variations in these factors mediate the outcomes of edu- cational interventions.

Dissemination could also be facili- tated by further exploring the inte- gration of family psychoeducation with psychosocial interventions— such as assertive community treat- ment, supported employment, and social skills training—and other evi- dence-based cognitive-behavioral strat- egies for improving the treatment outcomes of persons with mental ill- ness. Promising efforts have com- bined the energy, enthusiasm, and expertise of grassroots family organi- zations such as NAMI with profes- sional and clinical programs. ♦

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RReevviieewweerrss NNeeeeddeedd

Psychiatric Services seeks expert reviewers in the follow- ing areas:

♦ Water intoxication ♦ Cognitive-behavioral therapy ♦ Outpatient commitment ♦ Work with the police ♦ Psychiatry in other countries ♦ Experiences of patients and former patients ♦ Telemedicine and telecommunications ♦ Outcome and clinical measurement scales

Reviewers should be familiar with the literature in their areas of expertise, should have published in peer-re- viewed journals, and should be familiar with the content and focus of Psychiatric Services.

Prospective reviewers should send a curriculum vitae, specifying areas of interest, to John A. Talbott, M.D., Editor, Psychiatric Services, American Psychiatric Association, 1400 K Street, N.W., Washington, D.C. 20005 (e-mail, [email protected]).