When combined with pharmacotherapy, family psychoeducation and skills training are key strategies for preventing, delaying or minimizing the severity of illness episodes in major psychiatric disorders^1-3. High levels of expressed emotion – as indicated by critical comments, hostility and/or emotional overinvolvement from caregivers – are associated with high rates of recurrence in patients with schizophrenia, bipolar disorder and major depressive disorder. These familial attitudes can become more negative and fixed as the disorders progress⁴.

Early on in the illness trajectory, there is a window of opportunity for prevention or mitigation of disability in young persons. During this interval, patients and parents are usually most open to the collaborative approach of psychoeducation, in which they examine their thinking and behavior in relation to one another. Family psychoeducational interventions, however, have never completely “made it out of the shop”. Few practitioners have been trained in these methods. When psychoeducation is offered at all, it is usually in the form of unstructured support groups or canned didactic lectures. Moreover, support groups have limited reach: in a 2017 survey of 2,395 patient and caregiver respondents from the Depressive and Bipolar Support Alliance, a US-based support organization, 87% of persons with bipolar disorder were taking medications but only 10% attended support groups⁵.

When adolescents or young adults first experience symptoms of mood or psychotic disorders, both they and their families are understandably confused as to what is happening. Parents have basic questions about the diagnosis, the likely course of symptoms over time, and what treatments are likely to be successful. Unfortunately, many clinicians simply provide didactic information in rote fashion, instead of assisting the family and the patient in negotiating the complex challenges of a new illness.

What psychoeducational strategies help engage families and patients at these stages of illness development? Consider an 18-year old male, Zak, who has had an acute manic episode requiring hospitalization. Zak's father is able to describe the prodromal symptoms prior to his admission (e.g., rapid speech, irritable mood), but believes that his son has schizophrenia. His mother thinks that he is depressed. Zak thinks that there is nothing wrong with him. A psychoeducational family clinician will start with the provision of factual material: the key symptoms of mania and how they are different from those of a psychotic episode or normal teenage behavior. The clinician will personalize this information by encouraging Zak to describe the development of his symptoms and parents to chime in with their observations. The patient is identified as the “expert in the illness”, because “you can educate us as to what you've gone through and what might help you recover”. When their position in the family is elevated in this way, young people are more able to cope with the well-intended but often intrusive or critical comments of their relatives.

Moving a step further, the clinician will encourage the parents and offspring to explore the practical application of Zak's diagnosis: what might be the early warning signs of new manic or depressive episodes? A paper or online mood chart⁶, completed daily by Zak and his parents, will help the family to become familiar with his patterns of mood shifts. The parents’ attributions about the causes of these fluctuations (e.g., “He has a biologically-based mood disorder” versus “He's lazy”) will be addressed. The clinician will gently challenge parents as to the usefulness of certain beliefs, especially those that lead them to become harsher or expect an unrealistically high level of functioning in their offspring.

In a similar vein, families need help locating and evaluating the advantages and disadvantages of treatment options. They may be confused about how to decide on the intensity (e.g., weekly individual therapy vs. partial hospitalization) or type of care (e.g., pharmacotherapy, psychotherapy, or support groups). The parents may not agree on the need for medications or, if they do, they may not agree on what type or dosage is needed. They may need guidance in advocating for the child within the school system. Siblings may be confused as to their role in helping their ill brother or sister (or, at minimum, how not to trigger symptoms further).

A different set of questions may haunt young affected people during this period. These issues surround how the illness will impact their peer and school relationships or activities, or even how their identity has been changed by the illness. They may express considerable resentment toward their parents for seemingly overreacting to minor symptoms or for insisting on a regimented lifestyle. These issues can become intertwined with the young persons’ struggle for autonomy. Psychiatric treatment may come to symbolize the last bastion of their parents’ control over them, with the psychiatrist seen as an agent of the parents.

A key component of psychoeducation is the relapse prevention plan. The patient and the parents make a list of early warning signs of episodes and past stressors – major or minor – that appear to have triggered those episodes (e.g., the start of a new school year). Then, clinicians coach the family to make a list of potential coping strategies (e.g., try to regulate sleep and wake times) and potential obstacles to their implementation (e.g., foregoing late-night parties). The plan is modified over time as more data are collected on warning signs, eliciting stressors and effective coping strategies.

In later segments of psychoeducation, clinicians attempt to modify levels of expressed emotion by guiding families in effective communication and problem-solving. Clinicians elicit role-play interchanges between parents and offspring with practice of skills such as active listening, making requests for changes in each other's behaviors, and balancing positive and negative feedback. To reduce parent/offspring criticisms (e.g., “I resent the hours you keep”), clinicians can take several steps: a) reframe the criticism as coming out of positive intentions (e.g., “I am worried about you not getting enough sleep and getting ill again”); b) point out that the parent's manner of delivery is inadvertently alienating the offspring; and c) model for the parent how he/she might make a request for behavior changes (e.g., “I'd appreciate your helping me manage my own anxiety by keeping to a regular bedtime”). These exchanges can be followed by problem-solving exercises in which family members offer practical input about how to keep consistent nightly routines.

Severe family conflict often grows out of parents’ disappointments over failed expectations of the child. Input from the offspring about what they can or cannot accomplish while still symptomatic is essential. The offspring can be coached to make decisions that will enhance their chances of recovery (e.g., avoiding enrolling themselves in too many courses; discontinuing use of cannabis or psychostimulants). Recovery can be framed as an objective that must be achieved by the family as a whole, not only by the patient.

Randomized clinical trials indicate that, among youth in the early stages of bipolar disorder, a 12-session, 4-month protocol of family-focused therapy (psychoeducation, communication training and problem-solving) is associated with shorter depressive episodes, longer periods of wellness between episodes, and less suicidal ideation and behavior than briefer forms of education^{1, 7}. The broader availability of psychoeducational therapy may do much to reduce the long-term personal, familial and societal burdens imposed by severe psychiatric disorders.

当与药物治疗相结合时，家庭心理教育和技能培训是预防、延迟或最大程度减轻主要精神疾病发作严重程度的关键策略^1-3。高水平的情绪表达——如护理人员的批评性评论、敌意和/或情绪过度介入所表明的——与精神分裂症、双相情感障碍和重度抑郁症患者的高复发率相关。随着疾病的进展，这些家庭态度可能变得更加消极和固定⁴。

在疾病发展的早期，有一个预防或减轻年轻人残疾的机会之窗。在此期间，患者和家长通常对心理教育的协作方法最持开放态度，在这种方法中，他们检查彼此之间的思维和行为。然而，家庭心理教育干预措施从未完全“走出商店”。很少有从业者接受过这些方法的培训。当提供心理教育时，通常以非结构化支持小组或预设教学讲座的形式进行。此外，支持小组的影响范围有限：2017 年，美国支持组织抑郁症和双相情感障碍支持联盟对 2,395 名患者和护理人员进行了调查，87% 的双相情感障碍患者正在服用药物，但只有 10% 的人参加了支持小组⁵ .

当青少年或年轻人第一次出现情绪或精神障碍症状时，他们及其家人对正在发生的事情感到困惑，这是可以理解的。家长对诊断、随着时间的推移可能出现的症状以及哪些治疗可能会成功有基本的疑问。不幸的是，许多临床医生只是以死记硬背的方式提供教学信息，而不是协助家人和患者应对新疾病的复杂挑战。

在疾病发展的这些阶段，哪些心理教育策略可以帮助家庭和患者参与？以一名 18 岁男性 Zak 为例，他患有急性躁狂发作，需要住院治疗。扎克的父亲能够描述入院前的前驱症状（例如语速过快、情绪烦躁），但认为他的儿子患有精神分裂症。他的母亲认为他患有抑郁症。扎克认为自己没有什么问题。心理教育家庭临床医生将从提供事实材料开始：躁狂症的主要症状以及它们与精神病发作或正常青少年行为的不同之处。临床医生将通过鼓励扎克描述他的症状的发展并鼓励父母附和他们的观察来个性化这些信息。病人被认为是“疾病专家”，因为“你可以告诉我们你经历了什么以及什么可以帮助你康复”。当年轻人在家庭中的地位以这种方式得到提升时，他们就更能够应对亲戚善意但往往是侵入性或批评性的评论。

更进一步，临床医生将鼓励父母和后代探索扎克诊断的实际应用：新的躁狂或抑郁发作的早期预警信号可能是什么？扎克和他的父母每天填写一份纸质或在线情绪图表⁶，将帮助家人熟悉他的情绪变化模式。父母对这些波动的原因的归因（例如，“他有生物学上的情绪障碍”与“他很懒”）将得到解决。临床医生会温和地向父母质疑某些信念的有用性，特别是那些导致他们变得更加严厉或期望后代具有不切实际的高水平功能的信念。

同样，家庭需要帮助确定和评估治疗方案的优缺点。他们可能对如何决定强度（例如，每周单独治疗与部分住院治疗）或护理类型（例如，药物治疗、心理治疗或支持小组）感到困惑。父母可能不同意是否需要药物，或者即使同意，他们也可能不同意需要什么类型或剂量。他们可能需要指导在学校系统内为儿童辩护。兄弟姐妹可能会对自己在帮助生病的兄弟或姐妹中所扮演的角色感到困惑（或者至少不知道如何不进一步引发症状）。

在此期间，一系列不同的问题可能困扰着受影响的年轻人们。这些问题围绕疾病将如何影响他们的同伴和学校关系或活动，甚至他们的身份如何因疾病而改变。他们可能会对父母表现出相当大的怨恨，因为他们似乎对轻微症状反应过度或坚持严格的生活方式。这些问题可能与年轻人争取自治权的斗争交织在一起。精神科治疗可能象征着父母控制他们的最后堡垒，精神科医生被视为父母的代理人。

心理教育的一个关键组成部分是预防复发计划。患者和家长列出事件的早期预警信号和过去的压力源（主要或次要），这些压力源似乎触发了这些事件（例如，新学年的开始）。然后，临床医生指导家庭列出潜在的应对策略（例如，尝试调节睡眠和起床时间）以及实施这些策略的潜在障碍（例如，放弃深夜聚会）。随着时间的推移，收集到更多有关警告信号、引发压力源和有效应对策略的数据，该计划会不断修改。

在心理教育的后期阶段，临床医生试图通过指导家庭有效沟通和解决问题来改变表达的情绪水平。临床医生通过积极倾听、要求改变彼此行为以及平衡积极和消极反馈等技能，引发父母和子女之间的角色扮演交流。为了减少父母/子女的批评（例如，“我讨厌你坚持的时间”），临床医生可以采取以下步骤： a) 将批评重新定义为来自积极的意图（例如，“我担心你睡眠不足，并且又生病了”）；b) 指出父母的分娩方式无意中疏远了后代；c) 为家长示范他/她如何提出行为改变的请求（例如，“我很感激您通过保持规律的就寝时间来帮助我管理自己的焦虑”）。这些交流之后可以进行解决问题的练习，家庭成员可以就如何保持一致的夜间作息提供实际意见。

严重的家庭冲突往往是由于父母对孩子的期望落空而感到失望而产生的。后代关于他们在有症状时能够或不能完成什么的输入是至关重要的。可以指导后代做出增加康复机会的决定（例如，避免参加太多课程；停止使用大麻或精神兴奋剂）。康复可以被视为一个必须由整个家庭而非仅由患者来实现的目标。

随机临床试验表明，在双相情感障碍早期阶段的青少年中，为期 4 个月、12 个疗程的家庭治疗方案（心理教育、沟通训练和解决问题）与较短的抑郁发作、较长的抑郁期有关。与简短的教育形式相比，两次发作之间的健康状况以及更少的自杀意念和行为^{1, 7}。更广泛地提供心理教育治疗可能会大大减轻严重精神疾病给个人、家庭和社会带来的长期负担。