1. Involving Families in the Treatment of Schizophrenia Alex Kopelowicz, MD Geffen School of Medicine at UCLA Olive View-UCLA Medical Center
The psychopathology and associated disabilities experienced by persons with serious and persistent mental illness have only partially responded to conventional pharmacological and psychosocial treatment approaches. Moreover, there is some evidence to suggest that there may be additional challenges in using these approaches “off the shelf” with person of Hispanic background. In this presentation, I will describe efforts made to teach illness management skills to Hispanics with severe mental disorders using biobehavioral treatment and rehabilitation. Biobehavioral treatment and rehabilitation employs behavioral assessment, social learning principles, skills training, and a focus on the recovery process to amplify the effects of pharmacotherapy. This approach, when directed toward early detection and treatment of psychotic symptoms, collaboration between patients and caregivers in managing treatment, family and social skills training, and teaching coping skills and self-help techniques improves the course and outcome of severe mental disorders, as measured by symptom recurrence, social functioning, and quality of life.

2. Psychobiological Vulnerability Socioenvironmental Stressors
PROTECTIVE FACTORS
Continuity of Services
Therapeutic & Supportive Relationships
Psychotropic Medication
Skill Building
Family Support & Problem Solving
Supported & Transitional Employment
Supported & Transitional Housing
Assertive Community Treatment
RECOVERY STABLE RECURRENT RELAPSES REFRACTORY
CLINICAL PROGRESS & OUTCOMES
Symptoms & Relapse
Cognitive Impairments
Social Functioning
Quality of Life

3. Evidence Based Treatments are focused on Recovery: PORT recommendations
Standardized pharmacological treatment
Illness management skills training
Family psychoeducation
Supported employment
Assertive community treatment
Integrated dual disorders treatment
Finally, clinicians should understand the complementary role of psychosocial treatments in facilitating recovery. These are the evidence-based practices identified by Tony Lehman and his colleagues in the PORT project…
Kreyenbuhl et al., Schiz Bulletin 2010 3

4. Illness Management Training
The social problem-solving model focuses on improving impairments in information processing that are assumed to be the cause of social skills deficits
The model targets domains needing changes including medication and symptom management.
Each domain is taught as part of a module, with the purpose of correcting deficits in receptive, processing, and sending skills.
Read this slide.
,… and sending skills. This modular approach has been championed by Bob Liberman and colleagues at UCLA with demonstrated efficacy in a number of different domains. Click…

5. Meta-Analysis of 75 Studies of Skills Training in Schizophrenia
Improvement in Social Skills
Self-rating
Behavioral Performance
Generalization of Skills
Maintenance and Durability
Naturalistic Situations
Social Adjustment
Higher Rate of Hospital Discharge
Reduced Relapse Rates
Read this slide
Heinssen, Liberman & Kopelowicz, 2000

6. Illness Self-Management Skills
Identify the Warning Signs of Relapse
Manage these Signs and Use them to Enlist Help
Cope with Persistent Symptoms
Avoid Alcohol and Illicit Drugs
Obtaining information about Antipsychotic Medication
Knowing Correct Self-Administration of Medication
Identifying Side Effects of Medication
Negotiating Medication Issues with Healthcare Providers
These are the specific skills that are taught in the illness-self management curriculum. (Read them).

7. Module: Medication Self-Management Skill Area: Negotiating Medication Issues
Requisite behaviors:
Pleasant greeting
Describe problem specifically
Tell length of occurrence
Describe extent of discomfort
Specifically request action
Repeat/clarify advice/orders
Ask about expected time for effect
Thank for assistance
Good eye contact
Good posture
Clear, audible speech

8. Demonstrate the skills using video

9. Role play
using video

10. Coaching with
Positive
Reinforcement

11. Skills Training for Latinos with Schizophrenia (Kopelowicz et al 2003)
93 stable outpatients with schizophrenia and their key relatives
Randomly assigned to 3 months of skills training and customary care or CC only
13 weeks of group skills training, 4 days per week, 1 hour per day (Illness Management)
Family involvement included 13 weekly sessions and 2 home visits
After pilot testing our intervention, we received funding to conduct a randomized clinical trial of the culturally adapted approach versus treatment as usual. (Read the rest of this slide).

12. Number of Rehospitalizations
As you can see, the experimental intervention had a robust effect on relapse rates at both 9 months and 15 months post intervention.
Kopelowicz et al 2003

13. Kopelowicz et al. Schizophrenia Bulletin 29:211-227, 2003
In this path model, you can see that treatment had a significant effect on the acquisition of knowledge and the use of that knowledge in patients’ everyday lives. Interestingly, knowledge did not have a direct effect on relapse, but generalization did, meaning the cultural adaptation, the use of family members as generalization aides, was the critical component that made this intervention work.
Kopelowicz et al. Schizophrenia Bulletin 29: , 2003

14. Better outcomes in family psychoeducation
Over 20 controlled clinical trials, comparing to standard outpatient treatment, have shown:
Much lower relapse rates and rehospitalization
Up to 75% reductions of rates; minimally 50%
Increased employment
At least twice the number of consumers employed, and up to four times greater--over 50% employed after two years--when combined with supported employment
Improved family relationships and well-being
Reduced friction and family burden
Reduced medical illness in family members
Doctor visits for family members decreased by over 50% in one year
The literature supporting the use of family psychoeducation for severe mental disorders is perhaps the most extensive of any of the psychosocial treatments. Some of the findings from over 20 controlled clinical trials include (read the slide)…
Dixon et al 2003 14

15. Standard Approaches to Family Treatment in Severe Mental Illness
Psychoeducation
Communication skills training
Problem solving techniques
Social network development (MFG)
Although there are a variety of approaches to family treatment in severe mental illness, they have a number of commonalities, which are listed in this slide. These include (read slide)…

16. Stages of a Multifamily Group Family and patient separately
(McFarlane, 2004)
This slide illustrates the components of the multifamily group process. It starts with (read the slide)…
The group consists of approximately six clients and their families who attend 90 minute, twice monthly meetings led by two bilingual, bicultural therapists. The sessions include a 15-minute “checking in” followed by a 60 minute problem solving component and ends with a 15-minute “wrapping up” process.
The rationale for using this format for Mexican-Americans includes some of the same issue I mentioned previously including the emphasis on the family unit, the centrality of the family in Latino cultures, the importance of family preservation, and the need to uphold the family’s authority in decision making. In addition, the focus of the MFG approach is on education, not therapy, and the MFG trainers are willing to offer direct advice, which is very appealing to families who often feel completely in the dark about what is happening to their ill relative.
The content of the MFGs is usually determined by the problem the group selects as most pressing that day. We quickly realized that Latino families often did not spontaneously volunteer to identify problems. We thus modified the procedure by adding an extra level of structure; namely, focusing the groups around issues of medication adherence. Specifically, we chose to utilize a model for understanding medication adherence that seemed to have promise for this population. (Next slide)
Educa-
tional
workshop
Ongoing
MFG
Families &
patients
bi-weekly for 1 year
Joining
Family and patient separately
3-6 weeks
Families only
1 day

17. Psychoeducational Workshop
Symptoms and Clinical Presentation
The Causes of the Disorder
Treatments and Rehabilitation
The Importance of Family Participation 17

18. MULTIFAMILY GROUPS Five to Eight Families Two Clinicians
1 ½-Hour Sessions – Biweekly – 1 Year Minimum
Refreshments/Snacks are provided
Initial Sessions avoid emphasis on clinical issues
Initial Sessions emphasize establishing a working alliance by building group identity and developing a sense of mutual interest and concern. Drop outs are Failures

19. PROBLEM SOLVING IN MFGs
The CORE of MFG Sessions
Designed to compensate Information-Processing Deficits in Schizophrenia
FORMAT:
Checking in Minutes
Go-round Minutes
Selecting a Problem to Solve 5 Minutes
Solving the Problem 45 Minutes
Wrap-up Socializing Minutes
Clinicians should GET READY and HAVE A PLAN – IN ADVANCE

20. The key question is:
How should we incorporate cultural factors to engage Latino families in the psychoeducation approach?

21. The Mediating Role of Culture
Culture is the specific value orientations, belief systems, or sets of practices of a given group
Culture resides both in the individual and in the social group
Culture is a dynamic and creative process that is constantly changing through a person’s interactions with the social world
Before I go on to discuss other treatment modalities, this would be a good time to bring up the issue of cultural adaptation. First, one has to understand the role of culture. The definition I like is the following. Read this slide, then click.

22. The Assessment of Culture
Best undertaken by paying attention to people’s daily routines and how such activities are tied to families, social networks and communities
The key to a cultural assessment is asking what matters most to people or what is most at stake for people
Now, assessing culture is (read the slide)…

23. Cultural Modifications Necessary for Latino Families
Encourage participation of fathers
Acknowledge folk conceptions of illness
Reframe to fit family beliefs and attitudes
Focus on education rather than strictly on communication/problem solving skills
Acknowledge each family member’s role
Goal: Interdependence vs independence
Utilize prosocial EE factors (warmth)
Looking at the limitations of these two studies and other literature on culture, we identified a number of factors that should be considered when culturally adapting a family intervention for Latinos with severe mental illness. These include (read the slide)…
…The importance of prosocial EE factors such as warmth is highlighted in the next few slides…click

24. Cultural Adaptation of MFG to Mexican-Americans
Objectives
To increase utilization of professional mental health services
To improve treatment adherence
That was exactly the focus of our attempt to culturally adapt the MFG approach for Mexican-Americans with schizophrenia. Although our study aims were to improve treatment adherence and to increase utilization of professional mental health services, we thought that the way to achieve these aims was by educating the family about mental illness, thereby decreasing the stigma associated with the disorder and increasing the likelihood of continuing patients in treatment, obviously the first step in getting them better.

25. Application of Theory of Planned Behavior to MFG Approach
Attitudes
Client’s assumptions about mental illness and the benefits of treatment are targeted
Subjective Norms
Centrality of the family for decision making points to the need to encourage families to actively participate in treatment plan
Perceived Behavioral Control
External locus of control requires the utilization of problem solving techniques to overcome financial and transportation obstacles
TPB provides a coherent model for explaining adherence behavior among people with schizophrenia in terms of attitudes, subjective norms and perceived behavioral control. The importance of attitudes as a target for intervention is clear and not unique to MFG. The centrality of the family for Latinos suggests that subjective norms plays a key role in the decision whether or not to adhere to treatment. Moreover, the tendency for unacculturated Latino patients to report an external locus of control coupled with their “real world” experiences of barriers to the utilization of mental health aftercare points to the significance of perceived behavioral control. Finally, these constructs can be readily operationalized and incorporated into the MFG framework by addressing behavioral beliefs and consequence value, normative beliefs and motivation to comply, and control beliefs and perceived power.

26. MFG for Mexican-Americans with Schizophrenia (Kopelowicz et al 2012)
174 poorly adherent patients (80% inpatients) with schizophrenia and their key relatives
Randomly assigned to 12 months of MFG-A, MFG-S or customary care (1 year follow up)
All groups conducted in Spanish, bi-weekly for 90 minutes each session
MFG-A focused on adherence and based on Theory of Planned Behavior (Azjen 1991)
After pilot testing our intervention, we received funding to conduct a randomized clinical trial of the culturally adapted approach versus standard MFG vs. treatment as usual. (Read the rest of this slide).

27. Adherence to Medication
% Compliant
Month

28. Time to Hospitalization
% Not Rehospitalized
Months After Baseline
Overall log-rank Χ2=13.3, df=2, p=.001.
A vs S: Χ2=8.0, p=.005.
A vs C: Χ2=11.4, p=.001.
S vs C: Χ2=0.2, p=0.62.
Pairwise Wald tests from PH model, all df=1.

29. MFG-A
HOSPITALIZATION
B=-0.29 (0.07), p<.0001
ADHERENCE
B=0.91 (0.26), p=0.0005
B= (0.021) p<0.0001
MFG-A
HOSPITALIZATION
B=-.19 (0.072) p=.0085
Mediation Analysis of Treatment Effect on Adherence and Hospitalization
N=174. Sobel: -2.94, p=.003 (34% of the MFG-A-HOSPITALIZATION association)

30. PERCEIVED BEHAVIORAL CONTROL
CHANGE IN ATTITUDES a1
CHANGE IN SUBJECTIVE
NORMS b1 b2 a2 c’
MFG-A
ADHERENCE a3 b3
CHANGE IN
PERCEIVED BEHAVIORAL CONTROL
Paths
Parameters
±SE
Mediation
95% CI
Attitudes a1 b1
1.12± ±0.03*
0.15
Subjective Norms a2 b2
1.32±0.65* 0.11±0.03*
Perceived Behavioral Control a3 b3
1.61±0.71* 0.02±0.03
0.03
VISIT & BASELINE TPB
*p<0.05

31. Rates of Conformance with PORT Psychosocial Treatment Recommendations
The aim of the PORT study was not only to identify which interventions are empirically based, but to document how well they are used. In this slide you can see that the results of a nationwide survey of this issue are truly disappointing. Only 20% of severely mentally ill patients in the United States received case management services and less than that received vocational rehabilitation or family therapy. I’m sure that the rates for Hispanic patients is even less, which demonstrates how far we need to go to truly provide recovery-oriented, evidence-based practices to Latinos with serious mental illness. Thank you.
APA Office of Quality Improvement and Psychiatric Services, 2003

32. Conclusions
As investigators give a voice to the family, either through quantitative research, qualitative research or experience working in that community, they are more likely to be successful in engaging families in the treatment process.
Engagement is not a fixed entity. It is an iterative process in which clinical investigators engage the client and his/her family and continually evaluate their efforts.
Incorporating the family in a culturally appropriate fashion within routine clinical settings would improve access to treatment, integration of care and ultimately, clinical outcomes for Latinos with serious mental disorders.
So, let me conclude by reminding you that (read this slide)…