Behavioural family management in schizophrenia. Outcome of a clinic- based intervention

10.1192/bjp.164.4.501Access the most recent version at doi: 1994 164: 501-506 The British Journal of Psychiatry

  Liberman ET Randolph, S Eth, SM Glynn, GG Paz, GB Leong, AL Shaner, A Strachan, W Van Vort, JI Escobar and RP 

clinic- based interventionBehavioural family management in schizophrenia. Outcome of a  

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British Journal of Psychiatry (1994), 164, 501—506

Behavioural Family Management in SchizophreniaOutcome of a Clinic-Based Intervention

EUGENIA T. RANDOLPH, SPENCER ETH, SHIRLEY M. GLYNN, GEORGE G. PAZ,GREGORY B. LEONG, ANDREW L. SHANER, ANGUS STRACHAN, WALTER VAN VORT,

JAVIER I. ESCOBAR and ROBERT P. LIBERMAN

To test further the highlysuccessfuloutcomesof a controlledstudy of in-homebehaviouralfamilymanagement(BFM)for schizophrenicpatients,a clinic-basedversionof thisinterventionwas compared with customary care alone for 41 schizophrenicpatients in a VeteransAdministration(VA) mentalhealthclinic.MonthlyBriefPsychiatricRatingScale(BPRS)ratings,conductedbyclinicpsychiatristswho were ‘¿�blind'to the patients'assignment,revealedthat3 (14%) patientswho receivedbehaviouralfamily managementas well as customarycare,as comparedwith 11(55%) patientswho receivedcustomarycarealone, hadsymptomaticexacerbationsduringthe first year of treatment.

Time-limited psychoeducational and behaviouralfamily interventions for schizophrenia have beensuccessful in reducing rates of florid episodes(Goldstein et al, 1978; Falloon eta!, 1982, 1985; LeffCt al, 1982; Hogarty et al, 1986; Tamer et al, 1988).These well specified, practical, and structured treatment programmes have been designed to strengthenthe coping capacities of families experiencing thestress of living with a seriously mentally ill relative.Family stress in reacting to a person with schizophrenia often manifests itself as bewilderment ordenial' of the illness, together with unrealisticexpectations and consequent criticism of the affectedrelative's poor role performance. An alternativecoping style for the family is to compensate for theaffected relative's personal inadequacies and disabilities through emotional overinvolvement withand overprotectiveness of the impaired relative.These manifestations of stress, termed ‘¿�highexpressedemotion', have been shown to be one of the mostrobust and best replicated predictors of the shortterm course of schizophrenia after a florid episode(summarized in Leff & Vaughn, 1985; Tarrier &Barrowclough, 1990). Family interventions designedto reducestressand its accompanying ‘¿�highexpressedemotion' have been a logical extension of thesefindings.

The era of community care for the severelymentally ill has fostered a professional climatefavourable to the development and testing of familybased treatments. Linked to this climate havebeen the pressures from consumer and advocacyorganisations to provide supportive and educationalservices to the families of the mentally ill (Lefley &Johnson, 1990). The ascendancy of the stress

vulnerability conceptualisation of schizophrenia andthedevelopmentof new behaviourallyorientatedtreatment methods have provided a rationale forattempting to alter the course of schizophreniathrough social learning methods that help people andenvironments to change (Liberman, 1988).

A seminal study of behavioural family management by Falloon et al (1985, 1988), reporting thereduction of relapse rates in schizophrenia from 44%to 6% in nine months and from 83% to 17% in twoyears, has generated much enthusiasm and spurredother investigators to continue to evaluate familybased interventions for this disorder. Adaptations ofbehavioural family management, comprising education about schizophreniaand trainingin communication and problem-solving skills for patients andtheir relatives, have been undertaken in Germany(Hawleg, described in Tamer & Barrowclough, 1990)and the USA (Keith et a!, 1989).

Our research team at the Brentwood (Psychiatric)Division of the West Los Angeles Veterans Administration (VA) Medical Center (Los Angeles, CA,USA) conducted a test of behavioural family management (BFM), using the same BFM protocol developedby Falloon eta! (1982). However, in contrast to thehome-based BFM delivered by Falloon Ct a!, ourinterest was in testing the efficacy of this welldelineated family intervention when delivered in amental health clinic. We aimed to determine whetherbehavioural family therapy, embedded in a comprehensive array of mental health services, would beassociated with fewer major episodes of schizophrenia than with customary care alone.

Furthermore, we sought to test the efficacy ofthe intervention with a broad sample of relatives,

501

CharacteristicFamily

treatment(n=21)Group

Customary care(n=20)Age:

yearsmean(s.d.)32.7 (5.5)30.9(6.5)range21—4021—42Years

ofeducationmean(s.d.)13.0 (1.4)12.8(1.4)range10—1611—17Age

first hospitaladmissionmean(s.d.)22.3 (5.1)22.1(3.7)range9-3517-29Chronicitymean

(s.d.)9.6 (6.5)10.6(7.2)range0-211-23EthnicityWhite7

(33%)7(35%)Hispanic3(14%)2(10%)Black9(43%)10(50%)Asian2(10%)1(5%)Social

class'I-lI2(10%)3(15%)Ill5

(24%)7(35%)IV9(43%)4(20%)V5(24%)6(30%)Marital

statusnevermarried13 (62%)14(70%)married5

(24%)2(10%)separated/divorced3(14%)4(20%)Expressed

emotionlow9(43%)8(40%)high12(57%)12(60%)GAS

score2mean(s.d.)42 (6.5)44(7.0)range34-5532-61

502 RANDOLPH ET AL

including, but not limited to, those classified ashigh in expressed emotion (EE) or showing othercharacteristics associated with increased likelihood ofsymptomatic exacerbation in their ill family member.Many investigators and family advocates have decriedthe exclusion of low-EE families from treatmentprogrammes which might offer them support,encouragement, and training in coping skills.However, the absence of data on the efficacy offamily interventions for patients from low-EEfamilies has precluded the determination of whetherthese efforts are justified. Our setting in a generalmental health clinic serving a heterogeneous populationallowed us the opportunity to investigate the effectsof behavioural family therapy on patients with eitherhigh- or low-EE relatives.

Two hypotheses were generated for our study:

(a) clinic-based BFM would be significantly moreeffective than customary VA mental healthcare alone

(b) patients from high-EE families would derivemore benefit from BFM than those from lowEE families.

Method

Subjects were required to meet the following criteria:current or very recent symptomatic exacerbation (withinthe last three months), age 18—55years, DSM—III criteria(American Psychiatric Association, 1980) for schizophreniaor schizoaffective disorder confirmed by the expandedPresent State Examination (PSE) (Wing et al, 1974), aminimum of four hours per week of contact with a relative,and the use of English as the primary language in the home.Subjects were selected from consecutive in-patientadmissions to the West Los Angeles VA Medical Center,Brentwood Division, over a three-year period. All patientswith an admission diagnosis of schizophrenia or otherpsychotic disorder were screened. Because this hospital servesmany homeless persons, 70010of screened patients did nothave sufficient weekly contact with a family member to meetthe weekly contact criteria. Patients with histories of significant substance abuse comprising the diagnosis were alsoexcluded. Women were excluded because there werevery fewfemale veterans at this facility; hence, the small number ofwomen meeting criteria would not permit sex-basedanalyses.

Once patients confirmed a willingness to participate inthe study, a member of the project staff contacted therelative(s) of each subject and invited them to participate.All patients and relatives gave informed consent.

Research design

Once patients met symptom stabilisation criteria for relativeremission (ratings of 4 or lesson the Brief Psychiatric RatingScale (BPRS) psychoticism items, i.e. hallucinatorybehaviour, unusual thought content, and conceptual

disorganisation) for a four-week period, patients and theirfamilies were randomly assigned to receive either BFM inconjunction with VA customary care (CC) (n = 21), or VACC alone (n = 20). Distribution of family type was asfollows: 68% (n = 28) parental; 20% (n = 8) conjugal; 7%(n = 3) sibling; and 5% (n = 2) other, i.e. uncle and aunt.There were no significant differences in family type andgroup assignment. Level of EE, number of years ill,and psychiatric impairment as measured on the GlobalAssessment Scale (GAS: Endicott et a!, 1976) were usedas blocking variables in treatment assignment to ensure thatthe groups were equivalent on factors which might beassociated with treatment outcome.

Analyses of patient demographic and clinical characteristics showed no statistically significant differences betweenthe BFM and CC patients in familial EE, age, educationalattainment, ethnicity, social class, age of first hospitaladmission, chronicity, and level of psychiatric impairment(Table 1).

Table 1Characteristics of treatment groups

1. Based on Hollingshead Index, in which ‘¿�Vdenotes lower levelof occupational and educational attainment.2. GlobalAssessment Scale scores range from 0 (low)to 100 (high).

503FAMILY MANAGEMENT WITH SCHIZOPHRENIA

items covering all areas of psychopathology usually explored in a mental status examination. An expanded PSEwhich adds items from the Schedule for AffectiveDisorders and Schizophrenia (SADS) and historical psychiatric data was previouslydevelopedby Drs Libermanand Fallcon for the UCLA (University of California, LosAngeles), VA Clinical Research Center for Schizophrenia.This adaptation allows diagnoses of schizophrenia andaffectivedisordersalso to be made accordingto DSM-III.The PSE was administered during the initial baselineevaluation.

Brief Psychiatric Rating Scale. The BPRS (Overall& Gorham, 1962) provides an efficient and clinicallyviable means of assessingefficacy in clinical research.Itconsistsof 18symptomconstructsratedon a seven-pointscale of severity, ranging from I (not present) to 7(extremelysevere).The BPRS was administeredmonthlyastheprimarymeasureofpsychopathologyand degreeof remissionor exacerbation.SymptomaticexacerbationwasdeterminedbyBPRSratings.Ratingsof 5 (moderatelysevere) or above in one or more of the psychoticismscales(hallucinatorybehaviour,unusualthoughtcontent,and conceptualdisorganisation)indicatedan exacerbation.Individualitemson theBPRS weresummed to yieldfour subscale scores (schizophrenic thought, anxious depression,hostile suspiciousness,and emotional withdrawal!retardation), as well as a total score. The BPRS ratingswere conducted by study psychiatrists blind to treatment assignmentwho were trained to at least 80%interraterreliability.Randomchecksrevealedthat the interrater reliability coefficient remained above 0.80 forall assessors throughout the study, partly as a resultof periodic training on the BPRS to prevent rater‘¿�drift'.

Records of medication type and dosage, missed appointments, and compliance information were noted onsupplementsto the BPRS rating form. In cases ofsymptomatic exacerbation, the BPRS was administeredevery two weeksuntil patients stabilised.

Camberweil Family Interview (CFI). The CFI (Vaughn& Leff, 1976)is designedto measureEE (Leff & Vaughn,1985). It is a semi-structured, tape-recorded, 90 mm.interview conducted individually with each person inthe patient's household. It focuses on eliciting therespondent'sdescriptionof and attitude toward the patientinthethreemonthsbeforehospitaladmission.Thetaperecorded interviews were scored by one of two highlyexperiencedraterswho had beentrainedto reliability(greater than 0.80 reliability coefficient with a criterionsample). Tapes were rated for number of critical comments,number of positive comments, degree of warmth, hostility,andemotionaloverinvolvement.CFIscoresof sixormorecriticisms, or ratings of three (moderately high) orhigher on emotional overinvolvement were designatedhigh EE, in accordancewith standardcriteria.Relativesnot meeting these criteriawere classified as low EE.If any interviewedrelativewas classifiedas highEE, thefamily itself was considered to be high EE for theseanalyses.

Behavioural family management

The BFM provided patients and their families witheducation about schizophrenia,communication skills, andproblem-solvingtrainingto improve the family's ability tocope with stress. These three components were providedsequentially. BFM methods include instruction, rolerehearsal, modelling, social reinforcement, and homeworktasks. This family therapy intervention, as conducted in thisprotocol,hasbeendescribedin a detailedtreatmentmanual(Falloon eta!, 1984).The study protocol called for 25 BFMsessionstobeheldwithfamiliesovera 12-monthperiodon a decliningcontact basis. The clinic-basednatureof theinterventionresultedin occasional cancellationsof sessionsbecauseof familyillness,vacation,or transport problems.Overall, a mean of 21 (s.d. 5.7) family sessions were actuallyheld, including at least two devoted to behaviouralassessment, followed by an average of six (s.d. 1.9) devotedtoeducation,six(s.d.6.2)tocommunication,andseven(s.d.3.5)to problem-solvingtrainingsessions.A fullassessment of families' knowledge and skill acquisition was

conducted at severalpoints duringthe therapy. Results onthe effect of BFM participationon skill acquisition as wellas on the relation of skill attainment and outcome, will bepublished later.Threeprimarytherapists,two psychologistsand one

nurse-therapist, provided the family-management intervention.Theyweretrained by Robert Liberman,MD, andGayla Blackwell, RN, MSW. Dr Liberman is co-developerof the BFM modality, and Ms Blackwell was trained inBFM by Dr Falloon and has herself conducted BFMtraining and supervision for eight years. Therapists alsoparticipated in workshops provided by Dr Failcon.Therapistshad weeklysupervisionmeetingswithDrLiberman and Ms Blackwell.

Customary care. CC was provided by a VA out-patientclinic treatment team comprising four psychiatrists, two socialworkers, and one nurse. All members of the team were‘¿�blind'totreatmentassignment.Thisteamprovidedmonthlyclinical evaluation and medication management, vocationalandrehabilitationreferrals,andcrisis-interventionservices.Out-patient services available at this hospital includetraining in socialand independentlivingskillsand variousrecreational and occupational therapy groups and vocationalrehabilitation services.

Medication management. To permit application of ourresults to non-research settings, we intended to provideoptimal medication management, following criteria usedin standard medical practice. Depot medications were notappropriateforsomeofthepatients,inlightoftheirsideeffects profiles; in addition, some patients refused depotmedication. Patients in both conditions receivedadapteddosages of antipsychotic medication prescribed by psychiatrists blind to treatment condition.

Clinical ratings

Expanded Present State Examination. The PSE is astructuredpsychiatricinterviewschedulecomprising140

Symptomatic exacerbation CustomarycareCustomaryandfamilycaretreatment(n

=20)(n= 21)

504 RANDOLPH ET AL

Results blind to subject assignment, and who based pharmacologicaldecisions on their clinical evaluations of patients. Allpatients were prescribed antipsychotic medication. Therewas no significant group difference in mean percentage oftime the typical patient was prescribed depot as opposedto oral medication (BFT —¿�5l.2°lo, CC —¿�33.3%; t= 1.28,d.f.=1, NS).

To examine possible group differences in dosage, weconverted all medication amounts to chiorpromazine (CPZ)equivalents. A tendency for BFM patients to receive moreantipsychotic medication at the beginning of treatment, asexpressed in mean daily CPZ equivalents, was not statisticallysignificant (BFI' x= 1230.7) (s.d. = 1205.0), CC @=757.8(s.d. = 872.4); t = 1.43, d.f. = 1, NS). Similarly, there wasno statistically significant difference in prescribed averagedaily CPZ equivalents over the 12-month period (BFT

@=l087.5,CC@=727.8; t=l.27, d.f.=l, NS).For evaluation of prescription trends throughout the year,

each subject had a 13-coefficientgenerated by regressingtheir monthly dosage across the first year time-frame. Fornormalisation of the data distribution, log transformationsof dosage were calculated for each subject, and each of theselog values served as a monthly data point in fitting theregression line. The resulting fl-coefficient, or slope ofthe line, indicated whether medication dosage was increasedover time (positive slope), decreased (negative slope), orheld constant (zero slope). While individual subjects' dosageamounts varied over time, across the two groups,medication dosages were quite stable over the year,with the mean slope of the BFM patients' chlorpromazineequivalence being 0.01, and the CC patients' slope 0.00.A Mann—Whitneytest on these slopes revealed no groupdifferences in medication dosing over time (U= 205, NS).

Hospital stay

There was no significant difference between the twotreatment groups in number of days in hospital. BFMpatients were in hospital, on average, for 21 days, ascompared with 25 days for the CC group (1= 0.37, d.f. = 39,NS). Eight BFM patients (38%) and 100CC patients (50%)were admitted to hospital.

Most exacerbated patients in both conditions wereadmitted to hospital (3/3 (100%) in BFT, 8/11 (73% inCC). Most non-exacerbated patients in either condition werenot admitted to hospital (13/18 (72%) in BFT, 7/9 (78%)in CC). The five BFT and two CC patients who were nonexacerbated but in hospital were admitted for symptomsof depression and non-psychotic complications fromsubstance abuse. The three CC patients displaying psychoticexacerbationsbut not admittedto hospitalhad familieswithunusually high tolerance of psychotic behaviour and theresources to provide supervision for patients at home.

Symptomaticexacerbations, expressedemotion, andtreatment

We found no significant association between baseline EEand subsequent symptomatic exacerbations in this sample.One hypothesis of interest in this study concerned whether

Psychotic exacerbations and treatment

As shown in Table 2, three patients (l4.3°lo)receiving BFMcombined with CC experienced a symptomatic exacerbation,as compared with II patients (55%) receiving only CC(@=7.55, d.f. = 1, P=0.006). Thus, BFM significantlyreduced the number of patients who exhibited psychosiswhile participating in the study. With a more stringentsymptomatic exacerbation criterion requiring a documentedexacerbation of at least two weeks' duration, comparisonsindicated that one patient (5°lo)in the BFM group, incontrast to six patients (300lo) in the CC group, met thisduration criterion for symptomatic exacerbation (x2 =4.61, d.f. = I, P= 0.03). Attrition was minimal. One patientin the CC group moved out of California at the end of theyear. All BFM patients completed the protocol.

These same results were obtained when we examinedsymptomatic exacerbations which required a change inmanagement (i.e. hospital admission or a substantialincrease in medication), or which represented an increaseof at least two points on two or more of the three BPRSpsychoticism items. All exacerbated patients met this morestringent criterion. Twelveshowed the increase of two pointson at least two BPRS psychoticism items. Two had anincrease of at least two points on only one psychoticsymptom, but their florid psychopathology resulted inhospital admission.

Repeated measures analyses of covariance (baselineassessment as the covariate) on the BPRS factors and totaldid not yield significant treatment effects. Patient psychopathology in both groups was generally at low levels at thebeginning and end of the treatment period. In our sample,BFM participation resulted in fewer symptom exacerbations superimposed on generally low levels of residualpsychopathology.

Symptomatic exacerbations, medication, and treatment

The positive outcome in the BFM group could not beaccountedforbydifferencesinmedicationadministrationor dosages. As has been mentioned, medication type andamount were prescribed by study psychiatrists who were

Table 2Outcome at one year

ExacerbationNo exacerbation'

3(14.3%) 11(55%)18 (85.7%) 9 (45%)

Symptomatic exacerbation lasting at least two weeks2yes 1 (5%) 6 (30%)no 20 (95%) 14 (70%)

1 x2=@@@ d.f.=1, P=O.006.2. @2=4.61, d.f.=2, P=0.03.

505FAMILY MANAGEMENT WITH SCHIZOPHRENIA

72% kept all of their monthly clinic/medicationappointments. Only six patients missed more thanone appointment.

In contrast to Falloon et al's (1982) report, we didnot fmd a significant improvement in BPRS scoresat one year resulting from BFM participation. Theremay be several reasons for this. First, our patients wereextremely well stabilised at the beginning of the protocol. Patients had to meet a rigorous stabilisationcriterion for entry into the protocol, i.e. no ratingsabove 4 on the three psychoticism items. Consequently,all-factor baseline scores (means) were below 2 (range,1.2-1.7 where 1= not present, 2 = very mild). Statistically, it is extremely difficult to show significantimprovement from this initial levelof psychopathology.There may have been a ‘¿�flooreffect' in place.Second, our patients were generally compliant withmedication and well monitored throughout the protocol, resulting in a generally low level of symptomsthroughout the year of the study.

In this sample, BFM did not make a significantimpact on the utilisation of in-patient services. Apossible explanation for the findings has to do with thecharacteristics of both the patients at this facility andthe facility itself. Hospital admission is often theresult of ‘¿�lifecontingencies' rather than psychiatricsymptoms. This hospital serves a population whopossess few social and economic resources. As aresult, patients may actively seek hospital admissionwhen problems with housing arise or for symptoms ofdepression and anxiety associated with the declininglife opportunities that may accompany chronicpsychiatricimpairment. Similarly, families may seekhospital admission when they perceive themselves inneed of ‘¿�respitecare'. Given the usual number of bedsavailable and the option of services unencumberedby fees in this VA setting, psychiatrists are likely tooffer admission to hospital more as a humanitariangesture than out of clinical need.

Additional factors limit the inferences which canbe drawn from these findings on hospital admission.Because complete data on hospital admission havenot been reported for other family interventionstudies, we cannot assess the extent to which ourfindings replicate or deviate from previous studies.Second, institution-specific admission policies canlead to widely divergent rates. For example, thepositiveeffect of BFM on reducinghospitaladmissionreported by Falloon et a! (1982, 1985) applies topatients who met the legal criteria for involuntarycommitment at the time of admission. The metropolitan hospital serving the patients in that study hada severebed shortageat the time. In contrast, the VAhospital in our study had 400 beds available for a catchment area of 200 000 people. As a result, our VA

BFM would have a beneficial effect on patients from low-EE,as wellas high-EE, families.To examine this question specifically, we conducted a logistic regression, using EE levels andexperimentalconditionastheindependentvariablesandsymptomaticexacerbationsasthedependentvariable.Thisequationyieldeda non-significantgoodness-of-fitchi-square(@2=O.O4,P=0.95), suggestingthat thesevariablesdo makea substantialcontributionto our predictionof symptomaticexacerbations.However,onlytreatmentgroup, and not EEstatus, was a significant predictor in the model (treatment - @=7.%,d.f. = 1, P=0.003; EE - @=0.17,d.f. =7, NS). In a subsequent analysis, the treatment by EEinteraction term made a trivial contribution to the model(x@=O.O,d.f. =1, NS, B=0.0). In summary, these resultsindicate that BFM treatment achieved beneficial effects onpatients from both high- and low-EE families.

Customary care services

There were no significant differences in number and type ofVA services received by patients in both groups. While referrals for adjunctive rehabilitative services for most patientswere initiated, few patients in either group used these.

Discussion

The results of this study support the importance ofincluding family members in the community care ofpatients with schizophrenia. This study also shows thatclinic-based BFM, embedded in the usual range ofservices provided in out-patient clinics, is comparableto results of previously reported studies of home-basedBFM in reducing rates and duration of symptomaticexacerbations. Our results are further encouragingin that they were obtained in a sample marked byconsiderable chronicity. Our patients were typicallyolder, and had been ill longer than those included inthe Falloon et a! (1982, 1985) or Tarrier et a!(1988) and Tamer & Barrowclough (1990) samples.Additionally, this study shows that BFM offers protection against psychotic exacerbation for patients in bothhigh- and low-EE family environments. Preventingor delaying psychotic exacerbation appears to haveimportant prognostic value, as documented in a reviewof the treatment research literature (Wyatt, 1991).

We also found no evidence that the positiveoutcomes arising from BFM might be the result ofdifferential availability or utilisation of otherpsychiatric or rehabilitation services, or be confounded with medication - administration practices.In particular,there were no differences in referralsoractual use of adjunctive treatment services between thetwo groups. There were also no differences in medication dosage prescribed for the two groups of patients,most were generallycompliant with medication. Thestudy psychiatrists rated 82°loof study patients as‘¿�highlycompliant' with their medication regimens.Patients were typicallycooperative with the protocol;

506 RANDOLPH ET AL

psychiatrists had considerable discretionary privilegein admission policy. Not surprisingly, veterans at ourfacility are well aware of the relatively greater availability of in-patient services here, and they may havebecome accustomed to using them in their illnessmanagement strategies. Consequently, over 90°loof theadmissions in this study were voluntary, rather thaninvoluntary.

A major question at the outset of this study wasthe extent to which families would come to the clinicfor family therapy sessions. As Falloon et a! (1982)noted, home-based BFM has two desirable features:increased application of skills training to the homeenvironment: and decreased potential of missedappointments. In contrast to home-based BFM,families in clinic-based BFM missed more appointments, resulting in more time being required tocomplete the core treatment components, and fewerfollow-up sessions. To enhance engagement in theBFM, we made one or two home visits with mostfamilies, usually early in the programme.

Adaptations required to shift the model from thehome to the clinic were minimal. We were able to follow the protocol systematically if not always in a timelymanner. On occasion, more time passed betweensessions than might be desirable in a behaviourallyorientated intervention based strongly on reinforcement and rehearsal. The clinic-based model was subjectto all the disruptions that might not occur in thehome-based model, e.g. transport and child-careproblems, as well as the overt and covert resistance toparticipation that may be reflected in cancelling or‘¿�forgetting'the appointment. However, these resultsindicate that BFM is sufficiently ‘¿�robust'to protectagainst psychotic exacerbation even with a diminishedschedule and when delivered in the clinic.

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*Eugema T. Randolph, PhD, Research Sociologist, West LosAngeles VAMC (VeteransAdministration MedicalCenter) (B151J), 11301 Wilshire Boulevard, Los Angeles, CA 90073; Spencer Eth, r@m,ACOS for AmbulatoryCare, West Los Angeles VAMC (116A); Shirley M. Glynn, PhD, Research Psychologist, West Los AngelesVAMC (B151J); George G. Paz, MD, Staff Psychiatrist, West Los Angeles VAMC; Gregory B. Leong, MD,Staff Psychiatrist, West Los Angeles VAMC; Andrew L. Shaner, MD, Chief, Psychiatric Evaluation andAdmission, West Los Angeles VAMC; Angus Strachan, PhD, Clinical Psychologist, Santa Monica FamilyConsultants, 2510 Main Street, Suite 201, Santa Monica, CA 90405; Walter Van Vort, MD, Staff Psychiatrist,West Los Angeles VAMC; Javier I. Escobar, MD, Vice-Chair, Department of Psychiatry, University ofConnecticut, Farmington, 06107; Robert P. Liberman, MD, Director, Clinical Research Center forSchizophrenia, Department of Psychiatry, University of California, Los Angeles, CA 90025, USA*Correspondence

(First received September 1991, final revision April 1993, accepted May 1993)