The cup is both half empty and half full

Ian Falloon's summary of the efficacy and effectiveness of family treatment for mental disorders underscores both the strength and rigor of the evidentiary base for these interventions as well as the substantive gaps in our knowledge. Prevention of major episodes of psychopathology is the most consistent finding of studies of family interventions in schizophrenia. Remission of residual symptoms, enhanced social outcomes, family benefits and reduced cost have all been reported in high quality studies, though the results are not always consistent. One issue that remains somewhat under debate is precisely how to char- acterize the family interventions that achieve improved outcomes. Ian Falloon's review emphasizes the importance of 'stress management' and 'stress reduction' strategies. The article correctly points out that it is not entirely clear which combination of ingredients are 'active' in promoting the success of these programs. This lack of clarity increases the challenge of combining family interventions with other types of programs to optimize outcomes. An important challenge for future research is to close this knowledge gap so that the program can be delivered to the most people at the least cost. Ian Falloon's review underscores another issue: the relative dearth of controlled studies of family interventions for mental disorders other than schizophrenia. Every mental disorder affects the family, and it is likely that the converse is true. It makes sense that some level of family involvement is just part of good psychiatric practice, and that controlled trials of providing education and support should not be necessary. However, the paucity of well-articulated and well-conceptualized intervention programs that utilize family strengths and recognize family stresses with the range of different mental illness is no doubt a lost opportunity for our field. A final gap in our knowledge left unmentioned by Falloon's review is the proliferation of peer-based programs led by family members. These programs have the overt goal of helping families, and are not client-based. An example in the US of a very widespread peer-based family program is the National Alliance for the Mentally Ill's Family to Family Education Program (FFEP). This is a 12-week structured program that is provided within the community (not within the mental health system). It is based on a trauma recovery model. The FFEP provides education about mental illnesses, support, help in problem solving, and help negotiating the treatment system of the local community. The existence of these programs raises two important concerns: the lack of dissemination of clinic-based family intervention programs and the lack of efficacy data for peer-based programs. Programs such as the FFEP, like many peer-based programs, grew up in a tradition that excluded research. Research has been viewed with suspicion. Fortunately, this is changing as recovery-focused models have become more mainstream. Two recent studies of the FFEP, one uncontrolled (1) and one controlled (2), demonstrate that the program reduces the family's subjective illness burden and increases empowerment. Results were sustained six months after program completion. Clearly, more research is needed on the impact of peer-based programs. This leads to the final disappointing reality of the lack of widespread availability of professionally based effective family treatments for mental disorders. The barriers to dissemination of family interventions occur at the system, clinician, patient and even family levels. Perhaps the most important research agenda to be tackled is how to overcome these barriers and make these programs available to the patients and families who need them.