Transcript WHY IS FAMILY WORK WITH DD SO IMPORTANT

Multiple Family Groups: Using
Research Based Methods for
Improving Outcomes for Persons with
Psychosis
Susan Gingerich
Philadelphia, PA
[email protected]
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AGENDA
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History of family psychoeducation for
psychosis
Multiple family group model
Research support
Critical ingredients
Strategies for implementation
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HISTORICAL ANTECEDANTS TO
FAMILY PSYCHOEDUCATION (FPE)
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Lack of support for psychogenic theories
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Rise in biological-environmental theories
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Deinstitutionalization
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Family advocacy movement arguing for better
treatment & greater collaboration (e.g., National
Alliance on Mental Illness)
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Evidence that family stress worsens course
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9-Month Relapse Rate
Family Stress and Relapse
From: Butzlaff & Hooley (1998)
RESEARCH ON FAMILY
PSYCHOEDUCATION
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Multiple randomized controlled trials
Most early research focused on recently
hospitalized clients discharged to family
Preponderance of research on schizophrenia
More recent trials on bipolar disorder &
treatment refractory major depression
Striking effects on reducing relapses
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Combined Results of Family Intervention
Programs on 2-year Cumulative Relapse Rates
in Schizophrenia (11 Studies)
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RESEARCH RESULTS, cont’d
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Improved client functioning
Reduction in family burden
Reduced family stress
Cost-effective
Effective across a variety of cultures
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CONTROLLED RESEARCH
CONDUCTED IN DIFFERENT
CULTURES
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African American
Latino in U.S.
Spain, Italy, the Netherlands, Great Britain,
Germany
China
Japan
India
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WHAT CREATES POSITIVE
OUTCOMES?
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Reduction of family stress
Modifying relatives attributions about
symptoms and responsibility
Teaching more effective coping behaviors
(e.g., problem solving)
 Improved family monitoring of illness &
access to treatment team for rapid
intervention
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THE STRESS-VULNERABILITY-FAMILY COPING
SKILLS MODEL OF BFT (MUESER & GLYNN, 1999)
Psychotropic
Medication
Substance
Abuse
Relative’s SocioEnvironmental Stressors
Relative’s Coping
Biological
Vulnerability
Life Events
Patient’s SocioEnvironmental Stressors
Psychiatric Outcome
(Patient’s Symptoms,
Social & Vocational
Functioning
Patient’s Coping
VALIDATED MODELS OF
FAMILY
PSYCHOEDUCATION
 Falloon; Mueser & Glynn; Miklowitz: behavioral
family therapy/family-focused therapy bipolar
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Barrowclough & Tarrier: behavioral family
approach
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Anderson et al: eclectic family psychoeducation
including “survival skills workshop”
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VALIDATED MODELS,
CONT’D
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Leff et al: broad-based family psychoeducation
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McFarlane et al: multi-family group approach
based on Anderson et al group psychoeducation
“survival skills workshop” & Falloon problem
solving approach
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CRITICAL INGREDIENTS OF
EFFECTIVE MODELS
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Longer-term (9 months or longer)
Delivered by professionals
Broad view of who is “family”
Inclusion of individual in family sessions
Education of families about mental disorders
Concern & empathy demonstrated for individual &
relatives
Avoidance of blaming or pathologizing family
Fostering the development of all family members
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CRITICAL INGREDIENTS
(cont.)
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Improvement in communication & problemsolving skills
Flexible & tailored to each family needs
Encouragement of family members to
develop social supports outside the family
Instilling hope for the future
Developing a collaborative relationship with
family
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DISTINGUISHING FEATURES
BETWEEN MODELS
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Emphasis on social learning (skills training)
Format: single-family vs. multiple family vs.
combination
Systems perspective in understanding
impact of mental illness on role of family
Extent of focus on whole family vs. member
with illness
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MULTIPLE FAMILY GROUP
MODEL (MCFARLANE)
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Combines elements of behavioral family therapy
(problem-solving) with survival skills workshop
Provides support, additional ideas, hope,
inspiration from peers
Vehicle for cost effective use of staff time
Changes atmosphere to one of hope
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The History of Multifamily
Groups
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Originated 30+ years ago New York &
Vermont hospitals
Families were offered education in a group
format without patients
Patients wanted to join
Hospital staff noticed significant
improvements
improved family involvement and
communication
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
Core elements of multiple family
group model
Joining
Education
Problem-solving
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
Stages of treatment in family
psychoeducation
Joining
Family and
consumer
3-6 weeks
Educational
workshop
1 day
Ongoing
sessions
Families and
Consumer
1-4 years
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
JOINING
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Contents of Joining Sessions
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Getting to know each other, feel safe with
each other
Identify early warning signs of illness and
what has been done about them
Identify characteristic precipitants for relapse
(“triggers”)
Explore reactions to illness
Identify coping strategies
Review family social networks Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
The Psychoeducation
Workshop
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
6-8 Families Brought Together
After Individual Joining Sessions
6 hours of illness education
 relaxed, friendly atmosphere
 co-leaders act as hosts
 questions and interactions
encouraged
 Food
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Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
Psychoeducation
Workshop Agenda
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History and epidemiology
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Biology of illness
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Treatment: effects and side effects
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Family emotional reactions
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Family behavioral reactions
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Guidelines for coping (family guidelines)
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Socializing
Evidence-Based Practices
Copyright West Institute
William R. McFarlane, MD
The workshop is held in a
classroom or round table
format
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Promotes comfort
Families can interact without pressure
Encourages learning
Practitioners act as
educators
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
Family Guidelines
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GO SLOW (Recovery takes time.)
KEEP IT COOL.
(Tone it down.)
GIVE EACH OTHER SPACE. (Time out is
important for everyone.)
SET LIMITS. (A few good rules keep things clear. All
should know the rules)
IGNORE WHAT YOU CAN’T CHANGE
(Let some things go. Don’t ignore violence)
Family Guidelines (Cont.)
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KEEP IT SIMPLE (Say things clearly)
FOLLOW THE DOCTORS ORDERS
CARRY ON BUSINESS AS USUAL (Stay in touch
with family and friends)
NO STREET DRUGS OR ALCOHOL
PICK UP ON EARLY SIGNS (Changes)
SOLVE PROBLEMS STEP BY STEP (One thing at a
time)
LOWER EXPECTATIONS TEMPORARILY
MULTIPLE FAMILY
GROUP SESSIONS
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
Structure of Group Session
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Socialization: 10-15 minutes
Review of last session’s progress: 5-10 min.
Go round: 1 item of what’s going well, 1 item
of what’s not going well: 20 min.
Formal problem solving: 30-45 minutes
Final socialization: 5-10 minutes
Core of group sessions: Problem-solving
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Borrowed from organizational management
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Offers benefit of multiple, new perspectives
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Controls affect and arousal
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Compensates for information-processing
difficulties in some individuals and relatives
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Organized and systematic
Helps people succeed and overcome failure
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
6 Step Problem Solving
Method
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1. Define ( What is the problem or goal?)
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2. List all possible solutions
3. List pluses and minuses of each solution
4. Choose the best solution or combination of
solutions
5. Plan the steps to carry out the best solution (make
an action plan)
6. Follow up how the solution worked
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Suggested Hierarchy for Problem
Solving
 Safety
Issues in the home
 Medication or other treatment
adherence
 Street drug and alcohol use
 Life events
 Conflicts between family members
 Conflicts with family guidelines
Where can groups
be held?
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Out-patient settings
In-patient units
Partial hospital programs
ACT (Assertive Community Treatment)
programs
Nursing homes
Family advocacy organizations
In community,such as library, school,
church, synagogue or mosques
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
STRATEGIES FOR STARTING
FAMILY PROGRAMS
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Prioritizing families with a recent crisis (e.g.,
hospitalization)
Grouping families whose relatives have same
diagnosis
Focusing on families with highest levels of contact
with person (e.g., > 4 hours/week)
Planning how to respond to common concerns
raised by person (stress of participating, burdening
relatives) & their relatives (time commitment,
hopelessness)
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Strategies for Implementation, cont’d
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Using person to activate system: motivational
interviewing & ongoing dialogue about benefits of
involving family in treatment
Establishing clear organizational structure for
implementing (team approach with clear roles and
expectations)
Planning a range of family services (short and longterm)
Modifying model carefully when indicated
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Possible Modifications
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Briefer psychoeducational workshop (e.g., an evening
workshop 6PM-9PM with pizza)
Inclusion of different diagnoses
Groups run by clinicians for families on their own
treatment teams
Motivational interviewing to help clients make informed
decisions about involving relatives in their treatment
Cultural adaptations
Focusing on specific problem area (e.g., medication)
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POSSIBLE STEPS FOR LAUNCHING
FAMILY PROGRAMS
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Set up a team of provides and an advisory board
including family members
Survey the number of individuals receiving services
who have family contact
Target who your agency would like to provide
services to first
Consider targeting individuals who are newly
admitted or recently in crisis or newly diagnosed
Keep track of number of families served
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STRATEGIES FOR
LAUNCHING (cont.)
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Set goals for how many families your agency will
be serving at 3 months, 6 months, 1 year
Provide regular feedback to advisory group, staff
members, individuals, families regarding how
goals are being met
Measure family involvement and outcomes
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SUMMARY
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Family psychoeducation is an evidence-based
practice for psychosis shown to reduce relapses &
hospitalizations, improve client functioning, &
reduce caregiver burden
The multiple family group involves three stages:
joining, psychoeducation workshop, and twice
monthly multiple family sessions focused on
problem-solving
Family groups are enormously rewarding for both
families and professionals
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Closing Thoughts
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“Never doubt that a small group of thoughtful,
committed people can change the world. Indeed, it is
the only thing that ever has.” Margaret Meade
As part of this conference, you have joined a nationwide effort to change the course of mental illness for
individuals and their families.
Thank you for the opportunity to be a part of this.
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