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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EXECUTIVE SUMMARY

BACKGROUND

Since 2008, the President has signed two new laws expanding VA authority to provide family 

services for Veterans’ mental health care and creating a need to identify efficacious and 

promising family involved interventions for improving Veterans’ mental health outcomes. With 

one exception, prior reviews have traditionally focused on one condition at a time, limiting 

comparisons across conditions and preventing a synthesis of the evidence for all mental health 

conditions, including those with few randomized controlled trials (RCTs; e.g., Posttraumatic 

Stress Disorder or PTSD). Finally, prior reviews are potentially less relevant to VA populations 

due to their focus on studies conducted in non-Veteran populations.

Consistent with prior work defining empirically supported psychological treatments, we 

conducted a systematic review of the published evidence evaluating if (and which) family 

involved treatments improve patient outcomes (i.e., efficacy) and if (and which) family involved 

treatments are superior to alternative interventions (i.e., specificity or comparative effectiveness, 

especially those therapies that include solely the patient, not family members). This topic was 

nominated by Sonja Batten, PhD, Office of Mental Health Services, and is primarily intended 

to help refine clinical guidelines by providing information as to whether family treatments 

improve the outcomes for Veterans receiving care for mental health conditions and if they 

provide incremental benefits beyond treatment solely involving Veterans. To evaluate findings 

of greatest validity and relevance to the United States (and especially Veteran) populations, we 

included studies if they were RCTs conducted in the United States, and we focused on patient 

outcomes (i.e., final outcomes), including symptoms of mental health conditions and family/

couple functioning. Intermediate outcomes of interest included treatment adherence, treatment 

attendance, patient satisfaction, and social support for patients. 

We addressed the following key 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]?
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Family Involved Psychosocial Treatments for Adult Mental Health 

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METHODS

We searched MEDLINE (Ovid) and PsycINFO for RCTs and systematic reviews published 

from 1980 to November, 2011 using standard search terms. We limited the search to articles 

involving subjects over age 18 and published in the English language. Search terms included: 

family, couples, home nursing, legal guardians, couple therapy, family therapy, and marital 

therapy. Additional citations were identified from reference lists. Titles, abstracts, and articles 

were reviewed by trained research personnel. Due to existing prior reviews and the volume of 

potentially eligible articles identified at the time of full text review, we narrowed our inclusion 

criteria to studies published after 1995. We excluded studies conducted outside of the United 

States.

Study characteristics, patient characteristics, final outcomes, and intermediate outcomes were 

abstracted onto tables for each mental health condition of interest by a trained research associate 

and verified by a second research associate under the supervision of the Principal Investigator, 

a Veterans Affairs psychologist. Our primary outcomes included patient-centered mental health 

outcomes (i.e., symptom severity, relapse rates, and days abstinent from drugs and/or alcohol) 

and couple/family functioning (i.e., couple/family adjustment, conflict, communication, and 

intimate partner violence) for participants with mental health conditions. Intermediate outcomes 

included treatment adherence, treatment attendance, utilization of mental health care, patient 

satisfaction, and social support for patients. Pooled analyses were performed where possible, but 

due to heterogeneity of interventions and outcomes across studies, most findings were narratively 

summarized. We assessed risk of bias for individual studies according to established criteria for 

randomized controlled trials, taking into consideration whether the treatment was manualized 

and whether the treatment was monitored for quality and consistency (i.e., treatment integrity). 

Strength of evidence was determined for findings reviewed.

DATA SYNTHESIS

We constructed evidence tables for study characteristics and for outcomes, organized by mental 

health condition. We analyzed studies to compare their characteristics, methods, and findings. 

Findings from VA or active service populations were identified and highlighted. We compiled a 

summary of findings for each question based on qualitative and semi-quantitative synthesis of 

the findings.

PEER REVIEW

A draft version of this report was reviewed by members of our technical expert panel, nominated 

peer reviewers, as well as clinical leadership. Reviewer comments were addressed and our 

responses were incorporated in the final report.

RESULTS

We screened 2469 titles, of which 444 articles potentially met eligibility criteria. From these, 

5 systematic reviews and 51 publications, which represented 39 unique RCTs, met eligibility 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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criteria and were included. The findings are described below. The number of studies reviewed for 

each key question sum to over 39 trials due to trials with more than two conditions (e.g., family 

treatment, individual treatment, and wait list control). Most studies were of fair quality (10 good, 

20 fair, 9 poor), reported multiple outcomes, and may have limited long-term or site applicability. 

Many reported a large number of comparisons, including non-significant differences between 

treatment groups. Some of the benefits noted for treatments evaluated in single trials below may 

be due to chance or reporting bias and their broad clinical applicability should also be viewed 

with caution. Overall, the majority of studies reviewed compared a family intervention to another 

active treatment, limiting our conclusions for KQ1.

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]? 

We identified 8 RCTs that compared a family involved intervention to either waitlist/no treatment 

or medication management only and assessed the following mental health conditions: substance 

use disorders (1 trial), bipolar disorder (2 trials), PTSD (2 trials), sexual functioning (2 trials), 

and depression (1 trial). Low strength of evidence (one trial for each bullet point) was found 

regarding the impact of the following interventions on selected patient or intermediate outcomes 

(e.g., treatment utilization) over waitlist/drug treatment. 

Substance Use Disorders (1 trial)

Family involvement in aftercare planning

• No significant differences were found between conditions on substance use outcomes.

• 92% of patients whose families were involved in aftercare treatment planning initiated 

substance use treatment after a hospital stay for detoxification. This was a 30% improvement 

over patients hospitalized for detoxification whose families did not participate in aftercare 

planning (r = 0.36).

Bipolar Disorder (2 trials)

Family therapy

• Neither a general family therapy nor a disorder specific family therapy, delivered in multiple 

family groups, improved recovery rates over medication management alone.

• Among participants with high levels of family impairment:

○ Disorder specific psychoeducational group family therapy led to significantly fewer 

depressive episodes per year (mean = 1.4; d = 1.0), 14% percent less time in a mood 

episode (d = 0.82), and 1.7 fewer mood episodes, yearly (d = 0.92). All effect sizes were 

considered moderate to large in magnitude.

○ General family therapy led to 0.9 fewer depressive episodes per year (d = 0.70); 

additional comparisons were non-significant.
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Marital psychoeducational therapy

• Compared to medication management alone, marital psychoeducational therapy led to higher 

global functioning (a difference of 7 points on a 100 point scale; Global Assessment Scale) 

and greater medication adherence (a difference of 0.5 points on a 6 point scale).

• No significant differences were found between conditions on symptoms of bipolar disorder.

Schizophrenia (0 trials)

The efficacy of behavioral family therapy and supportive family therapy was established for 

schizophrenia prior to the timeframe of studies included in our review (i.e., studies published 

since 1995). The lack of RCTs comparing family treatments to waitlist is consistent with the 

more advanced nature of this literature. Prior reviews have concluded that family involved 

therapy leads to lower rates of relapse and hospitalization than waitlist or drug only treatment. 

PTSD (1 trial)

Support groups for family

Eighteen months after participation in Coffee and Family Education and Support groups 

(CAFES), the average number of patient mental health visits increased by 4 visits versus those 

assigned to waitlist.

Sexual Functioning (2 trials)

Couples sex therapy in addition to medication for erectile dysfunction

• One trial found subjects assigned to couples sex therapy plus medication reported greater 

satisfaction with treatment than those assigned to medication alone. Differences between 

conditions on erectile functioning up to two months after treatment were not significant.

• A second trial found no significant difference in erectile functioning between those assigned 

to four weeks of couples cognitive behavioral sex therapy plus medication versus those 

assigned to medication alone after 4 weeks of treatment.

Other Conditions Examined in Single Trials (2 trials)

Depression (1 trial)

Compared to waitlist, brief, disorder specific, cognitive behavioral couple therapy significantly 

improved depression symptoms and marital satisfaction for most comparisons in a small RCT (N 

= 35). 

Binge Eating Disorder (1 trial)

A trial of group cognitive behavioral therapy (CBT) for binge eating disorder found that CBT 

with or without spouse involvement resulted in better symptom improvement than waitlist. 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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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]?

For KQ2, we identified 33 RCTs addressing the following mental health conditions: substance 

use disorders (21 trials; 15 compared family involved treatments to individual behavioral 

treatment [KQ2A] with many conducted by a single investigative team), bipolar disorder (5 

trials; 2 for KQ2A), schizophrenia (4 trials; 1 for KQ2A), PTSD (1 trial for KQ2A), nicotine 

dependence (1 trial for KQ2A), and binge eating disorder (1 trial). We found low to moderate

strength evidence for the following conclusions:

Substance Use Disorders

Behavioral Couple Therapy (BCT) for Substance Use Disorders (21 trials)

Disorder-specific, BCT for substance use disorders compared to individual therapy (9 trials)

• BCT or Behavioral Family Therapy (BFT) lead to 4 fewer days of substance use per month 

and 44 fewer days per year than individual cognitive behavior therapy (ICBT), up to one year 

after treatment. Additionally, across 8 of 9 studies included in pooled analyses, participants 

reported a significantly slower rate of relapse when assigned to BCT or BFT versus 

individual therapy.

• BCT led to higher relationship adjustment scores (12.5%) one year after treatment, with those 

receiving BCT reporting relationship adjustment in the satisfied range and ICBT patients 

reporting scores in the distressed range.

• Effects were similar for men, women, drug use disorders, and alcohol use disorders

• Mixed findings indicated that BCT may result in lower rates of intimate partner violence and 

higher rates of session attendance than ICBT 

• Veterans participating in BCT demonstrated comparable or better rates of percent days 

abstinent (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 alcohol use disorder 

(AUD) trials included in our pooled analyses. However, without direct comparisons between 

Veteran and non-Veteran samples and between BCT and ICBT, we could not assess whether 

treatment response for Veterans differs from treatment response for non-Veterans.

Community Reinforcement and Family Training (CRAFT; 3 trials)

CRAFT led to 30-48% greater rates of treatment initiation among patients than non-CRAFT 

family interventions (e.g., Al-Anon, Johnson Intervention).

A series of single RCTs found significant benefits for specific family interventions over 

comparators. These findings fall within the category of ‘possibly efficacious’ interventions. 

In each case, findings within the trial itself were often mixed. Given only one trial for each 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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intervention (and the fact that not all comparison groups were individual therapy), our confidence 

in the consistency or applicability of these findings to other settings or compared to individual 

therapy is low or insufficient (low or insufficient strength of evidence). One trial each indicated:

Alterations and Alternatives to BCT for Substance Use Disorders

Adding relapse prevention to BCT (2 trials)

• The addition of family involved relapse prevention to BCT alone led to 13.2% more days 

of abstinence from alcohol up to 18 months after treatment (4 more days per month or 48.2 

more days per year). Differences were non-significant at the 30 month follow-up.

• The benefits of adding relapse prevention to BCT were especially pronounced for patients 

with the most severe substance use and poorest couple functioning.

• A second trial found no benefit from adding relapse prevention to BCT.

Alternatives to BCT (2 trials)

• One study found that the combination of reciprocal relationship counseling (disorder specific 

intervention), contingency management, and naltrexone use was superior to contingency 

management plus naltrexone only for improving family functioning but not for improving 

abstinence from substance use or days in treatment.

• A second study found that subjects in a motivational and psychoeducational intervention 

that included couple therapy for male heroin users with pregnant intimate partners, actually 

reported higher heroin use at short-term follow up, compared to a counselor-led drug 

treatment support group.

Bipolar Disorder (5 trials)

Family Focused Treatment (FFT; 3 trials) 

• FFT led to lower relapse 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.

• FFT led to lower relapse rates (28% vs. 60%) and lower hospitalization rates (12% vs. 60%) 

than individual therapy one year after the end of active treatment.

• No significant differences were found between FFT and individual therapy on medication 

adherence.

• One trial 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, but not superior, to other empirically 

supported, highly intensive interventions in improving symptoms of bipolar disorder.
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Family Involved Psychosocial Treatments for Adult Mental Health 

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Family-Focused Treatment-Health Promoting Intervention (FFT-HPI; an adaptation of 

Family-Focused Treatment; 1 trial)

FFT-HPI leads to fewer manic (4.2 points on the Young Mania Rating Scale, YMRS; d = 0.34) 

and depression symptoms (5.6 points on the Hamilton Depression Rating Scale, HAM-D; d 

= 0.67) among bipolar patients than health education provided to families via video diskettes 

(DVD).

Disorder specific (multifamily groups) versus general family therapy (Problem Centered 

Systems Therapy of the Family; 1 trial)

Differences in rates of recovery or between general family therapy and disorder specific family 

therapy, delivered in multiple family groups, were non-significant.

Schizophrenia (3 trials)

Multiple Family Groups (MFG; 1 trial)

• MFG as compared to an individually oriented psychosocial intervention, improved negative 

symptoms of schizophrenia (e.g., blunted affect, alogia, anhedonia, inattention, avolition). At 

the one year point of a two year intervention, there was a statistically significant difference 

of one point on a 25 point scale. Those in the MFG condition had a 12% lower rate of 

hospitalization at state level psychiatric hospitals at one year follow-up. 

• Differences on rates of overall hospitalization, community hospitalization, 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

No significant differences were found between groups on hospital admissions, symptoms, or 

family outcomes.

Applied Family Management (AFM; 1 trial)

• No significant differences were found in hospitalization rates, time to hospitalization/

relapse, or symptoms between more intensive AFM and less intensive Supportive Family 

Management (SFM).

• AFM improved family functioning (patient rejection scale) by 0.32 scale points at 1 year 

follow-up (medium effect size, 0.31) and 1.03 scale points (medium effect size, 0.30) at 2 

year follow-up, over less intensive SFM..

• Authors note that due to limited group differences, findings may have limited clinical 

significance.

Schizophrenia + Substance Use Disorder (1 trial)

• Subjects with a comorbid substance use disorder and serious mental illness (e.g., 

schizophrenia, bipolar disorder) demonstrated greater improvements in psychiatric symptoms 

(Brief Psychiatric Rating Scale or BPRS psychosis, medium effect size, 0.32; BPRS total, 

small effect size, 0.17) when assigned to a longer term (9-18 months) psychoeducational 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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family program than a brief (2-3 month) family intervention.

• Differences in substance use and global functioning across conditions were non-significant.

PTSD (2 trials)

One trial found no significant differences between exposure therapy with Behavioral Family 

Therapy (disorder specific family intervention) versus exposure therapy only on symptoms of 

PTSD or social adjustment; however the family-involved arm resulted in poorer rates of dropout 

than exposure alone.

Other Conditions Examined in Single Trials (2 trials)

There were no differences between a family involved intervention and individually-oriented 

treatment in abstinence from smoking or social support in one trial examining smoking cessation 

in pregnant women and in days of binge eating, depression scale scores, relationship adjustment 

scale scores, or treatment attendance in a second examining binge eating disorder.

DISCUSSION

The literature we reviewed examined a broad number of family involved interventions for mental 

health conditions. Importantly, many of our outcomes of interest, including treatment adherence, 

social support, treatment satisfaction, couple/family conflict, couple/family communication, 

and intimate partner violence were rarely presented. This was also true of a primary outcome 

(family and couple functioning) for bipolar disorder and schizophrenia. Some of the outcomes 

we describe are intermediate, rather than focused on patient symptoms and functioning. For 

example, while treatment initiation, participation, and attendance in counseling sessions were 

of interest, they may be of low-value (and actually indicate ineffective health care resource 

utilization) in the absence of demonstrated improvements in symptom or functioning outcome, 

especially if interventions lead to increased resource utilization without clinical benefit. 

Furthermore, many of the positive findings are based on multiple outcomes reported and longterm maintenance of effects beyond the study period are not well known. The majority of studies 

reviewed compared family interventions to another active treatment, limiting our ability to 

draw conclusions about the general efficacy (i.e., compared to waitlist or medication only) of 

the interventions reviewed. In particular some studies compared one form, type, intensity, and 

method of family or couple therapy versus another or to a waitlist. Thus the evidence regarding 

the incremental effectiveness of family or couple therapy compared to treatments that solely 

involve the patient or more ready access to care is limited especially outside of substance use 

disorders. Over half of the trials reviewed (56%; N = 22) examined family interventions for 

substance use disorders. For this condition many of the studies were conducted by a single 

investigative team and thus generalizability to other populations, settings, and therapeutic teams 

are not clearly known.

Generally, across the 39 trials, family involved treatments for mental health conditions were as 

effective as or more effective than alternative 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 
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Family Involved Psychosocial Treatments for Adult Mental Health 

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therapy alone or waitlist. 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-up than patients participating in usual care. With the exception of CRAFT and BCT, many 

of the trials comparing family therapies to alternative family or individual therapies found no 

significant differences when interventions were equally as intensive. 

Among good to fair quality studies with moderate strength of evidence, we reached the following 

conclusions:

1. Behavioral couple therapy (BCT), a disorder-specific couple therapy, results in lower rates of 

substance use and greater relationship adjustment than individually-oriented treatments over 

the year following treatment for drug use and alcohol use in both male and female patients

2. Community Reinforcement and Family Training (CRAFT), a disorder-specific and partnerassisted intervention, conducted solely with the family members of individuals with 

substance use disorders, leads to better rates of treatment initiation among individuals with 

substance use disorders than alternative family interventions.

Low strength of evidence from single trials indicated that some additional family interventions 

improve patient symptoms, family functioning, and treatment initiation (see Executive Summary 

Table below). The existing evidence is limited by small numbers of good to high quality studies 

and inconsistency of findings both across and within trials. Our findings and strength of evidence 

ratings are based solely on the results of our search, which included only US studies since 1995 

of family involved psychosocial treatments for mental health conditions that included patient 

outcomes. Consequently, conclusions do not include behavioral family therapy and supportive 

family therapy for schizophrenia which were established as efficacious prior to our review. 

Although a body of evidence supporting family treatment for schizophrenia for prevention or 

delay of relapse exists, many trials did not meet our search criteria. The quality of reporting in 

most these studies is poor and the applicability of some results from studies outside the United 

States, particularly in China, is limited. With the exception of behavioral couple therapy and 

CRAFT for substance use disorders, the literature in U.S. populations and especially Veterans is 

not well-developed.

FUTURE RESEARCH

The biggest needs for future research are for high quality RCTs of family interventions with 

Veterans, including BCT and CRAFT, and studies that replicate the family involved treatments 

identified above as ‘possibly efficacious.’ In particular, studies are needed (especially in 

conditions beyond substance use disorders) that compare family/couples interventions to 

interventions directed solely at patients in order to evaluate the incremental effectiveness of 

family/couple therapies. Additionally, there is a need for development and standardized reporting 

of patient centered outcomes (rather than intermediate or process measures) using measures 

and analysis strategies that are comparable across studies. The clinical significance of many of 

the reported outcomes including scale scores is not well established. Determining levels that 

establish clinical significance (and whether interventions achieve a clinically significant effect) 
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would be of value for practitioners, researchers and health care policy makers. Further work is 

also needed on groups underrepresented across the literature, but important to the VA. These 

include studies of women, minorities, non-traditional family constellations (i.e., close friends and 

same sex couples), and patients with complex conditions and common constellations of problems 

(i.e., those with multiple comorbidities). Also, some work has found that family therapies are 

especially beneficial when patients are experiencing high levels of family distress or more 

severe symptoms. Further work is needed to replicate these preliminary findings. RCTs of family 

interventions for mental health conditions in the US were especially sparse for PTSD, anxiety 

disorders, sexual functioning, depression, eating disorders, and personality disorders. Future 

reviews should also examine the effects of family involved interventions on caregiver outcomes, 

patient preferences for which family members to include and how to involve them in treatment, 

and methods of engaging patients and their families in family treatment.

EXECUTIVE SUMMARY TABLE.

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

Health (MH) 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 care Treatment-as-usual

1) Substance Use ND Low

2) Treatment 

Initiation 3 Low

Behavioral Couple Therapy + 

relapse prevention Behavioral Couple Therapy

1) Substance Use 3 Low

2) Relationship 

Adjustment ND Low

Behavioral Family Treatment Individual Behavioral 

Therapy

1) Substance Use 3 Low

2) Family 

Functioning ND Low

CRAFT 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 Treatment Individual Behavioral 

Therapy

1) Substance Use 3 Low

2) Family 

Functioning 3 Low

CRAFT Al-Anon/Nar-Anon

1) Substance Use ND Moderate

2) Family 

Functioning ND Low

3) Treatment 

Initiation 1 Moderate
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MH 

Condition Intervention Comparator Outcome EfficacyStatus

Strength 

of 

Evidence

Bipolar

Family-Focused Treatment-Health 

Promoting Intervention

Health information DVDs 

reviewed by caregivers 1) Symptoms 3 Low

Family-Focused Treatment 

Crisis management 

with two in-home family 

psychoeducation sessions

1) Symptoms 3 Low

2) Medication 

Adherence 3 Low

Problem-focused, 

psychoeducational 

Individual therapy

1) Symptoms 3 Low

2) Medication 

Adherence ND Low

Cognitive Behavior Therapy 1) Symptoms ND Low

Interpersonal and social 

rhythm therapy 1) Symptoms ND Low

Marital intervention + medication Medication only

1) Symptoms ND Low

2) Global 

Functioning 4 Low

3) Medication 

Adherence 4 Low

Schizophrenia

Multiple Family Groups 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 Management)

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 

Disorder)

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 

Support Waitlist 1) Number of MH 

Visits 4 Low

Depression Brief problem-focused couple 

therapy 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.

ND = No significant differences found

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.

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.
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ABBREVIATIONS TABLE

AA Alcoholics Anonymous

ABCT Alcohol Behavior Couple Therapy

ABIT Alcohol Behavior Individual Therapy

ABMT Alcohol Focused Spouse Involvement Plus Behavioral Marital Therapy

ACQ Area of Change Questionnaire

ACT Assertive Community Treatment

AFM Applied Family Management

AL-NAR FT Alcoholics Anonymous / Narcotics Anonymous Facilitation Therapy

ASI Addiction Severity Index

AUD Alcohol Use Disorder

BBCT Brief Behavioral Couple or Marital Therapy

BCT Behavioral Couple or Marital Therapy

BDI-II Beck Depression Inventory 2nd Edition

BFT Behavioral Family Therapy

BFTI Brief Family Treatment Intervention

BMRS Bech-Rafaelsen Mania Scale

BMT Behavioral Marital Therapy

BPRS Brief Psychiatric Rating Scale

CAFES Coffee and Family Education and Support

CAPS Clinician Administered Posttraumatic Stress Disorder Scale

CBQ Couples Behavior Questionnaire

CBT Cognitive Behavioral Therapy

CC Collaborative Care

CM Contingency Management

CRAFT Community Reinforcement and Family Training

CRT Community Reinforcement Training Intervention

CSQ Client Satisfaction Questionnaire

CTS Conflict Tactics Scale

DAS Dyadic Adjustment Scale

DSM Diagnostic And Statistical Manual of Mental Disorders

DVD Video Diskette

ED Erectile Dysfunction

EDEQ Eating Disorder Examination Questionnaire

EDITS Erectile Dysfunction Inventory of Treatment Satisfaction

EE Expressed Emotions

ESP Evidence-based Synthesis Program

FES Family Environment Scale

FFT Family Focused Training

FFT-HPI Family-Focused Treatment-Health Promoting Intervention

FIDD Family Intervention For Dual Disorders

FPE Family Psychoeducation

FSO Family or Significant Other

GAS Global Assessment Scale
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Family Involved Psychosocial Treatments for Adult Mental Health 

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

HAM-D Hamilton Depression Rating Scale

HOPE Helping Other Partners Excel

HSR&D Health Services Research & Development Service

ICBT Individual Cognitive Behavior Therapy

ICD International Classification of Diseases

IIEF International Index For Erectile Function

IOE Impact of Events Scale

IPT Interpersonal Psychotherapy

IPSRT Interpersonal And Social Rhythm Therapy

ITT Intention to Treat

KQ Key Question

LIFE-RIFT Longitudinal Interval Follow-Up Evaluation - Range of Impaired Function Tool

MAT Locke Wallace Marital Adjustment Test

MFG Multiple Family Group

MH Mental Health

MHS Marital Happiness Scale

MMSE Mini-Mental State Exam

M-PTSD Mississippi Scale for Combat-Related Posttraumatic Stress Disorder

MSANS Modified Scale for The Assessment Of Negative Symptoms

NA Not Applicable

ND No Significant Difference

NR Not Reported

NS Not Significant

OIF/OEF Operation Iraqi Freedom/Operation Enduring Freedom

PACT Psychoeducational Attention Control Treatment

PAIR Personal Assessment of Intimacy in Relationships

PDA Percentage of Days Abstinent

PDHD Percentage of Days of Heavy Drinking

PDPSU Percentage of Days Primary Substance Use

PL Public Law

PORT Patient Outcomes Research Team

PSBCT Parent Skills with Behavioral Couple Therapy

PTSD Posttraumatic Stress Disorder

QOL Quality of Life

RCT Randomized Control Trial

RHS Relationship Happiness Scale 

RP Relapse Prevention

SA Substance Abuse

SADS-C Schedule For Affective Disorders And Schizophrenia –Change Version

SAS Social Adjustment Scale

SAS-FV Social Adjustment Scale III, Family Version

S-BCT Standard- Behavioral Couple Or Marital Therapy

SC Standard or usual care

SFM Supportive Family Management

SO Significant Other
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Family Involved Psychosocial Treatments for Adult Mental Health 

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

SPSI Social Problem Solving Inventory

STEP-BD Systematic Treatment Enhancement Program For Bipolar Disorder

SUD Substance Use Disorder

SV Spousal Violence

RCT Randomized Control Trial

TAU Treatment As Usual

TLFB Time Line Follow Back

TX Treatment

US United States

VA Veterans Affairs

VS versus

VISN Veterans Integrated Service Networks

YMRS Young Mania Rating Scale