Robert Paul Liberman, M.D.Distinguished Professor of Psychiatry
UCLA School of MedicineDirector, UCLA Psych REHAB Program
Semel Institute of Neuroscience & Human Behavior
Robert Paul Liberman, M.D.Distinguished Professor of Psychiatry
UCLA School of MedicineDirector, UCLA Psych REHAB Program
Semel Institute of Neuroscience & Human Behavior
FAMILIES as MEMBERS of the TREATMENT TEAM
MAKE IT HAPPEN!
FAMILIES as MEMBERS of the TREATMENT TEAM
MAKE IT HAPPEN!
• When families are involved as key partners in treatment the relapse rates are When families are involved as key partners in treatment the relapse rates are cut in half and remissions of symptoms are tripledcut in half and remissions of symptoms are tripled
• By participating in treatment, families experience an alliance with psychiatrists By participating in treatment, families experience an alliance with psychiatrists and other treatment providers as well as a reduction in stress and the burden of and other treatment providers as well as a reduction in stress and the burden of caregivingcaregiving
FAMILIES CAN MAKE A POWERFUL THERAPEUTIC IMPACT ON THE PROGRESS OF PATIENTS TO RECOVERY
9 Months 24 Months
SEVERE MENTAL SEVERE MENTAL ILLNESSES ARE ILLNESSES ARE STRESS-RELATED WITH STRESS-RELATED WITH A A ““COOLCOOL”” FAMILY FAMILY EMOTIONAL CLIMATE EMOTIONAL CLIMATE PROTECTING AGAINST PROTECTING AGAINST RELAPSE AND RELAPSE AND DISABILITYDISABILITY
THE EMOTIONAL CLIMATE IN THE FAMILY
“HOT” VS. “COOL”
• Reluctance of mental health professionals to involve families in treatment Reluctance of mental health professionals to involve families in treatment assessment, planning and services: the false curtain of confidentialityassessment, planning and services: the false curtain of confidentiality
• Families lack of knowledge and understanding of mental illnesses with resulting Families lack of knowledge and understanding of mental illnesses with resulting unrealistic expectations, inadvertent impatience and criticism of the patient’s unrealistic expectations, inadvertent impatience and criticism of the patient’s limited functioning and social behaviorlimited functioning and social behavior
• Families “trying too much” to take responsibility and personal action to bring about Families “trying too much” to take responsibility and personal action to bring about improvement often leads to:improvement often leads to:
• Giving adviceGiving advice
• Observing excessivelyObserving excessively
• Doing “for the patient”Doing “for the patient”
that translates to emotional over-involvement and discomfort with the patient’s that translates to emotional over-involvement and discomfort with the patient’s need for privacy, personal space, autonomy, moratoriums and “social retreats”need for privacy, personal space, autonomy, moratoriums and “social retreats”
WHAT CAUSES STRESS-RELATED, OVERHEATED FAMILY EMOTIONAL CLIMATES?
BEHAVIORAL FAMILY MANAGEMENT HAS BEEN SHOWN TO BE EFFECTIVE THROUGHOUT THE WORLD FOR SCHIZOPHRENIA, BEHAVIORAL FAMILY MANAGEMENT HAS BEEN SHOWN TO BE EFFECTIVE THROUGHOUT THE WORLD FOR SCHIZOPHRENIA, BIPOLAR DISORDER & DEPRESSIONBIPOLAR DISORDER & DEPRESSION
HOW CAN MENTAL HEALTH PROFESSIONALS HELP FAMILIES TO LOWER THE EMOTIONAL TEMPERATURE IN THE HOME?
• Patient is viewed as the only person needing services and Patient is viewed as the only person needing services and the family is ignored or viewed as intrusive and difficultthe family is ignored or viewed as intrusive and difficult
• Hiding behind the false cloak of confidentialityHiding behind the false cloak of confidentiality
• Lack of training in structured “Lack of training in structured “teachingteaching” as therapy with ” as therapy with discomfort having families present for education and discomfort having families present for education and partners in treatment: partners in treatment: “same old, same old services”“same old, same old services”
• Politically correct, new fads that donPolitically correct, new fads that don’’t require training are t require training are funded while family involvement languishes in the shadows funded while family involvement languishes in the shadows of NAMI and mental health agenciesof NAMI and mental health agencies
WHY HASN’T BEHAVIORAL FAMILY MANAGEMENT BEEN IMPLEMENTED BY PRACTITIONERS AND MENTAL
HEALTH SYSTEMS OF CARE?
POLITICAL INFLUENCE & ACTIONPOLITICAL INFLUENCE & ACTION IS POWER, SELF- IS POWER, SELF-INTEREST, CONFLICT & COMPROMISE INTEREST, CONFLICT & COMPROMISE
JUDICIOUS USE OF POLITICAL ACTION vs. ACCEPTANCE OF JUDICIOUS USE OF POLITICAL ACTION vs. ACCEPTANCE OF THE STATUS QUO IS THE DIFFERENCE BETWEEN THE STATUS QUO IS THE DIFFERENCE BETWEEN
LIGHTNINGLIGHTNING and a and a LIGHTNING BUGLIGHTNING BUG
HOW CAN NAMI, FAMILIES AND PATIENTS CHANGE THE SYSTEM?
ASSERTIVE ADVOCACY AT THE FAMILY & ORGANIZATIONAL LEVELS
FAMILY INFLUENCE IS NOT ONLY WHAT YOU HAVE BUT WHAT FAMILY INFLUENCE IS NOT ONLY WHAT YOU HAVE BUT WHAT THE MENTAL HEALTH SYSTEM THINKS YOU HAVETHE MENTAL HEALTH SYSTEM THINKS YOU HAVE
NEVER GO OUTSIDE THE EXPERIENCE OF FAMILIESNEVER GO OUTSIDE THE EXPERIENCE OF FAMILIES
WHEREVER POSSIBLE, GO OUTSIDE THE EXPERIENCE OF THE WHEREVER POSSIBLE, GO OUTSIDE THE EXPERIENCE OF THE MENTAL HEALTH SYSTEMMENTAL HEALTH SYSTEM
TACTICS FOR CHANGING THE MENTAL HEALTH SYSTEM MEANS DOING WHAT YOU CAN WITH WHAT YOU HAVE
MAKE THE MENTAL HEALTH SYSTEM MAKE THE MENTAL HEALTH SYSTEM LIVE UP TO THEIR OWN BOOK OF LIVE UP TO THEIR OWN BOOK OF
RULES & ETHICSRULES & ETHICS
RIDICULE AND EMBARASSMENT IS RIDICULE AND EMBARASSMENT IS OUR MOST POTENT MEANS OF OUR MOST POTENT MEANS OF
CHANGING THE SYSTEMCHANGING THE SYSTEM
A GOOD TACTIC IS ONE THAT FAMILY A GOOD TACTIC IS ONE THAT FAMILY MEMBERS ENJOY AND BRINGS MEMBERS ENJOY AND BRINGS
ABOUT CHANGEABOUT CHANGE
A TACTIC THAT DRAGS ON FOR TOO A TACTIC THAT DRAGS ON FOR TOO LONG BECOMES A “DRAG”LONG BECOMES A “DRAG”
TACTICS FOR CHANGING THE MENTAL HEALTH SYSTEM MEANS DOING WHAT YOU CAN WITH WHAT YOU HAVE (cont’d)
KEEP THE PRESSURE ON WITH DIFFERENT TACTICS AND KEEP THE PRESSURE ON WITH DIFFERENT TACTICS AND ACTION, UTILIZING ALL EVENTS AND ALLIES AVAILABLEACTION, UTILIZING ALL EVENTS AND ALLIES AVAILABLE
THE MAJOR PREMISE FOR TACTICS IS TO MAINTAIN A THE MAJOR PREMISE FOR TACTICS IS TO MAINTAIN A CONSTANT PRESSURE ON THE SYSTEMCONSTANT PRESSURE ON THE SYSTEM
IF YOU PUSH HARD, LONG AND DEEP ENOUGH IT WILL BRING IF YOU PUSH HARD, LONG AND DEEP ENOUGH IT WILL BRING ABOUT CHANGEABOUT CHANGE
IN THE STRUGGLE FOR FAMILY INVOLVEMENT & IN THE STRUGGLE FOR FAMILY INVOLVEMENT & PARTICIPATION, DONPARTICIPATION, DON’’T STOP TO APOLOGIZET STOP TO APOLOGIZE
TACTICS FOR CHANGING THE MENTAL HEALTH SYSTEM MEANS DOING WHAT YOU CAN WITH WHAT YOU HAVE (cont’d)
PICK THE TARGET, FREEZE IT, PERSONALIZE IT AND PICK THE TARGET, FREEZE IT, PERSONALIZE IT AND POLARIZE ITPOLARIZE IT
DON’T LET THE DECISION-MAKERS SHIFT THE DON’T LET THE DECISION-MAKERS SHIFT THE RESPONSIBILITY OR “RESPONSIBILITY OR “PASS THE BUCKPASS THE BUCK””
TACTICS FOR CHANGING THE MENTAL HEALTH SYSTEM MEANS DOING WHAT YOU CAN WITH WHAT YOU HAVE (cont’d)
FAMILIES HAVE THE HIGHEST QUALITY, MOST VALID AND USEFUL INFORMATION ON THE HISTORY OF THE PATIENT, PAST FAMILIES HAVE THE HIGHEST QUALITY, MOST VALID AND USEFUL INFORMATION ON THE HISTORY OF THE PATIENT, PAST TREATMENT AND RESULTS OF PAST TREATMENTTREATMENT AND RESULTS OF PAST TREATMENT
THEREFORE, ASSERTIVE ADVOCACY REQUIRES US TO AFFIRM…..THEREFORE, ASSERTIVE ADVOCACY REQUIRES US TO AFFIRM…..
““Do not evaluate or treat my family member unless we are involved as sources of information, in Do not evaluate or treat my family member unless we are involved as sources of information, in goal setting and treatment planning.goal setting and treatment planning.””
WHAT ARE OUR TARGETS FOR SYSTEM CHANGE? PRIORITIES FOR SYSTEM CHANGE FOR FAMILIES & CONSUMERS
INVOLVE FAMILIES FROM THE VERY START IN DIAGNOSIS & TREATMENT PLANNING
MENTAL HEALTH PROFESSIONALS SEE AND EVALUATE THE PATIENT IN A MENTAL HEALTH PROFESSIONALS SEE AND EVALUATE THE PATIENT IN A TINY CROSS-SECTION OF TIMETINY CROSS-SECTION OF TIME
FAMILIES LIVE WITH AND OBSERVE THEIR RELATIVE-PATIENT 24 FAMILIES LIVE WITH AND OBSERVE THEIR RELATIVE-PATIENT 24 HOURS/DAY, 7 DAYS/WEEKHOURS/DAY, 7 DAYS/WEEK
WHAT ARE OUR TARGETS FOR SYSTEM CHANGE? (cont’d)
COLLABORATE WITH FAMILIES & PATIENTS IN SELECTING GOALS, TREATMENTS & EVALUATING PROGRESS
PATIENTS KNOW THEIR OWN SYMPTOM PATIENTS KNOW THEIR OWN SYMPTOM EXPERIENCES, PERSONAL GOALS, EXPERIENCES, PERSONAL GOALS,
PROBLEMS AND PROGRESSPROBLEMS AND PROGRESS
PATIENTS AND FAMILY MEMBERS NEED PATIENTS AND FAMILY MEMBERS NEED TO CONTRIBUTE TO THE MONITORING TO CONTRIBUTE TO THE MONITORING OF PROGRESS (OR LACK OF IT) AND OF PROGRESS (OR LACK OF IT) AND
PARTICIPATE IN DECIDING ON PARTICIPATE IN DECIDING ON TREATMENT ALTERNATIVESTREATMENT ALTERNATIVES
• SYMPTOMS – Brief Psychiatric Rating Scale, Beck Depression Scale, SYMPTOMS – Brief Psychiatric Rating Scale, Beck Depression Scale, Target Complaint ScaleTarget Complaint Scale
• SOCIAL FUNCTIONING – Independent Living Skills SurveySOCIAL FUNCTIONING – Independent Living Skills Survey
WHAT EVALUATION INFORMATION DOES THE PRACTITIONER, PATIENT & FAMILY NEED TO RATE,
MONITOR AND ASSESS PROGRESS OR LACK OF IT FOR MAKING TREATMENT DECISIONS?
- Personal HygienePersonal Hygiene
- Care of Personal PossessionsCare of Personal Possessions
- Appearance and ClothingAppearance and Clothing
- Money ManagementMoney Management
- Social Relations with Peers and FamilySocial Relations with Peers and Family
- Leisure and Community ActivitiesLeisure and Community Activities
- Illness Self-ManagementIllness Self-Management
- Work and SchoolWork and School
• ATTENDANCE & PERSONAL ATTENDANCE & PERSONAL GOALSGOALS
• SKILLS TRAINING PROCEDURESKILLS TRAINING PROCEDURE
• SKILLS USED IN EVERYDAY LIFE SKILLS USED IN EVERYDAY LIFE – – HOMEWORK!HOMEWORK!
• PARTICIPATION IN THE GROUPPARTICIPATION IN THE GROUP
• RECOMMENDATIONS FOR RECOMMENDATIONS FOR PARENTS & OTHER CLINICIANSPARENTS & OTHER CLINICIANS
ONGOING EVALUATION OF PATIENTS’ PERSONALLY-RELEVANT, RECOVERY-ORIENTED GOALS:
HOW ELSE CAN WE TELL IF TREATMENT IS WORKING?
UCLA NEUROPSYCHIATRIC & BEHAVIORAL HEALTH SERVICESUCLA Psych REHAB Program
Progress Report: PERSONAL EFFECTIVENESS for SUCCESSFUL LIVINGSocial Skills Training Group
CONSERVATORSHIP MADE POSSIBLECONSERVATORSHIP MADE POSSIBLE
MORE INPATIENT BEDS FOR PATIENTS MORE INPATIENT BEDS FOR PATIENTS NEEDING HOSPITALIZATIONNEEDING HOSPITALIZATION
MORE CRISIS HOMES FOR BRIEF MORE CRISIS HOMES FOR BRIEF INTERVENTION, REDUCING STRESS, INTERVENTION, REDUCING STRESS,
PREVENTING HOSPITALIZATION & RESPITE PREVENTING HOSPITALIZATION & RESPITE FOR PATIENTS & FAMILY MEMBERSFOR PATIENTS & FAMILY MEMBERS
MENTAL HEALTH PROFESSIONALS TRAINED MENTAL HEALTH PROFESSIONALS TRAINED IN SITU TO USE EVIDENCE-BASED, IN SITU TO USE EVIDENCE-BASED,
RECOVERY-ORIENTED AND PERSON-RECOVERY-ORIENTED AND PERSON-CENTERED TREATMENTS WITH CENTERED TREATMENTS WITH
MANAGEMENTMANAGEMENT’’S QUALITY IMPROVEMENTS QUALITY IMPROVEMENT
WHAT ARE OUR TARGETS FOR SYSTEM CHANGE? (cont’d)
CALIFORNIA STATE LEGISLATORSCALIFORNIA STATE LEGISLATORS
GOVERNORGOVERNOR
COUNTY SUPERVISORSCOUNTY SUPERVISORS
DIRECTOR OF COUNTY MENTAL HEALTH DEPARTMENTDIRECTOR OF COUNTY MENTAL HEALTH DEPARTMENT
MEDICAL & CLINICAL DIRECTORS AND CEO’S OF HOSPITALS, MEDICAL & CLINICAL DIRECTORS AND CEO’S OF HOSPITALS, CLINICS AND OTHER FACILITIESCLINICS AND OTHER FACILITIES
WHO ARE THE DECISION-MAKERS & INFLUENTIALS WHO WE MUST TARGET FOR OUR TACTICS?
THE BUCK STOPS HERE! IF IT’S TOO HOT IN THE KITCHEN, LET SOMEONE ELSE DO THE COOKING!
WE HAVE A CHOICE AS AN WE HAVE A CHOICE AS AN ORGANIZATION OF FAMILIES AND ORGANIZATION OF FAMILIES AND CONSUMERS: CONSUMERS: ““EITHER WE HANG EITHER WE HANG TOGETHER OR WE HANG ALONETOGETHER OR WE HANG ALONE””
IF WE DONIF WE DON’’T KNOW WHERE WE T KNOW WHERE WE ARE GOING, HOW CAN WE ARE GOING, HOW CAN WE EXPECT TO GET THERE?EXPECT TO GET THERE?
IF IF NAMINAMI DOES NOT KNOW WHAT DOES NOT KNOW WHAT HARBOR IT SEEKS, ANY WIND IS HARBOR IT SEEKS, ANY WIND IS
THE RIGHT WIND.THE RIGHT WIND.
IS IT TIME FOR ACTION IN ASSERTIVE ADVOCACY?
“IF NOT NOW, WHEN? IF NOT YOU, WHO?”
