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A Family-Focused Intervention for Prodromal Schizophrenia in Young Adults

A Family-Focused Intervention for Prodromal Schizophrenia in Young Adults


August 18, 2014

David J. Miklowitz, PhD


Professor of Psychiatry; Director, Child and Adolescent Mood Disorders Program (CHAMP), Division of Child and Adolescent Psychiatry; UCLA Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA

First published in
Psychiatry Weekly, Volume 9, Issue 10, August 18, 2014




Individuals at clinical high risk for psychosis (CHR) tend to be adolescents or young adults. The phenotypic characteristics of individuals with CHR include attenuated versions of positive and negative psychotic symptoms that are not fully developed but can cause functional deterioration. Because these symptoms often lack clinical severity, and because they may appear during adolescence or young adulthood when normal physical and social changes occur, it is usually parents and guardians who seek clinical help for the person. People at CHR may not even report their symptoms.

Family members are integral to seeking an intervention for CHR individuals, and also play a sizable role in the preventative therapeutic processes that often follow. For example, family-focused therapy (FFT), developed originally for treatment of bipolar disorder, has recently been applied to treatment of young adults at high risk of psychosis. Dr. David Miklowitz and colleagues have just published the first study to evaluate FFT in a young CHR population.

Family-Focused Therapy

The 129 participants in this trial averaged 17.4 years of age. The protocol for the FFT group (n=66) consisted of 18 family sessions over a 6-month period, with components focusing on psychoeducation, such as recognizing prodromal symptoms and keeping stress low; and skill training, including developing or honing non-combative communication styles and problem-solving skills. (The schizophrenia literature suggests that younger folks who come from highly conflictual families show less improvement over time.) The comparison therapy, “enhanced care,” included 3 family sessions that focused on developing a symptom-management plan. All participants were part of the ongoing 8-site North American Prodrome Longitudinal Study, 2 (NAPLS-2). The main outcome measures were changes in subthreshold positive and negative symptoms, assessed by treatment-blind independent evaluators using the Structured Interview for Prodromal Syndromes and the Scale of Prodromal Symptoms, among other psychometric tools.


At 6 months, FFT was associated with greater improvements in attenuated positive symptoms compared to enhanced care. Negative symptoms improved over time irrespective of treatment group, suggesting that, on the whole, participants may have become more activated as a result of both family interventions.

In the NAPLS-2 consortium, participants’ exposure to antipsychotic medications varied and was subject to change during the course of family therapy. The present trial did not exclude participants on the basis of existing or newly initiated antipsychotic therapy.

According to Dr. Miklowitz, “the majority of our participants weren’t on any medication. Twenty-one percent were receiving antipsychotic therapy at study baseline, and up to 35% of participants received an antipsychotic during the study period. We found that those on antipsychotics did better than those who weren’t, but antipsychotic use did not determine whether the person benefited from the FFT or not.

“We also found some interesting age effects when it came to functioning,” continues Dr. Miklowitz. “One of the things we try to do in these therapies is improve the high-risk individual’s functioning in the community—performance at school, working, friendships, etc. The results here were complicated, and not entirely what we predicted. There was a clear beneficial effect of FFT in the functioning of young adults, aged 20 years or older. In mid- to late-adolescence (ages 16–19 years), however, participants showed greater gains in functioning in the briefer enhanced care treatment than in FFT. It’s possible that too much family contact in adolescents of that age, who may already have paranoid symptoms, may not be a good thing. It might be better to focus the treatment more on peer relationships than on family functioning.”

Finally, although it was not a primary outcome measure in the present study, Miklowitz and colleagues examined the rate of conversions to psychosis during the 6-month study period. Among 102 participants who completed baseline and 6-month assessments, 6 (5.9%) converted to psychosis. Among those who converted, 5 were receiving enhanced care and one was receiving FFT. None of the participants who converted were receiving an antipsychotic medicine at baseline.


Antipsychotics are readily available to the clinician, but there are concerns about consigning patients at clinical high risk—a group with ultimately high false-positive rates of psychotic disease—to long-term pharmacotherapy. As clinicians continue to learn of the importance of early intervention for early symptoms of psychosis, the treatment frameworks available to them must become increasingly accessible. Dr. Miklowitz hopes to experiment with web-based clinician training protocols for FFT so that more therapists will be exposed to the protocol quickly. Other treatment protocols, including cognitive remediation therapy, mindfulness-based cognitive therapy, and traditional cognitive behavioral therapy, may also serve as early interventions.

This interview was conducted on July 29, 2014 by Lonnie Stoltzfoos

Disclosure: Dr. Miklowitz is supported by grants from the American Foundation for Suicide Prevention, the Attias Family Foundation, the Carl and Roberta Deutsch Foundation, the Danny Alberts Foundation, the Kayne Family Foundation, and the NIMH. He receives book royalties from Guilford Press and John Wiley and Sons.


Miklowitz DJ, O’Brien MP, Schlosser DA, et al. Family-focused treatment for adolescents and young adults at high risk for psychosis: results of a randomized trial. J Am Acad Child Adolesc Psychiatry. 2014;53:848-858.