1

RECLAIMED LIVES: A PROVEN TREATMENT FOR SCHIZOPHRENIA WE'RE IGNORING
By Art Levine

An unlikely revolution in therapy is taking place inside this mental health clinic in a small
town in south Maine. About 20 people -- patients with schizophrenia and their families -- are sitting
in a circle of folding chairs, shooting the breeze about the Red Sox and their holiday weekends. On
the walls of the classroom, there are a few heart-shaped collages with homilies reflecting the spirit
of the group, such as "Stick with me through thick and thin." The families have often been
struggling to do just that for years, and now, after seeing their loved ones go in and out of hospitals,
they've finally turned to this new multifamily "psychoeducation" group for information about the
illness, mutual support, encouragement to take medications and other help. The group may be
new -- only five months old -- but it's a treatment model that's been proving itself in controlled
studies for nearly 20 years; yet only in the last few years has it begun to spread and win recognition
as perhaps the most effective family-based treatment ever devised for any mental illness, reducing
relapses to as low as 10 percent annually when combined with medication.
The great irony of this treatment is that it turns the old view that the family causes
schizophrenia on its head: now the family is seen as an ally, critical to recovery. But along with
most other "evidence-based" treatments for schizophrenia and other severe mental illnesses, they
largely haven't been put into practice in the field, robbing millions of patients and their families of
the best-proven methods and accurately prescribed medications for dealing with their afflictions.
Even with the new publicity given schizophrenia earlier this year with the Oscars awarded A
Beautiful Mind, the child killings by Andrea Yates, and some magazine stories, there still hasn't
been much attention given so far to programs that really work. An initial report by a presidential
commission on mental health released in November promotes such programs, but it won scant
media attention and even when its final report is issued in April, it will probably have relatively
little actual impact on the country's scandalously poor mental health system. But what Dr. Michael
Hogan, the head of Ohio’s mental health department and chairman of the presidential commission,
said in November is still worth heeding: “The so-called mental health system is so fragmented and
in such disarray that it is often not capable of getting these treatments that work to people who
desperately need them.”
That's just one of the reasons it’s important to understand the success of family
psychoeducation and other well-proven programs that have slashed hospitalization and relapse
rates, cut health care costs and transformed the lives of the mentally ill. These treatments and
programs incorporate medications but go beyond that to offer the severely mentally ill the life-
skills instruction and support needed to live fulfilling, productive lives, including holding
mainstream, competitive jobs.
This multifamily group (MFG) in Maine is being gently guided by two "facilitators," clinical
social workers Dawn Hardy and Marilyn Wanyo, but there's no hiding the pain in the room.
Tonight, Wanyo, a tall, low-keyed counselor who sees several of the patients privately at the clinic,
soon steers the talk to the schizophrenia that has brought them together. "How have you been
handling the illness in the last two weeks?" she asks. As she passes a pencil as a signal for speaking
to Mike, a short-haired, former dockworker in his forties, who begins the "sharing" portion of the
meeting, it becomes clear how intractable -- but hardly hopeless – this illness remains, even with
the best drugs. (The names of “Mike” and other patients have been changed to protect
confidentiality.) His head is tilted down, as he mumbles something about starting new medications,
and then says what's really on his mind: "I was thinking about hearing voices and having bad
thoughts; a lot of them are true." He adds, "The Devil's on my case."
"This sounds really important," Wanyo says, calmly turning to his parents for their views,
unruffled by the patient's ongoing delusions. His mother offers a more reassuring perspective: "He
2

doesn't seem as drugged as he's usually been," she says, while noting that he's been experiencing
medical side-effects from new blood pressure medicine that he's also been taking. "It all comes
down to that I'm over the hill," he jokes as the rest laugh; it seems like a throwaway line, but it's
actually a small breakthrough for him: he hasn't participated much or shown any humor in
previous sessions. (Wanyo, comparing his current status to the progress he made with her in
individual therapy, later observes , "The patient is so much better.") As each new person speaks,
the sharing illustrates both the variations in the illness and the common bond between them.
For some patients, even being there at all is a major accomplishment. David, a plump 50-year-
old man afflicted with both autism and schizophrenia, sits bolt upright, eyes closed, talking in a
soft, slurred voice about the neighbors' voices he says come over his radio scanner: "They're after
me to clean my apartment." His sister Diane turns to him with a smile that's both loving and
embarrassed, and says, "I keep telling him he's doing a good job of house-cleaning and he shouldn't
worry about it." Wanyo says to him sympathetically, "This must scare you."
Later in the session Wanyo and the group will devise solutions to a patient's problem they'll
select to handle, through a process of group brainstorming, with the therapist having just one of
many equal voices worth hearing.
This is hardly therapy as usual -- if it's even therapy at all as we've come to understand it.
Unlike either traditional group therapy, private psychotherapy or family therapy, there was no
venting of emotions or blame, no probing for insights or hidden family dynamics. It may seem to
some therapists, schooled in the drama of conventional family therapy and other psychotherapeutic
methods, as rather prosaic -- but, along with anti-psychotic medications, it’s by far the most
carefully studied and proven approach for dealing with schizophrenia, the illness that first put
family therapy on the map in the 1950's and 1960's as an innovative new discipline.
Family therapy, a once-influential approach that focuses on the dynamics of family life as a
way to help individual family members, is just one of dozens of forms of psychotherapy --
including psychoanalysis -- being challenged by the new emphasis on evidence-based practices
such as psychoeducation. The initial report of President Bush's "New Freedom" Commission on
Mental Health, released November 1, cites the importance of implementing such approaches and
called for overcoming the barriers to doing so. Despite the controversy they generate in the often
hidebound therapy field, the common-sense principle undergirding these newer, scientifically-
proven treatments is an obvious one: "Treatments that have been shown to improve patient
outcomes ought to be used," says Dr. Anthony Lehman, the chairman of the psychiatry department
at the University of Maryland-Baltimore. He's a co-author of a pioneering federal report outlining
the best treatments for schizophrenia and one of the researchers leading a groundbreaking new
federally-funded pilot project starting later this year to implement several of the best practices for
schizophrenia and other illnesses in selected clinics; these model approaches include family
psychoeducation, community outreach treatment teams and appropriate medication levels. The
project is working with about 50 clinics in eight states to put into practice exemplary practices and
study how well they carry them out. The ultimate goal: spreading these methods to clinics and
hospitals throughout the country.
Unfortunately, relatively few of the nation’s nearly 11 million severely mentally ill patients
receive such treatments and less than a third of outpatients are correctly prescribed drugs, federal
studies show. Most community clinics, psychiatrists and psychotherapists haven't received the
training or sufficient insurance incentives to adopt well-proven treatments for schizophrenia and
other severe mental illnesses, such as bipolar disorder and major depression -- and, in some cases,
have even actively resisted using them. Today, this mental health crisis is only worsened by
managed care's overemphasis on simply dispensing medications and paying for costly
hospitalizations after breakdowns and relapses. Indeed, insurers and government agencies have
generally been unwilling to pay for some of the most effective treatments, usually funding little
3

more than a relative handful of superficial therapy sessions that generally don't offer much real
help, especially to those with schizophrenia. It's an illness that plagues 2.5 million Americans and
their families, but also contributes to broader social problems, including homelessness and the
violence and disorder that has swamped our jails and prisons with five times as many mentally ill
people (300,000) as are in all state hospitals combined (under 60,000).
The reluctance to embrace proven approaches -- and scientific evidence itself -- affects much
of our mental health system, but it's perhaps most dramatically seen in the case of family therapy.
Ironically, it's the same field that, by its failures, spawned a new generation of researchers who
rejected its ideology and forged the new family-based approaches to schizophrenia that actually
work. Even with its successes in helping treat such problems as adolescent substance abuse, family
therapy's historic failure in dealing with schizophrenia is emblematic of a broader weakness in
handling severe mental illness that cuts across much of psychotherapy today.
"Family therapy has pretty much folded the tent and walked away from schizophrenia -- but
the best evidence [now ] for family therapy being effective is in schizophrenia," says the leading
creator of the multifamily model, Dr. William McFarlane, the chief of Maine Medical Center's
psychiatry department. The psychoeducation approach has shown itself (when combined with
drugs) in 15 controlled studies worldwide to produce annual relapse rates as low as 10 to 15
percent, with the multi-family groups edging out individual family education. That's all compared
to a 40 percent or more relapse rate for those treated with medication and conventional therapies.
Now the American Psychiatric Association and a key federal mental health agency are promoting
family psychoeducation, although it must overcome major obstacles in reimbursement, training and
awareness before it becomes more widely used.
Yet despite its impressive track record, McFarlane's approach hasn't been widely embraced by
most family therapists, or other branches of psychiatry and psychotherapy. That's in part because it
poses a challenge to both the practices and philosophy of an older generation of therapists, to the
traditional view that families somehow cause schizophrenia and serious mental illnesses -- and to
the very culture of therapy itself, in which the therapist's art of aiding families and patients is often
seen as more important than the science of proving that the therapies actually work. Even so, the
multifamily approach may also be a harbinger of an era when the society will demand tightly
structured, well-proven therapies that rely more on a prescriptive format and patient education than
on any one therapist's skill and magnetism. In short, this could be the forerunner of what might be
seen as virtually therapist-proof therapy. "If we have to depend on the brilliance and charisma of a
therapist to get a treatment to work, we're in trouble," McFarlane says.
And McFarlane, a bearded, soft-spoken but fiercely determined 58-year-old psychiatrist, is
quite willing to play the role of both pioneer and scold in promoting this treatment -- as well as a
new paradigm of therapy.
"Empirical evidence isn't enough for the mental health field," complains McFarlane, who was
trained in family therapy. "Therapists are comfortable cruising along for 20 years on what they
learned in professional training without changing anything. They're not open to alternative models
of thinking, let alone practice. And our family work is a 180 degree turn in terms of attitudes
towards families: instead of blaming them and trying to find out what's wrong, we're collaborating
with them."
That collaboration is fully on display at the meeting in Maine, when Wanyo and the families
select a patient's problem on which to focus. One patient, Chuck, a sweet-tempered black man in
his thirties, had remarked, "I worry about what people are saying about me when I go shopping."
The group decides, with Chuck's assent, to offer suggestions on what he could do. In this open,
accepting atmosphere, the suggestions start to fly as Dawn Hardy writes them on a chalkboard:
"Realize they're no better than you are...smile...ignore it...check it out with someone
4

else..." Chuck decides which ones he'll try to work on, and Wanyo tells him, "So we'll check back
with you in two weeks on how you're doing with them." Soon, the meeting ends, and the families
chat among themselves while snacking on cake and juice.
For both patients and families, the group means something special to them, a way to both learn
about the illness and ease the isolation it imposes on them. To Karen, a 35-year-old woman who
has been hospitalized three times in recent years, "It was kind of scary at first being in a group, but
it's good knowing that there are other people suffering from the same problem who you can identify
with." For Karen, it's a long way up from where she was just a few years earlier, raving in a
Portsmouth clinic about being the Devil. And both she and her mother underscore the value of the
treatment's psychoeducation component; it not only explains the biological roots of the illness,
freeing the family from blame, but also offers pointers to families on creating a calm, low-stress
environment designed to defuse the often intense, hypercritical family response to patients that's
been dubbed by researchers as "expressed emotion." A new muted atmosphere in turn fosters
recovery and helps avoid relapses. "I think my parents understand me better, and aren't so apt to
criticize me," Karen says, now living with them after she had to give up her own business a few
years ago.
Her mother adds, "At first I just thought she was being a spoiled brat; I didn't understand the
illness." Indeed, most families and many doctors don't know that recovery from a psychotic
breakdown can take as long as two years, and that patients, even after they've stopped
hallucinating, exhibit such "negative" symptoms as fatigue, lassitude and apathy.
These gatherings also offer something rare with schizophrenia -- hope -- because the members
can see how other patients and families are coping. "It's great to share and compare what others are
doing in different circumstances," notes Diane, the sister of David.
At first, it might seem that these sort of common-sense benefits couldn't add up to much, let
alone a treatment that works up to three or four times more effectively than drugs and more
conventional therapies combined. But the multifamily group psychoeducation approach is artfully
constructed to produce remarkable long-term effects. As University of Miami psychiatry
professor Harriet Lefley, author of Family Caregiving and Mental Illness, says, "It is the most
powerful intervention in schizophrenia and it's being extended to other illnesses" -- including major
depression and bipolar disorders. It’s also so cost-effective that McFarlane’s earlier research in
New York State showed that that for every $1 spent on multi-family psychoeducation $34 was
saved in hospital costs during the second year of treatment.
"Something magical happens when families get together," McFarlane points out. It's hard to
dissect, but the social networks created by this kind of long-running group (nine months at
minimum) provide a healing camaraderie. Recent research indicates that social networks help
other chronic mental and physical illnesses as well.
But this is no mere support group. The treatment has three other key elements: the education
component, the group problem-solving and a novel form of preliminary recruitment and bonding --
"joining" – with family members and patients before the group even begins. The model's
design is so basic that Kit Perry, the clinical social worker who helped McFarlane recruit therapists
to run groups, recalls, "The biggest obstacle [for staff ] was that people thought it was too simple
and there should be more to it."
The centerpiece of the multifamily group's learning is a full-day psychoeducation workshop,
derived from the work of University of Pittsburgh researcher Carol Anderson and her colleagues.
The workshop teaches both the patients and families about schizophrenia as a biologically-based
illness that is especially vulnerable to stress and "expressed emotion." It's all codified in simple
"Family Guidelines," such as "GO SLOW. Recovery takes time...Things will get better in their own
time..."
5

Yet before they're even willing to learn about the illness and perhaps change their behavior,
families have to commit to attending this long-term program. And that's where the "joining," or
building of rapport, becomes so critical. To Kit Perry, the joining has a basic goal: "We want
to build a relationship with somebody that's strong enough to convince people to leave their house
when it's cold and icy in winter to come to the group." It's worked: McFarlane reports drop-out
rates from the multifamily groups as low as 10 percent, much lower than conventional therapy .
The treatment's approach to problem-solving also sets it apart from most traditional therapies.
The therapist isn't an all-knowing fount of wisdom, but an equal partner in the families' own
discoveries. Indeed, the entire framework of such psychoeducation programs is at odds with
conventional therapy, notes Lisa Dixon, a University of Maryland psychologist. "We're not trained
to look for competencies, but pathologies. The best therapist [in this method] is the one who is able
to pull out the competencies and strengths of those who are experts with living with the
illness: family members and patients," she says.
***
All of this psychoeducation and support may be critical to helping patients and families
recover, but in the real world, many families have their isolation, confusion and guilt only
compounded by the response of mental health professionals to their plight. In fact, less than 10
percent of all families receive even minimal education or support services, according to the
definitive 1998 federally-funded Schizophrenia Patient Outcomes Research Team (PORT)
recommendations co-authored by Dr. Lehman; an updated study will be released later this year.
( The PORT report also condemned using "psychodynamic" psychotherapies for treating
schizophrenia.)
Still, the families' burden and social stigma have been made even greater by the persistence of
outmoded ideas and useless strategies among some therapists. For instance, Carol Anderson
recently encountered a family whose therapist advised their schizophrenic son to try writing down
his symptoms on little pieces of paper, putting them in a paper bag and throwing it away. And
despite the overwhelming evidence of the biological role in schizophrenia -- the latest studies of
identical twins and other populations put the genetic factor at 83 percent -- there's a lingering
undercurrent of blame in many therapists' dealings with families. "It's still by far the biggest
complaint of families," notes Kit Perry. As one researcher, who asked to remain anonymous and is
affiliated with the American Association for Marriage and Family Therapy (AAMFT), concedes,
"Family therapy did blame family members for the illness, and some people are still holding on to
that viewpoint" -- along with some therapists in other disciplines.
These added family hardships are played out against a broader context: the wave of
deinstutionalization of state mental hospitals since the 1970s and the subsequent failure of the
patchwork of community mental health clinics to fill the gap. As a result, "the families have
become the primary caregivers and informal case managers, 24 hours a day," says Diane
Marsh, a psychology professor at the University of Pittsburgh and author of a recent book, A
Family-Focused Approach to Serious Mental Illness. Unfortunately, as one angry family member
told her, "Caring families get socked with most of the responsibility and blame but get little legal or
therapeutic support."
On top of all that, the PORT study and other researchers have found that most health
professionals remain relatively ignorant about schizophrenia, from not knowing the proper drug
treatments to not understanding the potential of most patients to lead productive lives. And
health professionals, many of whom still blame families for their offsprings' mental illness, also
often push families away. "The system often instills feelings of helplessness and hopelessness,"
Marsh observes.
For instance, an Ivy League-trained couple we'll call Kathy and Alan Jameson couldn't get any
useful assistance from medical professionals for their 17-year-old son after he had a schizophrenic
6

break and continued to relapse for months afterwards. Whatever meds he was taking weren't
working well; he was still occasionally hallucinating, seeing the paws and legs of dismembered cats
floating past him. Even so, the Jamesons were never really told if their son definitely had
schizophrenia -- nor how to deal with it at home. "We felt we were being kept in the dark," Kathy
says.
What's striking is that they even encountered this evasiveness, she claims, among the staff at
Maine Medical Center's outpatient psychiatric unit -- where some social workers, ironically, were
already starting psychoeducation groups under psychiatric administrator William McFarlane's
direction. But the Jamesons didn't learn anything about handling their sick son until Kathy Jameson
found a copy of a book, Schizophrenia -- A Guide For Families. There she discovered the
importance of maintaining a calm home environment and that recovery could take up to two years
following a psychotic episode. "Why hadn't anyone told us that?" she wonders now. "Up
until that point we were hoping for a miracle."
Now they're pleased with the progress he's made in a multifamily group. "He's flourishing,"
she notes, and making plans to go to college after a psychiatrist once told them to give up hope
for his future. But it took them months of struggle to get effective help for him from a system
that too often discourages family involvement and offers little but bleak assessments.
The multifamily groups, in contrast, help "promote recovery and offer a life-affirming
message of hope," psychology professor Diane Marsh says.
Despite such successes, even the clinical social workers at Maine Medical Center have been
sharply divided over the value of these multifamily groups. In part, that's due to what some staffers
say was resentment at being required to run these new after-hours programs at McFarlane's behest.
But it also reflects philosophical and generational differences over therapy itself. McFarlane's own
research has found that generally less experienced clinicians were more willing to try the program,
perhaps because they were less invested in older approaches. Kirsten Woodberry, a 37-year-old
social worker who has developed multifamily groups for Maine teens, says, "We were trained in an
era where society demanded results. We haven't gotten attached to models where what you do with
your patient is your business -- a mysterious process between the therapist and patient. We do what
we know works."
Others praise the method's calming, predictable format, which is reassuring for easily stressed
schizophrenics. "Its structure is its strength," social worker Joyce Perry observes.
But Laura Ely, the coordinator of family therapy training at the Maine center's outpatient
clinic, chafes at the tight structure. "I didn't like it and a lot of people don't like it: it's so
prescribed," she says. A 25-year-veteran of counseling and a self-described "Systemic Therapist,"
the 52-year-old family therapist doesn't hide her irritation at the multifamily model that was briefly
imposed on her a few years ago. "It's not very creative, challenging or interesting. It's very boring,"
she says dismissively. In fact, while conceding that younger therapists enjoyed their new exposure
to families, she contends that most therapists at the center wouldn't run such groups again -- a claim
disputed by McFarlane and some other staffers.
She's particularly irked at the group problem-solving method, which she believes is too
limiting. "As a clinician, there are things that should be addressed, but you can't because it's got to
be supportive," she says. She says the problem-solving exercises often just feed the delusions or
obsessions of her patients, rather than addressing more pressing needs.
Ely is also skeptical about all the evidence McFarlane and other researchers have compiled
over the last two decades proving the program's value. "All of us know research can prove anything
you want it to," she sniffs. "The multifamily group is the most researched family therapy, because
it's so cookbook. We all do most family therapies a little bit differently, so it's hard to compare and
research. I believe research would show that family therapy is helpful, but it's hard to prove."
7

McFarlane's amiable demeanor steadily hardens when he's told about Ely's views, particularly
her assertion that most therapists there wouldn't want to run groups again. "I'll have to fire her
tomorrow," he snaps (he didn't). As a researcher who has spent 20 years putting together careful
studies, he's also disturbed by her unproven claims on behalf of conventional family therapy. "She
and her counterparts couldn't get the results I did. They've had 45 years to come up with results, but
they haven't been able to do so," he says. (McFarlane does gives family therapy credit for being
effective with marriage problems and childhood behavior disorders, but not with serious mental
illnesses.)
McFarlane also defends the importance of the prescriptive format that therapists such as Ely
find so boring and restrictive. "This isn't designed for the entertainment of the therapist," he points
out. He adds bitterly, "In mental health, you can do what you find interesting for years even if it
isn't effective -- and you'll be just fine." In fact, he says, it's the highly formatted, prescriptive
therapies, such as cognitive therapy, dialectical behavior therapy (DBT) or psychoeducation that
generally have the best results -- even if they're less "interesting."
Curiously, these therapies generally do something else: undercut the traditional standing of the
therapist. They put a far greater emphasis on the value of patient education and self-help exercises,
thus downplaying to a certain degree the role of the therapist in directly bringing about change. In
McFarlane's treatment, for example, the therapist evolves over time from a leader and teacher to a
"back of the bus" guide.
Moreover, the pioneers of these more scripted treatments seem proud of the way they can be
replicated without requiring a highly skilled therapist. "It was designed to be somewhat therapist-
proof," McFarlane says of his approach. And McFarlane boasts that in his successful New York
State studies of multifamily groups -- prior to coming to Maine -- he worked exclusively with
public employees at clinics, including some case managers with no therapy experience at all. "They
weren't brilliant and they just got $20 an hour in overtime to do the groups," he says. "It worked
across the board: there's very little evidence that a therapist's unique characteristics and skills made
any difference."
Given all that, it's not surprising that McFarlane often refers to his system as a "technology" --
and concedes that it may not even be therapy as traditionally defined. "If you mean an organized
approach to achieving a significantly improved life, then it's therapy. But, if by therapy, you mean
trying to find what's wrong with the family, then it's not therapy," he says.
***

If McFarlane is one of the avatars of this new model of therapy, then Jay Haley, one of the
pioneering icons of family therapy, likely speaks for a significant portion in the field in rejecting
both psychoeducation's premises and methods. For instance, he dismisses as a "tremendous
propaganda job" the current consensus undergirding psychoeducation that schizophrenia is a
largely biologically-based illness. At 79, with his mane of graying hair and compelling presence, he
still embodies the charismatic proponent of family therapy, working as a professor at the United
State International University in San Diego, and offering training tapes and monthly workshops. In
his brand of therapy, the therapist is very much in charge, manipulating families to change.
In the last 40 years, there have been new findings about schizophrenia as a brain disease, along
with new drugs and treatments, but Haley still seems rooted in largely discredited notions from the
past. In the 1950s and 1960s, he, along with anthropologist Gregory Bateson, helped develop
approaches to schizophrenia that looked at contradictory, ambivalent communications by parents --
the "double bind" -- that purportedly created an emotional paralysis leading to schizophrenia.
Similar theories also often assumed that there were "schizogenic" mothers and families, and that
families should alter the unhealthy dynamics that kept the patient playing a schizophrenic "role."
8

But these perspectives never proved themselves with solid research or results, and by the mid-
1970s, a new generation of researchers critiqued these approaches as ineffective and perhaps
harmful. "They were about as wrong as they could be and still keep their jobs," McFarlane says of
most of the theorists of Haley's generation.
Although most leaders in the family therapy field -- and other psychotherapies -- eventually
drifted away from dealing with schizophrenia, Haley occasionally trains students in the illness
while continuing to see today's treatments through the prism of past theories. For example, he
remains generally opposed to anti-psychotic drugs, in part because "it's telling the family that the
kid is sick."
Since the patient is viewed as just playing a "role" in the family, it's the therapist's main job to
return the patient and family to normal functioning as quickly as possible, he argues. If a student
starts hallucinating, Haley believes, "you've got to get him back in to college as fast as you can,
because you assume a normal situation will produce normal behavior." That high-pressured
approach, of course, flies in the face of nearly 30 years of "expressed emotion" studies that have
shown that overly demanding families can promote relapses. "I don't know what that research
shows," Haley admits.
To an outsider, such views might seem just those of an isolated crackpot, but in fact he's a
well-regarded founding father of his brand of psychotherapy and his work on schizophrenia is still
quoted approvingly in some recent books and journals. More importantly, his ability to continue
to win acolytes reflects a widespread indifference -- even hostility -- to any well-designed scientific
research that challenges the worldviews of many in the therapy field, not just among family
therapists.
All of his unproven schizophrenia theories are on display in his recent training video, "A
Positive Approach With a Psychotic Couple." It shows an assured Haley advising a young therapist
and other students on dealing with a troubled, argumentative schizophrenic couple, both
hospitalized a few times in recent months. Haley's goal for the therapist: get the male patient back
to work quickly.
Haley's theories -- even if they lack evidence to support them -- have real-world
consequences. A week later, the film shows, the student therapist reports back that the patient has
become angry at being pushed into returning to work and is starting to hear more voices again.
Haley is undeterred, suggesting that they now recruit the wife's parents into prodding him to start
work. At a subsequent follow-up session, Haley remarks, "He's either going to react positively to
sessions when you push him to be more active, or he's got to relapse, and complain that it's
awful and he can't work." Haley, casually munching on pizza with his students, seems unperturbed
by that latter prospect.
At the end of the video, it's reported that two months after the first session, the husband has
fled the home to live with an out-of-state relative and hasn't been heard from again, while the wife
is back in therapy. The video features a shattered marriage and an uncertain, potentially disastrous
outcome -- and yet it's being hawked as a model treatment for other therapists.
***
It's precisely that sort of unscientific meddling with families beset by schizophrenia that
spurred McFarlane and a new generation of family therapists to develop fresh approaches to the
illness.
Even today, family therapy's in-house critics, such as Carol Anderson and Bill McFarlane, are
not just challenging old theories with impressive studies. They're also challenging a field that they
see as still indifferent to whether there's hard evidence for a therapy's effectiveness and that relies
on spellbinding anecdotal accounts instead. "Charisma accounts for almost everything in this field,"
Carol Anderson observes. "It's a very scary thing.”
9

For Bill McFarlane, the family therapy strategies of people like Haley simply weren't working
with schizophrenics in the Bronx public hospitals where he worked as a psychiatrist in the 1970's.
A former seminary student who was drawn to medicine and "public psychiatry" out of idealism,
McFarlane had trained with family therapy founder Nathan Ackerman and accepted the notion that
families helped cause the illness. "This was it!" he thought. "Now we understand why people are
crazy." But seeking to change family behaviors didn't help his patients much.
Eventually, he became intrigued by multifamily support groups being used at Vermont State
Hospital by psychiatrist Peter Laqueur. "After a while," he discovered while visiting there, "the
patients looked a whole lot better than they were supposed to. Something was going on we didn't
understand." On returning to the Bronx to see his own patients, he finally turned against family
therapy after one young Hispanic was hospitalized two days after what McFarlane thought was a
fruitful family session. He told himself, "I was possibly causing this kid to get worse."
By 1979, he created a multifamily psychoeducation group with just four families at the
Morrisania clinic in the Bronx, borrowing ideas from Anderson, Laqueur and others. "The families
were happy and grateful -- everything that wasn't happening in regular family therapy," he
remembers. "And the patients kept showing up."
Word of the promising early results -- all the kids in treatment got better simultaneously -- led
McFarlane to design important controlled studies of the treatment in the 1980s. He conducted
research in a New Jersey hospital and later, with a $1.5 million state grant, at six
hospitals in New York State. In multi-year studies, he produced an average annual relapse rate of
about 12 percent compared to the single-family psychoeducation approach, which averaged nearly
20 percent. Equally impressive, he showed that for every $1 spent on implementing the program, as
much as $34 was saved on second-year and subsequent hospitalizations. "We hit the combination,"
he says with quiet pride,
He then continued the quest that has consumed him for 20 years: proving and promoting his
therapy to the world. He lectured widely about his findings, well before his final report was
published in 1995 in the prestigious Archives of General Psychiatry.
Despite his achievements, mental health ideology intervened to thwart him. New York's new
commissioner of mental health scotched plans to expand the program in 1990, McFarlane says,
because the official didn't want to see potential critics of the system -- families -- regularly
visiting public clinics. "Screw this," McFarlane said, and fed up with the bureaucratic resistance --
as well as gang violence in the city that threatened his son -- he left New York with his family in
1992 to head the psychiatry department at Maine Medical Center.
***
Once there, he continued to promote and test the multifamily treatments. He also launched an
innovative "supported work" program, complete with job coaches and multi-family groups, that
helped 55 percent of unemployed, chronic schizophrenics to obtain competitive jobs, a rate five
times higher than conventional vocational rehab. McFarlane and his team see real employment --
not sheltered make-work jobs -- as vital to self-esteem and recovery. "I like Haley's [employment]
goal," he says, "but his methodology absolutely stinks." McFarlane further spread his
psychoeducation method with trainings that reached staffers of roughly 30 agencies and centers in
the state -- about half of which adopted it. Among other accomplishments, hospitalization costs
were cut up to 75 percent. He was backed by $300,000 in grants from the federal Center for
Mental Health Services (CMHS), which would like to see this "exemplary" practice adopted
nationwide. It was, in some ways, a dry run for the broader federal evidence-based project launched
this year. Even with that support, it's still an uphill battle to repeat the Maine experience on a wide
scale. One major obstacle: unlike Maine, most states' Medicaid regulations still need to be revised
to pay for psychoeducation – and almost no private health insurer pays for it.
10

In Maine, McFarlane was in a unique position to sell the program to other centers, as an
influential administrator in the state and an eloquent spokesman for the therapy he developed.
Ironically for a researcher like McFarlane, it was the personal, anecdotal enthusiasm of the
clinicians who used it in Maine -- rather than his 20 years of studies -- that sold the
state's clinic staffers on it. The response by them to all his painstaking research has been: "So
what?" -- another disturbing sign to him that therapists usually don't care about evidence.
Still, its clear-cut efficacy -- even without the advantage of McFarlane's personal lobbying --
has helped the method spread to pockets around the country: in Cleveland, Ann Arbor, New Jersey
and elsewhere. By the end of last year [2002], clinics in Maryland, New Hampshire and Vermont
began implementing the method as part of the new federal evidence-based practices project. In
Scandinavian countries, where there's national health insurance, the method is fast becoming the
dominant treatment for schizophrenia. Here at home, though, it may require the institutional
equivalent of a grass-roots political campaign (or hand-to-hand combat) to succeed -- and most
therapists won't be on the front lines.
"We can't expect someone to read a Bill McFarlane journal article and then say I'm going to do
psychoeducation," says Mike English, director of the aptly named Division of Knowledge
Development and Systems Change of CMHS. "We need to create incentives for clinicians to adopt
new practices. We've got to pay 'em and train 'em." State Medicaid agencies need to be
convinced to alter reimbursement as Maine did, and more spending is needed to pay for continuing
education for therapists, he argues. Such sweeping changes can come about if patients and families
are mobilized, and administrators are educated about the cost-effectiveness of evidence-based
treatments, he claims. To that end, his agency launched the campaign to promote effective
treatments such as family psychoeducation -- including using "toolkits" for therapists,
administrators and consumers with training materials, backed with in-person training -- and it has
already begun paying groups like the National Alliance for the Mentally Ill to lobby for proven
treatments. The agency’s evidence-based implementation project is significant because it brings
together the best treatments into a unified program to demonstrate their impact -- and then promote
their use nationally through technical assistance and training after seeing how they fare in the initial
clinics in eight states.
All the external pressure and reforms that must be applied are a sign that many therapists won't
be easily convinced to adopt the multifamily group model or other proven treatments on their own,
no matter how effective they may be.
Awareness of their value is also lagging among therapists, but the American Academy of
Marriage and Family Therapy two years ago took a first small step to overcome that by having a
plenary session at their annual conference called, "The Ones We Left Behind: Family Therapy and
the Treatment of the Mentally Ill." One AAMFT official observes, "We started out focusing on
these kinds of patients but we've kind of abandoned them in the last 30 or 40 years." At the session,
Carol Anderson and Diane Marsh reviewed the history of family treatments and the promise of
family psychoeducation. But it will take far more than a well-meaning lecture and the occasional
research paper to convince family therapists, or the old guard in the rest of the psychotherapy field,
to adopt such approaches.
McFarlane, for one, isn't expecting much from that quarter. "To change your philosophy and
your therapy, you've got to be willing to change a piece of yourself," he says, "and most people
aren't willing to do that." If he's right, it could be a loss for both the public and the mentally ill
among us. But the success he’s already shown with this approach, and the backing it’s receiving
from the federal government and health officials in several states, could ultimately help give his
treatment the widespread impact it’s always deserved. And that would be the sort of evidence
anyone who cares about the mentally ill could no longer ignore.
###
11