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Psychosocial interventions contribute significantly to the course and outcome of schizophrenia. They effectively lower relapse rate, reduce expressed emotion and improve outcome among individuals with schizophrenia (Penn et al., 1996; Goldstein, 1994; Bums, 1997). A variety of psychosocial interventions have been developed in the last decade and all tend to have a similar goal, i.e. to improve family atmosphere and thus reduce relapse. A popular model of psychosocial interventions is Behavior Family Therapy (BFT) (Anderson et al., 1980; Falloon et al., 1982). The intervention consists of three components: family education about schizophrenia, training in problem-solving skills and communication skills. These interventions were proposed as adjuncts and not alternatives to drug treatment.
Home-based BFT (Falloon et al., 1982)was first introduced for families with high expressed emotion (EE) and aimed to reduce relapse rates by lowering EE. Since then, adaptations of the original protocol have been conducted with some success. These include delivering the therapy in a clinical setting (Randolph et al., 1994), involving multiple families in group settings (McFarlane et al., 1995) and modification of various core components of BFT (McGorry et al., 1997). The need to modify intervention strategies to be culturally sensitive has also been suggested. A study in China (Xiong et al., 1994) and among less acculturated patients in USA (Telles et al., 1994) found that the Western or standard model of BFT was not suitable and too intrusive.
A local study found that poor compliance with medication was the main factor contributing to relapse (Razali & Yahya, 1995) and active psychosis was a major cause of family distress. In order to improve treatment compliance, family atmosphere and acceptance of treatment, Falloon et al.'s (1984) BFT model was modified for this study. This culturally modified model included the sociocultural approach of patient and family education and the addition of a new component to tackle poor drug compliance while retaining an emphasis on problem solving skill training.
Effective patient and family education needs a sociocultural approach because the majority of the Malay patients attribute mental illness to supernatural agents (Razali et al., 1996). They cannot accept explanations based on the Western model. In the absence of our advice they will visit traditional healers and subsequently default from psychiatric follow-up. The problem solving skill training is still maintained because the majority of the families could not handle the crisis which leads to frequent family distress (Salleh, 1994). We omitted communication skills training as this is the least important among the three core components of the standard model. This is supported by the finding that generally the carers of Malay schizophrenic patients could tolerate negative symptoms of schizophrenia (Salleh, 1994). The objective of this study is to assess the efficacy of the Culturally Modified Family Therapy (CMFT) against the Behavioral Family Therapy (BFT) in the management of schizophrenia in a developing country.
Once patients confirmed their willingness to participate in the study, they underwent a semi-structured interview based on a standard pro forma to assess sociodemographic variables, past psychiatric treatment and family support. The Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962) was administered as the primary measure of psychopathology. All the assessments were done independently by two research psychiatrists (SMR and CIH). All patients gave their written consent in a standard form after the study was fully explained to them.
The selected patients were randomly assigned to the study or control group. The study group received the CMFT and the control group was assigned with the BFT. The sessions were conducted in an outpatient setting. The CMFT consists of a sociocultural approach of family education, drug intervention program and problem solving skills. The sociocultural approaches to family education include explanations of the concept of schizophrenia from a cultural perspective and an attempt to correct negative attitudes toward modern treatment. The family education and drug intervention was delivered as a package. The drug intervention program includes drug counseling and close monitoring of compliance by a drug-intake check-list presented in every follow-up visit. The problem solving skill was delivered as in the standard model.
Since the two treatments were administered by different therapists it could be argued that the improvement observed is a therapist effect and not a treatment effect. This is unlikely since there were major differences between the treatments but no major differences between the therapists. Both were experienced, both had received specialized training and both were warm, empathic therapists. It is difficult to control completely for a therapist effect even if both treatments are delivered by the same therapist. In this situation the problem of fidelity to different models of treatment will arise. Will the therapist be more enthusiastic about the one rather than the other, for example? As with other areas of scientific endeavor an attempt should be made to replicate these results.
Mari & Streiner (1994) emphasized that one of the important ingredients of psychosocial family intervention :is to achieve changes in relatives behavior and belief system. Although we do not specifically measure their changes on attitude, we found that the sociocultural approach to family education changed the carers' attitudes toward their schizophrenic relative after they understood the nature of the illness, which has a spill over effect on compliance and family burden. Left et al. (1989) also found that if the patient's family understood the nature of the illness and were instructed in problem solving techniques, they would gain a new understanding of the patient's abnormal behavior. As a result, the relapse rate and expressed emotion in the family will be reduced; and subsequently, the patient' s social functioning would be partly recovered.
The importance of understanding patients' cultural backgrounds to avoid emotional conflict has long been recognized (Murphy, 1973; Henderson & Primeaux, 1981). Explanations that incorporate local concepts of illness would help patients and carers to accept and understood the illness better. Acceptance of the patient's interpretation of his or her symptoms will strengthen the therapeutic relationship. The modified model, which left out communication skills training, is suitable for eastern culture. The program such as training to communicate assertively and establishing eye contact with the elderly (especially one's parents) are regarded as disrespectful in the Malay culture. Furthermore a highly structured program is experienced as stressful and intrusive in the long run with the result that interest in the program slowly diminishes and finally stops half-way. The success of our program may also be attributed to the extended family system among the Malays (Yusof, 1976).
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