Research two (2) manufacturing or two (2) service companies that m.docx

Research two (2) manufacturing or two (2) service companies
that manage inventory and complete this assignment.
Write a five to seven (5-7) page paper in which you:
1. Determine the types of inventories these companies currently
manage and describe their essential inventory characteristics.
2. Analyze how each of their goods and service design concepts
are integrated.
3. Evaluate the role their inventory plays in the company's
performance, operational efficiency, and customer satisfaction.
4. Compare and contrast the four (4) different types of layouts
found with each company; explain the importance of the layouts
to the company's manufacturing or service operations.
5. Determine at least two (2) metrics to evaluate supply chain
performance of the companies; suggest improvements to the
design and operations of their supply chains based on those
metrics.
6. Suggest ways to improve the inventory management for each
of the companies without affecting operations and the customer
benefit package. Provide a rationale to support the suggestion.
7. Use at least three (3) quality resources in this assignment.
Note: Wikipedia and similar Websites do not qualify as quality
resources.
Running head: ANNOTATED BIBLIOGRAPHY

Annotated Bibliography
Your Name
Date

Article # 1
APA Citation
What is the article about?
Why was the research performed?
Findings
Strengths
Weaknesses
Implications for Practice
Key Words
Article # 2
APA Citation

Findings
Strengths
Weaknesses
Key Words
Article # 3
APA Citation
Findings
Strengths
Weaknesses
Key Words
Article # 4
APA Citation

Findings
Strengths
Weaknesses
Key Words
Article # 5
APA Citation
Findings
Strengths
Weaknesses
Key Words
Article # 6
APA Citation

Findings
Strengths
Weaknesses
Key Words
Article # 7
APA Citation
Findings
Strengths
Weaknesses
Key Words
Article # 8

APA Citation
Findings
Strengths
Weaknesses
Key Words
Article # 9
APA Citation
Findings
Strengths
Weaknesses
Key Words

Article # 10
APA Citation
Findings
Strengths
Weaknesses
Key Words
Running head: ANNOTATED BIBLIOGRAPHY
1
ANNOTATED BIBLIOGRAPHY
2

Annotated Bibliography
Article # 1
Feldman & Margolis (2016)

APA Citation
Feldman Farb, A., & Margolis, A. L. (2016). The teen
pregnancy prevention program (2010-2015): Synthesis of impact
findings. American Journal of Public Health 106(51), 509-515.
This article is a documentation of program evaluation for teen
pregnancy prevention. The research is basically a synthesis of
the impact findings as they relate to how the pregnancy
prevention program can be improved by focusing on
performance measures and recommendations advanced by the
study.
This research was performed because there are performance
issues regarding the effectiveness of teen pregnancy prevention
programs. The objective of the study was to assess the
effectiveness of existing teen pregnancy prevention programs
and use the outcome of the assessment to make
recommendations for improvement.
Findings
A number of issues were detected regarding the fit of the
current program in tackling the main problem. This assessment
was found to be very informative in determining situations
where the program is effective and others where they are not
effective. The research found out that a lot needs to be done to
improve the programs.
Strengths
This study uses a good source of primary data by engaging
directly with the programs and collecting performance data.
Additionally, there is sufficient depth as with regards to the
research evidence offered in support of the recommendations
provided.
Weaknesses
The researchers highlighted a problem with their model in
which the numerator was too small while the denominator was
too large.

The implication is that the findings of this study has direct
effect on the structure and effectiveness of teen pregnancy
prevention programs. It informs these programs on how to
update operations for better outcomes.
Key Words
Teen pregnancy, assessment, program, adolescent health, sexual
activity
Article # 2
Danieli, Budó, Ressel, & Seiffert (2015)
APA Citation
Danieli, G. L., Budó, M. L. D., Ressel, L. B., & Seiffert, M. A.
(2015). Perceptions about pregnancy and health education
experiences: perspective of teen pregnancy. Rev Enferm UFPE
Online, 9(2), 573-81.
This research is about evaluating the importance of pregnancy
for teenagers and how recognizing their experiences enhances
health education.
There has been very little focus in teenage experiences relating
to pregnancy. The existence of this void in research and
knowledge necessitated a study to promote health education for
teens by developing lessons from their experiences.
Findings
From an analysis of experiences, the study found out feelings
such as fear, anxiety, happiness and insecurity. The research
also found health education offered through lecturers and
guidelines insufficient for adolescents with feelings of
empowerment and awareness.
Strengths
As a qualitative research, the study derives its strengths from
qualitative data in which a Basic Health Unit in southern Brazil
was used. The case-study approach used allowed the study to

sufficiently interact with teenagers and get first-hand
information about their experiences.
Weaknesses
Given that this study focused on a specific region in which
teenage experiences are contextualized, the fact that
participants were localized in a limited environment affects the
ability to generalize the study to apply to teens in other
environments.
This research will be of direct help to the health unit where it
was performed because it sheds light on their struggles and the
effect of programs on the experiences of teens. Still, the
research is also relevant in other populations because teens
share a lot of experiences because of the environments they live
in.
Key Words
Pregnancy, feelings, socioeconomic status, health education,
experiences
Article # 3
Mangeli, Rayyani, Cheraghi & Tirgari (2017)
APA Citation
Mangeli, M., Rayyani, M., Cheraghi, M. A., & Tirgari, B.
(2017). Exploring the challenges of adolescent mothers from
their life experiences in the transition to motherhood: a
qualitative study. Journal of family & reproductive
health, 11(3), 165.
This article is about the experiences of early motherhood and
the health challenge that is a characteristic of developing
countries. The study evaluates the implications of early
motherhood on children, mothers, communities and families.
This research was performed to characterize the challenges
experienced by Iranian adolescent mothers with focus on the
experience of motherhood.

Findings
The challenges found in this study include social problems,
insufficiency in maternal role, insufficient support and
emotional and mental distress among others.
Strengths
As a qualitative study, this research utilized an inductive
conventional content analysis approach which is very reliable.
Additionally, the research collected data to the point of
saturation.
Weaknesses
While the research pursued many different variables, only 16
Iranian teenage mothers participated in the study which is a
relatively small sample size.
This study promotes knowledge on the experiences of early
mothers by going deeper into their lives and revealing their
feelings and experiences.
Key Words
Early motherhood, content analysis, ineffectiveness,
responsibility, child-care.
Article # 4
Mollborn (2017)
APA Citation
Mollborn, S. (2017). Teenage mothers today: what we know and
how it matters. Child development perspectives, 11(1), 63-69.
This article is a status update on the predicament of teenage
mothers today from a practical and research points of view. This
is a research study that provides details about the experiences of
teenage mothers, what is known through research and what
needs to be done.
This research was performed to establish a case for continued
research and shifts in policy to not only protect teens from
pregnancies, but to also offer a supportive environment for

young mothers.
Findings
This was a research review, it established that the depth of
knowledge and effectiveness of policies in place are
exceedingly wanting. There is need to improve societal
knowledge through research and improve the social environment
through policies.
Strengths
The main strength of this research is the depth of studies used
to inform the inferences made. Being a research review, the
study has utilized the most recent studies on the subject to
determine trends among teenage mothers today.
Weaknesses
As a research review, it has extensively relied on secondary
data. This means that in many instances, it has relied on facts
that have been influenced by perspectives as opposed to primary
data.
This research contributes to the level of awareness and health
education about teenage pregnancies and related experiences. It
calls for improvements in the socioeconomic environment that
teenage mothers live.
Key Words
Teenage mothers, policy, socioeconomic, teenage fertility,
societal trends
Article # 5
Kirven (2014)
APA Citation
Kirven, J. (2014). Maintaining Their Future After Teen
Pregnancy: Strategies for Staying Physically and Mentally
Fit. International Journal of Childbirth Education, 29(1).
This research is about how teenage mothers can engage coping
strategies to keep themselves physically and mentally fit.

This research was performed because adolescents are confronted
with varying levels of social pressure and mental torture that
impacts their physical and mental health. There is need to
communicate strategies that can help them cope and sustain a
healthy life after childbearing.
Findings
This research review found out that teenage mothers are not
well-informed of strategies they can use to avoid obesity and
other physical as well as emotional health effects of teen
childbearing.
Strengths
The research is highly descriptive and informative, this ensures
that it reaches its audience well.
Weaknesses
This research has failed to adequately illustrate the source of
data used or the origin of the recommendations offered as
strategies. The research should provide a scientific basis for its
strategies.
This research can be readily consumed by its target population
because it is straightforward and well-structured. Teens can get
the information they need quite easily and use it to better their
physical and emotional health.
Key Words
Stressors, obesity, coping strategies, risk factors, interventions.
Article # 6
Whitworth (2017)
APA Citation
Whitworth, T. R. (2017). Teen childbearing and depression: do
pregnancy attitudes matter?. Journal of Marriage and
Family, 79(2), 390-404.
This research is about evaluating how young women’s attitudes
influence the relationship between teen childbearing and
depression.

This research was performed to show that attitudes held by
teens before they become mothers has an effect on depression
induced by childbearing. Attitudes have an effect on emotions
and psychological health of teen mothers after delivery.
Findings
This research found significant variations as to the
manifestation of depressive symptoms among women of
different ages. However, the research showed that teens who
had negative pregnancy attitudes sustained these depressive
symptoms after childbirth.
Strengths
Besides retrieving data from a reliable database, this research
conducted a comprehensive literature review on the subject
which correctly positioned its contribution to the existing body
of research on the subject.
Weaknesses
The first limitation is that the research used participants, some
of which were approaching the end of their teen years.
Secondly, the research used unreliable wording for pregnancy
attitudes.
Despite the two limitations, this study will actively inform the
structure of programs that prevent teenage pregnancy by
recommending a new approach that focuses on their attitudes to
promote proper mental health before and after childbirth.
Key Words
Teen childbearing, depression, attitudes.

The Mediating Effect of Family Cohesion in Reducing Patient
Symptoms
and Family Distress in a Culturally Informed Family Therapy
for
Schizophrenia: A Parallel-Process Latent-Growth Model
Caitlin A. Brown and Amy Weisman de Mamani
University of Miami
Objective: Although both patients with schizophrenia and their
caregivers report elevated levels of
depression, anxiety, and stress (DASS), affective symptoms in
patients and family members seldom
constitute a primary treatment focus. The present study tested
whether a culturally informed family
therapy for schizophrenia (CIT-S) outperformed standard family
psychoeducation (PSY-ED) not only in
decreasing patient schizophrenia symptoms, but also in
decreasing individual DASS. Because CIT-S
fostered family cohesion throughout treatment, we predicted
that increases in family cohesion would
mediate treatment effects. Method: Participants included 266
patients and family members nested within
115 families, randomized to the CIT-S or PSY-ED conditions.
We specified a series of multilevel latent
growth and latent change models to examine direct effects of
CIT-S on patient schizophrenia symptoms,
individual DASS, and family cohesion over time. Next, we used
parallel-process growth models to test
the indirect effect of CIT-S on decreasing patient and caregiver
psychopathology over time via changes
in family cohesion. Results: The CIT-S treatment significantly

reduced patient schizophrenia symptoms
from baseline to follow-up (� � �1.72, 95% confidence
interval [CI] [�2.83, �0.60]), as well as
individual DASS (� � �4.39, 95% CI [�6.44, �2.34]) from
baseline to termination. In line with
treatment goals, CIT-S increased family cohesion from baseline
to midpoint (� � 0.93, 95% CI [0.06,
1.80]). The CIT-S-related change in cohesion mediated changes
in DASS (� � �0.87,
95% CI [�1.47, �0.27]), but not patient symptoms. Conclusion:
By integrating the family’s cultural
context into treatment, clinicians may foster family dynamics
that enhance treatment outcomes and
promote broad improvements in mental health.
What is the public health significance of this article?
This study found that a culturally informed family therapy for
schizophrenia (CIT-S) had a lasting
impact on reducing patient symptoms. In addition, by increasing
family cohesion, CIT-S decreased
patient and caregiver depression, anxiety, and stress. For a
family seeking treatment for 1 member
with schizophrenia, therapists may enhance patient gains by
incorporating relevant cultural variables
into treatment.
Keywords: schizophrenia, latent-growth modeling, multilevel
mediation, family therapy, psychosis
Schizophrenia is a chronic and disabling psychiatric disorder
that affects roughly 1% of the population (Minzenberg & Carter,
2012). The illness engenders pronounced distress in both
patients
and family members: Only 14% of patients with schizophrenia
achieve sustained recovery within the first 5 years of a
psychotic

episode (Insel, 2010), and only 10% to 20% of patients are em-
ployed (Marwaha & Johnson, 2004). Consequently, family
mem-
bers often live with patients and assume the caregiving
responsi-
bility (Pitschel-Walz, Leucht, Bäuml, Kissling, & Engel, 2015).
Because family members tend to spend significant amounts of
time
with patients in the caregiving role, transactional family
relation-
ships can constitute significant stressors for both patients and
caregivers. Accordingly, family therapy is a natural candidate
for
psychosocial interventions targeting schizophrenia, as it
addresses
the familial stressors that affect both patient symptom trajectory
and caregiver burden.
By targeting maladaptive communication patterns and ex-
pressed emotion (EE; Hooley, 2007), family therapy improves
patient outcomes across symptom clusters and beyond the
effects
of antipsychotics alone (Falloon, Boyd, & McGill, 1984). Al-
though positive symptoms of schizophrenia (e.g., hallucinations
and delusions) cause acute deterioration in functioning,
negative
symptoms (e.g., avolition and anhedonia) are linked to long-
term
functional impairment (American Psychiatric Association,
2013).
Notably, comorbid anxiety disorders affect approximately a
quar-
ter of patients with schizophrenia, and up to half of patients
with
schizophrenia suffer from concurrent depression (Buckley,

Miller,
This article was published Online First November 27, 2017.
Caitlin A. Brown and Amy Weisman de Mamani, Department of
Psy-
chology, University of Miami.
Correspondence concerning this article should be addressed to
Caitlin A.
Brown, Department of Psychology, University of Miami, 5665
Ponce de
Leon Boulevard, Coral Gables, FL 33146. E-mail:
[email protected]
.edu
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Journal of Consulting and Clinical Psychology © 2017
American Psychological Association
2018, Vol. 86, No. 1, 1–14 0022-006X/18/$12.00
http://dx.doi.org/10.1037/ccp0000257
1
mailto:[email protected]
mailto:[email protected]

http://dx.doi.org/10.1037/ccp0000257
Lehrer, & Castle, 2009; Tsai & Rosenheck, 2013). Comorbid
depression, in particular, relates to poorer quality of life and
poorer
clinical outcomes (Buckley et al., 2009). Consequently, along
with
addressing primary psychotic symptoms, therapies that target
and
monitor depression and anxiety symptoms may improve patient
well-being more globally. Family therapy, for instance,
produces
improvements in negative and disorganized symptoms by
enhanc-
ing nonhostile communication between patients and family
mem-
bers. Improvements in communication, in turn, help patients and
family members to gain coping mechanisms, reduce stress, and
compensate for social deficits that influence patients’ appraisal
and
response biases (Elis, Caponigro, & Kring, 2013).
Family therapy models connect improvements in family func-
tioning and caregiver well-being with a decreased risk of patient
relapse, with the idea that reducing blaming attributions and
care-
giver burden can improve patient outcomes (Koutra, Simos, Tri-
liva, Lionis, & Vgontzas, 2016). By enriching family members’
understanding of their relative’s illness, family psychoeducation
also improves illness management and treatment coordination
be-
tween the family and treatment team. However, studies of
family
therapy for schizophrenia have conceptualized caregiver mood
and

anxiety symptoms almost exclusively as a vehicle for improving
patient symptoms. Ethically, there is a need to consider
caregiver
mood and anxiety as outcomes of interest in their own right,
independent of patient functioning. Caring for a relative with
schizophrenia is a lifelong process associated with significant
burden and distress (Madianos, Economou, Dafni, Koukia, Palli,
&
Rogakou, 2004; Suro & Weisman de Mamani, 2013). In a study
on
Mexican American caregivers of family members with
schizophre-
nia, for example, 40% of the sample displayed clinically signifi-
cant symptoms of depression (Magaña, Ramírez García, Hernán-
dez, & Cortez, 2007). Beyond reducing caregiver burden and
patient symptom severity, family therapy has the potential to
target
caregiver mental health by encouraging familial unity,
developing
team-focused problem solving, and promoting participation in
shared activities as a family.
Research on family caregivers in collectivistic cultures has
illuminated the role of positive family factors in the
maintenance
of and risk for psychotic disorders, as well as the burden of
care.
For example, studies have linked family warmth, collectivism,
and
unity to lower patient symptoms (López et al., 2004), as well as
lower levels of reported caregiver burden (Weisman, Rosales,
Kymalainen, & Arnesto, 2005). For individuals who endorse
high
levels of family interdependence, caring for a relative may be a
more normative or expected process, which is in line with
empir-

ical evidence of a relationship between exhibiting collectivistic
attitudes and feeling a sense of obligation to care for an ill
relative
(Freeberg & Stein, 1996). Promoting positive factors such as
familial warmth and cohesion may thus enhance treatment
efficacy
for both patients and caregivers (Bertrando et al., 1992; Gurak
&
Weisman de Mamani, 2016; Weisman et al., 2005).
Weisman de Mamani and colleagues (2005) drew from research
on associations between cohesion, patient symptoms, and care-
giver outcomes to develop a culturally informed family therapy
for
schizophrenia (CIT-S; Weisman de Mamani et al., 2014).
Ground-
ing the culturally adapted components of CIT-S in theory on
culture, expressed emotion, and psychiatric symptoms, the re-
searchers proposed targeting family unity and cohesion to
improve
treatment outcomes. CIT-S is a 15-week treatment consisting of
five modules, each lasting three sessions. The first module of
CIT-S (Sessions 1 through 3), Family Collectivism, engages
fam-
ily members in dialogue about the family unit. Family members
discuss individual contributions to the family, focusing on
strengths of each player on the family team (Weisman de
Mamani
et al., 2014). The remaining four modules of CIT-S foster
adaptive
beliefs regarding the patient’s illness, improve communication,
and promote unified problem solving. During the
Psychoeducation
module (Sessions 4 through 6), clinicians note the significant
impact that critical comments and emotional overinvolvement

can
have on patient outcomes, again underscoring the importance of
working as a family team to treat the illness. In the Spiritual
Coping module (Sessions 7 through 9), therapists draw from the
family’s existing religious or spiritual beliefs to promote
adaptive
spiritual coping, encouraging family members to consider
spiritual
practices they can perform together, such as going to a service
or
praying. Family cohesion similarly serves as the foundation for
the
Communication Training module (Sessions 10 through 12),
which
helps the family to interact in a supportive manner. Family
mem-
bers foster relationships and confront problems in a style that
reduces blaming attributions and EE. The final module, Problem
Solving (Sessions 13 through 15), foments family members’
self-
conceptions as part of a team working toward a common goal in
order to address family issues.
Though informed by literature on ethnic differences in family
functioning and predictors of relapse (Weisman et al., 2005),
CIT-S has been demonstrated equally effective in reducing
patient
symptoms for Caucasian and ethnic minority families (Weisman
de Mamani et al., 2014). In prior studies using the same data set
as
we use in the current study, CIT-S was found to reduce schizo-
phrenia symptoms (Weisman de Mamani et al., 2014), as well as
caregiver burden (Weisman de Mamani & Suro, 2016), beyond
the
effects of a standard three session family psychoeducation
(PSY-

ED) intervention (see Appendix for details on data
transparency).
To date, however, no study has considered the efficacy of CIT-S
on patient and caregiver mood or anxiety symptoms.
Furthermore,
despite the fact that the authors developed CIT-S with a focus
on
the empirically based, intermediate treatment target of family
cohesion, mechanisms of the CIT-S treatment effects reported in
prior studies remain elusive. In order to determine whether the
cultural modifications were key ingredients of change, we
propose
testing whether changes in the theoretical contextual variables
(i.e.,
family cohesion) explain the reduction in symptom severity over
time observed with CIT-S.
When testing theory-based causal mediation processes, there is
a need to use statistical methods that allow for the analysis of
dynamic change processes (MacKinnon & Dwyer, 1993). Tradi-
tional pre-post analysis provides limited information regarding
the
relationships between mechanistic change processes and
changes
in outcomes of interest (Khoo, 2001). Fortunately, several
statis-
tical frameworks permit the flexibility of modeling slopes as
outcomes within a multivariate, multilevel, longitudinal frame-
work. In line with prior research on longitudinal mediation in
clinical trials (e.g., Cheong, MacKinnon, & Khoo, 2003), we
use
multilevel parallel-process growth modeling to analyze changes
in
family cohesion, our theory-based mediating variable, on slopes
of
outcome variables. Beyond allowing the researcher to model the

relationships between simultaneous change processes over time,
multilevel latent-growth models account for dependency in data
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2 BROWN AND WEISMAN DE MAMANI
due to nesting of patients within families. Ignoring dependency
due to nesting can bias parameter estimates, standard errors, and
degrees of freedom (Bauer, Gottfredson, Dean, & Zucker, 2013;
Kenny & Judd, 1986; Tasca, Illing, Joyce, & Ogrodniczuk,
2009).
Moreover, multivariate growth models allow for the
examination
of complex residual variance components that can be key to
understanding stability and change (Curran et al., 2012). Unlike
a
pre-post analysis, a growth model provides flexibility in
modeling
heterogeneity in growth at the individual and/or family level.
By
estimating random intercepts and slopes, multilevel growth
models
capture the heterogeneity in psychotic and mood symptoms due
to

individual and family factors, which may relate to differential
treatment response (Curran, Obeidat, & Losardo, 2010).
Because
parallel-processes can be modeled with measurements occurring
at
different time points, growth models help establish the temporal
precedence that provides greater confidence in a mediation
effect
(Cheong et al., 2003). Finally, latent-growth models offer
flexibil-
ity with missing data, which is often high due to elevated rates
of
treatment dropout in schizophrenia (Villeneuve, Potvin, Lesage,
&
Nicole, 2010).
Thus, in the present study, multilevel latent-growth and latent-
change models were used to assess whether CIT-S decreased
patient schizophrenia symptoms, reduced patient and caregiver
DASS, and increased family cohesion over time. By assessing
treatment effects for schizophrenia symptoms at 6-month
follow-
up, we extend prior findings that CIT-S decreased patient symp-
toms from baseline to treatment termination (Weisman de
Mamani
et al., 2014). Also novel is our test of CIT-S effects on patient
and
caregiver DASS, as well as reports of family cohesion over
time.
Specifically, we assessed the indirect effects of the CIT-S treat-
ment over time on patient and caregiver symptoms via changes
in
family cohesion, which was a major treatment target throughout
all
five modules of CIT-S. To establish temporal precedence of the

mediator and outcome, we examined family cohesion at
treatment
midpoint, which was during the seventh session (after
completing
the Psychoeducation module). The following hypotheses were
tested: (1) Compared to the PSY-ED group, patients in the CIT-
S
group will display greater decreases in psychiatric symptom se-
verity over time, and these effects will last through 6-month
follow-up. (2) Compared to the PSY-ED group, patients and
caregivers in the CIT-S group will display greater decreases in
depression, anxiety, and stress over time. (3) Compared to the
PSY-ED group, families in the CIT-S group will display greater
increases in average family cohesion from baseline to midpoint.
(4) Increases in family cohesion in the CIT-S group from
baseline
to midpoint will mediate the effect of CIT-S on reducing patient
symptom severity and patient and caregiver DASS.
Method
Participants
Demographic statistics of the full baseline sample are reported
in
Table 1, and Figure 1 contains a consort diagram of study
partic-
ipation. At baseline, 266 individuals (patients and family mem-
bers) from 115 families were eligible to participate in family
treatment for schizophrenia. Of these families, 64 were
randomly
assigned to CIT-S, a 15-week, culturally informed family inter-
vention. The other 51 families were assigned to PSY-ED, a 3-
week
standard family psychoeducation treatment (for additional
details

of both treatments, see Weisman de Mamani et al., 2014). Data
from participants who dropped out of the study after randomiza-
tion to treatment condition are included in the analyses. The
sample included data from 36 families at treatment midpoint, 46
families at termination, and 41 families at 6-month follow-up.
Table 1
Demographic Statistics for Patients and Family Members for
CIT-S and PSY-ED
CIT-S PSY-ED
Variable Patients (N � 52) Family members (N � 98) Patients
(N � 39) Family members (N � 77)
Age M � 37.24 M � 49.19 M � 38.72 M � 49.64
SD � 13.4 SD � 16.4 SD � 11.69 SD � 15.39
Gender 36.5% women 54.1% women 43.6% women 58.4%
women
Ethnicity 44% Hispanic; 34%
African American;
16% Caucasian; 6%
other
57.7% Hispanic; 22.7%
African American; 15.5%
Caucasian; 1% Asian
American; 3.1% other
53.8% Hispanic; 17.9%
African American;
28.2% Caucasian
46.8% Hispanic; 23.4% African

American; 25.9% Caucasian;
3.9% other
Education 1.9% advanced degree;
15.7% college
degree; 27.5% some
college; 21.6% HS
graduate; 12.6%
some HS beyond
grade 8; 5.9% grade
8 completed; 7.8%
below grade 8
10.2% advanced degree; 28.6%
college degree; 15.3% some
college; 27.5% HS graduate;
12.2% some HS beyond
grade 8; 3.1% grade 8
completed; 3.1% below
grade 8
0% advanced degree;
10.5% college
degree; 34.2% some
college; 31.6% HS
graduate; 21.1%
some HS beyond
grade 8; 0% grade 8
completed; 2.6%
below grade 8
9.4% advanced degree; 29.7%
college degree; 20.3% some
college; 25.7% HS graduate;
9.5% some HS beyond grade
8; 4.0% grade 8 completed;

1.4% below grade 8
Relationship to patient NA 45.9% parent; 17.3% partner;
12.2% sibling; 7.1% friend;
6.2% child; 11.3% extended
family
NA 37.7% parent; 22.1% partner;
16.9% sibling; 5.2% child;
2.6% friend; 15.5% extended
family
Note. CIT-S � culturally informed family therapy for
schizophrenia; PSY-ED � standard family psychoeducation; HS
� high school; NA � not
applicable.
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3FAMILY COHESION AND SCHIZOPHRENIA
Prior to testing our models, we analyzed predictors of dropout
for
both the CIT-S and PSY-ED families.

Procedures
Participant recruitment occurred through referrals from
hospitals
and community health centers, as well as advertisements in
newspa-
pers and on Miami’s aboveground rail system. When individuals
initially contacted the laboratory, they were administered a brief
phone screen to determine eligibility, at which point
participants who
met criteria were scheduled for a baseline assessment. In total,
169
patients were assessed for eligibility to participate in family
treatment.
Participants meeting criteria for schizophrenia or
schizoaffective dis-
order were included in the study, and some symptoms of
psychosis
were present in the majority of individuals participating in the
treat-
ment. Because extremely severe psychosis could interfere with a
participant’s ability to understand the material covered in
therapy or
sustain attention for the 1.5-hr session, we excluded participants
with
scores of “6” (severe) or “7” (extremely severe) on the Brief
Psychi-
atric Rating Scale (BPRS) items of unusual thought content,
suspi-
ciousness, hallucinations, and conceptual disorganization,
instead re-
ferring them to more comprehensive care. Additional exclusion
criteria included having been incarcerated for violent crimes,
current
suicidality, a suicide attempt during the last year, and

involuntary
hospitalization within the past 3 months.
Doctoral-level clinical psychology students under the supervi-
sion of the study’s principal investigator, a licensed clinical
psy-
chologist, conducted the CIT-S and PSY-ED intervention pro-
grams. Data on individual depression, anxiety, and stress were
collected at baseline, treatment midpoint, and termination (three
time points). Patient symptom severity on the BPRS was
measured
at baseline, termination, and 6-month follow-up (three time
points). Data on family cohesion, the proposed mediator, were
obtained at baseline and again at midpoint, following the
conclu-
sion of the Family Collectivism module.
Measures
Patient diagnosis. Patient diagnosis of schizophrenia or
schizoaffective disorder was confirmed using the Structured
Clin-
Figure 1. Consort diagram. CIT-S � culturally informed family
therapy for schizophrenia; PSY-ED �
standard family psychoeducation.
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y.
ical Interview for DSM–IV Axis I Disorders (Version 2.0,
Patient
ed.; SCID-I/P; First, Spitzer, Gibbon, & Williams, 2002). All
interviewers watched six videotapes of SCID-I/P interviews and
independently rated each video to determine whether a
diagnosis
of schizophrenia or schizoaffective disorder was present or
absent,
with strong interrater reliability (Cohen’s k � 1.0). Because the
majority of patients with schizophrenia have a comorbid
diagnosis
of a substance use, mood, or anxiety disorder (Tsai &
Rosenheck,
2013), comorbid diagnoses were not excluded.
Psychotic symptom severity. The BPRS (Lukoff, Liberman,
& Nuechterlein, 1986) was used to measure patient symptom
severity across four domains: positive, negative, affective
(depres-
sion/anxiety), and manic symptoms. The BPRS is a 24-item
mea-
sure, with each question rated on a 7-point Likert scale.
Clinicians
code some items based on observed behavior and speech, and
others on patient self-report. After extensive training with the
principal investigator of the study, interviewers coded six BPRS
training tapes (Ventura, Green, Shaner, & Liberman, 1993).
Intra-
class correlations between interviewer ratings and consensus
rat-

ings from Ventura et al. (1993) ranged from .79 to .98 for all
items.
Depression, anxiety, and stress. The Depression Anxiety
Stress Scale (DASS; Lovibond & Lovibond, 1995) measured
gen-
eral emotional distress in patients and caregivers. The DASS
consists of 42 questions answered on a rating scale of 0 (Did
not
apply to me at all) to 3 (Applied to me very much, or most of
the
time). The scale contains three factors (depression, anxiety, and
stress), with 14 items per factor, and a total score can also be
calculated by summing the 42 items. The reliability for the
DASS
in the present sample was strong (Cronbach’s alpha � .96).
Family cohesion. Family unity was measured with the Family
Cohesion subscale of the Family Environment Scale (FES; Moos
& Moos, 1981). The Family Cohesion subscale of the FES con-
tains nine items rated true or false, all of which assess the
degree
of support, commitment, and assistance family members provide
one another. A total score is obtained by summing the nine
items,
with higher scores indicative of greater cohesion. The FES dem-
onstrated good reliability in the present sample (Cronbach’s al-
pha � .79).
Statistical Analyses
Preliminary analyses. Preliminary data analyses were con-
ducted in RStudio. A visual inspection of the variables included
in
the models indicated no violations of the assumptions of
normality

and homoscedasticity. BPRS, DASS, and FES scores were nor-
mally distributed, with skew and kurtosis values within normal
limits (skew � �2, kurtosis � �7; Kline, 2015), and therefore,
no
transformations were executed (see Figures 2a, 2b, 2c). The tra-
jectories of change of the variables were plotted to determine
the
most appropriate functional form (i.e., shape of trajectory over
time). The plots indicated linear trends for all three variables of
interest (Figures 2d, 2e, 2f), with notable variability in
individual
intercepts and growth trajectories. Residuals and random effects
were plotted to assess homoscedasticity, normality, and
homoge-
neity of variance, and we found no evidence of violations of
regression assumptions. Table 2 contains means and correlation
values for cohesion, BPRS, and DASS at each time point.
Attrition. Before testing models, we conducted an analysis of
treatment attrition for the CIT-S and PSY-ED groups. Several
demographic variables were related to treatment dropout. We
found that ethnicity was a significant predictor of treatment
drop-
out for CIT-S families, F(5, 57) � 7.27, p � .001, with families
where the patient identified as Black completing fewer
treatment
sessions on average (B � �9.86, p � .001, 95% confidence
interval [CI] [�14.9, �4.82]). In addition, education was a sig-
nificant predictor of treatment dropout for CIT-S families, F(1,
61) � 32.81, p � .001, such that greater education was
associated
with more sessions completed (B � 3.34, p � .001, 95% CI
[2.18,
4.51]. For PSY-ED families, dropout was not significantly pre-
dicted by ethnicity, F(4, 43) � 1.56, p � .201, nor education,

F(1,
46) � 2.04, p � .16. None of the primary outcome variables
were
associated with patient dropout in either group. Patient
symptom
severity on the BPRS was not a significant predictor of dropout
for
CIT-S, F(1, 58) � 3.64, p � .061, or PSY-ED, F(1, 42) � 0.12,
p � .73, families, in line with reports by Weisman de Mamani et
al. (2014). Similarly, DASS did not predict dropout for CIT-S,
F(1,
59) � .19, p � .67, or PSY-ED, F(1, 42) � .04, p � .85, nor did
family cohesion: CITS: F(1, 59) � .88, p � .35; PSY-ED: F(1,
42) � .03, p � .87. Further details regarding predictors of
attrition
in the CIT-S group are provided by Gurak, Weisman de
Mamani,
and Ironson (2017).
Model specification. The first step in model specification
involved testing independent latent-growth or latent-change
mod-
els for the outcomes of interest, with treatment included as a
predictor in all models. Mplus takes a multivariate approach to
account for dependency due to repeated measures, such that a
standard latent-growth model in Mplus represents a two-level
model in a standard multilevel modeling framework (Muthén &
Muthén, 2012). Since BPRS was a family-level variable, we as-
sessed BPRS effects with a standard latent-growth model.
Because
DASS was measured at the individual level, we specified DASS
growth models using a two-level latent-growth model in Mplus,
which accounted for the nesting of time points within
individuals,
and of individuals within families. In line with standard growth-
modeling practices (Muthén & Muthén, 2012), loadings for the

intercept latent variable were constrained at one, and loadings
for
the slope latent variable were set equal to the number of months
after baseline at which the measurements were taken (0, 4, and
10
months for BPRS; 0, 2, and 4 months for DASS). Because
family
cohesion scores were obtained from two time points (at baseline
and midpoint, after the Family Collectivism module), and
latent-
growth modeling requires a minimum of three indicators per
latent
construct, the trajectory of family cohesion was modeled using
a
latent-change score. A latent-change score model is
theoretically
similar to a latent-growth model but can accommodate change at
just two time points (Coman, Picho, McArdle, Villagra, Dierker,
&
Iordache, 2013; McArdle, 2009). To fit the latent-change model,
we first created a latent variable representing change in
cohesion,
specified with the single indicator of cohesion at midpoint. The
latent-change variable was regressed on baseline family
cohesion,
with the loading of both cohesion indicators constrained at 1.
The
estimate of the latent variable regressed on the treatment
variable
provided a measure of the treatment-related change in family
cohesion from baseline to the end of the Family Collectivism
module.
In the next step of the model testing process, the latent-change
score model for the mechanistic variable (cohesion) and the
latent-

growth models for the outcome (BPRS or DASS) were entered
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into parallel-process latent-growth/change models, which
allowed
us to model relationships between the treatment-related change
in
cohesion and treatment-related growth in the outcomes (i.e.,
indi-
rect effects). For all models, model fit was assessed according
to
the following criteria suggested by Kline (2015): �2 � .05,
root-
mean-square error of approximation � .06, comparative fit in-
dex � .95, and standardized root-mean-square residual � .08.
Effect sizes on growth parameters were calculated in accordance
Figure 2. Histograms of (a) Brief Psychiatric Rating Scale
(BPRS), (b) depression, anxiety, and stress (DASS),
and (c) cohesion; functional forms of (d) BPRS, (e) DASS, and
(f) cohesion.

Table 2
Means, Standard Deviations, and Correlation Matrix for
Cohesion, DASS, and BPRS at Each Time Point
Variable Cohesion 0 Cohesion 2 DASS 0 DASS 2 DASS 4
BPRS 0 BPRS 4 BPRS 10
Mean (SD) 5.89 (1.80) 5.95 (2.40) 37.94 (11.40) 32.87 (11.18)
27.15 (20.35) 53.10 (15.13) 48.12 (18.40) 50.55 (16.22)
Cohesion 0 1
Cohesion 2 .713 1
DASS 0 �.725 �.797 1
DASS 2 �.568 �.944 .798 1
DASS 4 �.607 �.621 .762 .674 1
BPRS 0 �.109 �.116 — — — 1
BPRS 4 �.024 �.186 — — — .292 1
BPRS 10 �.191 �.267 — — — .334 .703 1
Note. DASS � depression, anxiety, and stress; BPRS � Brief
Psychiatric Rating Scale.
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with the recommendations of Feingold (2013, 2015), using the
formula d � (b � duration)/SD, where b is the treatment effect
on
the slope of the outcome and SD is the pooled within-group
standard deviation of the outcome variable. The result of this
formula represents a standardized mean difference (Cohen’s d)
between-groups after treatment, with values above 0.2, 0.5, and
0.8
indicating small, medium, and large effect sizes, respectively.
Results
Treatment Effects on Individual Growth Models
We fit individual latent-growth or latent-change models to test
direct treatment effects and ensure model fit was adequate
before
combining them into parallel-process models and examining
indi-
rect effects. The latent-change model testing the treatment
effect
on family cohesion from baseline to midpoint indicated a Time
Treatment interaction. The CIT-S group exhibited an average
increase of roughly 1 unit on the FES from baseline to midpoint
(� � 0.93, SE � 0.44, p � .03, d � 0.82), whereas cohesion
levels
did not change for the PSY-ED group (see Table 3 for full
results
of the latent-change model, including 95% CIs). CIT-S outper-
formed PSY-ED in decreasing patient BPRS scores from
baseline
to 6-month follow-up (� � �1.72, SE � 0.57, p � .001, d �
0.63), and in decreasing patient and caregiver DASS scores
from

baseline to termination (� � �4.39, SE � 1.05, p � .001, d �
0.87). Tables 3 and 4 contain full results of fixed and random
effects, as well as 95% CIs and model fit statistics, for
treatment
effects on BPRS and DASS. In other words, all CIT-S effects
over
time were significant in the expected direction, and the linear
latent-growth models had good fit, suggesting that it was appro-
priate to examine indirect effects as parallel processes.
Parallel-Process Model: BPRS on Treatment via
Family Cohesion
The model including BPRS and the indirect effect of family
cohesion exhibited good fit, �2(8) � 15.214, p � .06. There
were
no significant differences between treatment groups in baseline
BPRS (CIT-S: M � 53.51; PSY-ED: M � 52.39; p � .56) or
family cohesion scores (PSY-ED: M � 5.80; CIT-S: M � 5.96;
p � .53). The standard PSY-ED treatment did not change BPRS
scores over time (� � 0.141, p � .823). However, there was a
Time Treatment interaction, such that patients in the CIT-S
group displayed a significant decrease in BPRS scores over time
(� � �1.91, p � .04, d � 0.63). A pattern also emerged for
family
cohesion: while families in the PSY-ED group did not exhibit
significant increases in average family cohesion from baseline
to
midpoint, families in the CIT-S group displayed an increase of
roughly 1 point on the FES cohesion scale (p � .025, d � 0.88).
We did not observe a significant indirect effect of treatment on
BPRS via family cohesion, as evidenced by the nonsignificant
regression of random slope of the outcome (BPRS) on the
latent-
change score of the average family cohesion (a � b � �0.29, p

�
.35). An examination of the variance components revealed a
ran-
dom effect of BPRS at baseline (
2 � 117.31, p � .001), as well
as random variability in change in BPRS over time (
2 � 6.69,
p � .009) and at individual time points (
2 � 111.32, p � .001).
Table 4 contains results and indices of model fit, and the full
parallel-process latent-growth model is depicted in Figure 3.
Parallel-Process Model: DASS on Treatment via
Family Cohesion
Next, we estimated a multilevel parallel-process latent-growth/
latent change model, with the goal of testing whether increases
in
family cohesion drove the increases in the treatment-related
changes in patient and family member DASS over time. The
model
including the indirect effect of treatment on DASS via family
cohesion exhibited good fit, �2(12) � 15.42, p � .22. Despite
random assignment to groups, the CIT-S group had slightly
higher
initial DASS scores compared to the PSY-ED group (CIT-S: M
�
38.582; PSY-ED: M � 37.425, p � .001). There was a
significant
effect of treatment on change in DASS, such that for each
month
elapsed from baseline, individuals in families in the CIT-S
group
exhibited a decrease of 3.571 units in DASS (p � .001; d �
0.70),
whereas for those in the PSY-ED Group DASS did not change

significantly over time (� � �0.60, SE � 0.70, p � .32). There
was not a significant increase in cohesion from baseline to mid-
point for the control group (� � �0.46, SE � 0.31, p � .144),
whereas the CIT-S group displayed an average increase of 0.94
units in cohesion over time (p � .001, d � 0.79). Furthermore,
there was a significant indirect effect of treatment on DASS via
family cohesion, such that for every unit increase in cohesion
from
baseline to midpoint, individuals in the CIT-S group displayed
an
additional 0.87-unit decrease in DASS on average (p � .004, d
�
0.17). We observed random effects of intercept and slope at the
individual level (intercept
2 � 811.522, p � .001; slope
2 �
17.048, p � .012), and of the intercept at the family level (
2 �
155.362, p � .001). Notably, individuals who started at higher
levels of DASS exhibited greater decreases in symptoms over
time
(
2 � �94.960, p � .001), and initial levels of DASS were nega-
tively associated with baseline family cohesion (
2 � �16.232, p �
.001). The full results and indices of model fit are contained in
Table 5, and Figure 4 presents a visualization of the full latent-
growth model.
Table 3
Latent Change Model for Family Cohesion
Effect Estimate (SE) 95% CI
Fixed

Cohesion_0 5.80�� (0.21) [5.40, 6.20]
Cohesion change (�) 1.08 (1.05) [�0.97, 3.13]
Treatment ¡ cohesion_0 0.16 (0.25) [�0.33, 0.65]
Treatment ¡ � 0.93� (0.44) [0.06, 1.80]
Cohesion_0 ¡ � �0.249 (0.13) [�0.49, 0]
Random
2 between families
Cohesion_0 3.382�� (0.24) [2.91, 3.86]
Cohesion change 2.78�� (0.44) [1.92, 3.64]
Note. Because the model was just identified, model fit statistics
were not
computed. CI � confidence interval.
� p � .05. �� p � .01.
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pu
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y.
Discussion
Capitalizing on statistical advances to study mechanisms and

growth trajectories, the present study builds upon published
find-
ings using the same clinical trial data, which indicated that CIT-
S
was effective in reducing schizophrenia symptom severity and
caregiver burden at treatment termination (Weisman de Mamani
et
al., 2014; Weisman de Mamani & Suro, 2016). We found that
the
CIT-S treatment effects lasted beyond the 15 weeks of therapy,
demonstrating that patients maintained a reduction in BPRS
symp-
tom severity at 6-month follow-up. Recognizing the importance
of
addressing the high rates of depression and anxiety in both
patients
with schizophrenia and their family caregivers, we addressed
whether CIT-S affected patient and caregiver DASS more
broadly,
a question that had not been previously assessed in the
literature.
In line with hypotheses, CIT-S yielded significant decreases in
depression, anxiety, and stress over time. Because family
cohesion
constituted a theoretical change mechanism, we evaluated the
relationship between treatment-related changes in cohesion and
BPRS/DASS over time. Representing tentative evidence for the
change theory, increases in cohesion with CIT-S were linked to
reductions in patient/caregiver DASS over time, although there
was not an indirect effect of treatment via cohesion on patient
schizophrenia symptoms on the BPRS.
While prior research demonstrated that CIT-S decreased care-
giver burden at treatment termination (Weisman de Mamani &
Suro, 2016), the current study is the first to demonstrate that
CIT-S

also significantly decreased patient and caregiver mood and
anx-
iety symptoms over the course of therapy. Given the elevated
risk
of emotional distress and mood symptoms associated with care-
giving (Magaña et al., 2007), it would be remiss to neglect care-
giver depression, anxiety, and stress in family therapy. More
than
a vehicle to reducing EE and patient relapse risk, caregiver
emo-
tional distress represented a key outcome in CIT-S. Similarly,
our
finding that CIT-S reduced individual DASS is promising with
regard to decreasing mood and anxiety symptoms in patients
with
schizophrenia, since negative and mood symptoms often persist
even in the absence of acute positive symptoms (Buckley et al.,
2009). Along with the difficult symptoms of psychosis, patients
experience complicated emotional distress surrounding stigma
and
illness-related burden, with evident implications for quality of
life
(Huppert & Smith, 2005). In spite of striking comorbidity rates
of
depressive and anxiety disorders in schizophrenia samples
(Buck-
ley et al., 2009); however, DASS is seldom a target of family
therapy. According to the present study, by infusing cultural
com-
ponents into traditional family psychoeducation, CIT-S led to
improvements in patient mental health in a broader sense. The
Table 4
Model Fit Statistics and Estimates of Fixed and Random Effects
for Latent Growth of BPRS and
Indirect Effect From Treatment to BPRS via Family Cohesion

Model 1: BPRS only Model 2: BPRS and cohesion
Statistic Estimate (SE) 95% CI Estimate (SE) 95% CI
Model fit statistics
Chi-square �2(3) � 7.093, p � .07 �2(8) � 15.214, p � .06
RMSEA 0.065 0.053
CFI 0.93 0.93
SRMR 0.029 0.05
Fixed effects
BPRS intercept (�) 52.37�� (1.48) [49.47, 55.27] 52.39��
(1.48) [49.49, 55.29]
BPRS slope (
) 0.28 (0.45) [�0.60, 1.16] 0.141 (0.63) [�1.09, 1.37]
Cohesion_0 5.80�� (0.21) [5.40, 6.20]
Cohesion change (�) 0.94 (1.06) [�1.13, 3.00]
Treatment ¡ � 1.22 (1.94) [�2.57, 5.02] 1.12 (1.91) [�2.63,
4.86]
Treatment ¡
�1.72�� (0.57) [�2.83, �0.60] �1.73� (0.86) [�3.41,
�0.05]
Treatment ¡ � 1.00� (0.45) [0.12, 1.88]
Cohesion_0 ¡ � �0.24 (0.12) [�0.48, 0]
� ¡
�0.29 (0.27) [�0.81, 0.23]
Indirect effect (a � b) �0.29 (0.31) [�0.89, 0.32]
Random effects
2 within families 101.42�� (17.04) [68.01, 134.82] 111.32��
(17.02) [77.96, 144.68]

2 between families
BPRS intercept 127.70�� (27.66) [73.48, 181.91] 117.31��
(26.10) [66.16, 168.45]
BPRS slope 5.00�� (1.87) [1.32, 8.67] 6.69�� (2.55) [1.70,
11.69]
BPRS intercept, slope �8.79 (7.00) [�22.51, 4.93] �7.629
(7.58) [�22.49, 7.23]
Cohesion_0 3.38�� (0.24) [2.91, 3.86]
Cohesion change 2.79�� (0.45) [1.91, 3.66]
BPRS intercept, cohesion_0 �3.06 (1.80) [�6.58, 0.45]
Note. BPRS � Brief Psychiatric Rating Scale; CI � confidence
interval; RMSEA � root-mean-square error
of approximation; CFI � comparative fit index; SRMR �
standardized root-mean-square residual.
� p � .05. �� p � .01.
T
hi
s
do
cu
m
en
t
is
co
py
ri

us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
impact of CIT-S on patient and family member DASS dovetails
with research on family stress and schizophrenia, which links

reductions in family stress with decreased rates of relapse risk
for
patients with schizophrenia (Liberman, Kopelowicz, Ventura, &
Gutkind, 2002), as well as improvements in both patient and
caregiver well-being.
Beyond demonstrating effects on DASS, the present study pio-
neers the investigation of mechanisms of action relevant to CIT-
S,
with a focus on the relationship between dynamic family
behaviors
and reductions in negative mental health outcomes. The increase
in
family cohesion for CIT-S families suggests that the early treat-
ment segments, and the Family Collectivism module in
particular,
successfully increased average perceptions of family warmth
and
positive sentiments. Family cohesion, a component introduced
in
the first treatment module but reinforced throughout the 15
weeks
of therapy, represented a key treatment ingredient for CIT-S.
Therapists fostered shared family values and experiences, with
the
idea that this would yield improvements in caregiver mental
health, as well as symptoms of psychopathology in patients with
schizophrenia (Weisman de Mamani et al., 2014). Given that
family cohesion was theoretically central to treatment
outcomes,
testing changes in cohesion—and the relationship of these
changes
to treatment results—was a key question in understanding the
impact of the culturally modified components that distinguish
CIT-S from other family therapies. Furthermore, this project
speaks to the utility of parallel-process growth modeling for

testing
dynamic mediation pathways, a practice that is underused in
clin-
ical trials (Cheong et al., 2003).
As discussed earlier, a number of cross-sectional studies have
reported a significant negative association between family cohe-
sion and schizophrenia symptom severity (González-Pinto et al.,
2011; Gurak & Weisman de Mamani, 2016), although this re-
search says little about the ability to cultivate family cohesion
in
therapy, and whether that would, in turn, yield patient benefits.
In
line with prior research, we found that there was a significant
baseline covariance of family cohesion and DASS (
2 � �16.232,
p � .001). A handful of longitudinal studies have shown that a
positive family environment predicts improvements in social
func-
tioning and psychiatric symptomatology in high-risk samples
(O’Brien, Gordon, Bearden, López, Kopelowicz, & Cannon,
2006). To our knowledge, however, this is the first study to
examine whether therapists can actually target family cohesion
in
treatment, and whether changes in this variable fuel changes in
psychiatric treatment outcomes. As part of CIT-S, families
spent
time discussing perceptions about the illness, engaging in
activities
to build cohesion, and working through problems with
communi-
cation skills. Given that CIT-S promoted active problem solving
and fostered team dynamics through shared activities, we
expected
the latent change in cohesion to predict decreases in depression,
anxiety, and stress in patients and caregivers alike, which was

supported by the data. By fostering family cohesion in therapy
through cultural modifications, clinicians can enhance
therapeutic
benefits for patients and caregivers alike.
Results of the current analysis should be considered in light of
several limitations that point to direction for continued research
on
CIT-S. In the present trial, treatment dropout was relatively
high
Figure 3. Parallel-process latent-growth model of direct and
indirect effects of treatment on patient schizo-
phrenia symptoms (BPRS). Full results of the model are
displayed in Table 4. BPRS � Brief Psychiatric Rating
Scale. � p � .05. �� p � .01.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh

er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
and led to missing data, unequal groups, and a general decrease
in
power. A key caveat of this was the lack of power to perform
groupwise analyses by ethnicity. Although Weisman de Mamani

et
al. (2014) reported that CIT-S was equally effective in reducing
schizophrenia symptoms across ethnic groups, there remains the
possibility that treatment mechanisms operate in a distinct
manner
according to ethnicity, particularly given that family cohesion
relates to a collectivistic orientation. Understanding differential
treatment mechanisms according to cultural factors such as col-
lectivism and interdependence will be an important question for
future studies on CIT-S. Thus, although growth models present
an
ideal framework for accounting for missingness (Curran et al.,
2010), testing CIT-S with larger samples and using more regular
outcome monitoring (e.g., every other session) is necessary to
understanding exactly how CIT-S taps into cultural factors.
While
dropout was not related to primary study variables, we did find
that
the demographic variables of ethnicity and education related to
attrition in the CIT-S group, with participants identifying as
Black
and reporting fewer years of education terminating treatment
sooner. Gurak, Weisman de Mamani, and Ironson (2017) ad-
dressed predictors of attrition in the context of religiosity,
noting
that religious participants may leave treatment earlier because
they
find sufficient recourse in spiritual coping or involvement with
their religious institution. By attempting to reduce dropout and
including a matched-length treatment-as-usual group in subse-
quent clinical trials of CIT-S, we may achieve greater
confidence
in the effects of specific CIT-S components.
It is also important to recognize that family cohesion is but one

of a number of treatment targets that may be relevant in
reducing
patient and caregiver symptoms, and within the construct of
family
cohesion, there may be specific aspects that are more relevant to
treatment outcomes than those captured by the Family Environ-
ment Scale (FES). As discussed in the introduction, we chose to
focus the present study on the mediating role of family cohesion
because it was distinctive among potential treatment targets.
Not
only is family cohesion a key construct in the Family
Collectivism
module, it is unique in that subsequent modules heavily
reinforce
the importance of family cohesion in order to achieve success in
therapy skills (e.g., family communication, problem solving).
However, in future research on CIT-S it will be important to
Table 5
Model Fit Statistics and Estimates of Fixed and Random Effects
for Multilevel Latent Growth of
DASS and Indirect Effect From Treatment to DASS via Family
Cohesion
Model 1: DASS only Model 2: DASS and cohesion
Statistic Estimate (SE) 95% CI Estimate (SE) 95% CI
Model fit statistics
Chi-square �2(3) � 8.364, p � .40 �2(12) � 15.42, p � .22
RMSEA 0.013 0.033
CFI 0.997 0.979
SRMRwithin 0.083 0.089
SRMRbetween 0.118 0.114
Fixed effects

DASS intercept (�) 37.66�� (3.61) [30.59, 44.73] 37.43��
(2.22) [33.07, 41.78]
DASS slope (
) �0.14 (.83) [�1.77, 1.48] �0.60 (0.70) [�1.80, 0.59]
Cohesion_0 5.92�� (0.22) [5.48, 6.35]
Cohesion change (�) �0.46 (0.31) [�1.07, 0.16]
Treatment ¡ � 1.07 (4.40) [�7.55, 9.69] 1.16�� (0.20) [0.77,
1.54]
Treatment ¡
�4.39�� (1.05) [�6.44. �2.34] �3.57�� (0.32) [�4.19,
�2.95]
Treatment ¡ � 0.94�� (0.23) [0.49, 1.38]
Cohesion_0 ¡ � �0.03� (0.02) [�0.06, �0.01]
� ¡
�0.93�� (0.10) [�1.13, �0.73]
Indirect effect (a � b) �0.87�� (0.31) [�1.47, �0.27]
Random effects
2 within person 111.92�� (40.18) [33.18, 190.66] 107.52��
(23.93) [60.61, 154.43]
2 within families
Time-specific variance 0.01 (4.51) [0, 0] 0 (�.001) [0, 0]
DASS intercept 796.65�� (104.25) [592.33, 1000.97]
811.52�� (88.07) [638.90, 984.15]
DASS slope 15.71� (7.80) [0.42, 31.00] 17.05� (6.81) [3.71,
30.39]
DASS intercept, slope �85.73�� (20.01) [�124.95, �46.50]
�94.96�� (20.74) [�135.61, �54.31]

2 between families
DASS intercept 163.15� (90.80) [�14.81, 341.10] 155.36��
(0.29) [154.80, 155.92]
Cohesion_0 3.25�� (0.36) [2.55, 3.96]
Cohesion change 2.58�� (0.54) [1.53, 3.63]
DASS intercept,
cohesion_0
�16.23�� (0.82) [�17.83, �14.64]
Note. DASS � depression, anxiety, and stress; CI � confidence
interval; RMSEA � root-mean-square error
of approximation; CFI � comparative fit index; SRMR �
standardized root-mean-square residual.
� p � .05. �� p � .01.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te

an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
include measures of other key treatment targets in order to test
alternative mediators, including communication skills.
Relatedly,
future studies may reconsider the way in which family cohesion
is

measured. While the items on the Family Cohesion subscale of
the
FES capture perceptions of the home environment, they may not
measure all aspects of interdependence, particularly those with
the
strongest theoretical links to patient functioning (Weisman &
López, 1996). Using measures of family cohesion that capture
changes in family dynamics in a more active way, such as in-
creased problem solving and engagement in shared activities,
may
help to illuminate any existing relationships between CIT-S,
fam-
ily functioning, and patient outcomes.
Nevertheless, the use of parallel-process latent-growth/change
models in an MSEM framework conferred a number of
significant
Figure 4. Parallel-process, two-level latent-growth model of
direct and indirect effects of treatment on patient
and caregiver depression, anxiety, and stress (DASS). Full
results of the model are displayed in Table 5.
� p � .05. �� p � .01.
T
hi
s
do
cu
m
en
t

is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss

oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti

cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in

di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

advantages with regard to characterizing growth at the
individual
and family level. Given the high proportions of missing data
due
to dropout, in line with typical rates of dropout in family
therapy
for schizophrenia (Weisman de Mamani et al., 2014), the growth
models allowed for flexibility with regard to unequal groups,
observations, and timing of data collection. Moreover, we were
able to capitalize on the multivariate multilevel modeling
frame-
work to establish temporal precedence of the mechanistic
variable
of interest, family cohesion. Rather than look at changes
between
mean levels of cohesion and our outcomes of interest, we
analyzed
the relationship between the change in DASS and change in
cohesion using a procedure that better reflects the dynamic
nature
of the theory underlying the development of CIT-S.
Ultimately, the results of the present analysis provide increased
support for the efficacy of CIT-S in reducing patient and
caregiver
psychopathology, and in promoting family cohesion, with
signif-
icant implications for clinical practice with diverse families.
With
regard to schizophrenia symptoms, CIT-S appears to exert a
lasting
impact on reducing patient psychosis, as the treatment effect

was
maintained at 6-month follow-up. Through empirically
grounded
cultural adaptations of family psychoeducation, CIT-S improved
symptoms of depression, anxiety, and stress in patients
grappling
with serious mental illness, as well as their caregivers. Future
studies will help to clarify further the parallel growth processes
at
work in explaining the dynamic relationships between changes
in
positive family factors, patient symptoms, and patient and care-
giver emotional distress.
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(Appendix follows)
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http://dx.doi.org/10.1080/0954026021000016905
http://dx.doi.org/10.1080/0954026021000016905
http://dx.doi.org/10.1037/0021-843X.113.3.428
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http://dx.doi.org/10.1016/0005-7967%2894%2900075-U
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http://dx.doi.org/10.1037/a0020141
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Appendix

Data Transparency
Prior manuscripts have been published using these data, which
were collected as part of a larger study of a randomized clinical
trial (RCT) of a culturally informed family therapy for
schizophre-
nia (CIT-S). Gurak, Weisman de Mamani, and Ironson (2017)
described predictors of attrition for CIT-S participants, with a
focus on religiosity, which we do not address. While another
study
examined the relationship between family cohesion and patient
symptoms (Gurak & Weisman de Mamani, 2016), they only as-
sessed these relationships using a cross-sectional design, before
treatment. In the current study, we look at how family cohesion
and psychiatric symptoms change dynamically over time with
treatment. Weisman de Mamani et al. (2014) focused on changes
in schizophrenia symptoms on the Brief Psychiatric Rating
Scale
(BPRS) from baseline to termination, whereas we examine
BPRS
scores at 6-month follow-up, which is key to understanding
whether CIT-S has a lasting impact on symptoms. Similarly,
although Weisman de Mamani and Suro (2016) tested the effect
of
CIT-S on caregiver burden and self-conscious emotions, it did
not
address the direct and indirect effects of CIT-S on DASS, which
is
a primary focus of this article. Furthermore, this is the first
study
to examine treatment mechanisms involved in the observed CIT-
S
effects over time, with a focus on family cohesion. We assessed
these mechanisms using a novel, multilevel, parallel-process

growth modeling framework, which we feel may serve as a
helpful
example of an underutilized resource for researchers evaluating
mediation processes in clinical trials.
Received June 12, 2017
Revision received August 23, 2017
Accepted August 28, 2017 �
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The Mediating Effect of Family Cohesion in Reducing Patient
Symptoms and Family Distress in a Cu
...MethodParticipantsProceduresMeasuresPatient
diagnosisPsychotic symptom severityDepression, anxiety, and
stressFamily cohesionStatistical AnalysesPreliminary
analysesAttritionModel specificationResultsTreatment Effects
on Individual Growth ModelsParallel-Process Model: BPRS on
Treatment via Family CohesionParallel-Process Model: DASS
on Treatment via Family
CohesionDiscussionReferencesAppendix Data Transparency
Understanding the complex family experiences

of Behavioural Family Therapy
Brendan O’Hanlon,a Laura Hayes,b
Amaryll Perleszc and Carol Harveyd
Family psychoeducational interventions including Behavioural
Family
Therapy have an impressive evidence base in the treatment of
schizo-
phrenia. While there are challenges in their implementation
including
the engagement of families, in the few qualitative studies of
Behavioural
Family Therapy, families report largely positive experiences.
Under-
standing more about families’ experiences of Behavioural
Family Ther-
apy could guide changes to practice to improve implementation.
This
qualitative study involved interviews with twenty clients
diagnosed with
schizophrenia and twenty relatives who participated in
Behavioural Fam-
ily Therapy in Australia. Participants valued sharing
experiences
between family members and their relationship with the
practitioner.
Unlike previous studies they reported discomfort in sessions
and disap-
pointment in aspects of Behavioural Family Therapy. Greater
emphasis
on addressing this discomfort and on therapeutic alliance may
help over-
come implementation challenges.

Practitioner points
• Practitioners can use their therapeutic alliance with families to
promote shared understanding by providing information as well
as facilitating information sharing between family members
• Practitioners need to recognize and respond to the high levels
of
discomfort experienced by families and particularly the vulner-
ability of the person with schizophrenia
• An increased focus on engagement and the therapeutic alliance
may improve the implementation of BFT in services
Keywords: Adult mental health; psychosocial and
psychoeducational approaches;
therapeutic relationship; qualitative research.
a Mental Health Program Manager, The Bouverie Centre, La
Trobe University, 8
Gardiner Street Brunswick, Victoria, 3056, Australia.
[email protected]
b Research Specialist, Parenting Research Centre.
c Adjunct Professor, The Bouverie Centre, La Trobe University.
d Director, Psychosocial Research Centre, Department of
Psychiatry, University of
Melbourne.
VC 2016 The Association for Family Therapy and Systemic
Practice
Journal of Family Therapy (2018) 40: 45–62
doi: 10.1111/1467-6427.12139

Introduction
Behavioural Family Therapy (BFT) is a form of family
psychoeduca-
tion, a group of approaches that focus on providing information
about mental illness and skills training to help families support
the
recovery of their mentally ill relative and reduce stress within
the fam-
ily. Family psychoeducation has been the subject of extensive
interna-
tional research indicating that it improves outcomes for people
experiencing schizophrenia and their families (McFarlane,
2016;
Pharoah, Mari, Rathbone and Wong, 2010). However, only a
small
number of British studies have sought to understand the actual
expe-
rience of families who have participated in BFT and similar
forms of
family psychoeducation (Budd and Hughes, 1997; Campbell,
2004;
James, Cushway and Fadden, 2006). This qualitative study
explores
the experience of family participants in BFT in Australia.
BFT consists of components of individual goal setting,
information
sharing about mental illness and skills training in
communication and
problem solving in the context of a supportive relationship
between a
practitioner and a family where a member experiences mental
illness
(Mueser and Glynn, 1999). In a number of controlled trials BFT
has

been associated with a reduction in relapse for people
experiencing
schizophrenia (Berglund, Vahlne and Edman, 2003; Glynn et
al.,
1992; Randolph et al., 1994; Schooler et al., 1997). BFT has
also been
found to reduce symptoms and the use of psychotropic
medication
and improve the functioning of the person with the condition
(Ber-
glund et al., 2003; Magliano et al., 2005; Magliano, Fiorillo,
Malan-
gone, De Rosa and Maj, 2006b; Montero et al., 2001; Schooler
et al.,
1997). In relation to family members, BFT has been associated
with
reduced carer burden and improved carer coping and family
func-
tioning (Berglund et al., 2003; Magliano et al., 2005; Magliano
et al.,
2006b; Mueser et al., 2001).
While outcome research is vital in demonstrating the value of
BFT, it provides less guidance about the practice of BFT and
how
the model might be improved (Mairs and Bradshaw, 2005).
Further-
more, despite impressive benefits, BFT and other forms of
family
psychoeducation are not provided in many jurisdictions
(Fadden,
2006; Haddock et al., 2014; Rummel-Kluge, Pitschel-Walz,
Bauml
and Kissling, 2006). Implementation of BFT in mental health
serv-
ices has proven challenging, with low levels of uptake by

practi-
tioners following training (Fadden, 2006; Onwumere, Grice and
Kuipers, 2016). Another challenge to increasing participation in
Brendan O’Hanlon et al.46
Practice
BFT concerns difficulties in engaging and retaining families in
BFT
(Fadden, 2006; Harvey and O’Hanlon, 2013; Magliano et al.,
2005;
Magliano, Fiorillo, Malangone, De Rosa and Maj, 2006a;
Onwumere
et al., 2016).
Although a diverse range of factors influence the extent of
imple-
mentation of new practices, one useful avenue for addressing
these dif-
ficulties is to consider adaptations to intervention models and
their
associated training programmes. Such adaptations could be
informed
by a deeper understanding of families’ and clients’ experience
of par-
ticipating in BFTwith the potential to improve engagement of
families,
enhance the relationship between the family and mental health
practi-
tioners and reduce premature cessation of the intervention
(Lambert,
Skinner and Friedlander, 2012; Priebe and McCabe, 2006).

However, despite the potential value of understanding the
family
and client perspectives concerning participating in BFT, their
experi-
ence has been infrequently investigated. Previous research
concern-
ing family experience of BFT or similar interventions is limited
to
three studies conducted in the United Kingdom with largely
English-
speaking families (Budd and Hughes, 1997; Campbell, 2004;
James
et al., 2006). The common themes that emerged in these studies
relate to the importance of practitioners’ personal qualities and
the
value of collaborative and supportive relationships between
family
and practitioners (which BFT enhanced). These accounts of the
experience of BFT were almost exclusively positive, with
families
endorsing the value of the approach (Budd and Hughes, 1997;
James et al., 2006).
Building Family Skills Together was a project based in
Melbourne,
Australia, that aimed to establish BFT in an adult community
mental
health service and research both the process of implementation
(O’Hanlon, 2015) and the outcomes (Hayes, 2014). The research
questions in this study were: What are the client and family
experien-
ces of BFT in an Australian mental health context? How do
these
experiences provide guidance about how the BFT model could
be

best practised and implemented in mental health services?
Method
Setting
Behavioural Family Therapy (BFT) was conducted at two
community
mental health centres located in disadvantaged urban and
suburban
Family experiences of BFT 47
Practice
areas of Melbourne, Australia. All the practitioners at each of
the
centres completed a five-day training programme and were
provided
with a practice manual developed by the Meriden Family
Programme
(Falloon et al., 2004). Practitioners were also provided with
follow-up
support in use of the model, including co-working as part of the
Building Family Skills Together project.
Intervention
Families were usually seen for BFT sessions at weekly or
fortnightly
intervals for one hour at a home or office setting. The length of
con-
tact varied with an average of twelve sessions (68SD) conducted

over
six to nine months. Most sessions were conducted with two
practi-
tioners, one of whom was directly responsible for the client’s
ongoing
treatment and usually a novice practitioner of BFT. The other
was an
experienced family therapist and BFT practitioner from a
specialist
family mental health service that was supporting the
implementation
of the approach.
Participants
Forty-seven families who had participated in BFTwere
approached to
participate in interviews about their experience of the
intervention.
Nineteen clients and seventeen carers (ten parents, three
spouses and
four siblings) completed individual interviews; four family
dyads (two
parent/adult child, one husband/wife, and one sibling pair)
completed
the conjoint interviews. Three clients and one relative
participated in
both the individual and conjoint interviews. Overall twenty
clients
and twenty carers were interviewed.
The age of the clients ranged from 18 to 60 years. Fourteen
were
male and seventeen were never married. Seven were working at
least
part-time.

The relatives’ age ranged from 25 to 61 years. Thirteen were
female, eleven were currently partnered, and ten were working
at
least part-time.
Fourteen of the clients lived with their relatives, and sixteen of
the
relatives lived with their family member who was a client.
Three cli-
ents and six family members were born overseas (three clients
and
five carers from Europe and one carer from Asia).
Brendan O’Hanlon et al.48
Practice
Data collection
Two interview approaches were used. The first was in-depth
hour-
long interviews with the client and self-nominated family
member
interviewed together by the first author (BOH), six to twelve
months
after the conclusion of BFT sessions. Using combination
purposeful
sampling (Patton, 2002), clients and their families were
identified,
firstly, on the basis that they had participated in at least eight
sessions
of BFT. Secondly, families were selected to reflect the mix of

cultural
backgrounds and family constellations (partner, parental and
sibling
groupings) of the treatment group.
The second approach involved brief (10 to 15 minutes) semi-
structured interviews, using an interview guide, and with a self-
nominated family member and the client separately. The second
author conducted these interviews immediately following the
conclu-
sion of BFTsessions.
The two different interview approaches maximized the
opportunity
to capture the widest variation in responses, due to differences
in time
after treatment (both immediate response and later reflections),
analo-
gous to post-testing and follow-up assessments in quantitative
methods,
interview length, interview structure and sampling strategy. The
use of
conjoint and split interviews allowed exploration of a wider
range of
responses to the family sessions. Shared experiences were
discussed in
conjoint interviews and split interviews allowed participants to
freely
state reflections on their experience that they might have been
uncom-
fortable expressing in front of other family members.
Interviews were recorded digitally and then transcribed or
through field notes taken by the interviewer.
Data analysis

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