Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service

February 2012

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Quality Enhancement Research Initiative

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

Minneapolis VA Medical Center

Minneapolis, MN

Timothy J. Wilt, MD, MPH, Director

Family Involved

Psychosocial Treatments

for Adult Mental Health Conditions:

A Review of the Evidence

Investigators:

Principal Investigator:

Laura Meis, PhD

Co-Investigator:

Joan Griffin, PhD 

Research Associates:

Maureen Carlyle, MPH

Nancy Greer, PhD

Agnes Jensen, BS

Roderick MacDonald, MS

Indulis Rutks, BS
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Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

PREFACE

The Quality Enhancement Research Initiative’s (QUERI’s) Evidence-based Synthesis Program 

(ESP) was established to provide timely and accurate syntheses of targeted healthcare topics 

of particular importance to Veterans Affairs (VA) managers and policymakers, as they work to 

improve the health and healthcare of Veterans. The ESP disseminates these reports throughout 

VA.

QUERI provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient outcomes 

and to support VA clinical practice guidelines and performance measures, 

and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of QUERI field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Meis L, Griffin J, Greer N, Jensen A, Carlyle M, MacDonald R, 

Rutks I, Wilt T. Family Involved Psychosocial Treatments for Adult Mental Health Conditions: A 

Review of the Evidence. VA-ESP Project #09-009; 2012

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at Minneapolis VA Medical Center, Minneapolis, MN funded by the 

Department of Veterans Affairs, Veterans Health Administration, Office of Research and 

Development, Quality Enhancement Research Initiative. The findings and conclusions 

in this document are those of the author(s) who are responsible for its contents; the 

findings and conclusions do not necessarily represent the views of the Department 

of Veterans Affairs or the United States government. Therefore, no statement in this 

article should be construed as an official position of the Department of Veterans Affairs. 

No investigators have any affiliations or financial involvement (e.g., employment, 

consultancies, honoraria, stock ownership or options, expert testimony, grants or patents 

received or pending, or royalties) that conflict with material presented in the report.
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Family Involved Psychosocial Treatments for Adult Mental Health 

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TABLE OF CONTENTS

EXECUTIVE SUMMARY

Background.................................................................................................................................................... 1

Methods......................................................................................................................................................... 2

Data Synthesis............................................................................................................................................... 2

Peer Review................................................................................................................................................... 2

Results ........................................................................................................................................................... 2

Discussion...................................................................................................................................................... 8

Future Research............................................................................................................................................. 9

Executive Summary Table........................................................................................................................... 10

Abbreviations Table..................................................................................................................................... 12

INTRODUCTION

Types of Family Treatments for Mental Health Conditions........................................................................ 15

Present Study............................................................................................................................................... 16

Objectives.................................................................................................................................................... 18

METHODS

Topic Development...................................................................................................................................... 20

Search Strategy............................................................................................................................................ 20

Study Selection............................................................................................................................................ 20

Data Abstraction .......................................................................................................................................... 20

Quality Assessment ..................................................................................................................................... 21

Data Synthesis............................................................................................................................................. 21

Rating the Body of Evidence....................................................................................................................... 22

Peer Review................................................................................................................................................. 22

RESULTS

Literature Flow ............................................................................................................................................ 23

Overview of Trials....................................................................................................................................... 24

Results by Key Question ............................................................................................................................. 47

Key Question #1. What is the efficacy of family involved interventions in improving outcomes 

for adult patients with mental health conditions [i.e., how do family involved psychosocial 

treatments compare to no psychosocial treatment: (a) waitlist/no treatment or (b) medication 

management only]? ..................................................................................................................................... 47

Key Question #2. What is the effectiveness of family involved interventions compared to 

alternative interventions in improving outcomes for adult patients with mental health conditions 

[i.e., how do family involved interventions compare to (a) any individually-oriented psychosocial 

intervention or (b) any alternative family involved intervention]? ............................................................. 50

SUMMARY AND DISCUSSION

Summary of Evidence by Key Question ..................................................................................................... 76

Efficacy........................................................................................................................................................ 82

Strength of Evidence ................................................................................................................................... 82
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Conclusions ................................................................................................................................................. 84

Limitations................................................................................................................................................... 86

Recommendations for Future Research....................................................................................................... 87

REFERENCES ................................................................................................................................................... 90

TABLES

Table 1. Empirically Supported Couple and Family Treatment for Mental Health Conditions 

(Baucom 1998).....................................................................................................................................17

Table 2. Number of Publications and Number of Unique Trials for Each Mental Health Condition.............23

Table 3. Summary of Baseline Characteristics, Substance Use Disorders Studies (22 Trials).......................25

Table 4. Summary of Heterogeneity, Substance Use Disorders Studies (22 Trials)........................................26

Table 5. Main Findings, Substance Use Disorders Studies (Alphabetical Order by First Author).................29

Table 6. Intermediate Findings, Substance Abuse Disorder Studies (Alphabetical Order by First Author) ..34

Table 7. Summary of Baseline Characteristics, Bipolar Disorder Studies.......................................................36

Table 8. Summary of Heterogeneity, Bipolar Disorder Studies.......................................................................37

Table 9. Main Findings, Bipolar Disorder Studies (Alphabetical Order by First Author)..............................38

Table 10. Summary of Baseline Characteristics, Schizophrenia Spectrum Disorder Studies...........................39

Table 11. Summary of Heterogeneity, Schizophrenia Spectrum Disorder Studies...........................................41

Table 12. Main Findings, Schizophrenia Spectrum Disorder Studies (Alphabetical Order by First Author)..42

Table 13. Main Findings, Post Traumatic Stress Disorder Studies (Alphabetical Order by First Author).......43

Table 14. Main Findings, Sexual Functioning Disorders Studies (Alphabetical Order by First Author).........45

Table 15. Main Findings, Depression, Eating Disorders, and Smoking Cessation Studies......................... 47

Table 16. Family Interventions since 1996 that Improve Outcomes for US Patients with Mental 

Health Conditions....................................................................................................................... 83

FIGURES

Figure 1. Analytic Framework ................................................................................................................... 19

Figure 2. Literature Flow Diagram ............................................................................................................ 24

Figure 3. Differences between BCT and ICBT: Percent Days Abstinent for Alcohol and Drug Use....... 54

Figure 4. Differences between BCT and ICBT: Relationship Adjustment for AUD and Drug Use 

Disorder Studies.......................................................................................................................... 59

APPENDIX A. Search Strategies............................................................................................................ 100

APPENDIX B. Criteria Used in Quality Assessment...................................................................... 101

APPENDIX C. Peer Review Comments/Author Responses .......................................................... 102

APPENDIX D. Evidence Tables

Table 1. Study Descriptive Information -Substance Abuse Studies..............................................................108

Table 2. Patient Outcomes - Substance Abuse Studies..................................................................................131

Table 3. Family Outcomes - Substance Abuse Studies..................................................................................140

Table 4. Intermediate Outcomes - Substance Abuse Studies.........................................................................149

Table 5. Study Descriptive Information - Bipolar Disorder Studies.............................................................152
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Table 6. Patient Outcomes - Bipolar Disorder Studies..................................................................................160

Table 7. Family Outcomes - Bipolar Disorder Studies..................................................................................165

Table 8. Intermediate Outcomes - Bipolar Disorder Studies.........................................................................166

Table 9. Study Descriptive Information - Schizophrenia Spectrum Disorder Studies.................................167

Table 10. Patient Outcomes - Schizophrenia Spectrum Disorder Studies......................................................174

Table 11. Family Outcomes - Schizophrenia Spectrum Disorder Studies......................................................178

Table 12. Intermediate Outcomes - Schizophrenia Spectrum Disorder Studies.............................................179

Table 13. Study Descriptive Information - Post Traumatic Stress Disorder Studies......................................180

Table 14. Patient Outcomes - Post Traumatic Stress Disorder Studies...........................................................182

Table 15. Family Outcomes - Post Traumatic Stress Disorder Studies...........................................................183

Table 16. Intermediate Outcomes - Post Traumatic Stress Disorder Studies..................................................183

Table 17. Study Descriptive Information - Sexual Functioning Disorders Studies........................................184

Table 18. Patient Outcomes - Sexual Functioning Disorders Studies.............................................................186

Table 19. Family Outcomes - Sexual Functioning Disorders Studies.............................................................187

Table 20. Intermediate Outcomes - Sexual Functioning Disorders Studies....................................................188

Table 21. Study Descriptive Information - Depression, Eating Disorders, and Smoking 

Cessation Studies ..............................................................................................................................189

Table 22. Patient Outcomes - Depression, Eating Disorders, and Smoking Cessation Studies.....................192

Table 23. Family Outcomes - Depression, Eating Disorders, and Smoking Cessation Studies.....................194

Table 24. Intermediate Outcomes - Depression, Eating Disorders, and Smoking 

Cessation Studies ..............................................................................................................................194

APPENDIX E. Forest Plots from Pooled Analyses for Alsohol and Drug Use Studies

Figure 1a. Percent Days Abstinent, Differences between BCT and ICBT: Studies Not Conducted 

with Data from Fals-Stewart.................................................................................................... 195

Figure 1b. Percent Days Abstinent, Differences between BCT and ICBT: Studies Conducted with

Data from Fals-Stewart..................................................................................................................196

Figure 2. Percent Days Abstinent, Differences between BCT and ICBT: Alcohol Use Disorder

Studies Only...................................................................................................................................197

Figure 3. Percent Days Heavy Drinking, Differences between BCT and ICBT: Alcohol Use

Disorder Studies Only....................................................................................................................198

Figure 4. Percent Days Abstinent, Differences between BCT and ICBT: Drug Use Disorder

Studies Only...................................................................................................................................199

Figure 5. Relationship Adjustment using Dyadic Adjustment Scale, Difference in Mean Scores

between BCT and ICBT: Alcohol Use Disorder Studies Only....................................................200

Figure 6. Relationship Adjustment using Dyadic Adjustment Scale, Difference in Mean Scores

between BCT and ICBT: Drug Use Disorder Studies Only ........................................................201

Figure 7. Percent Days Abstinent, Differences between BCT and ICBT: Studies with Female

Subjects Only .................................................................................................................................202

Figure 8. Relationship Adjustment using Dyadic Adjustment Scale, Difference in Mean Scores

between BCT and ICBT: Studies with Female Subjects Only ....................................................203

Figure 9. Percent Days Abstinent, Differences between BCT and ICBT: Studies with Male

Subjects Only .................................................................................................................................204

Figure 10. Relationship Adjustment using Dyadic Adjustment Scale, Difference in Mean Scores

between BCT and ICBT: Studies with Male Subjects Only........................................................205
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Family Involved Psychosocial Treatments for Adult Mental Health 

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EVIDENCE REPORT

Introduction

Since 2008, the President has signed two new laws establishing or expanding VA authority to 

provide family services for Veterans’ mental health care. The first law, Public Law 110-387: 

Veterans’ Mental Health and Other Care Improvements Act of 2008, was signed into law on 

October 10, 2008. Section 301 of the Act amends title 38 of United States Code (U.S.C.) § 

1701(5)(B) and 38 U.S.C. § 1782(a) and (b). This law expands VA authority to provide enhanced 

family mental health services, such as consultation, professional counseling, marriage and 

family counseling, and training to families of patients with Service Connected and Non-Service 

Connected injuries or conditions when 1) no Veteran treatment would otherwise occur without 

the family member’s involvement, 2) the Veteran’s treatment would be less or not effective without 

family member’s involvement, 3) or, the treatment can be delivered most efficiently when the family 

member is included in treatment. The second law, Public Law 111-163: Caregivers and Veterans 

Omnibus Health Services Act, signed in May, 2010, allows, among other things, the VA authority 

to provide these same services to family caregivers of Veterans and directs the VA to provide 

additional benefits (e.g., financial stipends and health care benefits) to a select group of eligible 

caregivers, namely those providing essential care to Veterans injured in Operation Iraqi Freedom 

(OIF) and Operation Enduring Freedom (OEF). Of note, current eligibility criteria for VA familyrelated services do not extend to close friends or intimate partners who do not reside with the 

Veteran. These new laws, along with the VA’s adoption in primary care of Patient-Aligned Care 

Teams, or a patient-centered medical home model, recognize the important role families have 

on a treatment team and their influence over a patient’s care and related outcomes. Synthesis of 

the scientific literature on the effectiveness of involving family or intimate partners (referred to 

hereafter as family, encompassing both intimate partners, spouses, and other family members) in 

psychosocial interventions to treat or improve a broad range of mental health conditions, family 

problems, marital strain, and physical health conditions, including an examination of both patient 

outcomes and caregiver and family outcomes, is essential to shaping the VA’s provision of family 

involved care but beyond the scope of a single review. The focus of the present review is on one 

of these vital areas for synthesis: the effectiveness of family involved interventions in treating 

mental health conditions. This synthesis is intended to help clarify the evidence for potential best 

practices within the VA in family involved mental health care to guide both policy and clinical 

practice. While these family or couple interventions likely also affect caregivers, the focus of 

this review is specifically on patient outcomes (versus caregiver or family member’s personal 

functioning), including patients’ family functioning. 

Types of Family Treatments for Mental Health Conditions

While individual psychotherapies for mental health problems have long been the standard 

for mental health care, family problems are pronounced among patients with mental health 

conditions. Among OEF/OIF Veterans recently returning from deployment, interpersonal 

problems have been identified as increasing at a greater rate than any other health-related 

problem,1 and relationship distress in intimate relationships can facilitate or hinder treatment 

seeking.2 Consequently, family involvement has been explored for a number of conditions, 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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including depression,3 substance use,4 bipolar disorder,5 schizophrenia,6 panic disorder with 

agoraphobia,7

 and posttraumatic stress disorder (PTSD).8 Family interventions for mental 

health conditions can take multiple forms, as outlined by Baucom and colleagues,9

 and may fall 

across any given category or combination of categories.

Partner or Family Assisted Treatment9

In this case, family member(s) act as surrogate therapists or coaches to help the patient. Typically, 

the family aids the patient in completing out-of-session homework within a cognitive-behavioral 

treatment, and relationships between the patient and family are not a focus of treatment. This 

category of family involvement capitalizes on prior work establishing robust associations between 

social support, instrumental support, and treatment adherence across multiple medical conditions.10

Disorder Specific Couple or Family Treatment9

For interventions taking this approach, family behavior and relationships that are theorized to fuel 

disorder symptoms are addressed. Family relationships are targeted only to the extent to which they 

directly influence the patient’s disorder or treatment. Such interventions, especially for schizophrenia 

or bipolar disorder, often target expressed emotions (EE) or related constructs. EE includes family 

members’ expressed criticism, hostility, and emotional over-involvement toward the patient and 

is tied to poor medication adherence, including among patients with schizophrenia,11 and greater 

relapse rates and symptom severity among patients with schizophrenia, eating disorders, depression, 

PTSD, and bipolar disorder,12-15 EE likely reflects disturbances within the entire family system, 

including family organization, emotional climate, and transactions.16 Supported mechanisms 

underlying EE include a family member’s attributions of patient’s negative behavior to controllable 

factors, personal factors, and beliefs that the patient is not making appropriate efforts at selfimprovement.16, 17

Additionally, behavior patterns between family and patients and specific to a given disorder can be 

conceptualized as maintaining the condition, with reciprocal associations postulated between mental 

health symptoms and family functioning.18, 19 For example, environmental contingencies have been 

theorized to maintain use for substance use disorders20 and avoidance of trauma cues for individuals 

with PTSD.21 Additionally, for those with substance use disorders, relationship distress may increase 

substance use cravings, reinforce the use of substances to cope with distress,19 or even motivate 

patients to remain sober due to fears of relationship dissolution.22

General Marital OR Family Treatment9

Interventions taking this approach directly address general family or relationship distress, under 

the assumption that improving family functioning will reduce patient stressors and improve 

patient functioning.9

Present Study

With one known exception,9 prior reviews have focused on a discrete number of mental health 

conditions at a time (i.e., a review of family treatments for depression). To the best of our 

knowledge, the most recent comprehensive review that included family involved interventions for 

any mental health condition was published in 1998.9

 A comprehensive review is called for to update 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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the evidence, to serve VA needs, and to facilitate comparisons of the evidence across conditions. 

Additionally, such a review can highlight family interventions for mental health conditions that may 

not have been addressed in recent prior reviews due to too few RCTs to warrant a disorder specific 

review (i.e., sexual functioning disorders, PTSD). Prior reviews are potentially less relevant to VA 

populations due to their focus on studies conducted both nationally and internationally. Studies 

conducted outside the US (i.e., family interventions within Eastern societies) may be less relevant 

to US Veterans, given important cultural differences in family structure and function. Finally, given 

the VA’s interest in including families in order to improve the quality of care provided in the VA, an 

important question to address is the comparative efficacy of family involved interventions versus 

individual-only treatment approaches.

In the only known comprehensive review of family involved psychosocial treatments for mental 

health conditions, Baucom and colleagues9

 established categories for evaluating the efficacy of 

a couple/family intervention, based upon Chambless and Hollon’s23 definition of empirically 

supported treatments (i.e., “clearly specified psychological treatments shown to be efficacious 

in controlled research with a delineated population,” p. 7). They define an efficacious treatment 

as one in which the intervention has demonstrated superiority over waitlist control in studies 

conducted by two independent research teams. An efficacious and specific intervention has 

demonstrated superiority in at least two studies conducted by independent research teams over 

a placebo, nonspecific, or alternative intervention. They modify these labels with possibly (i.e., 

possibly efficacious and possibly efficacious and specific) when the above criteria are met by a 

single study. Using these criteria, the conclusions from the 1998 review are outlined in Table 1. 

Table 1. Empirically Supported Couple and Family Treatments for Mental Health Conditions 

(Baucom 19989)

Mental Health Condition Intervention Efficacy Status

Schizophrenia

Behavioral Family Therapy24-28 1

Supportive Family Therapy29 30-32 1

Family systems33 3

Alcohol Use Disorders Community Reinforcement Approach34-36 3

Behavioral Marital Therapy37, 38 3

Female orgasmic disorder Sexual skill training for primary female orgasmic disorder39, 40 3

Masters and Johnson for female orgasmic disorders41 3

Mixed female sexual 

dysfunctions Behavioral Marital Therapy + Masters and Johnson42 3

Female hypoactive sexual 

desire Marital + orgasm consistency training43 3

Depression Behavioral Marital Therapy44, 45 4

Obsessive Compulsive 

Disorder

Family-assisted exposure therapy46 4

Partner-assisted exposure therapy47, 48 4

Agoraphobia

Partner-assisted exposure therapy49-53 4

Partner-assisted Cognitive-Behavioral Therapy54 4

Partner-assisted exposure + couple communication training55 4

Efficacy Status:

1 = Efficacious & Specific; superior to placebo, nonspecific, or alternative intervention in at least two studies 

conducted by independent research teams.

2 = Efficacious; superior to waitlist in RCTs conducted by two independent research teams. 

3 = Possibly Efficacious & Specific; criteria met for efficacious and specific from a single study. 

4 = Possibly Efficacious; criteria met for efficacious from a single study.9, 23
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Baucom and colleagues9concluded that family involved treatments for schizophrenia were 

clearly efficacious for reducing relapse rates. These family treatments often incorporated 

elements from all three types of approaches to family involvement (family assisted interventions, 

disorder specific interventions, and family/couple therapy). These findings are largely 

consistent with larger reviews of empirically supported treatments.23 Chambless and Ollendick56

reviewed the American Psychiatric Association’s Task Force and various other work groups’ 

recommendations for psychosocial interventions considered efficacious and possibly efficacious, 

using similar criteria and including family treatments. Their review largely overlaps with 

Baucom and colleagues’9

 conclusions, with a few exceptions. First, one group57 identified 

behavioral marital therapy as efficacious for depression among patients with marital discord and 

a second58 identified behavioral marital therapy as possibly efficacious for depression. Second, 

multiple work groups identified the Community Reinforcement Approach and behavioral couple 

therapy for alcohol use disorders as either efficacious or possibly efficacious.

OBJECTIVES 

The present study provides an update to prior work conducted by Baucom9 and others56by 

examining the effectiveness of family involved psychosocial treatments in US samples for 

mental health conditions. Due to our focus solely on mental health conditions and US studies, 

our findings are not intended to be a strict replication and extension of Baucom and colleagues’9

prior review. We conducted a systematic review of randomized controlled trials (RCTs) of 

psychosocial interventions, addressing a mental health condition through a family intervention. 

Given prior work already conducted in this area, we focused on only those studies conducted 

after 1995. To optimize relevance to Veterans and the VA, in addition to a focus on US studies, 

we limited our review to improvements in patient functioning, including patient symptoms and 

family/couple functioning (primary outcomes) and treatment adherence, treatment attendance, 

patient satisfaction, and social support for patients (intermediate outcomes). Figure 1 provides 

our analytic framework, depicting our population, interventions, comparators, and outcomes 

of interest. We were interested in reviewing the evidence of the efficacy of family involved 

interventions (compared to no psychosocial intervention), as well as the degree to which family 

involved interventions are superior to an alternative individually-focused or family involved 

intervention (i.e., specificity). 

We sought to address two specific questions: 

Key Question #1. What is the efficacy of family involved interventions in improving outcomes 

for adult patients with mental health conditions [i.e., how do family involved psychosocial 

treatments compare to no psychosocial treatment: (a) waitlist/no treatment or (b) medication 

management only]?

Key Question #2. What is the effectiveness of family involved interventions compared to 

alternative interventions in improving outcomes for adult patients with mental health conditions 

[i.e., how do family involved interventions compare to (a) any individually-oriented psychosocial 

intervention or (b) any alternative family involved intervention]?
19

reatments for Adult Mental Health

dence Evidence-based Synthesis Program

Final OutcomesPatient Outcomes: Symptom improvement, functional improvement, quality of life, length of stay, discharge disposition, utilization Family Outcomes: Family functioning, relationship/couples functioning

Intermediate Patient OutcomesTreatment attendance/ adherence, social support for patients, patient satisfaction with care

arators: 

No psychotherapy or 

acebo

Individually-oriented 

atment/usual 

re/alternative family 

atment

ention: 

 involved care

Adverse

Effects
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Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

METHODS

TOPIC DEVELOPMENT

This project was nominated by Sonja Batten, PhD, Office of Mental Health Services. The key 

questions and scope were refined with input from a technical expert panel.

SEARCH STRATEGY

We searched MEDLINE (Ovid) and PsycINFO for randomized controlled trials (RCTs) and 

systematic reviews published from 1980 to November, 2011 using standard search terms. We 

limited the search to articles involving adolescents and adults and published in the English 

language. Search terms included: family, couples, home nursing, legal guardians, couple therapy, 

family therapy, and marital therapy. The search strategies are presented in Appendix A.

We obtained additional articles from systematic reviews, reference lists of pertinent studies, and 

suggestions from members of our technical expert panel.

STUDY SELECTION

Titles and abstracts were reviewed by researchers trained in the critical analysis of literature. 

Full text versions of potentially eligible articles were retrieved for review. Although our search 

identified studies of patients with both mental health and physical health conditions published 

from 1980 to the present, due to the volume of eligible articles identified by our search, we 

narrowed our inclusion criteria at the time of full-text review to include the following:

• RCT conducted in the United States or systematic review or meta-analysis of RCTs.

• Study involves a patient age 18 and over with a DSM-III or DSM-IV mental health

condition.59, 60

• Intervention must involve family members or caregivers of the adult patient (patient may 

or may not be present for the intervention).

• Study reports intermediate patient outcomes or final outcomes of interest as outlined in 

the analytic framework (Figure 1).

• Control group must be used; control group may be no treatment/placebo or an alternative 

active treatment (e.g., usual care, individually-oriented treatment, or another family/

couple-oriented intervention).

• Study published in a peer-reviewed publication after 1995.

DATA ABSTRACTION

We abstracted the following study characteristics for each included study: author, date of 

publication, funding source, sample characteristics (gender, age, race/ethnicity, marital status, 

education, Veteran status, family characteristics, and recruitment method), inclusion and 

exclusion criteria (mental health condition, how the condition was assessed, family/caregivers 

involved, specific inclusion and exclusion criteria), treatment groups, intervention characteristics 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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(format, whether manualized, number of sessions, treatment length, approach, and treatment 

integrity), outcomes assessed (list of patient, family/couple, and intermediate outcomes 

assessed), and study quality (allocation concealment, blinding, analysis approach, description 

of withdrawals). We extracted final outcomes (patient outcomes and family/couple functioning 

measures) and intermediate outcomes, by mental health condition, for each treatment arm, where 

reported, and noted whether the analysis included all patients randomized or study completers 

only. Final patient outcomes of interest were: symptom improvement, global functioning, 

quality of life, length of stay, disposition at discharge, and health care utilization. The family/

couple functioning outcome of interest in all studies was global function or satisfaction. We 

also were interested in intimate partner violence, communication skills and relationship conflict, 

observational data of communication skills among couples, and sexual satisfaction. Sexual 

satisfaction was abstracted under patient symptom improvement for studies of treatment for 

sexual dysfunction and as a measure of couples functioning in the studies of treatment for 

substance abuse. Intermediate outcomes of interest were treatment attendance, adherence, social 

support for the patient, and satisfaction with care. We assessed outcomes at a number of different 

time points in order to determine initial and persistent changes in behavior. When available, 

we examined behavior at baseline, after treatment (post-treatment), short-term follow-up (up 

to 6 months), and long-term follow-up (up to 12 months or longer) across treatment arms. All 

abstraction was done by trained research personnel and verified by a second research associate 

under the supervision of the Principal Investigator.

QUALITY ASSESSMENT

We assessed study quality of included trials (all were randomized, controlled trials) according to 

the following criteria: 1) adequate allocation concealment, 2) blinding of key study personnel, 

3) analysis by intention-to-treat, and 4) reporting of number of withdrawals/dropouts by group 

assignment.61 We also considered whether the treatment protocol was manualized and whether 

the quality and consistency of the treatment protocol was evaluated (i.e., treatment integrity) as 

part of the quality assessment for individual studies. Studies were rated as good, fair, or poor 

quality. A rating of good generally indicated that the treatment was manualized and integrity 

was assessed. In addition, the trial reported adequate allocation concealment, blinding, analysis 

by intent-to-treat, and reasons for dropouts/attrition. Studies were generally rated poor if the 

treatment was neither manualized nor assessed for quality, the method of allocation concealment 

was inadequate or not defined, blinding was not defined, analysis by intent-to-treat was not 

utilized, and reasons for dropouts/attrition were not reported and/or there was a high rate of 

attrition. 

DATA SYNTHESIS

We constructed evidence tables showing the study characteristics and results for all included 

studies, organized by clinical condition. We critically analyzed studies to compare their 

characteristics, methods, and findings. We compiled a summary of findings for each key question 

and drew conclusions based on qualitative synthesis of the findings or pooled analyses where 

feasible.
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Family Involved Psychosocial Treatments for Adult Mental Health 

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RATING THE BODY OF EVIDENCE

We assessed the overall strength of evidence using the method reported by Owens et al.62 The 

overall evidence was rated as: (1) high, meaning high confidence that the evidence reflects the 

true effect; (2) moderate, indicating moderate confidence that further research may change our 

confidence in the estimate of effect and may change the estimate; (3) low, meaning there is low 

confidence that the evidence reflects the true effect; or (4) insufficient, indicating that evidence 

either is unavailable or does not permit a conclusion. 

PEER REVIEW

A draft version of this report was reviewed by members of our technical expert panel and VA 

clinical leadership. Their comments and our responses are presented in Appendix C. Responses 

were also incorporated into the final report. 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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RESULTS

LITERATURE FLOW

We reviewed 2,469 titles and abstracts from the electronic search. After applying our initial 

inclusion/exclusion criteria at the abstract level, 2,025 references were excluded. We retrieved 

444 full-text articles for further review and another 397 references were excluded. Inclusion 

criteria added at the full-text review stage included limiting the scope of the review to patients 

with mental health conditions and articles published after 1995. Four articles were identified 

by hand search. We therefore identified a total of 51 references for inclusion in the current 

review representing 39 unique projects. We grouped the studies by mental health condition and 

addressed the key questions for each condition. Table 2 details the number of publications and 

number of unique projects per condition.

Table 2. Number of Publications and Number of Unique Trials for Each Mental Health Condition

Mental Health Condition Publications Unique Trials

Substance Use Disorders 26 22

Schizophrenia Spectrum 8 4

Bipolar 10 6

Depression 1 1

Eating Disorders 1 1

Nicotine Dependence 1 1

Posttraumatic Stress Disorder (PTSD) 2 2

Sexual Dysfunction 2 2

Total 51 39

Figure 2 details the exclusion criteria and the number of references excluded at the abstract and 

full-text review stages. 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Figure 2. Literature Flow Diagram

Excluded = 2,025 references

Study not conducted in the US. = 315

Not adult population = 361

Not a peer reviewed, randomized trial = 291

Not a condition of interest, or study is about prevention = 281

Intervention is not counseling, therapy, education, 

 or family based treatment involving a family member = 587

No patient outcomes of interest = 172

Not a mental health diagnosis = 17

Paper published prior to 1990 = 1

Search results =

2,469 references

Excluded = 397 references

Study not conducted in the U.S. = 121

Not adult population = 9

Not a peer reviewed, randomized trial = 34

Not a condition of interest, or study is about prevention = 17

Intervention is not counseling, therapy, education, 

 or family based treatment involving a family member = 33

No patient outcomes of interest = 48

Not a mental health diagnosis = 78

Paper published prior to 1990 = 36

Paper published 1990 – 1995 = 21

Pulled for full text review =

444 references

Identified by hand search/author 

correspondence = 

4 references

Included = 51 references

(39 unique studies)

OVERVIEW OF TRIALS

Substance Use Disorders

The largest set of studies that met our criteria was from the substance use disorder (SUD) 

literature. Detailed descriptions of the study characteristics and outcomes are provided in 

Appendix D, Tables 1 to 4. We found twenty-six papers that met our criteria for substance use 

disorders, representing twenty-two unique RCTs. As summarized in Table 3 below, the 22 RCTs 

were nearly split between trials for treatment of alcohol (n=11) and drug use (n = 9) and two 

studies included treatment for either alcohol or drug use.63, 64 Most studies (16 of 22) verified the 

SUD by a structured interview using DSM criteria.60

Population Studied

Subject and intervention characteristics are summarized in Tables 3 and 4. There were a total 

of 1623 patients studied, ranging from 29 to 184 participants in a single trial. Samples sizes for 

treatment conditions were small. Over 60% of the twenty-two trials (n=14) had an intervention 

condition arm with 30 or fewer subjects. The average patient and family member were each 38 
25

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

years old. Patients were racially diverse (69% non-white, on average) and typically male (77%) 

with a female participating family member or intimate partner (76%). All subjects were married 

or cohabitating in all but four of the trials reporting marital status. Two trials4, 65 were conducted 

with Veteran samples; none reported whether the family member was a Veteran. Eleven trials 

limited their participants to men,4, 63, 65-73 including five alcohol use disorder (AUD) trials,4, 65, 71-

73 five drug use disorder trials,66-70 and one trial that included those with drug use or alcohol use 

disorders.63 Three trials limited patients to women.74-76 These included two AUD trials74, 75 and 

one drug use disorder trial.76 The remaining seven trials included both men and women.64, 77-82 Of 

these, two were AUD trials,79, 81 four were drug use disorder trials,77, 78, 80, 82 and one trial included 

subjects with either alcohol or drug dependence.64

Table 3. Summary of Baseline Characteristics, Substance Use Disorders Studies (22 trials)

Characteristics Number/mean (range) Number of trials reporting

Total number of patient/family dyads randomized 1623 (29-184) 19

Total number of patients from dyads analyzed 1589 (28-184) 19

Total number of family randomized for family only 

studies (patient not involved in intervention)

252 (32-130) 3

Total number of family only analyzed (patient not 

involved in intervention)

252 (32-130) 3

Marital status, % married 82% (17-100%) 16

Patient gender, % male 80% 20

Family member gender, % female 76% 17

Race, % non-white patients 31.5% (2-59.5%) 18

Veterans, % 100 2

Age of patients, years 38.0 (27.7-47.8) 19

Age of family members, years 37.8 (28.8-55.3) 13

Although we had a broad definition of family for inclusion in our review, most of the studies 

examined the effects of including a spouse or romantic partner in treatment. Of the twenty-two 

trials, 15 included a spouse or partner (wife/female partner = 10; husband/male partner = 3; 

either husband or wife/romantic partner = 3) of the subject.4, 63, 65-67, 69-76, 78, 79 Seven trials did not 

restrict to wives or partners, allowing adult children, partners, or friends to participate.64, 68, 77, 80-83

One of these trials specified any family member who was not a spouse or partner was eligible.82

Inclusion of Patients with Comorbid Conditions

Rates of co-occurring conditions among participants were not typically reported. However, in 15 

trials, individuals with co-occurring serious mental health conditions defined as an organic mental, 

paranoid, psychotic disorders or schizophrenia, were typically excluded from participation. Patients 

at risk of harming oneself or others, including those with suicidal/homicidal ideation or history of 

domestic violence were excluded in three trials and one study reported excluding anyone with a 

psychiatric condition that may affect informed consent for treatment.

Intervention

By far the most commonly investigated family involved intervention (17 of 22 trials) was 

behavioral couples, marital, or family therapy (BCT/BMT/BFT), a dyadic (one patient and one 

family member/intimate partner), disorder-specific, couple/family treatment, designed to address 

a SUD through 1) cognitive behavioral strategies to promote abstinence, involving the family 
26

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

member, and 2) traditional behavioral couple therapy techniques to enhance communication, 

problem solving skills, and relationship satisfaction.9

 For simplicity, we use BCT in this review 

to refer to behavioral couple therapy for SUDs that includes either a spouse or an unmarried 

intimate partner (BCT or BMT). BFT refers to the same intervention, but including other 

family members. BCT/BFT were typically delivered in an outpatient setting, and with only two 

exceptions,4, 64 participants were recruited from outpatient settings, the community, or the media, 

rather than following an inpatient stay. The length of the intervention varied, ranging from 10 to 

56 weeks. The other psychological interventions reviewed included motivational enhancement 

treatment with psychoeducation and couple therapy (Helping Other Partners Excel or HOPE)70

and community reinforcement training with families (i.e., CRAFT), an intervention delivered 

solely to the families of patients with SUDs to enhance communication, build skills, and develop 

coping strategies that would encourage the family’s loved one to enter treatment.80, 81, 83 HOPE 

and CRAFT were conducted in outpatient settings, and treatments ranged from 2 to 24 weeks.

Table 4. Summary of Heterogeneity, Substance Use Disorders Studies (22 trials)

Number of trials 

reporting

Subjects diagnosed with: Alcohol use disorders only 11

Drug use disorders only 9

Either drug or alcohol use disorders 2

Diagnosis verified by structured interview: Yes 16

Not reported 6

Family intervention with: Wife/female intimate partner 11

Husband/male intimate partner 3

Husband/wife or male/female intimate partner 2

Any identified family member 5

Anyone but spouse 1

Family intervention compared to: Waitlist 0

Drug treatment only 2

Treatment as usual or individual treatment(s) 14

Other family treatment (s) 6

Subject gender: Men 12

Women 3

Both men and women 7

Comparison Interventions and Study Designs

Family involved treatments were compared to one (11 trials4, 64, 66-68, 70, 76, 79, 80, 82, 84-86), two 

(9 trials63, 65, 71-74, 77, 81, 83, 86, 87), or three (2 trials69, 78) comparison interventions. Comparison 

interventions included 1) medical observation only (1 trial64); 2) individual treatment(s) only (10 

trials66-68, 70, 75-77, 79, 80, 82); 3) individual and alternative family involved treatment(s) (8 trials63, 69, 71, 

73, 74, 78, 81, 83); or 4) only an alternative family involved treatment (3 trials4, 65, 72).

Comparison to Medical Observation

As noted, one study compared a family involved treatment to medical observation only and was 

reviewed for Key Question 1. In this study, authors tested the effect of a family intervention on 
27

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

the utilization of continuing care after patients were discharged following hospital admission 

for alcohol detoxification. Male and female participants admitted to an inpatient detoxification 

unit for alcohol use (with or without comorbid drug dependence) and a family member were 

randomized into either treatment as usual (consisting of assisting the patient with withdrawal 

symptoms, monitoring risks for developing serious problems during withdrawal, but no family 

involvement) or a brief family intervention. The family intervention included two meetings with 

participants and family members (either a spouse or parent) to review continuing care plans both 

prior to and after discharge and develop strategies for successful outcomes. This intervention 

was delivered by phone and in-person, depending on what was most convenient for the family 

member.

Comparison to Individual Treatment Only

Fifteen trials compared family involved treatments to individual behavioral treatment.63, 66-71, 73-79, 

82 These trials were reviewed to assess evidence for Key Question 2A. 

Seven of the fifteen trials were two-armed trials that directly compared BCT to individual 

cognitive-behavioral therapy (ICBT).66-68, 75, 76, 79, 82 An additional six trials compared BCT to 

ICBT and another family involved treatment(s) or variation of BCT. Three of the six trials63, 

73, 74 compared BCT to ICBT plus a psychoeducational program serving as an attention control 

condition. Two of these trials had the same psychoeducational program (Psychoeducational 

Attention Control Treatment or PACT)63, 74 while the other was slightly different, but had 

common strategies and education targets with the PACT treatment.73 Two other trials also 

included a comparison of BCT to ICBT and PACT, but also included a fourth arm to compare 

standard BCT to a briefer version of the therapy (B-BCT).69, 78 Another three-arm trial71 compared 

BCT to ICBT, but also a variation of BCT that included a parent training intervention. Results 

from these trials that compared a family involved intervention to an individual treatment were 

used to assess evidence for Key Question 2A.

The remaining two trials70, 77 did not use BCT, but instead another family involved treatment. 

One was three-arm trial that included male and female participants with a substance abuse 

diagnosis who were assigned either to 1) naltrexone with ICBT; 2) naltrexone, ICBT, plus 

contingency management (incentives for participants to remain in treatment); 3) naltrexone, 

ICBT, contingency management, and reciprocal relationship counseling for the patient and a 

family member, friend, spouse, or child.77 The second non-BCT trial was a two-armed trial that 

compared group motivational enhancement therapy with psychoeducation and couple therapy 

(Helping Other Partners Excel, HOPE) to a counselor-led drug treatment support group for men 

with drug use disorders.70

Comparison to Alternative Family Treatment(s) Only

Six trials compared family involved treatments to one or more alternative family treatments.4, 65, 

72, 80, 81, 83 Evidence from these trials were used to assess evidence for Key Question 2B. Two of 

these trials4, 72 compared Behavioral Marital Therapy (BCT) to BCT plus a relapse prevention 

condition. O’Farrell and colleagues 4 conducted a two armed trial that directly compared these 

two conditions; the trial by McCrady et al.72 was a three-armed trial that compared BCT to BCT 

plus relapse prevention or to BCT plus a self-help group for family members. Another trial that 
28

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

compared family involved treatments was also by O’Farrell et al.65 In that two-armed trial, a 

combination of BCT and ICBT was compared to BCT and interactional treatment, a therapy 

approach that does not pre-plan therapy sessions, but instead focuses on mutual support, sharing 

of feelings, and problem solving through discussion. The remaining three studies were unique 

in that they targeted the family members of patients with a drug use disorder, not the patient 

with the disorder, directly.80, 81, 83 Each of these three trials compared a family intervention to 

alternative treatments for families. In Kirby and colleges two-armed trial,80 family members 

(spouses, parents, siblings) were randomized into either a 12-step self-help group counseling 

program or a community reinforcement training (CRT) which included individual counseling 

for a family member to enhance communication, build skills, and develop coping strategies that 

were specific to the subject’s drug use disorder. The other two trials were similar. A variation 

of the community reinforcement training, called the community and reinforcement and family 

training (CRAFT) was tested. Like Kirby et al.,80 both compared CRAFT to a 12-step selfhelp group counseling program. In the trial by Meyers et al.,83 these two conditions were also 

compared to a CRAFT plus aftercare, which consisted of additional group therapy with family 

members for 6 months after the CRAFT intervention. In the trial by.81 CRAFT and the selfhelp conditions were compared to a Johnson Institute intervention, where families confront the 

alcoholic about their abuse and describe their own experiences and observations about the abuse 

in order to encourage treatment engagement. 

Outcomes

The most common patient outcomes reported were self-reported days of abstinence within a 

specified period of time, self-reported quantity and/or frequency of substance use, and initiation 

of treatment (utilization of care). The degree of symptom relief was commonly measured by the 

percentage of days abstinent (PDA) from alcohol or drugs or the percentage of heavy drinking 

days (PDHD), typically using the Time-Line Follow Back procedure (TLFB).88 Tables 5 and 6 

provide an overview of our findings. The most frequently reported family outcome was family or 

couple functioning, most often measured by the Dyadic Adjustment Scale (DAS). Length of time 

that participants were followed for assessments was variable, but typically included at the least 

a post-treatment or short-term assessment and in many cases assessments every 3 months for 12 

months after treatment termination.
29

reatments for Adult Mental Health

dence Evidence-based Synthesis Program

ance Use Disorders Studies (Alphabetical Order by First Author)

Patient Outcomesa Family Outcomes

s Symptoms Utilization Family Functioning Couple Functioning Intimate Partner Violence Communication/ Conflict

 ICBT+Contingency 

nt + Naltrexone vs.

Cond. 1) vs. 2): Post: nsCond. 1)& 2) vs. 3): Post: ns

Cond. 1) vs. 2): Post: +

5

 therapy 

(1996)Post: nsShort term: nsLong term: ns(2000) Long term: +

Marital Happiness Scale :(1996)Post: +Short term: nsLong term: ns(2000)Long term: +% days separated:Post: +Short term: +Long term: ns

(2002)Long term: +

(1996)Post: +Short term: nsLong term: ns

ent package vs.

ntenance (standard 

Post: + Post: +

Therapy vs.

erapy

Post: +Long term: +

Long term: +

apy vs.

vs.

trol treatment

Cond. 1) vs. 2)b

Post: nsShort term: nsLong term: +Cond. 3) vs. 2)Post: +Short term: +Long term: +Cond. 1) vs. 4)Post: nsShort term: +Long term: +Cond. 3) vs. 4)Post: nsShort term: nsLong term: ns

Cond. 1) vs. 2)b

Post: +Short term: +Long term: +Cond. 3) vs. 2)Post: +Short term: +Long term: +Cond. 1) vs. 4)Post: +Short term: +Long term: +Cond. 3) vs. 4)Post: +Short term: +Long term: +
30

reatments for Adult Mental Health

dence Evidence-based Synthesis Program

Patient Outcomesa Family Outcomes

s Symptoms Utilization Family Functioning Couple Functioning Intimate Partner Violence Communication/ Conflict

trol treatment

Cond. 1) vs. 2) Post: nsShort term: nsLong term: nsCond.1) vs. 3)Post: nsShort term: nsLong term: ns

Cond. 1) vs. 2) Post: +Short term: +Long term: +Cond.1) vs. 3)Post: +Short term: +Long term: +Cond. 2) vs. 3)Post: nsShort term: nsLong term: ns

Cond. 1) vs. 2)Long term: +Cond.1) vs. 3)Long term: +

apy vs.

vs.

trol treatment

Cond. 1) vs. 2)b

Post: +Short term: +Long term: +Cond.1) vs. 3) Post: nsLong term: nsCond. 3) vs. 2) Post: nsLong term: +Cond. 3) vs. 4) Post: nsLong term: +

Cond. 1) vs. 2)b

Post: +Short term: +Long term: +Cond.1) vs. 3) Post: nsLong term: nsCond. 3) vs. 2) Post: +Long term: +Cond. 3) vs. 4) Post: +Long term: +

Post: nsShort term: +Long term: +

Post: +Short term: +Long term: +

Excel vs.

Short term: - Short term: -

.

trol treatment 

Cond. 1) vs. 2) & 3)Post: +Short term:+Long term: +

Cond. 1) vs. 2) & 3)Post: +Short term: +Long term: +

oeducation vs. 

ntervention)

Post: ns Post: ns Post: ns
31

reatments for Adult Mental Health

dence Evidence-based Synthesis Program

Patient Outcomesa Family Outcomes

s Symptoms Utilization Family Functioning Couple Functioning Intimate Partner Violence Communication/ Conflict

uple Therapy

Cond. 1) vs. 2)b

Post: nsShort term: nsLong term: nsCond. 1) vs. 3) Post: nsShort term: nsLong term: nsCond. 2) vs. 3) Post: nsShort term: nsLong term: ns

Cond. 1) vs. 2)b

Post: +Short term: nsLong term: nsCond. 1) vs. 3) Post: nsShort term: nsLong term: nsCond. 2) vs. 3) Post: nsShort term: nsLong term: ns

Cond. 1) vs. 2)

Post: nsShort term: nsLong term: nsCond. 1) vs. 3) Post: nsShort term: nsLong term: nsCond. 2) vs. 3) Post: nsShort term: nsLong term: ns

ment + behavioral 

(1996)Cond. 1) vs. 2)

Post: nsCond. 1) vs. 3) Post: nsCond. 2) vs. 3) Post: ns(1999) Cond. 1) vs. 2)Short term: nsCond. 1) vs. 3) Short term: nsCond. 2) vs. 3) Short term: ns(2004)Cond. 1) vs. 2)Long term: nsCond. 1) vs. 3) Long term: nsCond. 2) vs. 3) Long term: ns

(1999) Cond. 1) vs. 2)Short term: nsCond. 1) vs. 3) Short term: nsCond. 2) vs. 3) Short term: ns(2004)Cond. 1) vs. 2)Long term: nsCond. 1) vs. 3) Long term: nsCond. 2) vs. 3) Long term: ns
32

reatments for Adult Mental Health

dence Evidence-based Synthesis Program

Patient Outcomesa Family Outcomes

s Symptoms Utilization Family Functioning Couple Functioning Intimate Partner Violence Communication/ Conflict

y vs.

apy

% PDAcPost: nsLong term: ns% PDHDPost: nsShort term: nsLong term: ns% complete abstinenceShort term: nsLong term: ns% no drinking Short term: nsLong term: ns

ns +

Family Training 

s facilitation therapy 

Cond. 1) vs. 2) Short term: nsLong term: nsCond. 1) vs. 3) Short term: nsLong term: nsCond. 2) vs. 3) Short term: nsLong term: ns

Cond. 1) vs. 2) Short term: +Cond. 1) vs. 3) Short term: nsCond. 1) vs. 3) Short term: +Cond. 1) vs. 2) Short term: +Long term: +Cond. 1) vs. 3) Short term: +Long term: +Cond. 2) vs. 3) Short term: nsLong term: ns

Cond. 1) vs. 2) Short term: nsCond. 1) vs. 3) Short term: nsCond. 2) vs. 3) Short term: ns

Cond. 1) vs. 2) Short term: nsCond. 1) vs. 3) Short term: nsCond. 2) vs. 3) Short term: ns

elapse Prevention vs.

Post: nsShort term: +Long term: +Final: ns

Post: nsShort term: nsLong term: nsFinal: ns

Post: nsShort term: nsLong term: nsFinal: ns
33

reatments for Adult Mental Health

dence Evidence-based Synthesis Program

Patient Outcomesa Family Outcomes

s Symptoms Utilization Family Functioning Couple Functioning Intimate Partner Violence Communication/ Conflict

Cond. 1) vs. 2)Post: nsCond. 1) vs. 3)Post: nsCond. 2) vs. 3)Post: ns

on vs.

Short term: ns Post: +

Short term: ns

Individual Based 

PDA :Post: nsShort term: nsPDPSU:Post: nsShort term: ns

Post: nsShort term: ns

ol-focused) vs.

ment in behavior 

Mean days abstinent:Cond. 1) vs. 2) Post: nsShort term: nsLong term: nsCond. 3) vs. 2) Post: +Short term: nsLong term: nsMean days heavy drinking:Cond. 1) vs. 2) Post: +Short term: +Long term: nsCond. 3) vs. 2) Post: +Short term: +Long term: ns

1) vs. 2)Post: nsShort term: nsLong term: nsCond. 3) vs. 2) Post: nsShort term: nsLong term: ns

Post: +Short term: +Long term: ns

Post: +Short term: nsLong term: ns

tween condition 1 and condition 2 unless otherwise noted: + effects favor condition 1; − effects favor the comparator treatment; = no differences; ns = 

on-significant (p > 0.05). Post refers to post-treatment assessment; short-term refers to the last assessment conducted within 6 months of treatment 

sessment conducted within 12 months of treatment ending; final refers to the last assessment conducted after 12 months of treatment ending

obal functioning.

by author, but in secondary analysis for this review.
34

reatments for Adult Mental Health

dence Evidence-based Synthesis Program

ioning, both short and long term.

s, Substance Abuse Disorder Studies (Alphabetical Order by First Author)

Intermediate Outcomes

, Year

ntions Attendance Adherence Satisfaction

 ICBT+ Contingency Management 

nt + Naltrexone vs.

Cond. 1) & 2) vs. 3): +Cond. 1) vs. 2): ns

Naltrexone adherence: Cond. 1) & 2) vs. 3): nsCond. 1) vs. 2): ns

5

 therapy 

ns ns

ent package vs.

ntenance (standard treatment)

ns ns

Therapy vs.

erapy

+

Naltrexone adherence: +

ns

rapy vs.

trol treatment

ns ns

trol treatment

ns ns

 vs.

rapy vs.

trol treatment

ns nsns ns

.

trol treatment 

ns
35

reatments for Adult Mental Health

dence Evidence-based Synthesis Program

Intermediate Outcomes

, Year

ntions Attendance Adherence Satisfaction

oeducation vs. (community 

+

uple Therapy vs.

ns

ment + behavioral marital therapy 

ns

Patient homework completedns (1996)+ (1999)

y vs.

apy

+

Family Training (CRAFT) vs.

s facilitation therapy 

ns

.

Cond. 1) vs. 2): +Cond. 3) vs. 2): +

lapse Prevention vs.

Anti-abuse contract:Post: ns Short term: nsLong term + Final: ns

Individual Based Treatment vs.

+

ol-focused) vs. 

ment in behavior change

ns

vidual Behavioral Therapy vs.

ns ns

etween condition 1 and condition 2 unless otherwise noted: + effects favor condition 1; − effects favor the comparator treatment; ns = differences 

ant (p > 0.05)
36

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

Bipolar Disorder

We included 6 unique RCTs (10 publications) of family interventions for subjects with bipolar 

disorder. Detailed descriptions of the study characteristics and outcomes are provided in 

Appendix D, Tables 5 to 8. Subject and intervention characteristics are summarized in Tables 7 

and 8. Table 9 is an overview of our findings.

Population Studied

Baseline characteristics of the study subjects are summarized in Table 7. There were a total of 

625 subjects; two trials had less than 50 subjects and 3 trials had more than 100 subjects. The 

mean age in all 6 studies was less than 50 years. The majority of subjects were white, less than 

half were male, and approximately half were married. No study specifically enrolled Veterans. 

Table 7. Summary of Baseline Characteristics, Bipolar Disorder Studies

Characteristic Mean (range) except as noted Number of trials 

reporting*

Total number of patients randomized Total=625 (40-293) 6

Gender, % male 42 (37-54) 6

Age of subjects, years 38 (26-48) 6

Race, % white 87 (60-94) 4

Veterans, % NR 0

Marital status, % married 52 (15-67) 5

*6 trials were presented in 10 articles

Five studies examined family involved interventions with patients with either bipolar I mood disorder, (3 studies89-91) or bipolar I or II mood disorder (2 studies92, 93). One study did not specify a bipolar 

type but included patients with “major affective disorder or bipolar disorder, manic, depressed, or 

mixed.”94 In five studies, the intervention targeted patients with these disorders,89-92, 94 while the sixth 

directly targeted the caregivers of individuals with either condition.93 Two studies enrolled participants predominantly while they were inpatients,89, 90 while the remaining studies enrolled participants 

predominantly while they were outpatients. Few requirements for participating family members 

were reported. In one study, the family member was a spouse or intimate partner.94 One study required that caregivers (family or other individual in close contact, supporting the patient financially, 

or involved in their treatment) had to have at least one physical or mental health problem.93

Inclusion of Comorbid Conditions

Rates of co-occurring conditions among participants were not typically reported. However, the five 

studies that enrolled patients89-92, 94 excluded individuals with a current alcohol or drug dependence 

disorder. Individuals with other co-occuring mental health diagnoses were not explicitly excluded 

although two studies did exclude patients with organic central nervous system disorder.91, 94 In two 

studies, the patient had to be either taking91, 92 or willing to take92 mood stabilizing medications. 

Intervention

The interventions included general marital or family therapy,89, 94 disorder-specific family therapy,90-92

and a combination of disorder-specific family intervention and family-assisted treatment.93 In 

the study by Clarkin et al.,94 the intervention was manualized psychoeducational marital therapy 

delivered by social workers with experience in family treatment.94 It is unclear whether the 
37

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

intervention was delivered to individual or multiple couples. In the study reported by Miller et al.,89

the family therapy program, titled Problem Centered Systems Therapy of the Family, was a 6 to 

10 session intervention with a patient and his or her family members, focused on problem solving, 

communication, roles, affective responsiveness, affective involvement, and behavior control. Several 

studies90-92 provided Family-Focused Treatment (FFT), a 9-month psychoeducation program (up 

to 21 sessions) providing education on bipolar disorder, communication training, and problemsolving skills training delivered to individual patients and their family members. Perlick et al.93

provided a variant of FFT referred to as Family-Focused Treatment-Health Promoting Intervention 

(FFT-HPI), a 12-15 session psychoeducational intervention focused on enhancing caregiver skills 

for managing their relative’s illness, defining self-care goals, resolving barriers to patient care and 

self-care, examination of core beliefs, and problem solving. It is unclear whether the caregivers met 

individually or in a group. FFT-HPI was explicitly developed to address both patient symptoms and 

health behaviors of the caregiver. Treatment periods generally ranged from 6 weeks to 9 months. All 

interventions were delivered in outpatient settings.

Comparison Interventions and Study Design

Comparator groups included medication only (2 trials89, 94), individual therapy plus medication 

(2 trials91, 92), multifamily group therapy with medication (1 trial89), crisis management with 

medication (1 trial90), ICBT with medication (1 trial92), collaborative care with medication (1 

trial92), and health education.93

Table 8. Summary of Heterogeneity, Bipolar Disorder Studies

Number of trials 

reporting*

Subjects diagnosed with: Bipolar I only 3

Bipolar II only 0

Bipolar I or Bipolar II 2

Not specified 1

Diagnosis verified by structured interview 6

Subjects recruited: Shortly after episode (hospitalization not 

reported) 1

While admitted to inpatient or outpatient 

services

4

Not reported 1

Family intervention with: Intimate partner only 1

Any single family member 1

Any combination of family members 4

One couple/family at a time 6**

Groups of families 1**

Family intervention compared to: Waitlist 0

Another treatment 6

Subject gender: Men 0

Women 0

Both men and women 6

*6 trials were presented in 10 articles

**Miller (2004) compared an intervention with one family at time to a multifamily group intervention (represented in 

both counts)
38

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

Outcomes

Five studies assessed subject symptoms using established rating scales89-91, 93, 94 with one study 

reporting recovery status,89 and one study reporting relapse,91 rather than the actual symptom 

scores. One study assessed clinical status based on DSM-IV criteria.92 Global family functioning 

was reported in one study.95 Two studies reported measures of global patient function,94, 95 and 

two reported hospitalization data.89, 91 Five studies reported intermediate outcomes related to 

treatment attendance or medication adherence.89-92, 94 Three studies reported post-treatment results 

following 5 months,93 9 months,95 or 11 months94 of treatment. One study reported results at 12 

months, 3 months after treatment programs lasting up to 9 months.92 Another reported results at 

28 months or 22 months after a 6 month treatment program.89 One study reported data following 

treatment (9 months) and 3 months post-treatment (12 months total)90 with 24 month follow-up 

in a subsequent publication.5 Finally, one study reported results after an active treatment year (9 

months treatment program) and after an additional follow-up year.91

Table 9. Main Findings, Bipolar Disorder Studies (Alphabetical Order by First Author)

Study, year

Interventions

Patient Improvement Family/Couple 

Improvementa

Symptoms Global 

Functioning Utilization Family Functioning 

Clarkin, 199894

1) Medication management + marital 

intervention vs 

2) Medication management only

ns +

Miklowitz, 2000,90 200396

1) Family focused + medication vs

2) Crisis management + medication

+

Survival without 

relapse: +

Miklowitz, 200792, 95

1) Family focused therapy vs

2) Inter-personal and social rhythm 

therapy vs

3) Cognitive behavioral therapy

4) Collaborative care 

# months wellb

: ns

Recoveryc: +

Miller, 2004,89 Solomon, 2008,97

Miller, 200898

1) Medication + family therapy vs

2) Medication + multiple-family group 

therapy vs

3) Medication only

Recoveryd

: ns nse

Perlick, 201093

1) Family focused, health promoting vs

2) Health education

+

Rea, 200391

1) Family focused + medication vs

2) Individual therapy + medication

Relapse, 

rehospitalization:

active treatment year: 

ns

post-treatment year: +

a

No family outcomes reported for couples’ global functioning, intimate partner violence, communication or conflict.

Note: For comparison of condition 1) to condition 2) except where noted + effects favor the intervention; − effects 

favor the comparator treatment; ns = differences between conditions are non-significant (p > 0.05). b

Conditions 1, 2, and 3 significantly different from 4; condition 1 not significantly different from 4

c

Conditions 1, 2, and 3 significantly different from 4; condition 1 also significantly different from 4

d

No differences between any treatments

e

Condition 1 not significantly different from condition 3; results reported only for subgroup of patients who recovered
39

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

Schizophrenia Spectrum Disorders

For schizophrenia spectrum disorders, 4 unique studies (8 publications) met inclusion criteria for 

the current review. Detailed descriptions of the study characteristics and outcomes are provided 

in Appendix D, Tables 9 to 12. Participant and intervention characteristics are summarized in 

Tables 10 and 11. 

Population Studied

Baseline characteristics of the study subjects are summarized in Table 10. There were a total of 

810 participants, with data analyzed for 595 of these participants. The mean age in all studies 

was less than 35 years. The majority of subjects were male and predominantly white. No study 

excluded patients based on gender. Current marital status was reported in two of four trials, and 

most subjects were not married (90%). No study reported subjects’ Veteran status. Each of the 

four studies included participation from the subject and any family member; Mueser et al.99, 100

expanded that definition to include any person in a “caring but non-professional relationship” 

with subject (e.g., clergy). None of the four studies required the subject and participating family 

member to reside together; however, two of the studies99-103 required a minimum four hours per 

week contact between them. 

Inclusion of Comorbid Conditions

Each of the four studies included subjects with a range of schizophrenia spectrum disorders, as 

verified by structured interview. The complexity of clinical presentation included in the above 

trials varied. Schooler and colleagues24, 104 employed the most restrictive inclusion/exclusion 

criteria, excluding participants with liver damage, chronic organic brain syndrome, or substance 

dependence,24, 104 but participants with substance abuse disorders were not excluded (unless 

diagnosed with schizophreniform disorder). A second trial also did not explicitly exclude 

participants who met criteria for a substance abuse disorder.101-103 Both Mueser et al.99, 100 and 

McFarlane et al.29 explicitly studied complicated cases by requiring eligible subjects to have 

either an active substance abuse disorder,99, 100 or a ‘complicating’ factor,29 including lack of 

consistent treatment participation, history of violence or suicidality, arrests, criminal convictions, 

homelessness, moderate to severe substance abuse, or frequent hospitalization. McFarlane et al.29

however, did exclude acutely violent or suicidal participants, or participants with a major medical 

illness or physical addiction that required hospitalization, until they were stabilized. Participants 

were not excluded for any other comorbid mental health diagnosis or co-occurring problem.

Table 10. Summary of Baseline Characteristics, Schizophrenia Spectrum Disorder Studies

Characteristics Mean (range) except as noted Number of trials 

reporting

Total number of subjects randomized 810 (68-528) 4

Total number of subjects analyzed 595 (68-313) 4

Gender, % male 69 (65-77) 4

Age of subjects, years 31 (30-34) 4

Race, % white 74 (71-78) 2

Veterans, % NR 0

Marital status, % married 10 (6-13) 2
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Intervention

All interventions were two years in length, with the exception of Mueser et al.99, 100 Mueser and 

colleagues99, 100 compared a brief treatment lasting 2-3 months to an intervention lasting 9-18 

months. All of the studies were conducted in an outpatient setting; however, two of the four 

studies recruited subjects after an acute psychotic episode or hospitalization,24, 29 while the other 

two recruited subjects from community mental health agencies.99-103

Two of the interventions29, 101-103 utilized multi-family groups. Multi-family groups combine 

disorder specific family intervention (emphasizing improvement of communication) with general 

family therapy goals (formal problem solving) and building of a social support network. The 

subject was included in the multi-family groups. Psychoeducation was a component to both 

interventions, to better understand the subjects’ mental illness and engage family members in 

the subjects’ recovery. McFarlane and colleagues29 examined Asserted Community Treatment 

(ACT), which included an initial family education and engagement component, one home visit, 

and multi-family groups.

Schooler and colleagues assigned subjects to either Applied Family Management (AFM) 

or Supportive Family Management (SFM).24, 104 Both AFM and SFM included an initial 

psychoeducational workshop, case management, and monthly support group meetings for both 

subjects and families over a two year period. The more intensive AFM added behavioral single 

family treatment conducted in the home. Subjects who stabilized (16-24 weeks) were further 

randomized into three double blind medication dosages of fluphenazine decanoate (continuous 

moderate or ‘standard’ dose, continuous low dose, or targeted dose only when symptomatic) and 

entered a two year maintenance phase.

Mueser et al.99, 100 utilized both the disorder specific and general family therapy approaches in 

their Family Intervention for Dual Disorders, which combines behavioral single family therapy 

with a family education component through the 9-18 month intervention. A multi-family support 

group was available after the active intervention up to the 36 month point.

A commonality with all interventions was that even if an initial “family only session” was 

provided, the subject was present and included in subsequent family therapy sessions. 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Table 11. Summary of Heterogeneity, Schizophrenia Spectrum Disorder Studies

Number of trials 

reporting

Subjects diagnosed with: Schizophrenia only 0

Schizoaffective disorder only 0

A range of possible schizophrenia spectrum 

disorders 4

Diagnosis verified by structured interview 4

Subjects recruited: Following a recent hospitalization 2

From community mental health setting 2

Family intervention with: Intimate partner only 0

Any single family member 4

Any combination of family members 0

One couple/family at a time 0

Groups of families 0

Family intervention compared to: Waitlist 0

Another treatment 4

Subject gender: Both men and women 4

Comparison Interventions and Study Design

In one study, with follow up for one year post-treatment,101-103 the comparison condition was 

standard care which consisted of individual case management and medication management 

services.

Three interventions24, 29, 99, 100, 104 compared more to less intense family intervention. In McFarlane 

et al. (1996), the intervention and comparison groups both participated in manualized Asserted 

Community Treatment (described above), but the comparison group did not include multi-family 

groups. Additional family interaction with the treatment team occurred throughout the two 

year intervention only in the event of a crisis. Schooler et al.24 included case management and 

monthly family group meetings in the comparison condition (Supportive Family Management) 

throughout the two year intervention. Mueser et al.99, 100 provided only brief psychoeducation (2-3 

months) in the comparison group; however, a multi-family support group was available after the 

active intervention up to the 36 month point.

Outcomes

Patient outcomes assessed included hospitalization,24, 29, 102, 103 service utilization,102, 103 symptom 

severity,101 global functioning,29 and time to relapse/rescue medication (medication added with 

prodromal relapse signs and discontinued after stabilization).24 Mueser and colleagues100 reported 

on numerous dual diagnosis patient outcomes including substance use, psychiatric functioning, 

problem solving, and knowledge of disease. Family outcomes were assessed in two studies29, 

104 using the Social Adjustment Scale and the Patient Rejection Scale.104 All studies reported 

outcomes post-treatment, with the exception of McDonell and colleagues,103 who reported one 

year-post-treatment outcomes, and Mueser and colleagues,100 who included 36 month outcomes. 

Table 12 is an overview of our findings.
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Table 12. Main Findings, Schizophrenia Spectrum Disorder Studies (Alphabetical Order by First 

Author)

Study, year

Interventions Patient Improvement Family/CoupleImprovement

Symptoms Global 

Functioning Utilization Family Functioning

Couple 

Functioning

Dyck, 2000,101 2002,102

McDonell, 2006103

1) Multiple Family Group vs. 

2) Standard Care

+

State Hospitalization: 

+

Any Hospitalization: 

ns

Crisis/urgent care: ns

McFarlane, 199629

1) Assertive Community 

Treatment + Multiple Family 

Group vs 

2) Assertive Community Care + 

Crisis Care only

ns ns ns ns

Mueser, 200999 and in press100

1) Family Intervention for Dual 

Disorders vs

2) Family Psychoeducation 

Schizophrenia 

symptoms: +

substance 

use: ns

+

Schooler, 199724

1) Applied Family Management 

vs 

2) Supportive Family 

Management 

ns ns

SAS/Social: 

NS

PRS +

SAS Friction: 

+

SAS/Sexual: 

ns

Note: For comparison of condition 1) to condition 2) except where noted + effects favor the intervention; − effects 

favor the comparator treatment; ns = differences between conditions are non-significant (p > 0.05).

SAS = Social Adjustment Scale (family friction, social/leisure and sexual/romance factors); PRS = Patient Rejection 

Scale 

Posttraumatic Stress Disorder

There were two studies which met our search criteria examining family involved interventions 

for PTSD. Detailed descriptions of the study characteristics and outcomes are provided in 

Appendix D, Tables 13 to 16. 

Population Studied

The two studies included a total of 233 participants. All patients in the trial conducted by Glynn 

and colleagues8

 were recruited from the Los Angeles VA (either inpatient or outpatient care). 

Participants for Weine105 trial were recruited from the community. For Glynn and colleagues8

 (N 

= 36) the average patient was 47 years old, 45% were white, and all participants were Vietnam 

Veterans with combat-related PTSD (100% male). Ninety percent participated in the family 

intervention with their wife or intimate partner. For Weine and colleagues105 (n = 197), all 

patients were Bosnian refugees, screening positive for PTSD, and not currently in mental health 

treatment. The average patient was 38 years old, most were married (82%), and half were male 

(48%). Veteran status was not reported. All adult family members were invited to participate and 

descriptive information on family members’ relationship to patients was not described. Most 

family members were female (60%) with mean age of 36 years.
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Inclusion of Comorbid Conditions

Glynn and colleagues8

 excluded participants with a number of conditions, including organic 

brain disorder, psychotic disorders, severe dissociative conditions, current substance dependence, 

or overt physical aggression to self or others in the past year. Weine105 excluded participants with 

active psychosis, substance intoxication or withdrawal, or an acute confusional state. Participants 

were not excluded for any other comorbid mental health diagnosis or co-occurring problem.

Intervention

The family involved treatment condition in Glynn and colleagues’ trial8

 included 9 weeks of 

exposure therapy (18 sessions) followed by PTSD-specific behavioral family therapy, which 

included psychoeducation about PTSD, anger management, and communication training 

(disorder-specific family treatment;9

 34 sessions). Weine and colleagues105 examined a 9 session 

(16 week) family involved support group intended to increase the access of Bosnian refugees 

with PTSD to mental health services (Coffee and Family Education and Support; CAFES; 

disorder specific family therapy9

). Both trials were delivered through outpatient treatment. 

Comparison Interventions and Study Design

Glynn and colleagues8

 compared the family involved treatment (exposure therapy with BFT) 

to two conditions: 1) exposure therapy alone (18 sessions, 9 weeks) or 2) wait list followed by 

behavioral family therapy (16 sessions) for interested dyads. Weine and colleagues105 compared 

CAFES to a no treatment control group. 

Outcomes

Primary outcomes relevant for the present study examined by Glynn and colleagues8

 included a 

composite of symptoms of PTSD assessed through structured clinical interview and self-report, 

social adjustment, and rates of treatment dropout. Outcomes were assessed at post-treatment and 

6 months post-treatment. Weine and colleagues105 examined the number of mental health visits 

attended by participants who screened positive for PTSD at 6, 12, and 18 months post-treatment. 

Main findings are reviewed in Table 13.

Table 13. Main Findings, Post Traumatic Stress Disorder Studies (Alphabetical Order by First Author)

Study, year

Interventions

Patient Improvement Family/Couple Improvementa

Symptoms Global 

Functioning Utilization Family Functioning

Couple 

Functioning

Glynn, 19998

1) Exposure Therapy + 

Behavioral family therapy vs. 

2) Exposure Therapy vs.

3) Wait list

ns ns +

Weine, 2008105

1) Coffee and Family 

Education and Support vs.

2) No treatment control

+

Note: For comparison of condition 1) to condition 2) except where noted + effects favor the intervention; − effects 

favor the comparator treatment; ns = differences between conditions are non-significant (p > 0.05). a

No family outcomes reported for intimate partner violence, communication or conflict.
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Sexual Functioning Disorders

There were two studies which met our search criteria examining family involved interventions 

for sexual functioning disorders. Detailed descriptions of the study characteristics and outcomes 

are provided in Appendix D, Tables 17 to 20. Main outcomes are summarized in Table 14. 

Population Studied

The two studies included a total of 97 participants. For both studies, all patients were males with 

erectile dysfunction (ED) who participated with their female intimate partner. Both samples were 

highly similar in terms of age (Aubin et al.,106 mean age = 52 years; Banner et al.,107 mean age = 

57years) and race (Aubin:106 86% white; Banner:107 85% white). For the trial conducted by Aubin 

and colleagues,106 eight-six percent were married. Rates of marriage were not reported by Banner 

and colleagues.107 Veteran status was not reported in either study. 

Inclusion of Comorbid Conditions

Both studies included only participants in heterosexual relationships of at least 6 months 

(Banner,107: 6 months; Aubin106: 12 months) and whose intimate partners did not have a sexual 

functioning disorder. Aubin and colleagues106 included participants with ED, regardless of the 

etiology of the condition (50% not due to a medical condition; findings not stratified by etiology 

of ED). They excluded participants who reported a history of gender identity disorder, screened 

positive for depression, reported intimate partner violence, reported an extra-marital affair in the 

last year, discussed separation in the last year, and reported sexual dysfunction among intimate 

partners. Banner and colleagues107 only included patients whose ED was not due a medical 

condition. They also excluded patients diagnosed with a number of medical conditions which 

could cause ED, participants with significant mental health conditions, and participants whose 

intimate partner had one of a number of sexual functioning disorders.

Intervention

The family involved treatment Aubin and colleagues106 examined consisted of 12 weeks (8 

sessions) of medication (Sildenafil) plus outpatient sex therapy that included a combination 

of existing couple and sex therapy techniques including communication skills, sensate focus, 

sexual fantasy training, and cognitive restructuring. Banner and colleagues107 examined 

medication (Sildenafil) plus cognitive-behavioral sex therapy. They assigned participants to 

either medication plus cognitive-behavioral sex therapy or medication only for four weeks. At 

four weeks, they then provided cognitive-behavioral sex therapy to those in the medication only 

condition with continuing symptoms. Due to contamination across conditions after 4 weeks, only 

outcome data at 4 weeks are presented.

Comparison Interventions and Study Design

Aubin and colleagues106 compared the family involved treatment to 12 weeks of medication 

management (Sildenafil), including 8 brief, typically individual, 15 minute, medication pick up 

visits to discuss any medical concerns. Banner and colleagues107 compared the family involved 

intervention to medication management (Sildenafil) that included a pre-treatment information 

session.
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Outcomes

Primary outcomes for both studies included the International Index for Erectile Function 

(IIEF)108 and the Dyadic Adjustment Scale (DAS)109 although DAS findings were not reported 

by Banner and colleagues.107 Aubin and colleagues106 also assessed relationship functioning 

using the Personal Assessment of Intimacy in Relationships scale (PAIR),110 as well as treatment 

satisfaction through the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS).111

Assessments were conducted at post-treatment and 2 months after treatment completion. 

Banner and colleagues107 also assessed patient global functioning through the Beck Depression 

Inventory,112 and Beck Anxiety inventory.113

Table 14. Main Findings, Sexual Functioning Disorders Studies (Alphabetical Order by First 

Author)

Study, year

Interventions

Patient Improvementa Family/Couple 

Improvementb

Symptoms Global Functioning Couple Functioning 

Banner, 2007107

1) Sildenafil + couple sex therapy 

vs

2) Sildenafil + couple sex therapy 

for treatment non-responders 

ns

Aubin, 2009106

1) Sildenafil + couple sex therapy 

vs

2) Sildenafil only

ns ns

Note: For comparison of condition 1) to condition 2) except where noted + effects favor the intervention; − effects 

favor the comparator treatment; ns = differences between conditions are non-significant (p > 0.05). a

No patient outcomes were reported for health care utilization. 

b

No studies reported family/couple outcomes for intimate partner violence, communication, or conflict.

Other Conditions

We identified one trial each of family involved interventions for depression, eating disorders, and 

smoking cessation. The findings are summarized in Table 15. Subject characteristics treatment 

descriptions and outcomes are presented in Appendix D, Tables 21 to 24.

Depression 

The depression study114 included 35 heterosexual couples in which the woman was diagnosed 

with depression and the male partner was non-depressed. The mean age of the women was 43.2 

years; the mean age of the men was 45.0 years and 94.3 percent of the couples were married. 

Eighty-eight percent of the sample were non-Hispanic white, 5.6 percent were Hispanic, 3.1 

percent were black, and 3.1 percent were Asian. Couples were excluded if there was infidelity in 

the past 6 months or more than two acts of aggression in the past year. Couples were mildly to 

moderately distressed with severely discordant couples excluded. The women could be receiving 

other treatment for depression if they had been in individual psychotherapy for at least 12 

weeks or on a stable dose of psychotropic medication for at least 8 weeks. The intervention was 

brief, problem-focused couple therapy for depression with wait list control as the comparator. 

Outcomes included measures of depression and relationship satisfaction. Thirty couples 

completed the 5 week treatment conducted in an outpatient setting. Three month follow-up data 

were obtained for twenty-seven couples. 
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Eating Disorders

Overweight women with binge eating disorder were the focus of the study by Gorin et al.115

Women were excluded if they engaged in purging behaviors more than once per month or 

met diagnostic criteria for anorexia nervosa, bulimia nervosa, or eating disorder of no specific 

origin. They also could not be receiving concurrent treatment for weight loss, including appetite 

suppressants. The women were required to have a spouse or cohabiting partner willing to 

participate in treatment but marital status was not reported. The mean age of the women was 

45.2 years, and 86 percent of the sample was Caucasian. The intervention was group CBT for 

binge eating disorder with involvement of the spouse or intimate partner. The goal was for both 

partners to understand binge eating disorder, identify coping resources, agree about a plan of 

action, and feel confident in their ability to address binge eating disorder (i.e., a disorder specific 

couple intervention.)9

 The comparators were standard group CBT and wait list control. The 

primary outcomes were binge eating frequency assessed with both a 7 day calendar recall and the 

Eating Disorder Examination Questionnaire (EDEQ).116, 117 The treatment phase was 12 weeks 

with an additional 6 month follow-up; participants were outpatients. 

Nicotine Dependence

The smoking cessation study118 targeted women, pregnant for 20 weeks or less, who were current 

smokers or recent quitters. The women were required to be living with an intimate partner and 

willing to have the partner contacted regarding participation in the study. The mean age of the 

women was 24 years, 77 percent were white, and 96 percent were married. It was reported that 

77% of the women had tried to quit smoking, with a mean of 3 prior attempts. Fifty-two percent 

of partners were smokers. The intervention was individual counseling calls by a health advisor 

with partners assisting in a coaching capacity (partner-assisted treatment9). The comparators were 

individual counseling and usual care. Outcomes of interest were support for cessation, general 

support, and smoking status. The patients were followed to 12 months post-partum, and the study 

was conducted on an outpatient basis.
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Table 15. Main Findings, Depression, Eating Disorders, and Smoking Cessation Studies

Study, year

Interventions

Patient Improvement Family/Couple Improvementa

Symptoms Global 

Functioning Utilization Family Functioning

Couple 

Functioning

DEPRESSION: Cohen, 

2010114

1) Brief Couple Therapy 

vs. 

2) Wait list control

+ +

EATING DISORDERS: 

Gorin, 2003115

1) Group Cognitive 

Behavioral Therapy (CBT) 

with spouse vs. 

2) Group CBT vs.

3) Wait list control 

nsb nsb nsb

SMOKING CESSATION: 

McBride, 2004118

1) Partner assisted + 

woman-only care vs 

2) Woman-only care vs

3) Usual care

nsb

Note: For comparison of condition 1) to condition 2) except where noted + effects favor the intervention; − effects 

favor the comparator treatment; ns = differences between conditions are non-significant (p > 0.05). a

No family outcomes reported for intimate partner violence, communication or conflict.

b

No differences across all treatment conditions

RESULTS BY KEY QUESTION

KEY QUESTION #1. What is the efficacy of family involved 

interventions in improving outcomes for adult patients with mental 

health conditions [i.e., how do family involved psychosocial treatments 

compare to no psychosocial treatment: (a) waitlist/no treatment or (b) 

medication management only]? 

Substance Use Disorders

Detailed descriptions of the outcomes are provided in Appendix D, Tables 2 to 4.

As noted above, no studies that we reviewed compared a family involved intervention to 

waitlist, but one study directly compared family treatment to medication-only care. O’Farrell 

and colleagues64 tested the effect of a family intervention on the utilization of continuing care. 

Male and female subjects admitted to an inpatient detoxification unit for alcohol use (with or 

without comorbid drug dependence) and a family member were randomized into either treatment 

as usual, consisting of assistance with withdrawal symptoms, monitoring risks for developing 

serious problems during withdrawal, but no family involvement, or a brief family intervention. 

The family intervention included meeting with subjects and family members (either a spouse 

or parent) to review continuing care plans both prior to and after discharge. This intervention 

was delivered by phone and in-person, depending on what was most convenient for the family 

member. Three months post-discharge, there were no significant differences between conditions 
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in the percent of days using alcohol or drug use. However, those in the brief family condition 

were twice as likely to enter continuing care programs compared to the usual care group (r = 

0.36; medium effect). The authors did not report any family functioning outcomes. 

Bipolar Disorder

None of the studies we identified included a wait-list control or no-treatment arm; two studies 

included a medication only arm.89, 94 Outcomes are presented in Appendix D, Tables 6 to 8. In 

one study, it was noted that the psychiatrist provided support, encouragement, and direct advice 

as needed but avoided the use of psychotherapy.89 Clarkin and colleagues94 reported on change 

in symptoms when medication management plus marital therapy was compared to medication 

management only. The symptom change in scores over time did not differ significantly for the 

two treatment groups. However, they did find greater improvement in post-treatment medication 

adherence (p = 0.008) following marital therapy. Additionally, significantly improved global 

functioning was also reported (change in Global Assessment Scale, GAS, of 8.6 points in the 

marital therapy group compared to a change of 1.0 point in the medication only group).

The second study, evaluating Problem Centered Systems Therapy of the Family (PCSTF), 

reported no differences in recovery, median time to recovery, or relapse after recovery between 

subjects receiving medication plus family therapy (PCSTF) or multi-family group therapy 

(MFG) and subjects receiving medication only. There were also no differences in recovery 

or relapse when level of family impairment was considered. However, there were significant 

family impairment by treatment interactions for the number of depressive episodes per year, 

percentage of time in episode, and percentage of time in a depressive episode, indicating family 

therapy resulted in an improved course of illness for participants with high family impairment.89, 

98 Compared to medication management, the disorder specific psychoeducational family therapy 

(MFG) led to 1.4 fewer depressive episodes per year (d = 1.0), 14% percent less time in a mood 

episode (d = 0.82), and 1.7 fewer mood episodes, yearly (d = 0.92). The general family therapy 

(PCSTF) led to 0.9 fewer depressive episodes per year (d = 0.70) than medication management, 

additional comparisons between these groups for impaired families were non-significant.

No significant difference in number of medication sessions attended for the entire study 

population were reported, but significantly greater number of sessions were attended among 

those in PCSTF than the medication only group when only subjects who recovered were 

analyzed.89, 97, 98

Summary

No studies compared a family intervention to no intervention. Of two studies that compared 

marital or family therapy to medication only, marital therapy was associated with improved 

overall functioning and better medication adherence but not with improvement in symptoms. 

Problem Centered Systems Therapy of the Family was not found to be associated with recovery. 

However both PCSTF and MFGs were associated with improved depression over medication 

management only for patients in distressed families. No studies reported a family or couple 

function outcome. 
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Schizophrenia Spectrum Disorders

No studies compared a family intervention to no treatment or medication only. 

Posttraumatic Stress Disorder

Each of the two studies of family involved interventions for PTSD compared the family involved 

intervention to a waitlist control. Results are presented in Appendix D, Tables 14 to 16. Glynn 

and colleagues8

 found that those assigned to either exposure therapy plus behavioral family 

therapy or exposure therapy alone reported fewer post-treatment PTSD symptoms than waitlist 

controls, however this difference eroded with time (differences non-significant at 6 month 

follow-up) and differences between groups on social adjustment were non-significant at each 

time point. Additionally, those who participated in exposure therapy plus behavioral family 

therapy were more likely to drop out of treatment than waitlist controls.8

 However, Weine and 

colleagues105 found the patients of family members who participated in a family support group 

(i.e., CAFES) were significantly more likely attend mental health care treatment (the primary 

study outcome) than no treatment controls. Weine and colleagues105 also collected data relevant 

to our key questions on PTSD symptoms and depression. However, differences on these 

variables across conditions were not presented. Also, the role of family distress in predicting 

treatment response was not examined.

Sexual Functioning Disorders

Two studies compared a family involved intervention to a medication only condition.106, 107

Outcomes are reported on Appendix D, Tables 18 to 20. Findings suggested that sex therapy 

plus medication resulted in greater satisfaction with treatment106 and cognitive-behavioral sex 

therapy plus medication did not result in greater erectile functioning on continuous scale scores. 

Differences were provided in rates of patient exceeding cutoffs indicating clinical improvement 

of erectile functioning (48% in the sex therapy condition and 29% in the medication only 

condition), but significance tests of these differences were not provided.107 All other results 

indicated non-significant differences between conditions on couple functioning.106

Other Conditions

Findings from studies of depression, eating disorders, and smoking cessation are presented in 

Appendix D, Tables 22 to 24.

Depression

We identified one trial of couple therapy for depression that met our inclusion criteria.114 Briefly, 

35 heterosexual couples (94% of whom were married) were randomly assigned to Brief Couple 

Therapy (18 couples) or wait list control (17 couples). In each couple, the female was diagnosed 

with depression; male partners could not meet diagnostic criteria for depression. While single 

time point, univariate analyses at the 3 month follow-up demonstrated significant differences 

only in HAM-D119 and not Beck Depression Inventory 2nd Edition (BDI-II) scores,.120 analyses 

using hierarchical linear modeling found that BDI-II (d = 0.54) and HAM-D (d = 0.72) scores 

decreased significantly over the course of the study (both p < 0.01, mean follow-up of 24.2 

weeks). It was reported that 67% of women in the treatment group improved (a 50% or greater 

reduction in BDI-II or HAM-D scores) compared to 17% in the control group and that 47% of 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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the treatment group showed full recovery (BDI-II score below 11 and HAM-D score below 6) 

compared to 8% of the control group. Scores for marital satisfaction, as measured by the Dyadic 

Adjustment Scale (DAS),109 did not differ between treatment and control using the univariate 

approach. However, using hierarchical linear modeling, greater improvements in marital 

satisfaction were observed for treatment couples than control couples (p < 0.01). At the 3 month 

follow-up, the average participant in couple therapy reported relationship adjustment in the 

satisfied range (above 97.5;121 mean = 102.1) while those in the waitlist condition reported scores 

indicating clinically significant relationship distress for the average participant (mean = 92.4).

Summary

One trial met our inclusion criteria and compared disorder-specific brief couple therapy to wait-list 

control. When examined over time through hierarchical linear modeling, brief couple therapy was 

associated with greater improvements in symptoms and greater marital satisfaction, though at any 

given time point, there were no significant differences in depression symptoms or marital satisfaction.

Eating Disorders

We included one study of family involved treatment of eating disorders that included a wait-list 

control.115 The study enrolled women ages 18 to 65 years who were diagnosed with binge eating 

disorder. Participants were randomized to group CBT with spouse involvement, standard CBT, or 

wait-list control. Wait-list control results were only available at the end of the 12 week treatment 

period. There was no direct test for differences between the CBT with spouse group and wait-list 

controls. Data from the two CBT groups were combined and the “active CBT” group was found 

to have higher post-treatment self-reported abstinence rates (p = 0.02) and greater reductions in 

self-reported number of days binged (p=0.04) than the waitlist condition. However, scores on 

the EDEQ,116, 117 administered as a confirmatory measure of binge eating frequency, did not differ 

significantly.

Summary

Group CBT for binge eating disorder with spouse involvement was not directly compared 

to wait-list control. Active CBT (i.e., CBT with spouse or individually) subjects had better 

symptom improvement than wait-list controls.

KEY QUESTION #2. What is the effectiveness of family involved 

interventions compared to alternative interventions in improving 

outcomes for adult patients with mental health conditions [i.e., how 

do family involved interventions compare to (a) any individually-oriented 

psychosocial intervention or (b) any alternative family involved intervention]?

Substance Use Disorders

Overview

The remaining 21 SUD trials (25 papers) in our review addressed Key Question 2. Outcomes 

data are presented in Appendix D, Tables 2 to 4. The majority of studies that addressed Key 

Question 2 were aimed at three different time points in the trajectory of treatment: treatment 
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initiation or initial engagement, attendance or adherence, and treatment response. Results, 

therefore, were first organized by these stages. Trials providing data on treatment response are 

organized by common outcomes of interest: substance use or abstinence, relationship adjustment, 

and intimate partner violence. Within these categories, we then reviewed studies that addressed 

any SUD, including an alcohol use disorder (AUD) or a drug use disorder. Lastly, we reviewed 

the studies that compared different types of family interventions and then results by various subgroups of interest, including Veteran status, gender, and family composition.

Studies by Fals-Stewart

Fifteen studies compared family involved treatment to an individual treatment. Of these, ten 

(67%) were either written by Dr. William Fals-Stewart66-69, 74, 78, 79, 84, 85 or based on data he 

collected.63, 71, 76 In 2010, Dr. Fals-Stewart was criminally charged by the State of New York with 

fraud that allegedly occurred during a scientific misconduct hearing held to review evidence 

about whether Dr. Fals-Stewart fabricated data in some of his federally-funded studies.122 Dr. 

Fals-Stewart died in 2010 soon after criminal charges were filed, and because of his death, 

associated legal proceedings never reached a conclusion. While his studies have not been 

retracted by any journal, given the nature of the potential misconduct, we present findings both 

with and without Dr. Fals-Stewart’s work. 

Initiation

Three studies examined family interventions to improve patient initiation to SUD treatment.80, 

81, 83 These studies were unique in that they did not directly involve the person with the AUD or 

drug use disorder in the intervention. Each trial compared one family involved intervention to at 

least one other alternative family involved intervention (KQ2B). No trials reviewed included an 

individually-oriented treatment for the subject with an AUD or drug use disorder as a comparator 

(KQ2A). Consequently, we can make no conclusions regarding the comparative efficacy between 

family involved interventions versus individually-oriented interventions, targeting patients only, 

in promoting treatment initiation. All three trials examined community reinforcement training 

with families (i.e., CRAFT). CRAFT was developed to enhance communication, build skills, and 

develop coping strategies that would encourage the family’s loved one to enter treatment. Kirby 

and colleagues80 randomized 30 family members (spouses, parents, siblings) of someone with a 

drug use disorder into either 1) an earlier version of CRAFT, community reinforcement training 

(CRT), or 2) a 12-step self-help group counseling program. Miller and colleagues81 randomized 

130 family members of alcoholics into either 1) a version of the CRAFT intervention refined for 

families of alcoholics, 2) the Johnson Institute intervention, where families confront the alcoholic 

about their abuse and describe their own experiences and observations about the abuse in order to 

encourage treatment engagement, or 3) Alcoholics-Anonymous (Al-Anon), a self-help group for 

families of alcoholics. Meyers et al.83 randomized 90 family members with a drug-abusing loved 

into either 1) CRAFT, 2) CRAFT plus 6 months of post-intervention group counseling sessions, 

or 3) Al-Anon/Narcotics-Anonymous (Narc-Anon), a 12-step program for family and friends of 

drug users. Across all three studies, the CRAFT intervention was significantly better at promoting 

initiation of treatment than the non-CRAFT approaches. Miller and colleagues81 also found that 

parents were more likely to persuade drinkers into treatment than spouses. Initiation of treatment, 

however, was narrowly defined. For example, in Kirby and colleague’s study,80 treatment initiation 
52

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

was defined as whether the drug user entered counseling or drug abuse treatment or attended a selfhelp group. Miller et al.81 defined initiation as completing an initial 4-hour assessment and at least 

one treatment session and Meyers et al.83 viewed a patient completing a baseline assessment and 

scheduling a substance use treatment session as treatment initiation. These findings suggest that 

CRAFT may be a useful intervention for promoting treatment engagement, but evidence is limited 

about whether it is effective in improving treatment attendance or adherence.

Attendance and Adherence (KQ2A and KQ2B)

Eighteen of our twenty-one trials (86%) reported outcomes on treatment attendance. Ten trials 

reported no statistically significant differences across treatment conditions. Six, however, 

reported significantly better attendance for those in family involved interventions.68, 75, 77, 80-82

Four of these six were drug us disorder trials; the other two were AUD trials. All six addressed 

Key Question 2A, since all compared attendance in a family involved treatment to attendance 

in an individual treatment. Three compared BFT or BCT to ICBT68, 75, 82 and another compared 

reciprocal relationship counseling to ICBT. In two of these trials, patient treatment attendance 

was significantly better for those in family involved treatments than for those enrolled in only 

individual treatment (5-8 more session attended; patients were male opioid users only68 or men 

and women with any substance use problem82). However, McCrady and colleagues75 found those 

in ICBT were significantly more likely to complete treatment than those in BCT (24% versus 

44% completed; patients were all female alcohol use disorder patients).

In the two other trials, both of which used CRAFT-type interventions80, 81 the subject in the 

intervention with the AUD or drug use disorder was not the target for the intervention; therefore, 

family attendance to intervention sessions was measured. Family members were more likely to attend 

CRAFT sessions than either a self-help group80 or the Johnson Institute training sessions.81 However, 

there was no evidence to suggest that family attendance to intervention sessions for any of the three 

family interventions examined affected the primary outcome, patient initiation of treatment. 

Two studies68, 77 of patients receiving outpatient treatment reported differences in adherence to 

naltrexone (a medication to reduce substance use cravings). Both studies compared medication 

adherence for those randomized into family involved treatment versus those in individual 

treatment. Findings were mixed. Carroll and colleagues77 did not find a significant difference 

in doses of naltrexone taken by condition, but Fals-Stewart and colleagues68 did find superior 

medication adherence in BCT versus ICBT. With only two studies reporting medication 

adherence data, there is little evidence to suggest that family treatment significantly improves 

abstinence supporting medication adherence among individual with an SUD.

Treatment Response

As noted, fifteen of the twenty-one AUD and drug use disorder trials that addressed Key 

Question 2 examined if outcomes from family involved treatments differed from outcomes of at 

least one individual based treatment.63, 66-71, 73-79, 82 We first review this evidence across all studies 

and then separately for studies addressing AUD and drug use disorder symptoms. 

The most common symptom-related outcomes were related to either abstinence or days of heavy use, 

most frequently collected using subject or family members’ self-report of abstinence, typically using 

the Time Line Follow Back (TLFB).88 These reports were then converted into the percent of days 
53

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

an individual was abstinent (percent days abstinent; PDA) from substances or the percent of days 

that alcohol or drugs were heavily used (percent days of heavy drinking; PDHD) during the period 

assessed. Only six used urine tests to assess reliability of self-reported abstinence or use. Participants 

were typically assessed post-treatment and at three months, six months, nine months, and twelve 

months after treatment and asked to recall their use since the last assessment. A few studies continued 

follow-up assessments up to 18 months after treatment. Researchers often used survival analyses and 

growth curve modeling to assess factors associated with cumulative PDA or time to relapse. For our 

report we categorize follow-up assessments into three time points: post-treatment, short-term follow 

up (within 6 months post-treatment), and long-term follow up (at least 12 months post-treatment). 

Substance Use Disorder Symptoms (Key Question 2A)

BCT Trials. Thirteen of the fifteen trials compared BCT/BFT to ICBT.63, 66-69, 71, 73-76, 78, 79, 82 Nine of 

these trials used PDA from alcohol or drug use as a primary outcome. All but one79 also included 

sample sizes for each condition. Consequently, for the remaining eight trials we were able to 

pool data and compare unadjusted weighted means in order to assess the evidence for these 

two conditions. Data from the pooled analysis examining PDA among these eight studies are 

presented below in Figure 3. Note that for one study (Kelley, 2002) we present data separately 

for the drug use and alcohol use populations. Although results from each individual study did 

not consistently show significant differences across conditions, on average, we found a 4% 

difference in mean days abstinent between BCT to ICBT at post-treatment. This translates into 

1.2 fewer days of drinking or drug use per month (30 day month) or 14.6 days per year for those 

in BCT/BFT. At short-term follow up (within 6 months of treatment completion), the mean 

difference in days abstinent was 11%, a statistically significant difference across conditions. This 

equates to 3.3 fewer days of drinking/drug use per month (30 day month) or 40 fewer days per 

year for those in BCT/BFT. This difference is even greater at long-term-follow up (within 12 

months of treatment completion), increasing to nearly 12%, which equates to 3.6 fewer days of 

drinking/drug use per month (30 day month) or nearly 44 fewer days per year for those in BCT/

BFT. The proportion of those abstinent decreased in both groups with each subsequent follow 

up, but those in the BCT/BFT condition showed less of a decrease in PDA than those in ICBT, 

suggesting the effects of the intervention eroded more slowly for those in BCT/BFT. Although 

not part of the pooled analysis, this trend is repeated in all but one of the studies used in the 

pooled analysis.63 Using survival analyses and growth curve modeling, all of these studies report 

a significantly slower rate of relapse for the BCT/BFT condition than for ICBT.

Of the studies not included in the pooled analysis, three used outcomes specific to alcohol use 

that are described in more detail below,69, 73, 75 and one used an addiction severity index to assess 

change,67 also described below. 

Alternatives to BCT Trials. Two of the fifteen trials did not compare BCT/BFT to ICBT.70, 77

Carroll et al.77 found no significant differences in the PDA from cocaine or opioid use between 

those who received naltrexone and reciprocal relationship counseling versus those who received 

ICBT and naltrexone. Jones et al.,70 however, found that subjects in HOPE, the motivational 

and psychoeducational group intervention with couple therapy, actually had higher heroin use 

at short-term follow up, compared to a counselor-led drug treatment support group for men with 

drug use disorders. The inconsistency of these data for non-BCT trials provides little evidence to 

support non-BCT interventions for improving abstinence, especially for drug use disorders.
54

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

Figure 3. Differences between BCT and ICBT: Percent Days Abstinent for Alcohol and Drug Use 

Study or Subgroup

1.1.1 Post-treatment

Fals-Stewart 1996

Fals-Stewart 2006

Fals-Stewart 2008

Kelley 2002 (Drug)

Kelley 2002 (EtOH)

Lam 2009

McCrady 2009

O'Farrell 2010

Winters 2002

Subtotal (95% CI)

Heterogeneity: Tau2 = 0.00; Chi2 = 3.12, df = 8 (P = 0.93); I2 = 0%

Test for overall effect: Z = 3.82 (P = 0.0001)

1.1.2 Short-term followup (6 months)

Fals-Stewart 1996

Fals-Stewart 2006

Fals-Stewart 2008

Kelley 2002 (Drug)

Kelley 2002 (EtOH)

Lam 2009

McCrady 2009

O'Farrell 2010

Winters 2002

Subtotal (95% CI)

Heterogeneity: Tau2 = 0.00; Chi2 = 0.81, df = 8 (P = 1.00); I2 = 0%

Test for overall effect: Z = 5.45 (P < 0.00001)

1.1.3 Long-term followup (12 months)

Fals-Stewart 1996

Fals-Stewart 2003

Fals-Stewart 2006

Fals-Stewart 2008

Kelley 2002 (Drug)

Kelley 2002 (EtOH)

Lam 2009

McCrady 2009

Winters 2002

Subtotal (95% CI)

Heterogeneity: Tau2 = 0.00; Chi2 = 3.00, df = 8 (P = 0.93); I2 = 0%

Test for overall effect: Z = 5.69 (P < 0.00001)

Test for subgroup differences: Chi2 = 14.59, df = 2 (P = 0.0007), I2 = 86.3%

Mean

95.4

96.3

94.1

85.9

90.2

92.3

80.5

71.1

94.2

81.5

85.9

84.1

77.6

80.6

85.1

75.7

57.7

81.9

73.2

59.6

79.3

74.1

66.9

70.9

77.8

75.4

74.2

SD

15.4

16.3

13.4

22.7

21.9

15.2

27.7

37

6.4

28.6

18.1

26.5

25.8

27.2

20.7

34.3

40.4

16.3

29.8

26.4

29.7

25.8

35.6

25.6

20.2

34.7

22.2

Total

40

46

46

22

25

10

50

15

36

290

40

46

46

22

25

10

50

15

31

285

40

62

46

46

22

25

10

50

33

334

Mean

91.1

93.6

88.3

81.8

86.6

88.3

74.2

43.6

90.2

70.4

75

70.3

63.6

71.4

78.2

61.4

46.4

71.9

65.1

49.3

60.2

60.2

53.4

60.4

70.2

63.1

65.4

SD

14.1

17.7

13

26.2

17.4

16.7

35

41.9

8

24.5

20.3

27.1

42.3

26.2

22.6

39.5

32

17.9

26.9

28.4

20.9

27.3

24.8

22.4

18.6

37.6

26.1

Total

40

46

46

21

22

10

52

14

36

287

40

46

46

21

22

10

52

14

32

283

40

62

46

46

21

22

10

52

35

334

Weight

12.3%

10.7%

17.7%

2.4%

4.1%

2.6%

3.5%

0.6%

46.1%

100.0%

11.9%

26.3%

13.6%

3.7%

7.0%

4.5%

7.9%

2.3%

22.8%

100.0%

10.9%

18.1%

15.3%

14.3%

5.1%

9.0%

5.8%

8.6%

12.8%

100.0%

IV, Random, 95% CI

4.30 [-2.17, 10.77]

2.70 [-4.25, 9.65]

5.80 [0.40, 11.20]

4.10 [-10.58, 18.78]

3.60 [-7.65, 14.85]

4.00 [-10.00, 18.00]

6.30 [-5.92, 18.52]

27.50 [-1.35, 56.35]

4.00 [0.65, 7.35]

4.43 [2.16, 6.70]

11.10 [-0.57, 22.77]

10.90 [3.04, 18.76]

13.80 [2.85, 24.75]

14.00 [-7.06, 35.06]

9.20 [-6.08, 24.48]

6.90 [-12.09, 25.89]

14.30 [-0.04, 28.64]

11.30 [-15.14, 37.74]

10.00 [1.55, 18.45]

11.21 [7.17, 15.24]

8.10 [-4.34, 20.54]

10.30 [0.65, 19.95]

19.10 [8.61, 29.59]

13.90 [3.05, 24.75]

13.50 [-4.77, 31.77]

10.50 [-3.22, 24.22]

7.60 [-9.42, 24.62]

12.30 [-1.73, 26.33]

8.80 [-2.70, 20.30]

11.93 [7.82, 16.04]

Couple/Marital Individual Mean Difference Mean Difference

IV, Random, 95% CI

-20 -10 0 10 20

Favors Individual Favors Couple/Marital

Horizontal bars for each study represent the study’s confidence interval. Confidence intervals extending below 0 

indicate non-significant differences. Size of box or diamond reflects sample size.

Fals-Stewart Studies. Given that six of the eight studies included in the pooled analyses were 

either first-authored by Dr. Fals-Stewart or were based on data he collected, we also conducted 

the pooled analyses using the two studies that did not include Dr. Fals-Stewart’s studies75, 82

(forest plots shown in Appendix E; Figures 1a and 1b). In this analysis, at post-treatment, there 

was not a significant mean difference in PDA between those in BCT and ICBT. At the short term 

follow-up, however, those in BCT had a significantly higher mean PDA than those in ICBT. The 

difference in mean PDA was 13.6%, which equates to 4 fewer days of drinking/drug use per 

month or nearly 50 fewer days per year for those in BCT/BFT. Only the McCrady et al.75 study 

measured long term outcomes, and there was no significant difference between BCT and ICBT 

during that follow-up period. 
55

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

Alcohol Use Disorder Symptoms (Key Question 2A)

Of the fifteen studies that family treatment to individually-oriented treatment, seven trials 

examined AUDs.63, 69, 71, 73-75, 79 Kelley et al.63 included subjects with both AUD and drug use 

disorders and stratified data by disorder.63

BCT. All but one of the seven trials compared BCT to an individual treatment.73 Five included 

measures of PDA63, 71, 74, 75, 79 and three included measures of PDHD69, 75, 79 during the follow-up 

period of interest using the TLFB procedure.88 As noted previously, one trial79 did not include 

sample sizes for each condition and was not included in the pooled analysis. As shown in 

Appendix E, Figure 2, pooled analyses demonstrated no significant difference in PDA between 

BCT and ICBT post-treatment. However, at both short- and long-term follow up, those in BCT 

had significantly more PDA than those in individual treatments. Those in BCT, on average, had 

nearly 11% more days abstinent (3.3 more days abstinent per month; 40 fewer days per year) 

than ICBT at 6 months and 12.5% more days abstinent at 12 months (3.8 days per month; 45.6 

per year). Although there were far fewer studies, this same pattern was found for PDHD: there 

was no significant difference in PDHD between BCT and ICBT post-treatment, but at both 

short- and long-term follow up, those in BCT had a significantly lower PDHD than those in 

ICBT (Appendix E, Figure 3). On average, we found that those in BCT had 10.2% fewer days of 

heavy drinking than those in ICBT at 6 months (3 days per month; 37 days per year) and nearly 

14% fewer days at 12 months (4 days per month; 51 days per year). It should be noted that one 

of these studies, a trial conducted by McCrady and colleagues,75 included both PDA and PDHD 

outcomes, and was the only study not based on data collected by Dr. Fals-Stewart. In that study, 

neither PDA nor PDHD showed a significant difference across treatment conditions. 

One study not included in the pooled analysis was by conducted by Walitzer et al.73 It was not 

included because neither the comparator nor the outcomes were similar to the pooled studies. 

Instead of comparing BCT to ICBT, BCT was compared to individual group counseling and 

a combination of abstinence, light drinking days, and heavy days of drinking per month were 

assessed at post-treatment, short-term follow-up, and long-term follow up. Means days abstinent 

or days light drinking were not significantly different across conditions. The mean days of heavy 

drinking at post-treatment and short-term follow-up, however, were significantly different, with 

fewer subjects in the BCT condition drinking heavily compared to individual group counseling. 

Long-term outcomes were not significantly different across conditions.

Alternatives to BCT. We did not find any studies that met our criteria that tested differences 

between alternative family treatments to BCT or BFT and individual treatment for AUDs.

Drug Use Disorder Symptoms (Key Questions 2A and 2B)

Of the fifteen studies that compared family treatment to individually-oriented treatment, eight 

trials examined drug use disorders.63, 66-68, 70, 76-78 One of these trials66 had three papers included 

in our review.66, 84, 85 A trial conducted by O’Farrell and colleagues82 included those with drug 

use disorders and alcohol dependence.82 Of the eight trials that examined drug use disorders, 

all but two compared BCT to ICBT. One of the two alternative interventions to BCT and ICBT, 

described in detail below, compared a combination of motivational enhancement therapy (MET), 

psychoeducation, and couple therapy to a weekly, counselor-led support group for drug users,70

The second trial compared a program that included naltrexone, contingency management, and 
56

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

group CBT with reciprocal relationship counseling to a similar program but without reciprocal 

relationship counseling.77

BCT. Five of the eight studies examined BCT and included measures of PDA using the TLFB.63, 

66, 68, 76, 78, 88 As shown in Appendix E, Figure 4, pooled analyses demonstrated a significant 

difference in PDA between BCT and ICBT for the four studies that included post-treatment 

assessments and short-term follow ups. Five studies included outcomes at the long-term follow 

up and these findings were also consistent with earlier time points. We found that, on average, 

those in BCT/BFT had nearly 4.5% more days abstinent (1.3 days per month; 16 days per year) 

than ICBT at post-treatment. At 6 months, they had, on average, 11.5% more days (3.5 days per 

month; 45.4 days per year) and at 12 months they had 10.4% more days abstinent (3 days per 

month; 38 days per year). All of these studies were conducted by or had data collected by Dr. 

Fals-Stewart, making it impossible to examine the effects of treatment among non-Fals-Stewart 

studies. 

Alternatives to BCT. As noted, two studies did not compare BCT to ICBT. In the first study, 

62 opioid-dependent male partners of pregnant women received either psychoeducation and 

support in individual group sessions (usual care) or an intervention program called Helping 

Other Partners Excel (HOPE), which included pregnancy and SUD psychoeducation for couples 

and motivational enhancement therapy, case management, and contingency management for 

symptom reduction for subjects.70 Results showed that, at short-term follow up, those in the 

HOPE condition had spent more days in outpatient treatment and fewer days on public assistance 

than those in usual care. However, although days of heroin use were significantly lower for both 

conditions compared to baseline, these gains were not sustained at the same rate. Those in the 

HOPE condition, in fact, had significantly more days of heroin use at short-term follow up than 

those in usual care. Because of the multi-factorial intervention, however, it was not clear if any 

one part of the intervention reduced the intervention’s effectiveness. 

In the second non-BCT study, Carroll and colleagues77 examined male and female subjects with 

a drug use diagnosis who were assigned either to 1) naltrexone (a medication to reduce cravings 

for alcohol or drugs) plus group CBT, 2) naltrexone, group CBT, plus contingency management 

(incentives for subjects to remain in treatment), or 3) naltrexone, group CBT, contingency 

management, and reciprocal relationship counseling for the patient and a family member, friend, 

spouse, or child. There were no significant differences in the number of naltrexone doses taken or 

PDA from cocaine or opioid use between those in the naltrexone-only group and the group that 

included relationship counseling. The authors did find, however, that those participating in the 

relationship counseling condition reported significantly improved family functioning over time, 

as assessed by the Addiction Severity Index, compared to the other two groups. 

Alternative Comparison Conditions. Although the majority of studies examining symptom 

reduction compared BCT to ICBT, six trials included additional conditions which were also 

compared to BCT and ICBT. These additional conditions included BFT with parenting skills 

training (1 trial71); a psychoeducational attention control treatment (PACT) as an additional 

comparison condition in trials with BCT and ICBT treatment groups (4 trials63, 69, 74, 78); and, an 

alternative form of BCT.65 Two additional trials, one for AUDs and one for SUDs, compared 

standard BCT with a briefer version of the treatment.41,69
57

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

In the parenting skills study, Lam and colleagues71 examined a sample of 30 married fathers with 

an AUD and found, although all three groups showed significant improvement at 12-months 

compared to baseline, neither attendance rates nor PDA at baseline, post-treatment, or 12-months 

post-treatment were significantly different across conditions (BCT, ICBT, BCT + parent skills 

training). Nor did the authors find any significant reductions in interpersonal violence, dyadic 

adjustment, or relationship satisfaction related to treatment condition.

Across the four studies that compared PACT to BCT and ICBT, the authors found that the pattern 

of differences between BCT and PACT was similar to the pattern of differences between BCT 

and ICBT. Specifically, across each study, there were no significant differences between BCT and 

PACT in PDA at post-treatment, but by 12 months, the difference in PDA between conditions 

was significant compared to those in PACT. Similar findings were reported for the effect of 

treatment on couple functioning. Significantly greater improvements in couple functioning 

were found for those in BCT than those in PACT at post-treatment and at short- and long-term 

assessments. Two of the studies that included a PACT condition also included both a standard 

and brief version of BCT.69, 78 In both of these studies, the standard and brief versions showed 

significant differences in PDA compared to ICBT and PACT, but few differences between the 

two versions. 

One study examined the effect of different family involved treatments on symptom reduction.65

BCT was compared to interactional treatment, a therapy approach that does not pre-plan therapy 

sessions, but instead focuses on mutual support, sharing of feelings, and problem solving through 

discussion. In this study, which included 36 participants with an AUD, PDA or PDHD were not 

reported, but relationship functioning, measured as sexual satisfaction was. The data show that 

subjects in the two treatment conditions did not significantly differ in their reports of sexual 

satisfaction. 

Effectiveness of Interventions on Relapse Prevention for AUDs and Drug Use Disorders (KQ2B)

Two studies, by McCrady and colleagues72 and O’Farrell and colleagues,4

 specifically compared 

BCT to BCT plus relapse prevention. McCrady and colleagues compared 1) BCT, 2) BCT with 

enhancements to prevent relapse (BCT/RP), and 3) BCT plus Al-Anon in their clinical trial of 

90 men with AUDs and their spouses/female partners. Relapse prevention training included 

strategies to anticipate risky situations and identify potential signs for relapse. The addition 

of relapse prevention to BCT did not significantly increase participant’s time before relapse 

or improvements in relationship functioning at 6 or 18 months after treatment. However, in a 

sample of 59 male alcoholics and their female spouses, O’Farrell and colleagues4

 found that 

those who received BCT plus relapse prevention had more PDA at 6 and 12 months than those 

who received BCT alone. At 18 months after treatment, those assigned to BCT plus relapse 

prevention reported 13.2% more days abstinent than those in BCT (4.0 more days per month 

or 48.2 more days per year). However, differences were no longer significant at the 30 month 

follow-up. Those with the most severe drinking and poorest couple functioning at baseline 

reported the greatest benefit from BCT plus relapse prevention. Finally, those with the lowest 

severity of marital problems at baseline were more likely to maintain complete abstinence 

through 18 months.

No studies specifically examined relapse prevention for those with drug use disorders. 
58

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

Family Functioning (Family Involved versus Individual Treatment; KQ2A)

The primary family outcome in studies that met our inclusion criteria was family or couple 

functioning. Twenty-one of the twenty-two trials, including both drug use disorder and AUD 

trials, reported either family or relationship functioning outcomes. Multiple instruments were 

used to measure functioning, but the most prevalent was the Dyadic Adjustment Scale (n=9) 

followed by the Marital/Relationship Happiness Scale (n=4) and the family/relationship subscale of the Addiction Severity Index (n=3). 

BCT. Overall, nine trials reported differences in relationship adjustment between individuals 

participating in BCT versus ICBT using the Dyadic Adjustment Scale (DAS) at post-treatment, 

short-term follow-up, and long-term follow-up assessments. We pooled data to analyze the 

effect of treatment conditions on DAS scores but, as previously reported, one trial79 did not 

include sample sizes for each condition and, therefore, was not included in the pooled analysis. 

Pooled analyses that included unadjusted weighted means are presented in Figure 4. Again, we 

reported separate findings for drug use and alcohol use subjects in the 2002 study by Kelley et 

al. Findings were consistent with findings for PDA. At post-treatment, on average there was a 

12% difference in DAS scores, with those receiving BCT having significantly higher couple 

and family functioning than those in ICBT. The total weighted mean post-treatment for BCT 

was 112.7 and for ICBT, 100.5, both of which are above the threshold of 97.5 used as a screen 

for relationship distress (scores range from 0 – 151; Christenson et al.121). At short-term follow 

up (within 6 months of treatment completion), those in BCT had scores 14% higher than those 

in ICBT, with a total weighted mean of 106.8 for BCT and 93.5 (below the threshold indicating 

relationship distress) for ICBT. At 12 months, BCT scores were 12.5% higher than ICBT, and 

while weighted mean scores for BCT remained above 97.5 (mean = 101.2), scores for ICBT 

were below (mean = 90), consistent with couples experiencing clinically meaningful relationship 

distress. 

Of the trials comparing BCT to ICBT not included in the pooled analysis,66, 68, 75, 82 all measured 

different elements of relationship distress, including marital adjustment,66 family functioning,68

separation,75 and relationship happiness,82 yet none reported significant differences across 

conditions.
59

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

Figure 4. Differences between BCT and ICBT: Relationship Adjustment for AUD and Drug Use 

Disorder Studies

Study or Subgroup

1.17.1 Post-treatment

Fals-Stewart 2001

Fals-Stewart 2005

Fals-Stewart 2006

Fals-Stewart 2008

Kelley 2002 (Drug)

Kelley 2002 (EtOH)

Lam 2009

Walitzer 04 CAF+BCT

Winters 2002

Subtotal (95% CI)

Heterogeneity: Chi2 = 5.74, df = 8 (P = 0.68); I2 = 0%

Test for overall effect: Z = 8.75 (P < 0.00001)

1.17.2 Short-term followup (6 months)

Fals-Stewart 2005

Fals-Stewart 2006

Fals-Stewart 2008

Kelley 2002 (Drug)

Kelley 2002 (EtOH)

Lam 2009

Walitzer 04 CAF+BCT

Winters 2002

Subtotal (95% CI)

Heterogeneity: Chi2 = 5.55, df = 7 (P = 0.59); I2 = 0%

Test for overall effect: Z = 8.98 (P < 0.00001)

1.17.3 Long-term followup (12 months)

Fals-Stewart 2005

Fals-Stewart 2006

Fals-Stewart 2008

Kelley 2002 (Drug)

Kelley 2002 (EtOH)

Lam 2009

Walitzer 04 CAF+BCT

Winters 2002

Subtotal (95% CI)

Heterogeneity: Chi2 = 18.79, df = 7 (P = 0.009); I2 = 63%

Test for overall effect: Z = 6.97 (P < 0.00001)

Test for subgroup differences: Chi2 = 0.83, df = 2 (P = 0.66), I2 = 0%

Mean

97.9

119.3

123

114.2

103.6

115.4

114.6

108.4

105.3

112.6

117.2

109.8

93.6

103.9

105.9

107.8

93.4

109.3

112.4

106.9

90.7

91.4

99.8

101.2

86.2

SD

16.4

11.9

12.1

15.1

22.1

18.2

16.8

14.4

13.2

16.2

13.7

16

17.2

16.2

19.6

12.7

22.7

17.2

14

16.5

22.3

19.9

20.3

15.9

25.2

Total

17

25

46

46

22

25

10

19

36

246

25

46

46

22

25

10

16

31

221

25

46

46

22

25

10

17

33

224

Mean

79.2

104.6

111.2

101.9

88.7

102.2

98.1

105.4

97.2

98.4

102.2

94.1

77.8

86.7

93.9

108.3

84.3

96

98

87.3

75.8

82.1

88.9

113.6

82.8

SD

18.1

11.6

18.6

13.6

16.4

19.1

17.9

26.2

16.1

11.6

14.4

14.8

18.7

19.2

20.2

25.6

23.6

19.3

18.8

17.2

20.4

20.7

22

23

25.9

Total

19

25

46

46

21

22

10

21

36

246

25

46

46

21

22

10

15

32

217

25

46

46

21

22

10

14

35

219

Weight

5.9%

17.7%

18.3%

21.8%

5.6%

6.6%

3.3%

4.5%

16.3%

100.0%

15.5%

28.6%

23.8%

8.2%

9.0%

3.1%

4.6%

7.2%

100.0%

12.1%

27.0%

26.1%

7.6%

9.1%

3.6%

6.1%

8.4%

100.0%

IV, Fixed, 95% CI

18.70 [7.43, 29.97]

14.70 [8.19, 21.21]

11.80 [5.39, 18.21]

12.30 [6.43, 18.17]

14.90 [3.30, 26.50]

13.20 [2.49, 23.91]

16.50 [1.28, 31.72]

3.00 [-9.94, 15.94]

8.10 [1.30, 14.90]

12.25 [9.51, 15.00]

14.20 [6.39, 22.01]

15.00 [9.26, 20.74]

15.70 [9.40, 22.00]

15.80 [5.05, 26.55]

17.20 [6.97, 27.43]

12.00 [-5.44, 29.44]

-0.50 [-14.87, 13.87]

9.10 [-2.33, 20.53]

14.08 [11.01, 17.15]

13.30 [3.17, 23.43]

14.40 [7.63, 21.17]

19.60 [12.71, 26.49]

14.90 [2.13, 27.67]

9.30 [-2.35, 20.95]

10.90 [-7.65, 29.45]

-12.40 [-26.62, 1.82]

3.40 [-8.75, 15.55]

12.51 [8.99, 16.03]

Couple/Marital Individual Mean Difference Mean Difference

IV, Fixed, 95% CI

-20 -10 0 10 20

Favors Individual Favors Couple/Marital

Horizontal bars for each study represent the study’s confidence interval. Confidence intervals extending below 0 

indicate non-significant differences. Size of box or diamond reflects sample size.

Alternatives to BCT. Two trials70, 77 did not compare BCT to ICBT. Both included measures of 

relationship functioning. In the trial conducted by Carroll et al.,77 those randomized to naltrexone 

plus CBT plus relationship counseling had significantly higher reports of family functioning 

post-treatment, as assessed by the Addiction Severity Index sub-scale, than those in the CBT 

plus naltrexone only condition. In the trial conducted by Jones et al.,70 however, there were no 

significant differences in couple functioning, as measured by the Partner Support Questionnaire 

and the Relationship Assessment Form, across conditions, either during or after treatment.
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Family Functioning - Alcohol Use Disorder Studies (KQ2A)

BCT. Seven trials examined treatments for AUDs and six used the DAS as a measure of couple 

or family functioning. All six compared BCT to ICBT. We pooled data from all but one of these 

studies;79 a study that did not provide sample sizes by condition. At post-treatment, there was a 

significant difference in DAS scores (12.5, p<0.001), with those in BCT reporting significantly 

higher couple and family functioning (Appendix E, Figure 5). Weighted means at post-treatment 

were 117.8 for BCT and 106.2 for ICBT, both above the clinical cut-point for relationship 

distress. This same pattern persisted at short-term follow up: those in BCT had scores nearly 

14% higher than those in ICBT (p<0.001), although the weighted means were lower than posttreatment (BCT, mean = 111.4 and ICBT, mean = 98.6). At 12 months, scores were nearly 10% 

higher (p<0.001), with weighted means indicating that, while BCT patients were still in the 

satisfied range on relationship adjustment, those in IBCT were, on average, reporting relationship 

adjustment scores consistent with relationship distress (BCT, mean = 104.9; ICBT, mean = 95.7). 

Only one of these studies, a study by Walitzer et al (2004), was not first-authored by and did 

not use data collected by Dr. Fals-Stewart. Although a small study (N = 64 across 3 treatment 

conditions), this one study did not show any significant differences in DAS scores across 

conditions.

Two studies that compared BCT to ICBT were not included in the pooled analysis. One, as 

noted, was due to sample sizes not being available.79 In this analysis, however, the authors 

reported that compared to ICBT, those in BCT had significantly higher DAS scores at posttreatment, short-term follow-up, and long-term follow-up. The other was a study by McCrady et 

al.75 that assessed separation rates. At long-term follow up, there was no significant difference in 

separation rates across conditions.

Alternatives to BCT. We did not find any studies that met our inclusion criteria, tested differences 

in family functioning among patients with only AUDs, and compared a non-BCT/BFT family 

treatment to individual treatment.

Family Functioning - Drug Use Disorder Studies (KQ2A)

BCT studies. Eight trials examined treatments for drug use disorder s.63, 66-68, 70, 76-78 Of those, 

six compared BCT to ICBT 63, 66-68, 76, 78 and four of the six63, 67, 76, 78 used the DAS to assess 

relationship functioning. As with AUDs, we pooled data from those trials that included an 

assessment of DAS and found that those in BCT had significantly higher family functioning at 

post-treatment, short-term follow-up, and long-term follow-up (Appendix E, Figure 6). Four 

studies reported post-treatment DAS scores and those in BCT had scores nearly 12% higher 

than those in ICBT. Weighted mean scores at post-treatment were lower than those for AUD, 

with the average BCT score being 107.3 and the average for IBCT being 94.7 (consistent with 

a positive screen for relationship distress). Three studies reported data for short- and long-term 

outcomes. For short-term, those in BCT conditions had 14.5% higher scores than those in ICBT. 

The weighted mean score at short-term follow up for BCT was consistent with relationship 

satisfaction (above the clinical threshold for relationship distress; mean = 101.1), but this was not 

the case for ICBT, with scores indicating the average participant was experiencing relationship 

distress (mean = 87.5). The difference across conditions at the long-term follow-up was even 

larger. Those in BCT or BFT had DAS scores over 15.5% higher of than those in ICBT at least 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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one year after treatment, although the weighted mean DAS scores had declined with time with 

both groups now falling within the clinically distressed range on relationship adjustment (BCT, 

mean = 96.6; ICBT, mean = 83.4). All of the studies in the pooled analysis used data from, or 

were first-authored by, Dr. Fals-Stewart.

Two studies, both conducted by Fals-Stewart and colleagues,66, 68 compared BCT to ICBT, 

assessing relationship functioning through alternate measures. In Fals-Stewart et al.’s 1996 trial,66

the Locke Wallace Marital Adjustment Test (MAT) was used to assess couple functioning. No 

significant differences were reported across conditions at any follow up. Likewise, in the FalsStewart and colleagues68 trial, using the Addiction Severity Index to assess family functioning, 

no significant differences were found across conditions at post-treatment.

Alternatives to BCT. As previously reported, the trials conducted by Jones et al.70 and Carroll 

et al.77 did not compare BCT, but alternatives to BCT. The Carroll et al.77 trial found significant 

differences in family functioning, with the family treatment having better outcomes than 

the individual treatment. Jones et al.,70 however, found no significant differences in couple 

functioning across conditions.

Intimate Partner Violence

BCT. Three studies, 2 examining subjects with AUDs and 1 with drug use disorders, assessed 

whether BCT compared to ICBT reduced intimate partner violence among those with a drug use 

disorder .71, 74, 85 Lam found no significant changes across conditions at any time point. In FalsStewart et al.’s85 paper, violent behaviors are reported, but tests of association by condition were 

not. In Fals-Stewart and colleagues’74 study, however, those in BCT reported significantly less 

physical aggression at long-term follow up than those who participated in ICBT. 

Alternatives to BCT. We were unable to locate studies meeting our inclusion criteria that 

examined intimate partner violence outcomes among patients with a SUD that examined 

alternatives to BCT. 

Family Functioning (Comparisons among Different Family Treatments; KQ2B)

Six trials compared family involved treatments to one or more alternative family treatments.4, 65, 72, 80, 

81, 83 All but Meyers and colleagues83 reported outcomes associated with family or couple functioning. 

Because study designs and measures used were different across studies, these data were not pooled. 

Of the two trials that tested variations of the CRAFT intervention,80, 81 neither reported significant 

differences in couple or family functioning across conditions at any follow up assessment. McCrady 

et al.,87 a 1996 trial of BCT versus BCT + Al/Anon versus BCT + relapse prevention, reported no 

significant long-term differences in marital happiness across conditions. O’Farrell et al.,4 a study 

of BCT versus BCT + relapse prevention, also did not find any significant differences in marital 

happiness post-treatment or in the short- or long-term follow-up across conditions. However, 

using repeated measures analysis of covariance to assess the effects of the intervention over time 

(as opposed to one specific time point), they found that couples randomized to BCT with relapse 

prevention had greater marital satisfaction over longer periods of time than those randomized to BCT 

only. In O’Farrell et al.’s65 trial that analyzed data on sexual satisfaction, no significant differences 

were found across conditions. No evidence from any of the trials we reviewed, therefore, show that 

one family involved treatment improves relationship functioning more than another. 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Sub-Groups of Interest

Veterans. As noted, only two studies reported Veterans as study participants.4, 65 In both studies, 

all participants were Veterans. In one of these studies, comparing BCT to BCT plus relapse 

prevention, researchers found that the addition of relapse prevention to BCT resulted in more 

PDA at 6 and 12 months than those who received BCT alone (see above for further discussion). 

In the other study, also by O’Farrell et al.,65 there were no differences in sexual satisfaction, a 

common problem associated with AUDs, between those randomized to BCT and those receiving 

interactional treatment. With the inconsistency of these findings, there is little evidence about 

whether BCT is effective with Veteran populations. No evidence exists to evaluate whether 

Veterans respond differently to BCT than non-Veterans. However, the average PDA reported for 

Veteran BCT participants in the one trial reporting this information4

 found PDAs (post-treatment: 

98.0%; short-term follow-up: 87.6%; long-term follow-up: 82.7%), that were comparable, if 

not better, than average rates of PDA reported in the AUD trials included in our pooled analyses 

(post-treatment: 80.5-96.3%; short-term follow-up: 75.7-85.9%; long-term follow-up: 70.9-

79.3%).

Women. Overall, four studies examined women with drug use disorders or AUDs.74-76, 79 One 

examined drug use disorders in both men and women, but did not stratify the results by gender.82

McCrady and colleagues75 found that women in the ICBT group were significantly more likely 

to attend treatment sessions and complete all sessions than those in the BCT group. Additionally, 

women with an additional Axis I disorder had significantly higher PDA with BCT than ICBT, 

women with poor relationship functioning at baseline reported greater declines in substance 

use when assigned to BCT than ICBT, and women in BCT with drinking behavior that was 

influenced by their spousal or romantic relationship prior to treatment reported greater declines 

in substance use than those assigned to ICBT. Women with the best relationship functioning at 

baseline also had a slower decrease over time in PDA. In growth curve models, Fals-Stewart74

found that women in BCT increased their alcohol use at a slower rate than women in ICBT or 

PACT at 12 months, but not post-treatment. 

Three of the four studies that limited participation to women reported PDA and two reported 

mean DAS scores; therefore, we pooled these results (Appendix E, Figures 7 and 8). In order 

to compare women to men, we also pooled data from trials comparing BCT to ICBT that were 

limited to men and assessed PDA (4 trials) and DAS (3 trials) (Appendix E, Figures 9 and 

10). At each follow-up, women in BCT had significantly greater PDA than those in ICBT. At 

post-treatment, women in BCT had nearly 4% greater PDA than women in ICBT. This equates 

to 1.2 fewer days per month (30 day month) or 14.6 days per year. At short-term follow up 

this difference was 11%, or 3.3 days a month or 40 days per year, and at long-term follow up, 

the difference increased to almost 14% (4.2 days per month or 51 days per year). The mean 

difference between BCT and ICBT at post-treatment and short-term follow up was nearly the 

same for men, but at long-term follow up, the difference between conditions was less for men 

than women, with almost a 10% difference between BCT and ICBT (3 days per month or 36.5 

days per year). 

For DAS, women in BCT were also significantly more likely to have higher scores than women 

in ICBT. At post-treatment, women in BCT had over 10% higher scores than women in ICBT. 

Weighted mean scores at post-treatment were 115.2 for BCT and 105.1 for ICBT. At short term 
63

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

follow up, women in BCT had 14% higher scores than women in ICBT, with weighted mean 

scores of 107.6 for BCT and 94.9 for ICBT, with ICBT patients meeting the clinical cutoff 

consistent with relationship distress. At long term follow up mean DAS scores for women in 

BCT were nearly 12% higher than for women in ICBT. Weighted mean scores at long term 

treatment were 101.5 for BCT and for ICBT, 91.4. ICBT patients at the long term follow-up 

assessment had scores that met the clinical cutoff consistent with relationship distress. For men, 

the difference in mean scores across conditions was greater, but overall weighted means were 

lower. At post-treatment, men in BCT had over 14.5% higher scores than men in ICBT. Weighted 

mean scores at post-treatment were 110.7 for BCT and 96.1 for ICBT. At short term follow up, 

however, men in BCT had a nearly 16% higher score than men in ICBT, with a weighted mean 

score of 100.3 for BCT. For ICBT, the weighted mean score was 84.5. At long term follow up, 

mean DAS scores for men in BCT were 11.7% higher than for men in ICBT. Weighted mean 

scores at long term treatment were 92.6 for BCT and for 80.9 for ICBT. Men in ICBT conditions 

had DAS scores at each follow up that met clinical criteria for relationship distress; men in BCT 

conditions, however, had scores that met the clinical cutoff consistent with relationship distress 

only at long-term follow up. 

Intimate Partner versus Family Involvement. As noted, most of the studies in our review 

included spouses or romantic partners of someone with an AUD or drug use disorder. Of the 

seven trials that included family members and did not restrict participation to wives or intimate 

partners, three were the CRAFT interventions that targeted the family member of individuals 

with a drug use disorder to encourage the drug use disorder patient’s treatment initiation,80, 81, 83

and one targeted family members as a means of encouraging patients completing hospitalization 

for substance use detoxification to initiate continuing care and treatment.64 Although data were 

typically not stratified by relationship status, Miller and colleagues,81 as previously noted, did 

find that parents were better at encouraging drinkers to engage in treatment than spouses. All 

four studies did show that interventions targeting families broadly, and not restricted to spouses, 

were effective at promoting treatment initiation. Three other studies68, 77, 82 that did not restrict 

therapy to spouses compared a family involved to an individually-oriented treatment. Two trials 

compared BFT to ICBT.68, 82 Findings from these two studies, however, were not consistent. 

Fals-Stewart and colleagues68 found that, compared to ICBT, participants in BFT attended 

significantly more sessions, took naltrexone on more days ICBT, and had significantly higher 

PDA for opioids, cocaine, alcohol and all drugs combined at 12 months post-treatment. They 

also had significantly longer periods of abstinence from opioids during treatment and higher 

family functioning at 12 months post-treatment. O’Farrell and colleagues,82 however, found that, 

although participants with an SUD in the BFT condition attended more sessions than those in 

ICBT, subjects did not have greater PDA from drinking or other illicit drugs or fewer days using 

their primary substance than those in ICBT at post-treatment or 6-month follow up. Similarly, 

Carroll and colleagues,77as described above, found no significant differences in the number of 

naltrexone doses taken or PDA from cocaine or opioid use between those in the naltrexone and 

CBT group therapy conditions than those who received naltrexone, group CBT, contingency 

management, and reciprocal relationship counseling.

Same Sex Couples. One study examined the impact of family involved treatment on same 

sex couples. Fals-Stewart and colleagues79 compared BCT to ICBT among men (n=52) and 

women (n=48) in same sex relationships who were entering outpatient treatment for an AUD. 
64

Family Involved Psychosocial Treatments for Adult Mental Health 

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Subjects were randomized into 20 weeks of BCT or 20 weeks of ICBT only. The authors found 

that there were no significant differences in attendance across conditions nor was there any 

difference post-treatment in percent days of heavy drinking (PDHD). However, for both groups 

at 6- and 12-month follow-up assessments, those in BCT had significantly fewer PDHD, and at 

12-months, using growth curve modeling, both men and women in the BCT condition increased 

their heavy days of drinking at a significantly slower rate than those in ICBT only. Findings were 

similar on for couple functioning. Both men and women in the BCT condition reported better 

couple functioning at post-treatment, 6-month follow-up, and 12-month follow-up. Growth curve 

modeling showed faster improvements in relationship adjustment (DAS scores) during treatment 

and slower declines in relationships adjustment over the 12-months after treatment completion 

among BCT than ICBT participants. 

Summary

In contrast to Key Question 1, there is more evidence to address the second key question, what 

is the effectiveness of family involved interventions compared to alternative interventions in 

improving outcomes for adult patients with mental health conditions [i.e., how do family involved interventions compare to (a) any individually-oriented psychosocial intervention or (b) 

any alternative family involved intervention]? The majority of studies addressing Key Question 

2 are aimed at the three different time points in the trajectory of treatment: treatment initiation 

or engagement, attendance, and treatment response. As with the results, the discussion focuses 

on the evidence at these stages and then discusses some of the methodological considerations for 

this set of studies.

Initiation

The largest amount of evidence on treatment initiation came from the three studies that assessed 

CRAFT. While these studies varied in quality, their consistency suggests that CRAFT is 

efficacious at promoting treatment initiation for people with SUDs, but there is little evidence on 

whether that engagement is sustained or if that engagement leads to reduced patient symptoms. 

Evidence from O’Farrell and colleagues64 also supports the finding that active family involved 

interventions improve patient engagement.

Attendance and Adherence

We found some evidence from five trials to suggest that family treatment improves treatment 

attendance in AUD and drug use disorder trials. Ten trials, however, did not show any differences 

in attendance by condition. The evidence, therefore, is inconsistent on whether family involved 

treatments improve session attendance. Likewise, there was conflicting evidence, based on two 

studies, on whether family treatment significantly improved medication adherence.

Effectiveness of Interventions on Treatment for AUD and Drug Use Disorder Symptoms

Although results from individual studies that assessed whether treatment that included families 

as active participants improved abstinence or reduced substance use behaviors were not 

consistent, results from pooled analyses showed that, across studies, family involved treatments, 

specifically BCT or BFT, resulted in a significantly higher proportion of days abstinent than 

ICBT. These differences were consistent and persistent across all time points, but the short-term 
65

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

effect appeared to be strongest. These same patterns were seen when data from AUD and drug 

use disorder trials were stratified. These findings are largely consistent with a recent prior review 

of BCT for SUDs which reported ‘robust’ findings that BCT was better than control conditions 

in reducing the frequency of use (d = 0.45), reducing the consequences of use (d = 0.50), and 

improving relationship satisfaction (d = 0.51).123Powers and colleagues123 included non-US 

studies and child-focused studies of BCT.

However, when the only two studies not either conducted or first-authored by Dr. Fals-Stewart 

(both targeted at AUDs) were examined separately in pooled analyses, these patterns differed 

slightly. There were no differences between BCT and ICBT at post-treatment or long-term, but 

there were significant differences in the short-term. Because all of the drug use trials included 

were either first-authored by or used data collected by Dr. Fals-Stewart, we have no evidence, 

outside of his work, on trials that met our inclusion criteria, to compare BCT to ICBT for drug 

use disorders. Therefore, although there is compelling evidence to suggest that BCT is effective 

at improving PDA, especially for periods within 6 months of treatment completion, questions 

remain about its effectiveness immediately post-treatment and for long-term abstinence or harm 

reduction.

Effectiveness of Interventions on Treatment for Family Outcomes (Couple and Family Functioning)

Like findings on abstinence and reduction of drug or alcohol use behaviors, active family 

treatments for SUDs showed better short- and long-term improvements in couple functioning 

than individual treatments in pooled analyses, although for individual studies these differences 

were not always statistically significantly, especially at later time points (e.g., 12 months). 

Passive attention control treatments that included families were not significantly different 

from ICBT, but they were significantly different from BCT, with BCT showing significant 

improvements in couple functioning. Some evidence from three studies of variable quality (1 

poor, 1 fair, and 1 good quality) suggests BCT also reduces intimate partner violence.

Effectiveness of Interventions on Relapse Prevention for AUDs and Drug Use Disorders

Our findings showed mixed results in treatments that added additional relapse prevention 

treatment to standard BCT, with one study72 failing to show significant differences in AUD 

between those assigned to BCT and those assigned to BCT with relapse prevention and another 

study4

 demonstrating a significant increase in PDA for those assigned to BCT plus relapse 

prevention versus those in standard BCT at both short-term and long-term assessments. In the 

latter study, those with the most severe drinking and poorest couple functioning at baseline 

benefitted the most from BCT plus relapse prevention. The interaction between marital happiness 

and relapse was also considered in the former study, but this relationship was not significant. No 

studies addresses relapse for those in drug use disorder trials. 

Sub-Groups of Interest

Veterans. Two studies of the 22 studies reviewed identified Veterans as participants. No direct 

comparisons between Veterans and non-Veteran samples were found among studies that met 

our inclusion criteria. Findings from the one trial we reviewed that provided substance use 

outcomes with Veterans4, 65demonstrated comparable or better rates of PDA from alcohol use 
66

Family Involved Psychosocial Treatments for Adult Mental Health 

Conditions: A Review of the Evidence Evidence-based Synthesis Program

(post-treatment: 98.0%; short-term follow-up: 87.6%; long-term follow-up: 82.7%) than average 

rates of PDA reported in the AUD trials included in our pooled analyses. However, without 

direct comparisons within trials between Veteran and non-Veteran samples and between BCT 

and ICBT, we can draw few conclusions on whether treatment response for Veterans differs from 

treatment response for non-Veterans.

Intimate Partners versus Other Family Members. While the data are limited, it appears that 

treatments involving family members, including those who are and are not intimate partners, are 

successful in increasing SUD treatment initiation among those with SUDs. Once in treatment, 

however, the data are mixed (one study supported BFT over ICBT or medication only,68

another found non-significant differences between BFT and ICBT77). Only one study82 limited 

participation to non-intimate partners. While subjects in the BFT arm were more likely to attend 

treatment than those in ICBT in this trial, there were no significant differences across conditions 

in PDA or PDHD across any time point.

Women. Pooled analyses showed little difference by gender in the overall effect of BCT 

compared to ICBT. One study by McCrady and colleagues,75 however, found women with 

psychological comorbidities had significantly higher PDA with BCT than ICBT, those with poor 

relationship functioning at baseline responded better to BCT than ICBT, and those with the best 

relationship functioning at baseline had smaller differences over time in PDHD.

Bipolar Disorder

Overview

We identified 2 studies that addressed KQ2A, comparing family treatment to individual 

therapy.91, 92 Three studies addressed KQ2B comparing a family therapy with a different family 

intervention.89, 90, 93 Outcomes are presented in Appendix D, Tables 6 to 8.

Treatment Response: Symptoms

Comparisons with traditional individual-oriented therapies (KQ2A; 2 trials)

FFT. One study reporting symptoms compared FFT to alternative, empirically supported individual 

therapies (cognitive behavioral therapy or interpersonal and social rhythm therapy), with clinical 

status assessed at follow-up visits.92 Based on DSM-IV criteria, the odds of being well in any given 

study month were greater for patients in any one of three intensive therapy groups (one of which 

was FFT) compared to the control condition, individually-oriented collaborative care. However, 

when the authors stratified the intensive therapy group by type of therapy, there was no difference 

between family-focused therapy and collaborative care. No significant differences between 

conditions were reported,92 suggesting FFT may perform similarly to other empirically supported, 

intensive interventions in improving symptoms of bipolar disorder. 

Relapse and recovery outcomes were reported in two studies comparing FFT to individual 

therapy. No significant differences in recovery or time to recovery were observed between FFT 

and either of two other intensive, individual therapy control groups (cognitive behavioral therapy 

or interpersonal and social rhythm therapy). Both the combined intensive therapy group and 

the FFT group alone (secondary analysis) were significantly better than individually-oriented 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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collaborative care.92 A second study found no difference in number of subjects with one or more 

relapses during one year of active treatment but 32% lower rates of relapse and 48% lower rates 

of hospitalization in the FFT group compared to the individually-focused treatment group during 

the year after treatment.91

Comparisons with alternative family therapies (KQ2B; 3 trials)

FFT. Another study reported symptoms when FFT was compared to another therapy with some 

family involvement. A significant treatment versus time interaction was observed for symptoms scores 

at both 12 and 24 months follow-up, indicating FFT results in greater improvement in symptoms 

than participants in a ”crisis management” group (modeled after standard community care with 2 

family psychoeducation sessions).90, 96 There was also a significant difference between FFT and crisis 

management participants in the percentage of subjects who survived one year without relapse (71% 

vs. 47%) when study dropouts were excluded. Using the intent-to-treat sample, relapse at 24 months 

was significantly lower in the FFT group.90, 96 Relapse rates at 24 months after randomization were 

35% for FFT participants and 54% for crisis management participants. Patients in crisis management 

relapsed an average of 20 weeks sooner than FFT participants.

Relapse and family functioning interactions. This same trial found no main effect of family 

distress or a treatment by family distress interaction for relapse among patients randomized to 

FFT or crisis management.90 Differences in percent relapsed were noted for participants with 

parental relatives (fewer relapses in participants from low expressed emotion parental homes 

compared to those from high expressed emotion parental homes) but not spousal relatives.90

FFT-HPI. Participants whose caregivers received FFT-HPI had significantly fewer symptoms 

of depression (5.6 points on the HAM-D; d = 0.67, medium effect) and mania (4.2 points on the 

YMRS; d = 0.34, small effect), indicating greater symptom relief, than patients whose caregivers 

received health education only.93

Problem Centered Systems Therapy for the Family (PCSTF). Miller and colleagues (2004) failed 

to find differences in recovery between a general family therapy (PCSTF; 10 to 15 sessions 

focused on comprehensive assessment, problem identification, and task-oriented problem 

solving) and an alternative family therapy (disorder-specific multifamily groups [MFGs]).89 The 

multifamily psychoeducational group therapy (6 sessions with 4 to 6 patients and their family 

members) focused on providing information about bipolar disorder, coping strategies for living 

with a family member with a mood disorder, and a forum to discuss differences in patients’ 

and family members’ perspectives on bipolar disorder. Among patients who recovered, the 

frequency of mood episode recurrence did not differ among the treatment groups but frequency 

of hospitalization was lower in the multifamily therapy group (5%) versus family therapy 

conducted with one family at a time (31%) or medication only (38%).97

Treatment Response: Family or Couple Functioning

Comparisons with traditional individual-oriented therapies (KQ2A; 1 trial)

FFT. Family or couple function was evaluated in one study. Significantly greater improvements in 

relationship functioning and satisfaction were found among subjects receiving intensive psychosocial 

treatment (family or individual) than those receiving individually-focused usual care.95
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Comparisons with alternative family therapies (KQ2B). No trials. 

Treatment Attendance and Medication Adherence

FFT

Attendance at therapy sessions was reported in two studies. FFT was not significantly different 

from multifamily therapy89 or from other individually-oriented intense treatments.92 A study 

of FFT compared to individual care reported no difference in medication adherence.91 Family 

therapy (compared to crisis management with a limited family component)90 resulted in greater 

medication adherence following treatment.

Summary

Two studies reported greater recovery at 12 months92 or lower relapse at 24 months91 based 

on symptom assessment in individuals who participated in family-focused therapy compared 

to individually oriented treatment (KQ2A). Rehospitalization was also lower in the familyfocused therapy group.91 In addition, the odds of being classified as “well” in any given month 

were greater for participants in any of 3 intensive therapies (including family-focused therapy) 

compared to individually-focused collaborative care.92

Two studies reported reduced symptom scores among patients whose family participated in 

family-focused therapy90 or family-focused therapy with a health-promoting focus93 versus 

an alternative family involved intervention (KQ2B). Lower relapse and longer relapse-free 

survival following family-focused therapy were also reported in one of the studies.5

 However, 

one study reported no difference in recovery at 28 months between family treatment delivered to 

individual families and multi-family therapy.89 This study involved a shorter treatment interval 

(all treatment completed within 6 months vs. 9 months in the other two studies).

One study reported a significant difference between three intensive therapies (one of which was 

family-focused therapy) and individually-oriented collaborative care (KQ2A) in relationship 

functioning or satisfaction.95 In two studies, problem-centered family therapy89 and three 

intensive therapies (including family-focused therapy)92 were not observed to improve treatment 

attendance compared to individually-focused collaborative care (KQ2A) 92 or multifamily 

therapy (KQ2B.)89 Results for improvements in medication adherence were mixed with no 

difference in a study of family-focused therapy compared to individual therapy (KQ2A)91

or family-focused therapy compared to crisis management with limited family involvement 

(KQ2B).5

Overall, although studies typically assessed symptoms and reported either the symptom scores 

or relapse/recovery based on symptom scores, few studies assessed other outcomes of interest 

including global functioning (2 studies), health care utilization (1 study), family outcomes (1 

study), attendance (2 studies), or medication adherence (3 studies). No study reported quality of 

life or satisfaction with care. 

Many of the studies reviewed above were cited in a systematic review of family psychosocial 

interventions for bipolar disorder completed by Justo et al.124 All of the studies in their review 

were randomized or quasi-randomized trials that enrolled adults and involved psychoeducational 

interventions or psychotherapy. Overall, based on 5 studies reviewed by Justo and colleagues124
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that compared family interventions to no intervention, two of which met eligibility for our 

review,89, 94 no added effect of the family intervention to medication only was observed. In 

three studies that compared one family intervention to another family intervention or individual 

therapy, all of which were included in our review,89-91 results were inconsistent. Of the 7 studies 

in the Justo et al. review, 5 were conducted in the United States. Four of the five studies were 

eligible for inclusion in our review.5, 89, 91, 94 The fifth study was published in 1990 and did not 

meet our eligibility criteria. As reported in the Cochrane review, that study found no significant 

clinical improvement when a family intervention was compared to no intervention.

Schizophrenia Spectrum Disorders

Overview

Four studies addressing KQ2 met our search criteria; one comparing a family intervention 

to individual oriented therapies (KQ2A) and three comparing two family involved therapies 

(KQ2B). Data are presented in Appendix D, Tables 10 to 12. 

Comparisons with Traditional Individual-Oriented Therapies (KQ2A; 1 trial)

One trial examined differences between a two-year multiple family group (MFG) intervention 

and standard individual mental health care (case management and medication management) 

within outpatient mental health service clinics.101-103 While the present review focuses on 

treatment comparisons at post-treatment and after treatment completion, the length of this 

intervention (2 years) increases the relevance of mid-treatment findings. At mid-treatment 

(1 year post-baseline), subjects in the MFG group showed significant improvement in 

negative symptoms as measured by MSANS (Modified Scale for the Assessment of Negative 

Symptoms),101 with subjects in the MFG scoring, on average, one point better on a 25 point 

scale. At post-treatment, there were no statistical differences in hospitalization between the two 

groups. MFG subjects had statistically higher use of outpatient services that was attributable 

to greater time spent in the intervention for MFG participants.103 At the one-year follow-up, 

differences between the MFG group and their standard care counterparts on overall psychiatric 

hospitalization rates were non-significant. However, hospitalization in state level facilities 

(which provide longer term care and include patients referred directly from the criminal justice 

system) was 12% lower (significant difference) for MFG subjects than for standard care 

subjects. No significant group differences were observed in outpatient service use at one year 

post-treatment.103 Differences between groups on family functioning or by distressed and nondistressed families were not reported. 

In another study of note (not reported in our tables), Herz and colleagues125 studied the 

effectiveness of a program of relapse prevention (an early intervention treatment strategy 

with psychoeducation for patient and family, active monitoring of the subject for prodromal 

symptoms, weekly group therapy for the patient, and a biweekly multifamily group) to treatment 

as usual. Treatment as usual included individual supportive therapy and medication management 

biweekly for 15 to 30 minutes. Significant differences in relapse and rehospitalization rates 

were found, favoring the intervention. However, only 29% (12 of 41) of the relapse prevention 

patients’ families actually attended family groups, and full results were not reported for those 

who attended family groups versus those who did not. Of note, only one patient from these 
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twelve families relapsed; however, this number is too low to draw conclusions as to the 

significance of the family component of the relapse prevention program. Given the lack of clarity 

regarding which subjects actually received family involvement in their care and the outcomes 

of those who received family involved care, this study did not meet eligibility criteria for our 

review. We elected to present findings here given their relevance.

Comparisons with Alternative Family Therapies (KQ2B; 3 trials)

One trial compared Assertive Community Treatment (ACT), which includes a family education 

and engagement component, to ACT plus a biweekly multi-family group.29 Number of hospital 

admissions, rates of annual rehospitalization, and subjects’ symptoms decreased throughout the 

two year intervention for participants in both groups pre-treatment to post-treatment; however, 

there were no significant differences between the groups. Data were not reported by treatment 

group and therefore are not included in appendix tables. One reported area of differing outcomes 

by treatment group was in employment rates. Employment rate for subjects in the MFG was 

significantly higher between months four and twenty (of the two year intervention); however, 

differences were non-significant at the final reporting point (end of the twenty four month 

intervention). Family outcomes (family dissatisfaction with the subject, reported friction between 

the subject and others) improved significantly for both groups pre- and post-treatment, but direct 

comparisons between the two treatment groups were not reported.

The trial comparing Applied Family Management (AFM) to Supportive Family Management 

(SFM)24, 104 showed no differences in the likelihood a subject would stabilize, and no significant 

interactions between family management and medication dosage. Rehospitalization and relapse 

outcomes were reported only for the 313 subjects who stabilized and only during the two years of 

treatment. There were no significant differences in rehospitalization, mean days to rehospitalization, 

time to psychotic relapse, or time to use of first rescue medication between the AFM and SFM 

groups overall.24 Rehospitalization also did not significantly differ when comparing the two levels 

of family treatment within the three medication dosage groups. There were also no significant 

differences in social adjustment between the two treatment groups from baseline to post-treatment 

in social functioning, family relationships, or the romance/sexual factors of the social adjustment 

scale.104 However, the more intensive AFM treatment was associated with significantly lower levels 

of rejecting attitudes by family members toward the subject (0.32 scale points at 1 year; 0.31 effect 

size; 1.03 scale points at 2 years; 0.30 effect size; p < 0.01) and significantly less family friction 

then the less intensive SFM intervention. However, authors note that given the non-significant 

differences on primary outcomes and small differences on family outcomes, differences across 

these treatment conditions may have limited clinical significance.

A third trial was comprised of 108 subjects with a dual diagnosis of active substance abuse or 

dependence and either schizophrenia, schizoaffective, or bipolar disorder.99, 100 Patients and a 

family member received weekly psychoeducation in both groups, however the FPE (Family 

Psychoeducation) arm sessions were brief, lasting 2-3 months. In the Family Intervention for 

Dual Disorders (FIDD) arm, 20-30 sessions (over 18 months) were conducted and problem 

solving strategies and training in communication were added. Additionally, patients and family 

members in both groups were encouraged to attend multiple family support groups for up to 

36 months. Engagement, defined as subjects participating in 2 or more sessions, was high for 

both groups (>80%) and not significantly different by group. Treatment exposure, defined as 
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attending at least 3 sessions for the FIDD group or 6 educational sessions the FPE group, did 

not differ between groups. Attendance in the multiple family support groups was low for both 

conditions (15% for FIDD and 11% for FPE; difference non-significant); these groups were 

discontinued three years into the study. The FIDD group Brief Psychiatric Rating Scale rating 

was significantly higher than the FPE group over the three year follow up period; the effect 

was small for total score (0.17) but moderate for the psychosis subscale (0.32). Overall subject 

functioning, as measured by the Global Assessment Scale, was higher in the FIDD group (p = 

0.08), over the three year follow up period. In the FIDD group, the BPRS psychosis symptom 

reduction was much stronger for women than for men. The more intensive FIDD subjects did 

not show significant improvement in alcohol or drug use or percent stable days compared to their 

FPE counterparts, but both groups improved significantly in these areas as compared to baseline. 

Social problem solving skills did not improve significantly for the FIDD group as compared to 

the FPE group, as was hypothesized. Outcomes on the individual functioning of family members, 

versus the family as a unit, and on how having a relationship with an individual with a mental 

illness affects the family member were collected; however, those outcomes are outside the scope 

of this review and thus are not reported here.

Results were not reported by relationship distress in trials comparing family involved therapies. 

Summary and Discussion

Evidence synthesized in numerous prior reviews supports the efficacy of family interventions, 

typically psychoeducational family treatments, that include elements of education on the illness, 

family support, crisis intervention, and problem-solving skills training to improve relapse 

and rehospitalization rates outcomes for schizophrenia spectrum patients, compared to no 

intervention or medication only (KQ1).126-130 Psychoeducational family treatments of at least 

9 months, in combination with medication, have been previously recommended by existing 

treatment guidelines127 with “good” evidence of leading to improved relapse rates among 

patients.6, 126-128

The Schizophrenia Patient Outcomes Research Team (PORT), funded in 1992 by the 

Agency for Health Care Policy and Research and the National Institute of Mental Health, 

issued psychosocial treatment recommendations in 1998, 2003, and 2009 which included 

recommendations for family based treatment. They recommend that patients with ongoing 

contact with their families, or who have “non-family” caregivers, should be offered psychosocial 

intervention that provides a combination of family education, family support, crisis intervention, 

and problem solving skills training,127 regardless of level of a family’s expressed emotion. Their 

initial recommendations were refined and expanded to include shorter interventions (less than 

nine months), in recognition that more complex and lengthy interventions are difficult to actually 

implement.128, 129

Research summarized in prior reviews has largely established that family psychoeducational 

treatments are superior to treatment as usual in reducing relapse rates.131, 132 However, these 

interventions are not consistently superior to comprehensive and intensive patient-only 

interventions132 and the effects of these interventions over long term follow-ups are mixed.33, 130, 

131, 133, 134 Recently a Cochrane review126 also supported the above review findings but cautioned 

that these effects may be overestimated due to poor methodological quality. Also, as noted in 
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the Cochrane review,126 many previous schizophrenia studies were conducted in China and other 

countries, so the results may not be applicable to a US. Veteran population. Family interventions 

for schizophrenia which met our inclusion criteria (conducted in the US since 1996 and including 

patient outcomes), have not included a no treatment, waitlist, or medication only comparison 

condition. Therefore, we cannot contribute to the body of literature establishing the general 

efficacy of family treatments compared to waitlist or medication management only (KQ1). While 

there is an important clinical need to provide some form of psychosocial intervention to patients 

with serious mental illness, comparisons of relatively untested programs to equally rigorous 

comparators complicate efforts to demonstrate the initial efficacy of untested programs.

Our findings address how family interventions compare to individually oriented care (1 trial) 

or other family interventions (3 trials) and include a wider breadth of patient outcomes and 

more complex patients with either co-occurring problems (1 trial) or co-morbid substance use 

disorders (1 trial) than trials conducted prior to our review period. Additionally, to address an 

existing gap in the literature,9, 130 one trial examined the efficacy of family involved treatments in 

improving patient outcomes for patients who are relatively stable (those who have not recently 

suffered a psychotic relapse or hospitalization)101-103 by recruiting participants from a community 

mental health setting, regardless of recent relapse or hospitalization. Dyck and colleagues101, 102

found an intervention including multiple family groups was superior to individually-oriented 

treatment at the mid-treatment time point (one year after randomization) in rates of negative 

symptoms and rates of hospitalization. At post-treatment and long term follow-up (1 year post), 

the only significant difference across conditions was in rates of state-level psychiatric facility 

hospitalizations.103 State-level psychiatric hospitalizations are reserved for those patients with the 

most severe symptoms, thus this finding may suggest that family intervention is more beneficial 

than individual care for those with the most severe symptoms, consistent with earlier findings.129

Additionally, these findings are consistent with prior work suggesting erosion of treatment effects 

can be found across conditions at long term follow-ups.33, 131

Three other trials each compared a less intensive to a more intensive family intervention.24, 

29, 99, 104 Few differences were found between conditions, although improvements in both 

groups as compared to baseline were noted for several outcomes. This is consistent with past 

reviews identifying that differences among intensive interventions and among alternative 

family interventions with different theoretical underpinnings are largely non-significant.130, 132

The subjects in McFarlane and colleagues29 Assertive Community Treatment trial all showed 

improvement over the two year intervention, but the addition of multiple family groups yielded 

only one significant additional benefit, employment rates during treatment. However, these 

differences were also non-significant at the 24 month end point.

Schooler et al.24 found that the addition of in-home behavioral single family therapy to a larger 

family-oriented treatment package did not provide significant additional benefits in subjects’

need for rescue medication, relapse delay, or hospitalization. Mueser et al.,104 examining 

subjects in the same study, found the more intensive family intervention lead to significantly 

less family friction and better attitudes towards the patient than the family-oriented treatment 

package delivered in clinics, without in-home BFT. There were no differences in patient social 

functioning between groups. Outcome data was collected only for subjects who successfully 

stabilized and complied with treatment, eliminating the most severely ill patients (41% of the 528 

randomized), who may stand to benefit more from the more intensive family treatment.
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Mueser and colleagues’ trial99, 100 enrolled subjects dually diagnosed with both schizophrenia 

spectrum and substance use disorders, and they expanded the definition of family to include 

“any caring, but non-professional relationship,” including clergy and friends as well as relatives. 

The longer, skills oriented intervention (FIDD) was associated with greater improvements in 

subject psychiatric functioning and symptoms than brief (2-3 month) family psychoeducation 

only treatment, but did not reduce substance use. The initial success in engaging subjects and 

their family members in both levels of treatment suggests acceptability of family intervention for 

dual diagnosis patients. However, the vast majority of families (over 80%) in both study arms 

did not participate in multi-family groups offered between the end of the psychoeducation and 

skills intervention and the final data collection point (three years after randomization). How to 

motivate families and patients to participate in program offerings post-treatment is an area that 

needs further research. None of the schizophrenia studies included in our review provided results 

comparing distressed to non-distressed families. 

Posttraumatic Stress Disorder

Overview

One study that met our criteria addressed KQ2. Relevant to KQ2A, Glynn and colleagues 

compared an individually-oriented treatment (exposure therapy) to that same intervention 

followed by PTSD-specific behavioral family therapy. Findings are presented in Appendix D, 

Tables 14 to 16.

Comparisons with Traditional Individual-Oriented Therapies

Differences in symptom change and social adjustment were non-significant between those who 

participated in exposure therapy versus exposure therapy plus BFT.8

 Additionally, Glynn and 

colleagues8

 collapsed all those participating in BFT with those not participating in BFT. They 

found greater increases in social problem solving skills over the course of treatment among 

those participating in BFT than those who did not participate in BFT. However, those who 

participated in exposure therapy plus BFT were more likely to drop out of treatment than those 

who participation in exposure therapy alone.8

No studies compared different family involved therapies. Additionally, the role of family distress 

in predicting differential response across conditions was not examined.

Sexual Functioning Disorders

No studies compared family interventions to traditional individual-oriented therapies or to 

different family interventions.

Other Conditions

Depression

No studies that met our inclusion criteria included a comparison of family involved therapy and 

individual or alternative family involved therapy. However, we did identify two recent Cochrane 

reviews that explored the role of family members in the treatment of depression. Barbato 

and D’Avanzo135 included randomized controlled trials or quasi-randomized controlled trials 
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comparing marital therapy to other psychosocial and medication treatments or to non-active 

treatments.135 The studies included heterosexual couples between the ages of 16 and 65 years 

with a depressed spouse (primary diagnosis by DSM-IV, International Classification of Diseases 

(ICD-10), or Research Diagnostic Criteria codes). Treatment was community or outpatient based. 

Eight trials were included; three of these were conducted in the United States (publication dates 

1989-1992). The overall conclusion from the review was that there was no evidence that marital 

therapy was different than individual psychotherapy in terms of depressive symptoms (data 

from 6 studies with a total of 167 subjects) or persistence of depression (3 studies, 106 subjects) 

following treatment. Marital distress was lower following treatment in the marital therapy groups 

than in the individual therapy groups (5 studies, 137 subjects). There was no difference in the 

number of drop-outs (6 studies, 210 subjects). In distressed couples, there was no difference 

in depression outcomes (4 studies, 90 subjects) or drop-outs (4 studies, 109 subjects). Marital 

stress was significantly reduced (4 studies, 90 subjects). Two studies (60 subjects) that compared 

marital therapy to no or minimal therapy did report a reduction in depressive symptoms 

following treatment. The three studies from the United States, all of which compared marital 

therapy to individual therapy, found no difference in depressive symptoms. Two of the studies 

reported persistence of depression with no difference between treatment groups. The authors 

of the review noted small sample sizes, unclear sample representation, short follow-up periods 

(or assessment only at the end of treatment), and large number of drop-outs as methodological 

weaknesses of this literature.

The second review focused on family therapy for depression.136 Randomized controlled trials and 

controlled clinical trials were included if the treatment involved 6 or more sessions of at least one 

hour duration and no group therapy with multiple families. Family therapy was compared to no 

intervention or an alternative intervention. Six studies were included in the review however two 

enrolled adolescents and one enrolled children. Of the three studies enrolling adults, two were 

conducted in the United States. In one study published in 1985, an inpatient family intervention 

(psychoeducation based) reduced symptoms, improved family attitude toward treatment, and 

improved global functioning compared to individual treatment. The results were significant only 

for the female patients. The second study is reviewed above.89 Overall, the authors of the review 

concluded that there was insufficient evidence to assess the effectiveness of family therapy 

for treatment of depression. The use of psychological interventions with an evidence base was 

recommended.

Summary

Recent prior reviews have established that there is low135 or insufficient136 strength of evidence 

to assess whether family therapy is more effective than no treatment or waitlist in reducing 

symptoms of depression and increasing family functioning. An early review9

 included data 

from 3 studies published prior to our inclusion date. One study of behavioral marital therapy 

found no difference between behavioral marital therapy and individual cognitive therapy for 

improving depression symptoms in maritally distressed couples;45 both interventions were 

superior to wait list control.45 A second study included distressed and non-distressed couples.44

In that study, behavioral marital therapy and individual cognitive therapy were comparable for 

maritally distressed couples. Cognitive therapy was superior for alleviating depression in nonmaritally distressed couples. A similar result was reported in a study comparing interpersonal 
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psychotherapy for depression (IPT) without family involvement to IPT delivered as a couple 

therapy (i.e., both the patient and his or her intimate partner participate in treatment sessions).137

The study that was eligible for and included in our review enrolled mildly to moderately 

distressed couples and found brief couple therapy to be superior to waitlist for reducing 

symptoms and improving couple function.114

Eating Disorders

The same study that reported outcomes for KQ1 (group CBT with spouse vs. wait list control) 

included a comparator active treatment group (standard CBT).115 Results (see Appendix D, Tables 

22 to 24) were reported post-treatment and at 6 month follow-up. There were no significant 

differences between the two active CBT groups for binge abstinence or days binged (either by 

7-day recall or the EDEQ.116, 117 Depression scores (BDI112) decreased for both groups but did not 

differ between groups. There were no differences between active CBT groups on the Rosenberg 

Self-Esteem Score.138 Couple functioning (Dyadic Adjustment Scale)109 did not differ between 

CBT groups post-treatment or at follow-up, however, subjects in the CBT with spouse group 

reported being in better agreement with their spouses regarding a plan of action for binge eating 

(p = 0.04). Attendance at treatment sessions was comparable.

Summary

Patient or couple functioning outcomes for women in the group CBT for binge eating disorder 

with spouse involvement group did not differ from results for women in the standard CBT group 

with the exception of better agreement on a plan for managing binge eating.

Smoking Cessation

One study of partner-assisted therapy in conjunction with individual counseling met eligibility 

criteria.118 The study was conducted at an Army Medical Center and enrolled 625 women who 

were pregnant and their intimate partners. Partner-assisted therapy with individual counseling 

was compared to individual counseling alone or to usual care. Outcomes were assessed at 28 

weeks of pregnancy and at 2-, 6-, and 12-months postpartum. Results are presented in Appendix 

D, Tables 22 to 24. No differences were observed between groups for abstinence from smoking, 

time to relapse, or social support (including smoking-specific support, instrumental support, or 

emotional support).

Summary

Abstinence from smoking, time to relapse, and social support did not differ for pregnant 

women who participated in partner-assisted therapy with woman-only counseling, woman-only 

counseling, or usual care.
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SUMMARY AND DISCUSSION

This evidence synthesis summarizes the efficacy of family involved psychosocial treatments in 

improving the outcomes of patients with mental health conditions in the US since 1995. Two 

key questions were identified. Our search yielded 51 articles (39 trials), including trials of family 

interventions for substance use disorders (22 trials), bipolar disorder (6 trials), schizophrenia and 

related disorders (4 trials), PTSD (2 trials), sexual functioning disorders (2 trials), depression (1 

trial), binge eating disorder (1 trial), and nicotine dependence (1 trial). 

Overall, this review represents a variety of studies examining family involved treatments for mental 

health conditions. Trials were highly heterogeneous in terms of intervention characteristics, size, 

population, and findings. In many cases, the family intervention was manualized and withdrawals 

from the trials were adequately described. Typically, well-validated outcome measures were 

employed, diagnoses were verified by structured clinical interviews, and exclusion/inclusion 

criteria were clearly described. However, few studies included a description of allocation 

concealment or blinding procedures and measures used to assess the same construct were highly 

variable across trials. Frequently, intent to treat analyses were either not described or not employed, 

assessments of treatment integrity were frequently not described, and for many studies, samples 

were small and analyses underpowered. Additionally, many studies were conducted on mostly 

white and male samples, who were under 40 years old, and in all but two trials, Veteran status 

among participants was not reported. While post-treatment symptom severity was frequently 

reported, many of our other outcomes of interest were not. Most notable was the frequent absence 

of assessments of global family/couple adjustment, communication, conflict, observational family/

couple interactions, intimate partner violence, adherence, attendance, and satisfaction with care. 

The substance use literature posed the largest exception to this, with studies frequently examining 

global family/couple adjustment, adherence, attendance, and satisfaction with care. This likely 

reflects the more advanced stage of development of this literature.

The majority of studies fell into either Baucom and colleague’s9

 disorder specific couple/family 

treatment and/or partner-assisted treatment categories. The purposes of family involvement also 

varied and included, but were not limited to, engaging patients in care, family members acting as 

out-of-session coaches, psychoeducation to improve family’s support for patients, and addressing 

family conflict that could exacerbate symptoms.

Summary of Evidence by Key Question

Key Question #1. What is the efficacy of family involved interventions in improving outcomes for adult patients with mental health conditions [i.e., how do 

family involved psychosocial treatments compare to no psychosocial treatment: (a) 

waitlist/no treatment or (b) medication management only]?

The level of development of the evidence for family involved treatments varied greatly 

across conditions. Consequently, family treatments for some conditions had a number of efficacy trials prior to our search timeframe (i.e., schizophrenia and substance use disorder). For 

these conditions, the trials reviewed were more applicable to KQ2. See Table 1 for a review 

of the efficacy status of family treatments for mental health conditions prior to our review. 
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Substance Use Disorders

One trial64 found that among patients completing an inpatient alcohol detoxification program, 

a single family session and single family follow-up to help plan for continuing care (partnerassisted treatment9

) did not result in significantly improved percent days abstinent post-intervention or greater attendance to continuing care. However, 92% of those receiving the family 

intervention were more likely to enter a continuing care program, a 30% improvement over 

patients hospitalized for substance use detoxification whose families did not participate in 

their aftercare planning.

Bipolar Disorder

Two trials compared a family intervention to a drug-only treatment. In one trial medication management alone was compared to medication management plus either Problem Centered Systems 

Therapy of the Family (PCSTF; a general family therapy9

) or psychoeducational multifamily 

groups (a disorder specific family intervention9

). There were no differences in symptoms between 

either family involved treatments or medication management alone.89, 97, 98 However, compared to 

medication management only, patients from distressed families reported significantly lower rates 

of depressive episodes (psychoeducational multifamily groups: 1.4 fewer episodes per year, d = 

1.0; PCSTF: 0.9 fewer episodes, d = 0.70), shorter duration of depressive episodes (psychoeducational multifamily groups: 14% less time; d = 0.82), and fewer mood episodes (psychoeducational 

multifamily groups: 1.7 fewer episodes, yearly, d = 0.82), suggesting a family intervention specific to bipolar disorder or a general family therapy could provide improved treatment response 

for patients with bipolar disorder in distressed families. In the other trial, while those assigned to 

psychoeducational maritial therapy (a disorder specific couple intervention) did not report greater 

symptom relief than those assigned to medication management only, patients in marital therapy 

did report better global functioning (7 points on the 100 point GAS) and medication adherence 

(0.53 points on a 6 point scale) than those assigned to medication management only.94 In both 

cases, family functioning outcomes were not reported.

Schizophrenia

No trials.

PTSD

One trial demonstrated exposure plus Behavioral Family Therapy (a disorder specific family 

therapy9) resulted in better PTSD outcomes than waitlist;8 however these differences eroded 

at follow-up and drop out was worse among those in the family treatment condition. Another 

trial demonstrated significantly better engagement in treatment for the patients (Bosnian refugees) of those who participated in family support groups (CAFES; a trauma-specific family 

therapy), than waitlist.105 Specifically, patients’ whose family members participated in CAFES attended 4 more mental health visits than waitlist controls.

Sexual Functioning

One trial106 found subjects assigned to sex therapy plus medication reported greater satisfaction with treatment than those assigned to medication alone (disorder specific couple treat-
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ment).9, 106 Differences between conditions on erectile functioning up to two months after 

treatment were not significant. A second trial found no significant difference between those 

assigned to four weeks of cognitive-behavior sex therapy plus medication versus those assigned to medication alone after 4 weeks of treatment. Further descriptive statistics on differences between the two groups were provided at this post-treatment assessment but further 

formal testing was not provided.

Other Conditions Examined in Single Trials

One small trial of brief couple therapy for depression (n = 35; disorder specific couple treatment) found that couple therapy led to significantly improved depression symptoms and 

marital satisfaction. On continuous measures, scores on the BDI-II (d = 0.54), HAM-D (d 

= 0.72), and DAS (d = 0.43) were each significantly improved for participants in couple 

therapy compared to waitlist controls.114 A trial of group CBT for binge eating disorder found 

that CBT with or without spouse involvement resulted in better symptom improvement than 

waitlist.115

Key Question #2. What is the effectiveness of family involved interventions 

compared to alternative interventions in improving outcomes for adult patients 

with mental health conditions [i.e., how do family involved interventions compare 

to (a) any individually-oriented psychosocial intervention or (b) any alternative family 

involved intervention]?

Substance Use Disorders

Twenty-one of 22 trials addressed KQ2. Fifteen trials compared family treatment to individually-oriented treatment as usual or manualized individual behavior therapy (13 of these 

trials examined BCT or BFT for an alcohol or substance use disorder; 2 trials examined alternative methods of family involvement in care) and 6 trials compared a family treatment to 

an alternative family involved treatment (3 trials examined CRAFT, a disorder-specific and 

partner-assisted treatment; 3 examined BCT or BFT). Findings are summarized by intervention below.

Behavioral Couple Therapy or Behavioral Family Therapy (disorder specific couple therapy9

)

Effects on substance use. BCT participants used substances for 1.2 fewer days per month 

(14.6 per year) at post-treatment, 3.3 days per month (40 per year) at 6 months, and 3.6 days 

per month (44 per year) for 12 month follow-ups. This same general pattern of results was 

found for studies addressing drug use only, alcohol use only, drug use disorders among men, 

and drug use disorders among women.

Effects on relationship adjustment. Better relationship adjustment following treatment was 

found among those assigned to BCT than ICBT, with 12.5% higher scores on the DAS, on 

average, among those who participated in BCT, one year after treatment.

Therapy with non-intimate partners (BFT). Findings are mixed for differences between 

ICBT and BFT, a version of BCT including non-intimate partners, with one trial finding no 

differences in substance use between BFT and individual treatment and a second trial finding 
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significantly lower rates of substance use among those in BFT than those in individual 

treatment at 18 months after treatment (13.2% fewer days abstinence). However, these 

differences eroded at 30 month follow-ups.

Brief BCT. Two trials examined both a brief version of BCT and standard BCT for substance 

use disorders and found both BCT and brief BCT led to significant differences in PDA 

compared to ICBT, but few differences were found between the standard and brief versions 

of BCT.

BCT with relapse prevention. Two trials added a relapse prevention intervention to BCT (2 

trials4, 72, 86, 87) with one trial finding no differences between conditions72, 86, 87 and the other 

finding greater reductions in substance use, with 13.2% fewer days of use 18 months after 

treatment.4

 These differences eroded and were non-significant at the 30 month follow-up. In 

this trial, the benefits of BCT with relapse prevention were strongest for those in the most 

distressed relationships and with the most severe drinking behavior.4

Same sex couples. One trial compared BCT to ICBT with same sex couples, finding 

fewer percent days heavy drinking among BCT participants at long term follow-ups and 

significantly slower rates of erosion in treatment effects among BCT participants (i.e., BCT 

participants were slower to increase their rates of heavy drinking than ICBT patients after 

treatment).

Veterans. Two studies examined Veterans with alcohol use disorders.4, 65 One found no 

difference between BCT and a general couple therapy on sexual satisfaction.65 Rates 

of substance use after treatment were not reported. The second compared BCT to BCT 

with relapse prevention, discussed above.4 Veterans participating in BCT4 demonstrated 

comparable or better rates of PDA from alcohol use (post-treatment: 98.0%; short-term 

follow-up: 87.6%; long-term follow-up: 82.7%) than average rates of PDA reported in the 

AUD trials included in our pooled analyses. However, direct comparisons within trials 

between Veteran and non-Veteran have yet to be conducted, and research has yet to evaluate 

BCT compared to individual therapy among Veteran samples.

CRAFT (disorder-specific and partner-assisted treatment9

)

Across 3 trials80, 81, 83 CRAFT was found to be superior to alternative family treatments in 

improving patients’ initiation of substance use treatment 30-48%. Trials did not provide data 

on differences in overall rates of session attendance or substance use.

Alternatives to BCT and CRAFT

BCT versus non-disorder specific couple therapy. Two trials compared BCT to an alternative 

non-disorder specific couple treatment65, 73 finding no differences between the couple 

interventions on substance use73 or relationship functioning.65, 73

Adding additional treatment components to BCT. One trial added parenting skills training 

to BCT71 and a second added attendance to AA and Al-Anon.72, 86, 87 Both trials found no 

differences in symptoms or couple functioning between BCT with additional treatment 

components versus standard BCT.
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Reciprocal relationship counseling. Carroll77 found that the combination of reciprocal 

relationship counseling (disorder specific intervention9), contingency management, and 

naltrexone use was superior to contingency management plus naltrexone only in family 

functioning, but not in percent days abstinent or days in treatment.

Motivational and psychoeducational treatment with couple counseling for heroin users 

with pregnant partners. Jones and colleagues70 found that subjects in a motivational and 

psychoeducational intervention that included couple therapy for male heroin users with pregnant 

intimate partners, actually had higher heroin use at short-term follow up, compared to an 

individual only counselor-led drug treatment support group.

Bipolar Disorder

Five RCTs provided data relevant to KQ2.

Family-Focused Therapy (FFT; 4 trials; disorder specific family treatment9

)

• FFT or an adapted version of FFT (FFT-HPI93) led to better symptom response than either 

individually-oriented care (1 trial91) or alternative family involved interventions (2 trials90, 93).

 FFT leads to lower rates of relapse than crisis management with limited family involvement, 24 months after randomization (35% relapse versus 54%). Patients in crisis management relapsed an average of 20 weeks sooner than those in FFT.5, 90

 FFT leads lower rates of relapse (28% versus 60%) and lower rates of hospitalization 

(12% versus 60%) than individual therapy one year after the end of active treatment.91

 No significant differences were found between FFT and individual therapy on medication adherence.91

 FFT-HPI leads to fewer manic (4.2 points on the YMRS; d = 0.34; small effect) and 

depression symptoms (5.6 points on the HAM-D; d = 0.67; medium effect) among bipolar patients than health education provided to families via DVDs.93

• One trial92 found no significant differences in symptoms of bipolar disorder or family functioning between FFT and either cognitive behavioral therapy or interpersonal and social 

rhythm therapy, suggesting FFT may perform similarly to other empirically supported, highly 

intensive interventions in improving symptoms of bipolar disorder.

• Mixed findings limit conclusions that can be drawn about the role of FFT in session 

attendance or medication adherence.

Disorder Specific versus General Family Therapy (1 trial89, 97, 98)

The difference in rates of recovery between general family therapy and disorder specific family 

therapy, delivered in multiple family groups, were non-significant.

Schizophrenia

Three trials addressed KQ2 (1 trial for KQ1 and 3 for KQ2 due to greater than 2 comparison 

conditions). 
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Multiple Family Groups (MFG; 1 trial)101-103

• One trial compared MFGs (disorder specific family therapy9), an interventions focused 

on psychoeducation, family functioning, and social support, to individually oriented 

psychosocial intervention. Results indicated that, at the one year point of a two year 

intervention, MFGs improved negative symptoms of schizophrenia (e.g., blunted affect, 

alogia, anhedonia, inattention, avolition) an average of one point on a 25 point scale and 

led to 12% lower rates of hospitalization at state level psychiatric hospitals than individual 

treatment. 

• Differences in rates of hospitalization overall or at non-state level facilities, or use of crisis 

care, were non-significant at post-treatment and one year after treatment. 

Assertive Community Treatment (ACT) With and Without a Biweekly Multi-Family Group (1 

trial29)

• No significant differences were found between groups on hospital admissions, symptoms, or 

family outcomes. 

• Employment rates for ACT and multifamily groups were significantly different during treatment but non-significant at the final follow-up.

Applied Family Management (AFT; 1 trial104)

• Non-significant differences were found between intensive and less intensive family interventions in symptoms or rates of hospitalization. Authors note group differences may have limited clinical significance.104

• A more intensive family therapy (AFM) improved family functioning (patient rejection scale) 

by 0.32 scale points at 1 year (medium effect size, 0.31) and 1.03 scale points (medium effect 

size, 0.30 effect size) at 2 year follow-up, over less intensive family interventions.

Family Intervention for Dual Disorders (1 trial; disorder specific family treatment9) 

• Subjects with a comorbid substance use disorder and serious mental illness (e.g., 

schizophrenia, bipolar disorder) demonstrated greater improvements in psychiatric symptoms 

(BPRS psychosis, medium effect size, 0.32; BPRS total, small effect size, 0.17) when 

assigned to a longer term (9-18 months) psychoeducational family program than a brief (2-3 

month) family intervention.100

• Differences in substance use and global functioning across conditions were non-significant

PTSD

One trial found no significant differences in PTSD outcomes between exposure therapy with 

Behavioral Family Therapy (disorder specific family intervention9) versus exposure therapy 

only,8

 however the family involved arm resulted in poorer rates of dropout than exposure 

alone. 

Sexual Functioning

No trials. 
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Other Conditions Examined In Single Trials

There were no differences between family involved interventions and individually-oriented 

treatments in one trial examining smoking cessation in pregnant women118 and a second 

examining binge eating disorder, with the exception of greater agreement between spouses 

regarding a plan of action for binge eating.115

Efficacy

In Table 16 below, we summarize the efficacy status23 and strength of evidence62 for outcomes 

of interest (i.e., symptoms, family/couple functioning, and, in some cases, treatment 

engagement) for those family treatments demonstrating benefits over their comparators that 

met our review criteria. In three cases, studies demonstrated an individually-oriented, disorder 

specific intervention plus a family intervention led to greater improvements than waitlist/drug 

only conditions, but the combined treatment did not demonstrate significant gains over the 

individually-oriented treatment alone in the same trial.8, 77, 115 Consequently, these trials are not 

included in the table below. These findings represent only studies performed in the US in the last 

15 years that report on patient outcomes. Studies finding no significant differences between the 

treatment and the comparator at post-treatment or follow-up assessments on our outcomes of 

interest are not included as ‘possibly efficacious studies’ and, consequently, not incorporated.

Strength of Evidence

In addition to identifying studies that have demonstrated efficacy or are possibly efficacious, we 

rated the confidence with which we draw these conclusions for the outcomes of interest (i.e., the 

‘strength of the evidence that underlies conclusions,’ p. 513, Owens et al.62). Strength of evidence 

was considered by mental health condition, given the wide variety of interventions, techniques, 

and treatment targets of these interventions. In general, with the exception of behavioral couple 

therapy for SUDs, CRAFT for increasing treatment initiation among patients with SUDs, and 

Family Focused Therapy (FFT) for bipolar disorder, each intervention was typically examined 

in one or two trials. Additionally, the FFT studies contained highly diverse sets of comparison 

conditions and findings were largely mixed, limiting our confidence in the strength of evidence 

across these trials. 

Several of the individual trials were of good or fair quality (low or medium risk of bias) but 

with a single, often small trial of a particular intervention for a particular outcome and imprecise 

estimates of effect, we have low confidence that the available evidence for the interventions 

examined in single trials reflect the true effect. As such, the strength of evidence for any given 

intervention, with the exception of BCT for drug use disorders and CRAFT for increasing 

treatment initiation among those with an SUD, is generally low. Specific ratings for treatments 

deemed efficacious or possibly efficacious are presented in Table 16. Importantly, our strength 

of evidence ratings are based solely on the results of our search, which included only US studies 

of family involved psychosocial treatments for mental health conditions since 1995 that included 

patient outcomes. Also, this Table should be considered in tandem with Table 1, which identifies 

those interventions established as efficacious prior to our review, including behavioral family 

therapy and supportive family therapy for schizophrenia.6, 9
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Table 16. Family Interventions since 1996 that Improve Outcomes for US Patients with Mental 

Health Conditions

MH 

Condition Intervention Comparator Outcome EfficacyStatus

Strength of 

Evidence

Alcohol Use 

Disorders

Behavioral Couple Therapy Individual Behavioral Therapy

1) Substance Use 1 Moderatea

2) Relationship 

Adjustment 1 Moderatea

3) Intimate Partner 

Violence 3 Low

4) Attendance 3 Low

Brief family intervention to 

promote continuing care64 Treatment-as-usual 1) Substance Use ND Low

2) Treatment Initiation 3 Low

Behavioral Couple Therapy + 

relapse prevention64 Behavioral Couple Therapy

1) Substance Use 3 Low

2) Relationship 

Adjustment ND Low

Behavioral Family Treatment82 Individual Behavioral Therapy 1) Substance Use 3 Low

2) Family Functioning ND Low

CRAFT81 Alternative Family Treatments

1) Substance Use ND Low

2) Family Functioning ND Low

3) Treatment Initiation 3 Low

Drug Use 

Disorders

Behavioral Couple Therapy Individual Behavioral Therapy

1) Substance Use 1 Moderatea

2) Relationship 

Adjustment 1 Moderatea

3) Intimate Partner 

Violence 3 Low

4) Attendance 1 Lowb

Behavioral Family Treatment68, 82 Individual Behavioral Therapy 1) Substance Use 3 Low

2) Family Functioning 3 Low

CRAFT80, 83 Al-Anon/Nar-Anon

1) Substance Use ND Moderate

2) Family Functioning ND Low

3) Treatment Initiation 1 Moderate

Bipolar

Family-Focused Treatment-Health 

Promoting Intervention93

Health information DVDs 

reviewed by caregivers 1) Symptoms 3 Low

Family-Focused Treatment 

Crisis management 

with two in-home family 

psychoeducation sessions5, 90

1) Symptoms 3 Low

2) Medication 

Adherence 3 Low

Problem-focused, 

psychoeducational Individual 

therapy91

1) Symptoms 3 Low

2) Medication 

Adherence ND Low

Cognitive behavior therapy92, 

95 1) Symptoms ND Low

Interpersonal and social 

rhythm therapy92, 95 1) Symptoms ND Low

Marital intervention + medication94 Medication only

1) Symptoms ND Low

2) Global Functioning 4 Low

3) Medication 

Adherence 4 Low
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MH 

Condition Intervention Comparator Outcome EfficacyStatus

Strength of 

Evidence

Schizophrenia

Multiple Family Groups101-103 Standard, Individuallyoriented care

1) Symptoms ND Low

2) Any Hospitalization ND Low

3) State 

Hospitalization 3 Low

4) MH Care Utilization ND Low

Family intervention + in home 

behavioral family therapy 

(Applied Family Management24, 104

Family intervention

1) Symptoms ND Low

2) Family Functioning ND Low

3) Patient Rejection 

by Family 3 Low

4) MH Care Utilization ND Low

5) Attendance ND Low

Schizophrenia 

& Substance 

Use Disorder

Psychoeducation + skills oriented 

training ( Family Intervention for 

Dual Disorder99, 100

Short term psychoeducation

1) Schizophrenia 

Symptoms 3 Low

2) Substance Use ND Low

3) Global Functioning 3 Low

4) Medication 

Adherence ND Low

PTSD Coffee and Family Education and 

Support105 Waitlist 1) Number of MH 

Visits 4 Low

Depression Brief problem-focused couple 

therapy114 Waitlist

1) Symptoms 4 Low

2) Relationship 

Adjustment 4 Low

Efficacy Status: 

1 = Efficacious & Specific = superior to placebo, nonspecific, or alternative intervention in at least two studies conducted by 

independent research teams.

2 = Efficacious; superior to waitlist in RCTs conducted by two independent research teams. 

3 = Possibly Efficacious & Specific; criteria met for efficacious and specific from a single study. 

4 = Possibly Efficacious; criteria met for efficacious from a single study (Baucom, 1998;9

 Chambless & Hollon,199823) 

ND = No significant differences found; MH = Mental health

Strength of Evidence: 

High = High confidence evidence reflects true effect. The effect and confidence in the estimate of effect is unlikely to change with 

further research. 

Moderate = moderate confidence that evidence reflects true effect. The effect and confidence of the effect may change with further 

research.

Low = Low confidence evidence reflects true effect. The effect and confidence of the effect will likely change with further research.62

a

Seven of the nine trials comparing these conditions were written by or based on data collected by Dr. Fals-Stewart. See 

Substance Use Disorders Results for KQ2 for discussion.

b

Several studies also found non-significant differences, leading to low strength of evidence.

CONCLUSIONS

Nearly half of the trials we located were examinations of family involved treatments for 

substance use disorders, typically BCT or BFT for substance use disorders (disorder specific 

couple or family therapy9

). While findings were not without contradiction, behavioral couple 

therapy is superior to individual behavior therapy for improving substance use and relationship 

distress. CRAFT81, 83 also increases the rates with which patients with substance use disorders 

initiate substance use treatment. Mixed findings indicate relapse prevention added to behavioral 

couple therapy may improve outcomes, especially among those with the most severe substance 

use and relationship distress. Finally, unlike other mental health conditions, two trials were 

conducted with Veterans,4, 65 but only one trial reported substance use outcomes and compared 

BCT to BCT with relapse prevention (O’Farrell, 1998a), making it difficult to draw conclusions 
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about whether Veteran samples achieve the same benefits from BCT as other samples. More 

research is clearly needed examining the efficacy of family involved treatments with Veteran 

samples.

Findings for bipolar disorder were also mixed, with single trials demonstrating family therapy 

improves symptoms over medication management alone, particularly for those in distressed 

families, and FFT improves symptoms over alternative treatment approaches in two trials, 

but performs similarly to other empirically supported, individually-oriented interventions in 

another trial. Specifically, 1) FFT or an adapted version of FFT (FFT-HPI93) led to greater 

symptom improvements than either an individually-oriented treatment (1 trial91) or alternative 

family involved interventions (2 trials90, 93), 2) FFT performed similarly to other empirically 

supported, highly intensive, individually-oriented interventions in improving symptoms of 

bipolar disorder,92 3) for patients in distressed families, improved symptoms of depression 

were found for those in either a disorder specific multifamily group or general family therapy 

than medication management alone,98 and 4) marital psychoeducational therapy led to greater 

improvements in global functioning and medication adherence, but not in symptoms, than 

medication management alone.

Work conducted prior to the time frame of our review has established the efficacy of behavioral 

family therapy and supportive family therapy for schizophrenia.9

 Given the wealth of data 

prior to 1996 supporting these interventions for schizophrenia, we were surprised to find only 

4 US trials since that time. These trials expanded upon the work conducted in prior studies by 

including complex cases (i.e., multiple diagnoses or problems), but provided limited additional 

clarity regarding which family treatments enhance patient outcomes or if family treatments 

improve outcomes outside of relapse/rehospitalization rates. As noted in previous reviews,9

schizophrenia and bipolar disorders are chronic, lifelong illnesses. Consequently, appropriate 

outcomes include lengthening time to relapse, improving quality of life, and enhancing family 

functioning, rather than success in eliminating or ‘curing’ symptoms. Among our outcomes 

of interest, one trial found rates of state-hospitalization were lower among those in multiple 

family psychoeducational groups than those in a shorter individually-oriented intervention of 

psychoeducation only.103 A second trial found no differences on our outcomes of interest at final 

follow-ups for those participating in Assertive Community Training with or without a biweekly 

multiple family group.29 A third trial found family therapy with an in home behavioral family 

therapy component resulted in less patient rejection by families than the same intervention 

without in-home behavioral family therapy. Differences on symptoms and rates of hospitalization 

were non-significant. A final trial demonstrated greater improvements in symptoms of serious 

mental illness and functioning, but not lower substance use, among dually diagnosed patients 

(serious mental illness and SUDs) assigned to a 9-18 month psychoeducational family program 

versus a brief (2-3 month) family intervention. However, problems with recruitment and 

retention of these complex patients raises concerns about the feasibility of family treatment for 

this group, especially long-term interventions.100 Additional evidence from non-US trials exists 

supporting family treatments for schizophrenia for the prevention or delay of relapse over the 

past 15 years and was not included in the present review. The applicability of results to US 

Veterans and even US patients from studies outside the United States, particularly in China, is 

limited. A recent, more inclusive review of family treatments for schizophrenia concluded the 

quality of reporting in most these studies was poor.126
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Family treatments for a number of additional mental health conditions were examined in one or 

two trials, including PTSD (2 trials), erectile dysfunction (2 trials), depression (1 trial), binge 

eating disorder (1 trial), and smoking cessation (1 trial). A family support group to encourage 

treatment engagement among Bosnian refugees with PTSD found greater rates of engagement 

than waitlist only participants (one trial). Additionally, support was found for brief couple 

therapy for depression over waitlist in improving depression and couple functioning. Results 

from the remaining trials included largely non-significant differences between family treatments 

and either individual treatment (PTSD, binge eating, smoking) or, for erectile dysfunction, 

medication management.

Overall, the literature indicated family involved treatments for mental health conditions were as 

effective as or more effective than individually-oriented psychotherapies, with two exceptions. 

The addition of approximately 23 weeks of disorder-specific behavioral family therapy after 

9 weeks (18 sessions) of exposure therapy for PTSD lead to greater rates of treatment dropout 

than exposure therapy alone or waitlist.8

 Additionally, male opiod users with pregnant female 

partners who participated in a combination of motivational enhancement, case management, 

contingency management, and psychoeducational couple therapy reported greater heroin use 

at short-term follow-ups than patients participating in usual care. Outside of these two trials, 

findings either favored family involvement or demonstrated no significant differences between 

family interventions and comparator conditions, even when comparators were robust, active 

individually-oriented interventions. However, outside of the SUD literature, the number of trials 

testing the same intervention with the same or similar comparators was limited, leading to low 

confidence in the consistency of these conclusions. Additionally, many studies did not evaluate 

family and couple functioning after treatment, treatment adherence, or satisfaction with care. 

Additionally, most studies did not report Veteran status of their participants. Consequently, 

while the present study sought to optimize the relevance of this review to Veterans by examining 

only US studies, the generalizability of findings from these trials to Veterans’ samples is largely 

unknown.

LIMITATIONS

There were several important limitations to this review. First, in order to focus on recent, high 

quality studies, most applicable to Veterans, our review was limited to randomized controlled 

trials conducted over the last 15 years. As discussed above, some family interventions were 

established as efficacious prior to this time frame, limiting the need for, and consequently, 

volume of studies addressing KQ1. Secondly, this review was also limited to studies conducted 

in the US only. The efficacy of family interventions has been established in many studies 

internationally (i.e. in China for family treatments for serious mental illness), however, their 

applicability to the US Veteran population or US healthcare system is not known.129 Third, 

developing and advancing a psychosocial intervention such that it is appropriate for testing in 

an RCT is a major task requiring years of work and even further complicated by the need to 

recruit both patients and their families for participation. Consequently, there are numerous family 

involved interventions not included in our review that are in various stages of development or 

are currently under evaluation in RCTs (e.g., Couple therapies for PTSD,139 Family Member 

Provider Outreach Program,140 Coaching into Care,141 REACH142). While our focus on RCTs is 
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warranted, given the VA’s need for direction on which family interventions have established an 

evidence base, exclusions of these interventions under development is a potential limitation. 

Fourth, we elected to organize our findings by mental health condition, consistent with the 

organization of the DSM-IV. However, alternative methods of presenting findings exist. Findings 

could be presented comparing ‘serious mental illness’ (i.e., discussing schizophrenia and bipolar 

trials together) to other forms of mental illness or by type of intervention (family versus couple; 

disorder specific versus general family therapies; interventions using similar approaches, such as 

psychoeducational interventions). Conclusions using these alternative approaches to synthesizing 

findings would likely differ from those reached in this review.

Finally, interventions specifically targeting caregiver outcomes are important. However, given 

the VA’s traditional focus on Veteran outcomes, our review included only studies which assessed 

participants’ outcomes (including family and couple functioning). Interventions that solely seek 

to improve the distress and burden experienced by family members of those with mental illness 

are were not reviewed, and rates of improvement in the personal distress experienced by family 

members or caregivers were not included when reported in the trials reviewed. Our findings 

cannot speak to the efficacy of family interventions for mental health conditions in improving the 

functioning of patient’s family members and caregivers.

RECOMMENDATIONS FOR FUTURE RESEARCH

There are a number of important gaps in our findings that highlight the need for future work. 

As discussed above, further work is needed to integrate our findings on patient outcomes with 

research examining how family/couple interventions effect outcomes for spouses and other 

family members (i.e., caregiver burden, distress, anxiety, etc). For substance use disorders, 

further work is needed establishing that patients’ whose families participate in CRAFT have 

better reductions in substance use and better longer-term retention in treatment than those 

assigned to other interventions. Additionally, comparisons between BCT and other family 

involved interventions are warranted. Finally, a large number of the BCT trials reviewed were 

conducted within a single lab (i.e., Dr. Fals-Stewart) and further work outside of this laboratory 

is indicated.

A few trials found family interventions were most effective (i.e., resulted lower rates of 

symptoms) than comparison conditions for patients in distressed families and/or with more 

severe baseline symptoms (i.e., BCT with relapse prevention and family therapy for bipolar 

disorder). Family distress by condition interactions have also been found in studies of depression 

conducted prior to our review, suggesting that individuals benefit more from individual than 

marital therapy when in non-distressed relationships.44, 137 If replicated, these findings could 

have important implications to personalizing treatment for those with greater family distress 

and/or more severe symptoms of mental illness. Future work should continue to test for these 

interactions. 

With the exception of two interventions, BCT for substance use and CRAFT for the initiation 

of substance use treatment, in the past fifteen years, very few family treatments for improving 

adult mental health conditions have been investigated in more than one rigorous RCT in the 

US. Generally, the literature is in need of this work. Future trials are needed examining CRAFT, 
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BCT, and Family-Focused Therapy specifically in Veteran samples. Additionally, further 

work is needed to continue to establish the efficacy of interventions highlighted in Table 15 

as possibly efficacious as they have demonstrated some significant improvements in patient 

functioning over comparison conditions in at least one trial (rated 3 or 4 on the status of their 

efficacy). This includes further trials of relapse prevention in addition to BCT, CRAFT for 

alcohol use disorders, brief BCT for substance use disorders, BFT (with non-intimate partners) 

for substance use disorders, family involvement to increase treatment initiation among patients 

hospitalized for substance use detoxification, Family-Focused Treatment-Health Promoting 

Intervention for bipolar disorder, Family Focused Treatment for bipolar disorder, marital therapy 

for bipolar disorder, in home behavioral family therapy as an addition to family treatments for 

schizophrenia, combined treatments for co-occurring schizophrenia and substance use disorders 

(Family Intervention for Dual Disorder), and support groups to promote treatment use among 

patients with PTSD (CAFES). Such trials are needed that use large samples, longer-term followups, high quality methodologies, evaluate both patient and family outcomes, compare outcomes 

by ‘type’ of family member included (e.g., spouse, parent, sibling), and use standardized 

symptom measures that can facilitate comparisons across trials. 

Evaluating applications of these interventions to patients with comorbid conditions (e.g., 

substance use and serious mental illness), non-white samples, older patients (i.e., over 65), and 

Veteran groups is warranted. Additionally, alternative types of family constellations (i.e., close 

friends, same sex couples) have received little attention among existing RCTs. For Veterans, 

preferences for which family members to include (i.e., intimate partners versus other family 

members), how these preferences vary by era (i.e., recently returning Veterans versus Vietnam/

Korean War Veterans eras), and the availability and “type” of family members interested in 

participating (i.e., intimate partners versus other family members) is important to inform policy 

decisions, especially considering that current eligibility criteria for VA family-related services 

does not extend to close friends or intimate partners who do not reside with the Veteran. 

Additionally, research is needed evaluating methods of engaging families in care. This was 

demonstrating in a study of schizophrenia finding that 80% of families did not participate in 

optional follow up family group sessions.99, 100 Additionally, trials of family interventions for 

several mental health conditions were notably limited or absent from the published literature 

in the US in the past 15 years, including studies of family treatments for depression, PTSD and 

other anxiety disorders, personality disorders, eating disorders, and sexual functioning disorders, 

warranting further work with these conditions. 

Given the intent of the ESP is to provide an objective, non-biased approach to the review 

topic, providing our own cost-benefit analysis of interventions is beyond scope of this review. 

Additionally, this information was largely absent from RCTs reviewed. Consequently, future 

research is needed evaluating the costs and benefits of effective interventions. This work could 

further consider multifamily versus single family interventions for schizophrenia, intensive 

versus less intensive interventions for serious mental illness, and brief versus standard length 

interventions for substance use and other disorders (e.g., standard BCT versus brief BCT).

Finally, with the exception of a few studies within the schizophrenia literature, limited attention 

was paid among studies reviewed to interventions for patients with multiple diagnoses, 

conditions, or problems. Future research should work to identify efficacious family treatments 
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for patients with commonly co-occurring conditions important to VA populations, such as PTSD 

and substance use disorders, serious mental illness and substance use disorders, comorbid 

personality disorders among patients seeking treatment for an Axis I condition. Patients were 

not excluded from trials due to diagnosis of a personality disorder, but findings were typically 

not stratified by other co-morbid conditions, preventing comparisons of treatment response by 

co-morbid conditions. Additionally, in the substance use literature, couples and families in which 

both the patient and the family member have a substance use disorder are typically excluded 

from trials. However, in practice, dual SUD couples and family members are not uncommon. 

Further work is also needed to identify evidence based practices and approaches to family 

involvement for patients with co-occurring intimate partner violence, suicidality, self-injury, or/

or traumatic brain injury.
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