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Multiple Family Groups: Multiple Family Groups: Using Research Based Using Research Based Methods for Improving Methods for Improving

Outcomes for Persons with Outcomes for Persons with PsychosisPsychosis

Susan GingerichSusan GingerichPhiladelphia, PAPhiladelphia, PA

gingsusan@yahoo.comgingsusan@yahoo.com

AGENDAAGENDA

History of family History of family psychoeducation for psychosispsychoeducation for psychosis

Multiple family group modelMultiple family group model Research support Research support Critical ingredientsCritical ingredients Strategies for implementationStrategies for implementation

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HISTORICAL ANTECEDANTS HISTORICAL ANTECEDANTS TO FAMILY TO FAMILY

PSYCHOEDUCATION (FPE)PSYCHOEDUCATION (FPE) Lack of support for psychogenic theoriesLack of support for psychogenic theories

Rise in biological-environmental theoriesRise in biological-environmental theories

DeinstitutionalizationDeinstitutionalization

Family advocacy movement arguing for Family advocacy movement arguing for better treatment & greater collaboration better treatment & greater collaboration (e.g., National Alliance on Mental Illness)(e.g., National Alliance on Mental Illness)

Evidence that family stress worsens Evidence that family stress worsens coursecourse

Family Stress and RelapseFamily Stress and Relapse

From: Butzlaff & Hooley (1998)

9-M

onth

Rel

apse

R

ate

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RESEARCH ON FAMILY RESEARCH ON FAMILY PSYCHOEDUCATIONPSYCHOEDUCATION

Multiple randomized controlled trialsMultiple randomized controlled trials Most early research focused on Most early research focused on

recently hospitalized clients recently hospitalized clients discharged to familydischarged to family

Preponderance of research on Preponderance of research on schizophreniaschizophrenia

More recent trials on bipolar disorder More recent trials on bipolar disorder & treatment refractory major & treatment refractory major depressiondepression

Striking effects on reducing relapsesStriking effects on reducing relapses

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Combined Results of Family Combined Results of Family Intervention Programs on 2-year Intervention Programs on 2-year

Cumulative Relapse Rates in Cumulative Relapse Rates in Schizophrenia (11 Studies)Schizophrenia (11 Studies)

64%

28% 28% 26%

0%

10%

20%

30%

40%

50%

60%

70%Standard Care(N=179)

Single FamilyTreatment(N=207)

Multiple FamilyGroup Treatment(N=266)

Single & MultipleFamily GroupTreatment(N=243)

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RESEARCH RESULTS, RESEARCH RESULTS, cont’dcont’d

Improved client functioningImproved client functioning Reduction in family burdenReduction in family burden Reduced family stressReduced family stress Cost-effectiveCost-effective Effective across a variety of Effective across a variety of

culturescultures

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CONTROLLED RESEARCH CONTROLLED RESEARCH CONDUCTED IN CONDUCTED IN

DIFFERENT CULTURESDIFFERENT CULTURES African AmericanAfrican American Latino in U.S.Latino in U.S. Spain, Italy, the Netherlands, Spain, Italy, the Netherlands,

Great Britain, GermanyGreat Britain, Germany ChinaChina JapanJapan India India

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WHAT CREATES WHAT CREATES POSITIVE OUTCOMES?POSITIVE OUTCOMES?

Reduction of family stressReduction of family stress Modifying relatives attributions Modifying relatives attributions

about symptoms and responsibilityabout symptoms and responsibility Teaching more effective coping Teaching more effective coping

behaviors (e.g., problem solving)behaviors (e.g., problem solving) Improved family monitoring of Improved family monitoring of

illness & access to treatment illness & access to treatment team for rapid interventionteam for rapid intervention

THE STRESS-VULNERABILITY-FAMILY THE STRESS-VULNERABILITY-FAMILY COPING SKILLS MODEL OF BFT (MUESER & COPING SKILLS MODEL OF BFT (MUESER &

GLYNN, 1999)GLYNN, 1999)

PsychotropicMedication

BiologicalVulnerability

SubstanceAbuse

Psychiatric Outcome(Patient’s Symptoms,Social & Vocational

Functioning

Relative’s Socio-Environmental Stressors

Relative’s Coping

Patient’s Socio-Environmental Stressors

Patient’s Coping

Life Events

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VALIDATED MODELS OF VALIDATED MODELS OF FAMILY FAMILY

PSYCHOEDUCATION PSYCHOEDUCATION Falloon; Mueser & Glynn; Miklowitz: Falloon; Mueser & Glynn; Miklowitz: behavioral family therapy/family-behavioral family therapy/family-focused therapy bipolarfocused therapy bipolar

Barrowclough & Tarrier: behavioral Barrowclough & Tarrier: behavioral family approachfamily approach

Anderson et al: eclectic family Anderson et al: eclectic family psychoeducation including “survival psychoeducation including “survival skills workshop”skills workshop”

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VALIDATED MODELS, VALIDATED MODELS, CONT’DCONT’D

Leff et al: broad-based family Leff et al: broad-based family psychoeducationpsychoeducation

McFarlane et al: multi-family group McFarlane et al: multi-family group approach based on Anderson et al approach based on Anderson et al group psychoeducation “survival skills group psychoeducation “survival skills workshop” & Falloon problem solving workshop” & Falloon problem solving approachapproach

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CRITICAL INGREDIENTS CRITICAL INGREDIENTS OF EFFECTIVE MODELSOF EFFECTIVE MODELS

Longer-term (9 months or longer)Longer-term (9 months or longer) Delivered by professionalsDelivered by professionals Broad view of who is “family”Broad view of who is “family” Inclusion of individual in family sessionsInclusion of individual in family sessions Education of families about mental Education of families about mental

disordersdisorders Concern & empathy demonstrated for Concern & empathy demonstrated for

individual & relativesindividual & relatives Avoidance of blaming or pathologizing Avoidance of blaming or pathologizing

familyfamily Fostering the development of all family Fostering the development of all family

membersmembers

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CRITICAL INGREDIENTS CRITICAL INGREDIENTS (cont.)(cont.)

Improvement in communication & Improvement in communication & problem-solving skillsproblem-solving skills

Flexible & tailored to each family Flexible & tailored to each family needsneeds

Encouragement of family members Encouragement of family members to develop social supports outside to develop social supports outside the familythe family

Instilling hope for the futureInstilling hope for the future Developing a collaborative Developing a collaborative

relationship with familyrelationship with family

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DISTINGUISHING DISTINGUISHING FEATURES BETWEEN FEATURES BETWEEN

MODELSMODELS Emphasis on social learning Emphasis on social learning (skills training)(skills training)

Format: single-family vs. Format: single-family vs. multiple family vs. combinationmultiple family vs. combination

Systems perspective in Systems perspective in understanding impact of mental understanding impact of mental illness on role of familyillness on role of family

Extent of focus on whole family Extent of focus on whole family vs. member with illnessvs. member with illness

MULTIPLE FAMILY MULTIPLE FAMILY GROUP MODEL GROUP MODEL (MCFARLANE)(MCFARLANE)

Combines elements of behavioral Combines elements of behavioral family therapy (problem-solving) family therapy (problem-solving) with survival skills workshopwith survival skills workshop

Provides support, additional ideas, Provides support, additional ideas, hope, inspiration from peershope, inspiration from peers

Vehicle for cost effective use of staff Vehicle for cost effective use of staff timetime

Changes atmosphere to one of hope Changes atmosphere to one of hope

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The History of The History of Multifamily GroupsMultifamily Groups

Originated 30+ years ago New Originated 30+ years ago New York & Vermont hospitalsYork & Vermont hospitals

Families were offered education in Families were offered education in a group format without patientsa group format without patients

Patients wanted to joinPatients wanted to join Hospital staff noticed significant Hospital staff noticed significant

improvementsimprovements improved family involvement and improved family involvement and

communicationcommunicationEvidence-Based PracticesEvidence-Based Practices

CopyrightCopyright West Institute West Institute

William R. McFarlane, MDWilliam R. McFarlane, MD

Core elements of multiple Core elements of multiple family group modelfamily group model

JoiningJoining

EducationEducation

Problem-Problem-solvingsolving

Evidence-Based PracticesEvidence-Based PracticesCopyrightCopyright West Institute West Institute

William R. McFarlane, MDWilliam R. McFarlane, MD

Stages of treatment in family psychoeducation

Joining

Family and consumer 3-6 weeks

Educa-tional

workshop

1 day

Ongoing sessions

Families and Consumer 1-4 years

Evidence-Based PracticesCopyright West Institute

William R. McFarlane, MD

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Contents of Joining Contents of Joining SessionsSessions

Getting to know each other, feel Getting to know each other, feel safe with each othersafe with each other

Identify early warning signs of Identify early warning signs of illness and what has been done illness and what has been done about themabout them

Identify characteristic precipitants Identify characteristic precipitants for relapse (“triggers”) for relapse (“triggers”)

Explore reactions to illness Explore reactions to illness Identify coping strategies Identify coping strategies Review family social networks Review family social networks Evidence-Based Practices

Copyright West Institute

William R. McFarlane, MD

The The Psychoeducation Psychoeducation

WorkshopWorkshop

Evidence-Based PracticesCopyright West Institute

William R. McFarlane, MD

6-8 Families Brought 6-8 Families Brought Together After Individual Together After Individual

Joining SessionsJoining Sessions

6 hours of illness education6 hours of illness education relaxed, friendly atmosphere relaxed, friendly atmosphere co-leaders act as hostsco-leaders act as hosts questions and interactions questions and interactions

encouragedencouraged FoodFood

Evidence-Based PracticesCopyright West Institute

William R. McFarlane, MD

Psychoeducation Psychoeducation Workshop AgendaWorkshop Agenda

History and epidemiologyHistory and epidemiology

Biology of illnessBiology of illness

Treatment: effects and side effectsTreatment: effects and side effects

Family emotional reactionsFamily emotional reactions

Family behavioral reactionsFamily behavioral reactions

Guidelines for coping (family Guidelines for coping (family guidelines)guidelines)

SocializingSocializingEvidence-Based PracticesCopyright West Institute

William R. McFarlane, MD

The workshop is held The workshop is held in a classroom or in a classroom or

round table formatround table format Promotes comfortPromotes comfort Families can interact without Families can interact without

pressurepressure Encourages learningEncourages learning Practitioners act asPractitioners act as

educatorseducators

Evidence-Based PracticesCopyright West Institute

William R. McFarlane, MD

Family GuidelinesFamily Guidelines GO SLOW (Recovery takes time.)GO SLOW (Recovery takes time.) KEEP IT COOL. (Tone it down.)KEEP IT COOL. (Tone it down.) GIVE EACH OTHER SPACE. (Time out is GIVE EACH OTHER SPACE. (Time out is

important for everyone.)important for everyone.) SET LIMITS. (A few good rules keep SET LIMITS. (A few good rules keep

things clear. All should know the rules)things clear. All should know the rules) IGNORE WHAT YOU CAN’T CHANGEIGNORE WHAT YOU CAN’T CHANGE

(Let some things go. Don’t ignore (Let some things go. Don’t ignore violence)violence)

Family Guidelines (Cont.)Family Guidelines (Cont.) KEEP IT SIMPLE (Say things clearly)KEEP IT SIMPLE (Say things clearly) FOLLOW THE DOCTORS ORDERSFOLLOW THE DOCTORS ORDERS CARRY ON BUSINESS AS USUAL (Stay in CARRY ON BUSINESS AS USUAL (Stay in

touch with family and friends)touch with family and friends) NO STREET DRUGS OR ALCOHOLNO STREET DRUGS OR ALCOHOL PICK UP ON EARLY SIGNS (Changes)PICK UP ON EARLY SIGNS (Changes) SOLVE PROBLEMS STEP BY STEP (One SOLVE PROBLEMS STEP BY STEP (One

thing at a time)thing at a time) LOWER EXPECTATIONS TEMPORARILYLOWER EXPECTATIONS TEMPORARILY

MULTIPLE MULTIPLE FAMILY GROUP FAMILY GROUP

SESSIONSSESSIONS

Evidence-Based PracticesCopyright West Institute

William R. McFarlane, MD

Structure of Group Structure of Group SessionSession

Socialization: 10-15 minutesSocialization: 10-15 minutes Review of last session’s progress: 5-Review of last session’s progress: 5-

10 min.10 min. Go round: 1 item of what’s going well, Go round: 1 item of what’s going well,

1 item of what’s not going well: 20 1 item of what’s not going well: 20 min.min.

Formal problem solving: 30-45 Formal problem solving: 30-45 minutesminutes

Final socialization: 5-10 minutesFinal socialization: 5-10 minutes

Core of group sessions: Problem-solvingCore of group sessions: Problem-solving

• Borrowed from organizational management

• Offers benefit of multiple, new perspectives

• Controls affect and arousal

• Compensates for information-processing difficulties in some individuals and relatives

• Organized and systematic

• Helps people succeed and overcome failure

Evidence-Based PracticesCopyright West Institute

William R. McFarlane, MD

6 Step Problem 6 Step Problem Solving MethodSolving Method

11. Define ( What is the problem or goal?). Define ( What is the problem or goal?) 2. List all possible solutions2. List all possible solutions 3. List pluses and minuses of each 3. List pluses and minuses of each

solutionsolution 4. Choose the best solution or 4. Choose the best solution or

combination of solutionscombination of solutions 5. Plan the steps to carry out the best 5. Plan the steps to carry out the best

solution (make an action plan)solution (make an action plan) 6. Follow up how the solution worked6. Follow up how the solution worked

Suggested Hierarchy for Suggested Hierarchy for Problem SolvingProblem Solving

Safety Issues in the homeSafety Issues in the home Medication or other treatment Medication or other treatment

adherence adherence Street drug and alcohol useStreet drug and alcohol use Life eventsLife events Conflicts between family Conflicts between family

membersmembers Conflicts with family guidelinesConflicts with family guidelines

Where can groups Where can groups be held?be held?

Out-patient settingsOut-patient settings In-patient unitsIn-patient units Partial hospital programsPartial hospital programs ACT (Assertive Community ACT (Assertive Community

Treatment) programsTreatment) programs Nursing homesNursing homes Family advocacy organizationsFamily advocacy organizations In community,such as library, In community,such as library,

school, church, synagogue or school, church, synagogue or mosquesmosques

Evidence-Based PracticesCopyright West Institute

William R. McFarlane, MD

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STRATEGIES FOR STARTING STRATEGIES FOR STARTING FAMILY PROGRAMSFAMILY PROGRAMS

Prioritizing families with a recent crisis Prioritizing families with a recent crisis (e.g., hospitalization)(e.g., hospitalization)

Grouping families whose relatives have Grouping families whose relatives have same diagnosissame diagnosis

Focusing on families with highest levels of Focusing on families with highest levels of contact with person (e.g., > 4 hours/week)contact with person (e.g., > 4 hours/week)

Planning how to respond to common Planning how to respond to common concerns raised by person (stress of concerns raised by person (stress of participating, burdening relatives) & their participating, burdening relatives) & their relatives (time commitment, relatives (time commitment, hopelessness)hopelessness)

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Strategies for Strategies for Implementation, cont’dImplementation, cont’d

Using person to activate system: Using person to activate system: motivational interviewing & ongoing motivational interviewing & ongoing dialogue about benefits of involving family dialogue about benefits of involving family in treatmentin treatment

Establishing clear organizational Establishing clear organizational structure for implementing (team structure for implementing (team approach with clear roles and approach with clear roles and expectations)expectations)

Planning a range of family services (short Planning a range of family services (short and long-term)and long-term)

Modifying model carefully when indicatedModifying model carefully when indicated

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Possible ModificationsPossible Modifications

Briefer psychoeducational workshop (e.g., an Briefer psychoeducational workshop (e.g., an evening workshop 6PM-9PM with pizza)evening workshop 6PM-9PM with pizza)

Inclusion of different diagnosesInclusion of different diagnoses Groups run by clinicians for families on their Groups run by clinicians for families on their

own treatment teamsown treatment teams Motivational interviewing to help clients Motivational interviewing to help clients

make informed decisions about involving make informed decisions about involving relatives in their treatmentrelatives in their treatment

Cultural adaptationsCultural adaptations Focusing on specific problem area (e.g., Focusing on specific problem area (e.g.,

medication)medication)

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POSSIBLE STEPS FOR POSSIBLE STEPS FOR LAUNCHING FAMILY LAUNCHING FAMILY

PROGRAMSPROGRAMS Set up a team of provides and an advisory Set up a team of provides and an advisory

board including family membersboard including family members Survey the number of individuals Survey the number of individuals

receiving services who have family contactreceiving services who have family contact Target who your agency would like to Target who your agency would like to

provide services to firstprovide services to first Consider targeting individuals who are Consider targeting individuals who are

newly admitted or recently in crisis or newly admitted or recently in crisis or newly diagnosednewly diagnosed

Keep track Keep track of number of families of number of families servedserved

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STRATEGIES FOR STRATEGIES FOR LAUNCHING (cont.)LAUNCHING (cont.)

Set goals for how many families your Set goals for how many families your agency will be serving at 3 months, 6 agency will be serving at 3 months, 6 months, 1 yearmonths, 1 year

Provide regular feedback to advisory Provide regular feedback to advisory group, staff members, individuals, group, staff members, individuals, families regarding how goals are families regarding how goals are being metbeing met

Measure family involvement and Measure family involvement and outcomesoutcomes

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SUMMARYSUMMARY

Family psychoeducation is an evidence-Family psychoeducation is an evidence-based practice for psychosis shown to based practice for psychosis shown to reduce relapses & hospitalizations, reduce relapses & hospitalizations, improve client functioning, & reduce improve client functioning, & reduce caregiver burdencaregiver burden

The multiple family group involves three The multiple family group involves three stages: joining, psychoeducation stages: joining, psychoeducation workshop, and twice monthly multiple workshop, and twice monthly multiple family sessions focused on problem-solvingfamily sessions focused on problem-solving

Family groups are enormously rewarding Family groups are enormously rewarding for both families and professionals for both families and professionals

Closing ThoughtsClosing Thoughts

““Never doubt that a small group of Never doubt that a small group of thoughtful, committed people can change thoughtful, committed people can change the world. Indeed, it is the only thing that the world. Indeed, it is the only thing that ever has.” Margaret Meadeever has.” Margaret Meade

As part of this conference, you have joined As part of this conference, you have joined a nation-wide effort to change the course a nation-wide effort to change the course of mental illness for individuals and their of mental illness for individuals and their families.families.

Thank you for the opportunity to be a part Thank you for the opportunity to be a part of this. of this.

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