1. 1 Multiple Family Groups: Using Research Based Methods for Improving Outcomes for Persons with Psychosis Susan Gingerich Philadelphia, PA gingsusan@yahoo.com

2. AGENDA History of family psychoeducation for psychosis History of family psychoeducation for psychosis Multiple family group model Multiple family group model Research support Research support Critical ingredients Critical ingredients Strategies for implementation Strategies for implementation 2

3. 3 HISTORICAL ANTECEDANTS TO FAMILY PSYCHOEDUCATION (FPE) Lack of support for psychogenic theories Lack of support for psychogenic theories Rise in biological-environmental theories Rise in biological-environmental theories Deinstitutionalization Deinstitutionalization Family advocacy movement arguing for better treatment & greater collaboration (e.g., National Alliance on Mental Illness) Family advocacy movement arguing for better treatment & greater collaboration (e.g., National Alliance on Mental Illness) Evidence that family stress worsens course Evidence that family stress worsens course

4. Family Stress and Relapse From: Butzlaff & Hooley (1998) 9-Month Relapse Rate

5. 5 RESEARCH ON FAMILY PSYCHOEDUCATION Multiple randomized controlled trials Multiple randomized controlled trials Most early research focused on recently hospitalized clients discharged to family Most early research focused on recently hospitalized clients discharged to family Preponderance of research on schizophrenia Preponderance of research on schizophrenia More recent trials on bipolar disorder & treatment refractory major depression More recent trials on bipolar disorder & treatment refractory major depression Striking effects on reducing relapses Striking effects on reducing relapses

6. 6 Combined Results of Family Intervention Programs on 2-year Cumulative Relapse Rates in Schizophrenia (11 Studies)

7. 7 RESEARCH RESULTS, cont’d Improved client functioning Improved client functioning Reduction in family burden Reduction in family burden Reduced family stress Reduced family stress Cost-effective Cost-effective Effective across a variety of cultures Effective across a variety of cultures

8. 8 CONTROLLED RESEARCH CONDUCTED IN DIFFERENT CULTURES African American African American Latino in U.S. Latino in U.S. Spain, Italy, the Netherlands, Great Britain, Germany Spain, Italy, the Netherlands, Great Britain, Germany China China Japan Japan India India

9. 9 WHAT CREATES POSITIVE OUTCOMES? Reduction of family stress Reduction of family stress Modifying relatives attributions about symptoms and responsibility Modifying relatives attributions about symptoms and responsibility Teaching more effective coping behaviors (e.g., problem solving) Teaching more effective coping behaviors (e.g., problem solving) Improved family monitoring of illness & access to treatment team for rapid intervention Improved family monitoring of illness & access to treatment team for rapid intervention

10. THE STRESS-VULNERABILITY-FAMILY COPING SKILLS MODEL OF BFT (MUESER & GLYNN, 1999) Psychotropic Medication Biological Vulnerability Substance Abuse 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

11. 11 VALIDATED MODELS OF FAMILY PSYCHOEDUCATION Falloon; Mueser & Glynn; Miklowitz: behavioral family therapy/family-focused therapy bipolar Falloon; Mueser & Glynn; Miklowitz: behavioral family therapy/family-focused therapy bipolar Barrowclough & Tarrier: behavioral family approach Barrowclough & Tarrier: behavioral family approach Anderson et al: eclectic family psychoeducation including “survival skills workshop” Anderson et al: eclectic family psychoeducation including “survival skills workshop”

12. 12 VALIDATED MODELS, CONT’D Leff et al: broad-based family psychoeducation Leff et al: broad-based family psychoeducation McFarlane et al: multi-family group approach based on Anderson et al group psychoeducation “survival skills workshop” & Falloon problem solving approach McFarlane et al: multi-family group approach based on Anderson et al group psychoeducation “survival skills workshop” & Falloon problem solving approach

13. 13 CRITICAL INGREDIENTS OF EFFECTIVE MODELS Longer-term (9 months or longer) Longer-term (9 months or longer) Delivered by professionals Delivered by professionals Broad view of who is “family” Broad view of who is “family” Inclusion of individual in family sessions Inclusion of individual in family sessions Education of families about mental disorders Education of families about mental disorders Concern & empathy demonstrated for individual & relatives Concern & empathy demonstrated for individual & relatives Avoidance of blaming or pathologizing family Avoidance of blaming or pathologizing family Fostering the development of all family members Fostering the development of all family members

14. 14 CRITICAL INGREDIENTS (cont.) Improvement in communication & problem- solving skills Improvement in communication & problem- solving skills Flexible & tailored to each family needs Flexible & tailored to each family needs Encouragement of family members to develop social supports outside the family Encouragement of family members to develop social supports outside the family Instilling hope for the future Instilling hope for the future Developing a collaborative relationship with family Developing a collaborative relationship with family

15. 15 DISTINGUISHING FEATURES BETWEEN MODELS Emphasis on social learning (skills training) Emphasis on social learning (skills training) Format: single-family vs. multiple family vs. combination Format: single-family vs. multiple family vs. combination Systems perspective in understanding impact of mental illness on role of family Systems perspective in understanding impact of mental illness on role of family Extent of focus on whole family vs. member with illness Extent of focus on whole family vs. member with illness

16. MULTIPLE FAMILY GROUP MODEL (MCFARLANE)  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 16

17. The History of Multifamily Groups Originated 30+ years ago New York & Vermont hospitals Originated 30+ years ago New York & Vermont hospitals Families were offered education in a group format without patients Families were offered education in a group format without patients Patients wanted to join Patients wanted to join Hospital staff noticed significant improvements Hospital staff noticed significant improvements improved family involvement and communication improved family involvement and communication Evidence-Based Practices Copyright  West Institute William R. McFarlane, MD

18. Core elements of multiple family group model Joining Joining Education Education Problem-solving Problem-solving Evidence-Based Practices Copyright  West Institute William R. McFarlane, MD

19. 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 Practices Copyright  West Institute William R. McFarlane, MD

20. JOINING JOINING 20

21. Contents of Joining Sessions Getting to know each other, feel safe with each other Getting to know each other, feel safe with each other Identify early warning signs of illness and what has been done about them Identify early warning signs of illness and what has been done about them Identify characteristic precipitants for relapse (“triggers”) Identify characteristic precipitants 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

22. The Psychoeducation Workshop Evidence-Based Practices Copyright  West Institute William R. McFarlane, MD

23. 6-8 Families Brought Together After Individual Joining Sessions 6 hours of illness education 6 hours of illness education relaxed, friendly atmosphere relaxed, friendly atmosphere co-leaders act as hosts co-leaders act as hosts questions and interactions encouraged questions and interactions encouraged Food Food Evidence-Based Practices Copyright  West Institute William R. McFarlane, MD

24. Psychoeducation Workshop Agenda l History and epidemiology l Biology of illness l Treatment: effects and side effects l Family emotional reactions l Family behavioral reactions l Guidelines for coping (family guidelines) l Socializing Evidence-Based Practices Copyright  West Institute William R. McFarlane, MD

25. The workshop is held in a classroom or round table format Promotes comfort Promotes comfort Families can interact without pressure Families can interact without pressure Encourages learning Encourages learning Practitioners act as Practitioners act as educators educators Evidence-Based Practices Copyright  West Institute William R. McFarlane, MD

26. Family 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 important for everyone.) GIVE EACH OTHER SPACE. (Time out is important for everyone.) SET LIMITS. (A few good rules keep things clear. All should know the rules) SET LIMITS. (A few good rules keep things clear. All should know the rules) IGNORE WHAT YOU CAN’T CHANGE IGNORE WHAT YOU CAN’T CHANGE (Let some things go. Don’t ignore violence) (Let some things go. Don’t ignore violence)

27. Family Guidelines (Cont.) KEEP IT SIMPLE (Say things clearly) KEEP IT SIMPLE (Say things clearly) FOLLOW THE DOCTORS ORDERS FOLLOW THE DOCTORS ORDERS CARRY ON BUSINESS AS USUAL (Stay in touch with family and friends) CARRY ON BUSINESS AS USUAL (Stay in touch with family and friends) NO STREET DRUGS OR ALCOHOL NO STREET DRUGS OR ALCOHOL PICK UP ON EARLY SIGNS (Changes) PICK UP ON EARLY SIGNS (Changes) SOLVE PROBLEMS STEP BY STEP (One thing at a time) SOLVE PROBLEMS STEP BY STEP (One thing at a time) LOWER EXPECTATIONS TEMPORARILY LOWER EXPECTATIONS TEMPORARILY

28. MULTIPLE FAMILY GROUP SESSIONS Evidence-Based Practices Copyright  West Institute William R. McFarlane, MD

29. Structure of Group Session Socialization: 10-15 minutes Socialization: 10-15 minutes Review of last session’s progress: 5-10 min. 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. 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 Formal problem solving: 30-45 minutes Final socialization: 5-10 minutes Final socialization: 5-10 minutes

30. Core 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 Practices Copyright  West Institute William R. McFarlane, MD

31. 6 Step Problem Solving Method 6 Step Problem Solving Method 1. Define ( What is the problem or goal?) 1. Define ( What is the problem or goal?) 2. List all possible solutions 2. List all possible solutions 3. List pluses and minuses of each solution 3. List pluses and minuses of each solution 4. Choose the best solution or combination of solutions 4. Choose the best solution or combination of solutions 5. Plan the steps to carry out the best solution (make an action plan) 5. Plan the steps to carry out the best solution (make an action plan) 6. Follow up how the solution worked 6. Follow up how the solution worked

32. Suggested Hierarchy for Problem Solving Safety Issues in the home Safety Issues in the home Medication or other treatment adherence Medication or other treatment adherence Street drug and alcohol use Street drug and alcohol use Life events Life events Conflicts between family members Conflicts between family members Conflicts with family guidelines Conflicts with family guidelines

33. Where can groups be held? Out-patient settings Out-patient settings In-patient units In-patient units Partial hospital programs Partial hospital programs ACT (Assertive Community Treatment) programs ACT (Assertive Community Treatment) programs Nursing homes Nursing homes Family advocacy organizations Family advocacy organizations In community,such as library, school, church, synagogue or mosques In community,such as library, school, church, synagogue or mosques Evidence-Based Practices Copyright  West Institute William R. McFarlane, MD

34. 34 STRATEGIES FOR STARTING FAMILY PROGRAMS Prioritizing families with a recent crisis (e.g., hospitalization) Prioritizing families with a recent crisis (e.g., hospitalization) Grouping families whose relatives have same diagnosis Grouping families whose relatives have same diagnosis Focusing on families with highest levels of contact with person (e.g., > 4 hours/week) 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) Planning how to respond to common concerns raised by person (stress of participating, burdening relatives) & their relatives (time commitment, hopelessness)

35. 35 Strategies for Implementation, cont’d Using person to activate system: motivational interviewing & ongoing dialogue about benefits of involving family in treatment 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) Establishing clear organizational structure for implementing (team approach with clear roles and expectations) Planning a range of family services (short and long- term) Planning a range of family services (short and long- term) Modifying model carefully when indicated Modifying model carefully when indicated

36. 36 Possible Modifications Briefer psychoeducational workshop (e.g., an evening workshop 6PM-9PM with pizza) Briefer psychoeducational workshop (e.g., an evening workshop 6PM-9PM with pizza) Inclusion of different diagnoses Inclusion of different diagnoses Groups run by clinicians for families on their own treatment teams 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 Motivational interviewing to help clients make informed decisions about involving relatives in their treatment Cultural adaptations Cultural adaptations Focusing on specific problem area (e.g., medication) Focusing on specific problem area (e.g., medication)

37. 37 POSSIBLE STEPS FOR LAUNCHING FAMILY PROGRAMS Set up a team of provides and an advisory board including family members Set up a team of provides and an advisory board including family members Survey the number of individuals receiving services who have family contact Survey the number of individuals receiving services who have family contact Target who your agency would like to provide services to first 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 Consider targeting individuals who are newly admitted or recently in crisis or newly diagnosed Keep track of number of families served Keep track of number of families served

38. 38 STRATEGIES FOR LAUNCHING (cont.) Set goals for how many families your agency will be serving at 3 months, 6 months, 1 year 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 Provide regular feedback to advisory group, staff members, individuals, families regarding how goals are being met Measure family involvement and outcomes Measure family involvement and outcomes

39. 39 SUMMARY Family psychoeducation is an evidence-based practice for psychosis shown to reduce relapses & hospitalizations, improve client functioning, & reduce caregiver burden 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 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

40. Closing Thoughts “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 “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 nation- wide effort to change the course of mental illness for individuals and their families. As part of this conference, you have joined a nation- wide effort to change the course of mental illness for individuals and their families. Thank you for the opportunity to be a part of this. Thank you for the opportunity to be a part of this. 40