Behavioural family therapy and family psychoeducation

1. Introduction

Version followed: (a) Falloon's behavioural family therapy (BFT) as published in Falloon, Laporta, Fadden & Graham-Hole, Managing Stress in Families (1993; Routledge reissue 2023) and carried by the Meriden Family Programme (UK). Its session-level procedures are taken here from a Meriden-based NHS manual adaptation (Transformation Partners, Appendix 12) and the WFSAD 2003 guide that adapts Falloon's work with his permission. (b) Single-family psychoeducation (FPE) in the Anderson–McFarlane line, as taught in the EASA 2022 FPE curriculum (the SAMHSA EBP-toolkit lineage). The Falloon 1993 book and Anderson, Reiss & Hogarty (1986) are not drawn on in full [uncertain]. Multifamily groups are covered in guide 040 and appear here only for comparison.

These are two closely related family interventions for serious mental illness, chiefly schizophrenia and other psychoses. Both are also used for bipolar disorder and clinical-high-risk states, and the Falloon model has been used more widely. BFT is a home-based, skills-training model. The family, including the person with the illness, learns about the disorder, agrees an early-warning-signs plan, and is coached in four communication skills and a six-step problem-solving and goal-achievement method. It then runs its own weekly family meeting [source: NHS FIp Appendix 12; WFSAD 2003 Guide]. FPE joins with each family over three sessions and gives a structured educational workshop with a set of family guidelines. It then holds regular, tightly structured problem-solving sessions [source: EASA 2022]. The shared theory of change is stress–vulnerability. Relapse is made more likely by environmental stress, including critical or over-involved family climates ('expressed emotion'). It is made less likely when the family understands the illness, communicates clearly, solves problems in a structured way and keeps its social supports [source: Falloon et al. 1982 NEJM abstract; EASA 2022]. The family is treated as a partner and a resource, never as the cause of the illness [source: WFSAD 15 Principles].

2. Framework

A. Behavioural family therapy (Falloon / Meriden version)

Format. Sessions are held at home where possible, because skills learned in hospital transfer poorly [source: WFSAD 2003 Guide]. Every household member who wants to take part is included, not only the identified patient [source: NHS FIp]. Sessions last about an hour, at a fixed weekly time. Each one runs: review of treatment progress → review of problem-solving and homework progress → teaching one specific skill → planning its use in the coming week [source: WFSAD 2003 Guide]. Each session opens with a review of the previous homework [source: NHS FIp].

Dose. Falloon's original research schedule was 13 weekly home sessions, then 13 fortnightly sessions, then monthly sessions for up to about six further months [source: Bellack & Schooler 2001, describing Falloon's programme]. The simplified WFSAD version runs about 10–12 weekly sessions, with later meetings as needed [source: WFSAD 2003 Guide]. NICE's minimum recommended dose is [uncertain].

Phases (in order) and their goals [source: NHS FIp Appendix 12, Meriden-based]:

Engagement. Present the approach as evidence-based, collaborative and focused on practical here-and-now problems. Agree that the family need not disclose everything.
Individual assessment of each member. Cover each person's understanding of the problem, what helps and what worsens it, coping, supports, personal goals and other stressors.
Family problem-solving assessment. First an interview about how the family usually resolves problems (reported), then a 15–20-minute recorded family discussion (observed). Baseline skills are rated on the Communication and Problem Solving Checklist.
Information sharing. Education about the disorder and its treatment.
Early warning signs and staying well. A written relapse signature with planned family and service responses.
Communication skills modules A–D. Expressing pleasant feelings, making positive requests, expressing unpleasant feelings, active listening.
Problem-solving modules A–G. First the whole six-step method, then each step practised in turn, including planning and review.
Family meetings. A weekly, self-run meeting.
Reducing contact and ending. Reviews continue, and the family keeps its meetings going as the worker withdraws [source: NHS FIp; WFSAD 2003 Guide].

The order of steps 4–7 can flex. The WFSAD version puts illness understanding first, then life problems and goals [source: WFSAD 2003 Guide].

Criteria for moving on. Modules follow the skill sequence, and progress is re-checked against the Checklist and the Family Goal Record [source: NHS FIp]. The thresholds below are [synthesis]; the sources give no numeric cut-offs:

Move from education to skills once each member can describe the illness model, the medication rationale and the person's early warning signs in their own words.
Move from communication to problem solving once members use the components of each skill in session with only light prompting.
Reduce frequency once the family holds its weekly meeting without you and brings back completed plans.
The worker attends less often as the family becomes self-sufficient [source: WFSAD 2003 Guide].

Training and fidelity. No licence is needed to use the name. Meriden runs a skills-based BFT course followed by supervision, ongoing supervision by telephone, and a training-of-trainers course [source: Meriden FCDO page]. The original programme had quality control of its home visits [source: Bellack & Schooler 2001]. [synthesis] Practise under supervision from a Meriden-trained (or equivalent) supervisor, and rate your own recorded sessions against the module steps.

B. Family psychoeducation (Anderson–McFarlane single-family version, EASA curriculum)

Phases [source: EASA 2022]:

Entry and introduction of the family guidelines.
Joining. Three sessions with each individual and family, then more as needed, paced with session checklists.
Educational workshop. In a multifamily group this is one event of about 4–6 hours. For a single family the same content is spread over several meetings.
Group process introduction. Session 1: getting to know each other, including strengths and hobbies. Session 2: the 'impact' session, on how the illness has affected each person.
Ongoing structured problem-solving sessions for the length of the programme.

Frequency. Twice a month is the target and monthly the minimum workable. Single-family sessions run 60 minutes: 10 min socialising, 15 min go-around, 5 min problem selection, 25 min formal problem solving, 5 min closing socialising. (Multifamily: 90 min in a 15/20/5/45/5 split; see 040.) [source: EASA 2022]

Format choice. A single family has one facilitator and can meet at home or in the community. It is offered when a group is not feasible or not a good fit. Decide the format with the family and revisit it as needs change [source: EASA 2022].

Criteria for moving on. Joining → workshop once all three joining sessions are complete, the relapse-prevention or crisis plan is written and commitment to the format is gained. Workshop → ongoing sessions once the guidelines have been explained [source: EASA 2022]. Any further thresholds are [synthesis].

Training and fidelity. A fidelity scale exists, and programmes scoring higher on it are reported to get better outcomes [source: SAMHSA FPE Implementation Kit draft 2003]. Core fidelity elements are: the full joining sequence, the session structure and its time allocations, the problem-solving steps, use of the family guidelines, routine meetings, a shared team role as educators, and deliberate self-disclosure. Supports include session checklists and consultation calls [source: EASA 2022]. Formal training hours and certification were not found [uncertain].

3. Guiding principles

Sources: WFSAD 15 Principles (developed with Falloon, Leff and McFarlane); NHS FIp; WFSAD 2003 Guide; EASA 2022.

Coordinate care with the family as part of the team. Agree shared goals with prescriber, care coordinator and family, and tell everyone the plan.
Address social needs, not only symptoms. Ask about housing, income, work or activity, and recreation, and treat these as legitimate problem-solving targets.
Manage medication well. Review side effects and doses with patient and family. Education is meant to support adherence, not to police it.
Treat relatives as equal partners. Ask for their expertise, and offer home visits.
Explore and reset expectations. Find out what each member hopes for, say what is realistic, and expect goals to change after an episode.
Assess strengths and caregiver distress. Name what the family already does well. Screen carers for anxiety and depression and refer them if needed.
Respond sensitively to emotion. Read anger as concern, stay impartial in conflict and work toward compromise.
Acknowledge loss. Make room for grief over changed hopes before pressing for skills.
Give information at the right times. Start early and keep returning to it, tied to the family's current concerns.
Always have a crisis plan. Give named contacts and say how to reach the team when relapse threatens.
Encourage clear communication. Set simple ground rules and include the patient in discussions about them.
Teach structured problem solving, and start with an easy problem so the first experience is a success.
Rebuild social networks. Caregiving should not take over family life; link the family with relatives' groups.
Stay flexible. See members separately when needed, for example for private matters.
Keep access open after ending. Leave a phone number and a named contact.
Work collaboratively at the family's pace [source: NHS FIp]. Do not push content the family is not ready for.
Teach skills; do not solve the family's problems. You build their ability; they find the solutions [source: WFSAD 2003 Guide].
Skills must transfer to daily life. Every session ends with a between-session task [source: WFSAD 2003 Guide; NHS FIp].
Praise effort, however small, even when goals are missed [source: NHS FIp; WFSAD 2003 Guide].
Goals should be reachable in 3–6 months and broken into small steps [source: WFSAD 2003 Guide].
Make family members talk to each other, not to you. Keep the facilitator out of the discussion except to model a step [source: NHS FIp].
Be systemic, purposeful and culturally humble. Adapt to language, culture, developmental stage, disability and rurality [source: EASA 2022].
Predictability lowers stress. Keep to fixed times, a fixed structure and the same facilitator [source: EASA 2022].
Use deliberate self-disclosure. Plan small, humanising disclosures; evasiveness does not help [source: EASA 2022].
Keep asking 'What's next?' Advocate for the family and take follow-up items to the team meeting [source: EASA 2022].

4. Intervention inventory

Part A covers behavioural family therapy (Falloon / Meriden); Part B covers family psychoeducation (Anderson–McFarlane, single-family). Unless tagged otherwise, steps are paraphrased from NHS FIp Appendix 12 (A) and EASA 2022 (B). Worksheet names are given, but their content is not reproduced.

A1. Engagement sessions (BFT)

Purpose / when: the first contact with the household, to build a collaborative contract before any assessment.
Steps:
1. Meet everyone who is willing, at home if possible.
2. Present the approach as evidence-based and collaborative, focused on practical current problems.
3. Outline what it covers: information sharing, early warning signs and relapse prevention, communication, problem solving.
4. Agree that nobody has to disclose everything. Sensitive matters can be kept for private meetings.
5. Agree a fixed weekly time and who will attend.
6. [synthesis] Ask each person what they would want to be different in three months.
Example language (illustrative): "This isn't about blaming anyone. Families who learn a few specific skills together tend to cope better with stress. We'll work on the problems that matter to you, at your pace."
Watch for: a relative speaking for the patient, or a member who is absent or hostile. Offer that person a separate meeting rather than ruling them out. It is working when members agree a time and each names at least one personal concern.

A2. Individual assessment of each family member

Purpose / when: after engagement, before family work. Each person, including the patient, is seen alone.
Steps: Cover background; the person's own understanding of the problem; what helps and what makes it worse; current treatment; coping strategies; daily activities; supportive people; other stressors. Finish with personal goals: the steps toward each, who could help, and the likely barriers [source: NHS FIp].
Example language (illustrative): "What's your own explanation of what's been happening? What do you do when things get bad for you? If you had more time or energy, what would you want for yourself?"
Watch for: carer depression or anxiety, which you should screen and refer [source: WFSAD 15 Principles]. Also watch for risk, substance use and disclosures of abuse; see section 5. It is working when every member, not only the patient, has a recorded personal goal.

A3. Family problem-solving assessment (reported and observed)

Purpose / when: to set a baseline for communication and problem-solving skills, so that training targets the gaps.
Steps:
1. Reported: interview the family about how it usually settles issues. Who is involved? Where? How do they talk? Do they consider alternatives, reach consensus, plan, review? How stressed do they feel?
2. Observed: ask the family to discuss a current everyday problem, not a major conflict, for 15–20 minutes while you withdraw or step out. Record it if they consent.
3. Rate the discussion on the Communication and Problem Solving Checklist (a Meriden form, not reproduced).
4. Feed back strengths first, then the one or two skills to build.
Example language (illustrative): "I'd like to see how you work through something ordinary together, like planning the weekend. I'll sit back and won't join in."
Watch for: members appealing to you; stay out of it. Escalation: stop the task if tension becomes high [source: NHS FIp]. The Checklist is re-rated later as an outcome measure.

A4. Information sharing (education about the disorder)

Purpose / when: early, to give everyone a shared, non-blaming stress–vulnerability model.
Steps:
1. The worker assesses current symptoms.
2. Explain the disorder and its medication.
3. The family then discusses causes, what makes things better or worse, the likely course, and whether treatment is causing problems [source: WFSAD 2003 Guide].
4. [synthesis] Invite the patient to be the expert on their own experience of symptoms.
5. [synthesis] Check understanding with teach-back rather than lecturing.
Example language (illustrative): "Can you, as the person who's lived it, tell us what the voices were like? I'll add what we know from research. Then let's list together what seems to make things worse at home."
Watch for: information overload. Give it in small doses, repeated over time [source: WFSAD 15 Principles]. Listen for stigma and self-blame. It is working when the family uses the model to explain an event, for example: "he was up all night before it started".

A5. Early warning signs and staying-well plan

Purpose / when: after education, and then reviewed throughout. It turns knowledge into an agreed relapse-prevention response.
Steps:
1. With the patient leading, reconstruct the weeks before previous episodes and list the first changes noticed (sleep, withdrawal, irritability, odd ideas, and so on).
2. Ask relatives what they noticed.
3. Record on the Early Warning Signs record: each sign, what the family will do, and what the service agrees to do [source: NHS FIp].
4. Add a crisis plan with named contacts and how to reach the team [source: WFSAD 15 Principles].
5. Give copies to the family and the team.
Example language (illustrative): "Looking back, what was the very first thing that was different before you went into hospital? If your mum noticed that again, what would you want her to do, and what wouldn't you want?"
Watch for: relatives using the list for surveillance. Agree how signs will be raised respectfully. It is working when the family acts early on a sign and contacts the service as planned.

A6. Communication skills training: the common teaching method

Purpose / when: a single training format used for each of skills A7–A10.
Steps (six-part module structure):
1. Give the rationale.
2. Explore how much the family already uses the skill.
3. Teach the components.
4. Practise in session: each member rehearses with another member. Observe, give specific positive feedback, coach one improvement, and repeat the short rehearsal.
5. Set between-session practice with a worksheet.
6. Make notes and update the assessment [source: NHS FIp].
- Avoid contentious topics during early rehearsals [source: NHS FIp]. [synthesis] Model the skill yourself first.
Example language (illustrative): "That was good: you looked at him and said exactly what you liked. Try it once more, and this time add how it made you feel."
Watch for: members talking about each other in the third person; redirect them to speak to each other. Watch also for vague praise or criticism. It is working when the components appear unprompted.

A7. Expressing pleasant feelings

Purpose / when: usually the first skill. It raises warmth and counters a critical climate.
Steps: look at the person → say exactly what they did that pleased you → say how it made you feel. Practise daily, and open the next session by sharing examples [source: NHS FIp; WFSAD 2003 Guide].
Example language (illustrative): "Dad, when you made tea for everyone this morning I felt really looked after."
Watch for: generic praise ("you're great"), backhanded compliments, or a patient so low that noticing positives is hard. Then shrink the target to tiny behaviours.

A8. Making a positive request

Purpose / when: to replace nagging, demands and criticism.
Steps: look at the person → say exactly what you would like them to do → say how you would feel if they did it. Use 'I' statements, not 'you' statements [source: NHS FIp].
Example language (illustrative): "I'd like you to tell me if you'll be home after ten. I'd feel much less worried."
Watch for: requests that are really orders, or that are too large. It is working when requests are specific, polite and more often granted.

A9. Expressing unpleasant feelings

Purpose / when: after A7 and A8. It lets members raise upset without hostile criticism.
Steps: look at the person → say exactly what they did that upset you → say how you felt → move toward a resolution, by making a positive request or proposing a problem-solving discussion. Avoid highly contentious issues at this stage [source: NHS FIp].
Example language (illustrative): "When the music was loud at two in the morning I felt exhausted and fed up. Could we agree a time for headphones?"
Watch for: character attacks ("you're lazy"); coach the member back to the specific behaviour. If emotion escalates, pause the exercise.

A10. Active listening

Purpose / when: underpins problem solving and lowers misunderstanding.
Steps: look at the speaker → attend and cut distractions → encourage with nods or brief sounds → ask clarifying questions → summarise and check you understood [source: NHS FIp; WFSAD 2003 Guide].
Example language (illustrative): "So you're saying the hardest part is the mornings, when everyone's rushing. Have I got that right?"
Watch for: summaries that slip into rebuttal. It is working when the speaker confirms the summary was accurate.

A11. Six-step problem solving and goal achievement

Purpose / when: the core skill, taught after communication. It is used for family problems and for each member's personal goals.
Steps:
1. Pinpoint the problem or goal. Discuss it with active listening and write down one agreed, precise statement. Start with simple problems [source: WFSAD 2003 Guide].
2. List all possible solutions. Aim for five or six, with no evaluation yet.
3. Evaluate each one briefly. Note main advantages and disadvantages; avoid long debate.
4. Choose the most practical solution given time, money and skills, not necessarily the ideal one.
5. Plan. Who does what, with whom, how and when. Anticipate hitches, include the difficult steps, arrange monitoring and set a review time.
6. Review. What worked, what did not, what to change. Praise every effort [source: NHS FIp; WFSAD 2003 Guide].
Teaching sequence: Module A introduces the whole method. Modules B–G build each step, each with a rationale, the step itself, skills training (observe, feedback, coach, repeat short rehearsals), a between-session task, and updates to the Checklist and the Family Goal Record. Module F adds a Planning Checklist. Module G covers reviewing implementation: success, difficulties, modifications, learning, feedback [source: NHS FIp]. Personal goals should be reachable in 3–6 months and broken into small steps [source: WFSAD 2003 Guide].
Facilitator role: stay out of the discussion except to model a step. Interrupt only for gross misunderstanding or high emotional tension, and stop heated discussions [source: NHS FIp].
Example language (illustrative): "Let's write the problem as one sentence that everyone agrees with. Now, every idea goes on the list, even silly ones; we'll judge them later."
Watch for: the problem drifting into blame; the most vocal member choosing for everyone; plans without a 'when'. It is working when plans are carried out and reviewed, and when the family solves a new problem without you.

A12. Weekly family meeting

Purpose / when: begun once problem solving has been taught. It moves the skills into the home and lets you withdraw.
Steps:
1. Fix a 30-minute meeting at a time when most members are home.
2. Elect a secretary, who collects agenda items, reminds people to attend and keeps notes.
3. Elect a chairperson, who keeps to the agenda, makes sure everyone speaks, keeps behaviour appropriate, and starts and ends on time.
4. Give the chair the Planning Checklist.
5. Use the meeting for problem solving.
6. Report outcomes to the worker at the next session [source: NHS FIp].
- Meeting rules agreed by the family: no alcohol or drug use and no physical violence during meetings [source: WFSAD 2003 Guide].
Example language (illustrative): "Who'd be good at keeping time and making sure everyone gets a say? And who'll jot down what's agreed?"
Watch for: the patient always being the 'agenda item'; rotate roles and topics. It is working when meetings happen without prompting.

A13. Between-session tasks and records

Purpose / when: every session; this is how skills generalise.
Steps: set practice for each skill with a worksheet. Set problem solving at the family meeting, aimed at one main skill deficit. Keep the Early Warning Signs record and the Family Goal Achievement record up to date. Review worksheets at the start of the next session [source: NHS FIp].
Example language (illustrative): "Before next week, could each of you catch one other person doing something you liked and tell them? Jot it here; we'll start with those."
Watch for: see 'non-adherence' in section 5.

A14. Stress management and crisis intervention within BFT

Purpose / when: life crises, threatened relapse, or major events.
Steps: Falloon's book addresses crises and difficulties in therapy [source: Routledge book page], and stress management was part of the research programme [source: Bellack & Schooler 2001]. Their specific procedures are not drawn on [uncertain]. [synthesis] Activate the staying-well plan; use the six steps on the crisis with you chairing; increase session frequency temporarily; involve the care team. Refer suicidal responses to a specialist [source: WFSAD 2003 Guide] and follow standard risk-assessment practice.
Watch for: the family giving up the method under stress. It is working when the family uses the steps even in crisis.

A15. Reducing contact and ending

Purpose / when: once the family runs its own meetings and plans.
Steps: space sessions out; keep frequent reviews; ask the family to continue its meetings [source: NHS FIp; WFSAD 2003 Guide]. Leave a phone number and a named contact, and offer extra sessions at crises or major changes [source: WFSAD 15 Principles].
Example language (illustrative): "You're doing most of this yourselves now. Shall we meet monthly, and you call if an early warning sign shows up?"

B1. Entry and choice of format (FPE)

Purpose / when: at referral, to present FPE and decide between single-family work and a multifamily group.
Steps:
1. Present FPE as useful for the range of concerns common in your service.
2. Explain the purpose and benefits of each format.
3. Hear hopes and concerns.
4. Assess practical barriers and problem-solve them.
5. Agree the format together and revisit it later [source: EASA 2022].
- Single-family work is for those not in a multifamily group, or for whom a group does not fit [source: EASA 2022].
Example language (illustrative): "Some families meet with others in the same boat; others prefer to meet just with me at home. Both use the same approach. What would suit you?"
Watch for: the exclusions in section 5: life-threatening situations, and perpetrators of abuse or domestic violence.

B2. Joining sessions (three, then as needed)

Purpose / when: before any education. Build an alliance with each person and gather the material for relapse prevention.
Steps: Hold three joining sessions with the individual and with the family, paced by session checklists (not reproduced). Across them:
- listen to each person's story;
- explore precipitants, warning signs and the family's reactions (grief, fear, conflict, resilience);
- complete a relapse-prevention, wellness, stress-reduction or crisis plan;
- identify strengths;
- review coping strategies and social supports;
- describe the format options and gain commitment [source: EASA 2022].
- [synthesis] Joining is usually done separately with the family and with the person with the illness, so each can speak freely.
Example language (illustrative): "Before we talk about the illness itself, I'd like to hear how this has been for you, from the beginning. What did you notice first? What's helped you keep going?"
Watch for: joining being cut short. It is a fidelity element and should not be skipped [source: EASA 2022]. Unspoken grief or anger. It is working when the family is willing to attend the workshop and a written plan exists.

B3. Educational workshop (single-family delivery over several meetings)

Purpose / when: after joining. Give a shared biopsychosocial understanding and explain the family guidelines.
Content (EASA agenda, paraphrased):
- socialising at the start and end;
- history and prevalence of the diagnosis;
- symptoms and their biological, psychological and cultural aspects;
- content tailored to the condition (for example bipolar disorder or clinical high risk);
- normal adolescent and young-adult development and how it differs from symptoms;
- treatments, their effects and side effects;
- common family reactions (grief, conflict at onset, trauma);
- the family guidelines in detail;
- specific communication and coping skills;
- what the coming sessions will be like;
- lived-experience perspectives and questions [source: EASA 2022].
Steps: [synthesis] Split this across two to four meetings for a single family. Use handouts. Invite the young person's view, and bring in a peer or lived-experience speaker where possible.
Example language (illustrative): "Arguments about independence are normal at 19. The question is which bits are ordinary growing up and which may be early signs. Let's sort your examples together."
Watch for: relatives hearing 'lower stress' as 'it's our fault'. Restate the vulnerability model. It is working when relatives can link the guidelines to their own situations.

B4. Family guidelines

Purpose / when: introduced at entry and explained at the workshop. Then used in every go-around and as a source of problems to solve.
Content: the curriculum uses a set of 20 guidelines, grounded in biological, social and emotional stressors and needs. Their aims are to teach problem solving, reduce vulnerability to relapse, build shared understanding of what helps, and empower the family [source: EASA 2022]. The individual guidelines are not given in the sources [uncertain]. Do not improvise a list and present it as the McFarlane guidelines. The sources name the vulnerabilities the guidelines address: sensory over-stimulation, prolonged stress or heavy demands, rapid change, complexity, social disruption, substance use and negative emotional experience [source: EASA 2022].
Steps: [synthesis]
1. Give the family the curriculum's handout.
2. Ask which guideline feels most relevant or most difficult right now.
3. In each go-around, ask which guideline applied this week.
4. Treat a clash with a guideline as a candidate problem.
Example language (illustrative): "Which guideline was hardest to stick to this fortnight?"
Watch for: guidelines used as rules against the young person. Frame them as ways to reduce stress for everyone.

B5. Group-process introduction sessions

Purpose / when: the first two ongoing sessions. In EASA these are used in both single-family and multifamily formats.
Steps:
1. Session 1: everyone gets to know each other, including strengths and hobbies.
2. Session 2, the 'impact' session: each person describes how the mental-health problem has affected their life, and the facilitator models disclosure [source: EASA 2022].
Example language (illustrative): "Today isn't about problems. Tell me something you're good at, or something you used to love doing."
Watch for: the impact session becoming blaming; keep it to 'how it affected me'. It is working when members show empathy for each other's experience.

B6. Structured problem-solving session: the five-part format

Purpose / when: every ongoing session, twice a month (monthly at minimum).
Steps (single family, 60 min):
1. Social chat, about 10 min. Ordinary conversation, not illness talk.
2. Go-around, about 15 min. Each member reports the period's events, any relevant 'biosocial' information (for example sleep, stress, symptoms), and which guidelines applied.
3. Choose one problem, about 5 min. Use the hierarchy in B7.
4. Formal problem solving, about 25 min. Use B8.
5. Closing social chat, about 5 min [source: EASA 2022].
- Keep to the structure; never replace problem solving with a skills or social session [source: EASA 2022].
Example language (illustrative): "Let's go round. What's happened since we last met, anything about sleep or stress, and did any of the guidelines come up?"
Watch for: the go-around expanding into a debate; note issues and keep moving. It is working when the session runs to time and ends with a written plan.

B7. Problem-selection hierarchy

Purpose / when: step 3 of every session, to choose the most relapse-relevant problem.
Order of priority:
1. Medication concerns: access, side effects, effectiveness, changes.
2. Substance or alcohol use.
3. Life events.
4. Problems created by other agencies.
5. Conflicts between family members.
6. Conflicts with the family guidelines.
- Never ignore safety, medication or drug issues. A crisis or a complex high-risk issue is handled outside the session, with an immediate plan [source: EASA 2022].
Example language (illustrative): "You mentioned feeling slowed down since the dose changed. That goes to the top of the list today."
Watch for: choosing a big chronic conflict too early. Start with something small and solvable [source: WFSAD 15 Principles].

B8. Five-step problem solving (FPE version)

Purpose / when: step 4 of each session. It differs from Falloon's six steps in a few points.
Steps [source: EASA 2022]:
1. Define the problem clearly and narrowly, in behavioural terms and with relapse risk in mind.
2. Brainstorm. Everyone contributes, with no criticism. Limit the list to about 10–12 numbered ideas.
3. Weigh pros and cons of each. Do not tally them; not every 'con' is a real disadvantage.
4. Select. The person whose problem it is chooses one to three ideas to try.
5. Delineate tasks and carry them out. Give a written, specific action plan with clear steps.
- [synthesis] Review the plan at the next go-around.
Example language (illustrative): "It's your problem, so you get to pick. Which one, two or three of these would you be willing to try first? Let's write exactly who does what by when."
Watch for: the facilitator generating the solutions. You may add ideas, but the family chooses. It is working when plans get tried and reported back.

B9. Deliberate self-disclosure and the facilitator's role

Purpose / when: throughout, especially in the impact session. It humanises the facilitator and lowers hierarchy.
Steps: plan small, relevant disclosures in advance (with your co-facilitator if you have one) that convey similarity. Avoid evasiveness. Act as educator, family partner, trainer-coach and group member. Welcome everyone each time [source: EASA 2022].
Example language (illustrative): "I find it hard to switch off when I'm worried about someone in my family, too."
Watch for: disclosures that shift the focus onto you, or that are emotionally loaded. Keep them brief.

B10. Team integration and advocacy

Purpose / when: after every session.
Steps: bring specific follow-up items to the weekly team meeting, advocate for the family with the prescriber and other agencies, and keep the whole team aligned on the plan. The intervention is a planned one, supported by the team [source: EASA 2022; WFSAD 15 Principles].
Watch for: the family hearing contradictory messages from different staff.

5. Handling problems

Items tagged with a source come from the sources. Items tagged [synthesis] are my own guidance.

Exclusions and safety screening. Do not use FPE to resolve life-threatening or high-risk situations. Do not include perpetrators of abuse, neglect or domestic violence [source: EASA 2022].
- [synthesis] Screen for domestic abuse privately with each member during the individual assessment (A2) or joining (B2). If abuse is present, pause conjoint work and follow safeguarding procedures. Offer the victim individual support and the person with the illness separate family-informed care.
Suicide or self-harm risk during sessions. Refer suicidal responses to a specialist [source: WFSAD 2003 Guide]. Handle crises outside the problem-solving slot with an immediate plan [source: EASA 2022].
- [synthesis] Follow your service's standard risk assessment. Add lethal-means counselling to the staying-well plan: safe storage or removal of medicines and other means, agreed with the family.
Patient declines family involvement or consent. If a person will not consent, or barriers cannot be solved, consider alternatives [source: EASA 2022].
- [synthesis] Offer relatives education and support on their own, sharing general information but not confidential detail. Keep inviting the patient. Ask the patient what information they are happy to share.
Poor attendance and engagement. Explore barriers. Solve transport, childcare and scheduling problems, and provide food. Follow up after any missed meeting. Do not pre-cancel on assumptions. Keep sessions predictable [source: EASA 2022].
- Home sessions reduce drop-out barriers [source: WFSAD 2003 Guide]. Engagement may take time [source: NHS FIp].
Homework not done. [synthesis]
- Treat it as a problem to solve, not a failure. Use the six steps on 'what got in the way'.
- Shrink the task. Rehearse it in session.
- Make the chair or secretary responsible for prompting.
- Always praise partial attempts [source for praise: NHS FIp].
Heated conflict or high criticism (high expressed emotion) in session. Interrupt for high emotional tension and stop heated discussions [source: NHS FIp]. Listen to each side impartially and seek compromise [source: WFSAD 15 Principles]. Keep early skills practice off contentious topics [source: NHS FIp].
- [synthesis] Turn a criticism into a positive request (A8), or into unpleasant-feeling expression followed by a request (A9). Take a short break, or see members separately.
Family talks to the therapist instead of to each other. Explain that members should speak to each other, and re-seat them facing one another [source: NHS FIp].
Family wants the therapist to solve problems. Explain that you teach the method and they find the solutions [source: WFSAD 2003 Guide]. [synthesis] Offer at most one idea during brainstorming, labelled as just one option.
Unrealistic expectations, or hoping for a 'miracle cure'. Explore and reset expectations, and reassess them after each episode [source: WFSAD 15 Principles; NHS FIp].
Grief, burn-out and caregiver depression. Acknowledge loss. Screen and treat caregiver anxiety and depression. Link the family to relatives' groups [source: WFSAD 15 Principles].
Cognitive or concentration difficulties. Make sessions shorter and simpler [source: WFSAD 2003 Guide].
- For intellectual or developmental disability: attend to the physical set-up, use visual aids and rest breaks, review plans more often, and give everyone information about communication differences [source: EASA 2022].
Language and interpreters. When one member mainly speaks English, others may start addressing the workers; redirect. Use interpretation only to support the workers. Co-workers plan beforehand, summarise for each other and debrief afterwards [source: NHS FIp].
Cultural factors. Consider gender roles, the head of household's influence, generational differences, religious explanations (including spiritual explanations of illness), stigma and experiences of racism. In supervision, reflect on how far to adapt without pushing beyond what the family accepts [source: NHS FIp]. Practise cultural humility, with awareness of power [source: EASA 2022].
A member who struggles with structure, or dominates. This is named as a common challenge [source: EASA 2022]; the responses are [synthesis]:
- Agree speaking turns.
- Use the go-around strictly.
- Give the dominant member a role, such as secretary.
- Validate them briefly, then return to the step.
Adolescent or young adult autonomy mistaken for symptoms. Teach normal development so the family can tell the two apart [source: EASA 2022].
Substance use. It ranks high in problem selection and is never ignored [source: EASA 2022]. No drugs or alcohol during meetings [source: WFSAD 2003 Guide]. [synthesis] Coordinate with addiction services, and set substance-related goals the young person agrees to.
Medication disagreement. It is first in the problem hierarchy [source: EASA 2022]. Review side effects and medication jointly with the prescriber [source: WFSAD 15 Principles]. [synthesis] Avoid taking sides; problem-solve how to raise concerns with the prescriber.
Relapse during treatment. Activate the early-warning-signs plan and the crisis contacts [source: NHS FIp; WFSAD 15 Principles].
- [synthesis] Pause skills training, increase contact, and debrief afterwards: which signs appeared and how well the plan worked. Then update the plan.
Rupture with the therapist (for example a relative feels blamed, or the patient feels ganged up on). [synthesis]
- Name it directly and own your part.
- Restate the no-blame stress–vulnerability model.
- Offer an individual meeting.
- Check that the patient's voice is in every plan.
Confidentiality between members. Sensitive issues can be taken to private meetings [source: NHS FIp]. See members separately when needed [source: WFSAD 15 Principles]. [synthesis] Agree at engagement what will and will not be shared across members.
Fidelity drift (sessions turning into chats, joining skipped). Use session checklists and consultation calls. Keep the time allocations [source: EASA 2022]. Get Meriden-type supervision for BFT [source: Meriden FCDO page].
Dependency at ending. Hand over to self-run family meetings and leave a named contact [source: NHS FIp; WFSAD 15 Principles]. [synthesis] Taper sessions gradually and schedule booster sessions.

Sources

Sources:

Further reading (not drawn on in full; structure taken from the sources above):

Falloon, I. R. H., Laporta, M., Fadden, G., & Graham-Hole, V. (1993; reissued 2023). Managing Stress in Families: Cognitive and Behavioural Strategies for Enhancing Coping Skills. Routledge.
Anderson, C. M., Reiss, D. J., & Hogarty, G. E. (1986). Schizophrenia and the Family: A Practitioner's Guide to Psychoeducation and Management. Guilford Press. [uncertain: the original phase structure]

Attempted but not readable: Lemos Giráldez & Vallina Fernández (2000), Dos décadas de intervenciones familiares en la esquizofrenia, Psicothema 12(4) (PDF refused); an OpenEdition chapter (bot check).

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