1. The Power of Family Work: Findings Old and New Recent Outcomes, New Models and Future Prospects Fifth Annual Grampians Mental Health Conference March 1-2, 2005 William R. McFarlane, M.D. Center for Psychiatric Research Portland, Maine University of Vermont

2. Interaction of patient symptoms and family process: A simple causal model

3. Effects of EE and medication on relapse in schizophrenia Bebbington and Kuipers, 1994

4. Effects of EE and contact on relapse in schizophrenia Bebbington and Kuipers, 1994

5. * p < 0.001 **p = 0.582 Tienari, et al, BJM, 2004

6. Positive Outcomes from FPE The patient and family work together towards recovery. Can be as beneficial in the recovery of schizophrenia and severe mood disorders as medication.

7. Research with Family Psychoeducation This treatment is an elaboration of models developed by Anderson, Falloon, McFarlane, Goldstein and others. Outcome studies report a reduction in annual relapse rates for medicated, community-based people of as much as 50% by using a variety of educational, supportive, and behavioral techniques.

8. Research with Family Psychoeducation Functioning in the community improves steadily, especially for employment. Family members have less stress, improved coping skills, greater satisfaction with caretaking and fewer physical illnesses over time.

9. Core Elements of Psychoeducation Joining Education Problem-solving Interactional change Structural change Multi-family contact

10. Outcomes in family psychoeducation The evidence for being an evidence- based practice

11. Relapse outcome, controlled trials, 1980-1997

12. Comparison of single and multifamily formats

13. Relapse outcomes in clinical trials

14. Hospitalizations before vs. during treatment

15. Family Psychoeducation in Schizophrenia Psychoeducational multiple family group (PEMFG) vs.. Psychoeducational single family treatment (PESFT) N = 172

16. Family Psychoeducation in Schizophrenia Project Sites Creedmoor Psychiatric Center Queens, N.Y. Harlem Hospital Center New York City Hudson River Psychiatric Center Poughkeepsie, N.Y. Kings Park Psychiatric Center Islip, N.Y. Rochester Psychiatric Center Rochester, N.Y. South Beach Psychiatric Center Staten Island & Brooklyn, N.Y

17. Psychiatric Characteristics of Patients by therapy modality Variable Age of onset Mean s.d. Diagnosis Schizophrenia Schizoaffective Schizophreniform Prior hospitalization Mean s.d. Substance abuse No history Positive history PEMFG PESFT 18.5 19.6 5.5 6.2 81.9% 88.3% 13.8% 8.5% 4.3% 3.2% 4.0 5.5 4.5 5.5 61.7% 66.0% 38.3% 34.0% Modality differences: all not significant Total 19.0 5.8 85.1% 11.2% 3.7% 4.8 5.1 63.8% 36.2%

18. Remission to 2 years N: PEMFG=83; PESFT=92 Main effect, all cases: p=.07 Main effect, completers: p<.05

19. Risk for relapse over two years N: MFG=83; SFT=89

20. Medication dosages in MFG and SFT

21. Risk factors and treatment type : Effects on two-year relapse rates Number of factors, any combination: High EE, high BPRS, white race

22. Anxious depression, critical comments and treatment type: Differential effects on relapse rates

23. Differential relapse rates by number of prior hospitalizations

25. Functioning as an effect of repeated psychotic episodes

26. Other effects in clinical trials Improved family-member well-being Increased patient participation in rehabilitation Substantially increased employment rates Decreased psychiatric symptoms, including deficit syndrome Improved social functioning Decreased family medical illnesses and medical care utilization Reduced costs of care

27. Family satisfaction with treatment

28. Negative symptom outcomes: MFGs vs standard care MFG vs SC: p<.05, all f/u time pointsDyck, et al., 2000

29. Family influences on work Modeling Information Encouragement Buffering Guidance Adjusting expectations Ancillary support Cueing Personal connections

30. Rehabilitation effects of multifamily groups  Reducing family confusion and tension  Tuning and ratification of goals  Coordinating efforts of family, team, consumer and employer  Developing informal job leads and contacts  Cheerleading and guidance in early phases of working  Ongoing problem-solving

31. Work Outcome Employed at baseline 17.3% (p=.001) Employed at 2 years 29.3% Gain in % employed PEMFG 16% PESFT 8% (n.s.)

32. Family-aided Assertive Community Treatment (FACT): A clinical and employment intervention Psychoeducational multifamily groups Clinical case management using ACT principles and methods Integrated, multidisciplinary teams Supported employment MH Employers’ Consortium Cognitive assessments used in job accommodation

33. Vocational specialists on FACT teams: Principal tasks – Developing contacts with employers – Case-specific job development – Job assessment – Assessment of patients' cognitive, physical and social capacities – Setting career goals – Practicing interviews and resumes – Assistance with job interviews – On- or near-job support – Intervening with employers – Close coordination with clinicians

34. Rehabilitation effects of multifamily groups  Reducing family confusion and tension  Tuning and ratification of goals  Coordinating efforts of family, team, consumer and employer  Developing informal job leads and contacts  Cheerleading and guidance in early phases of working  Ongoing problem-solving

35. Outcomes in Family-aided Assertive Community Treatment FACT vs ACT William R. McFarlane, M.D. Peter Stastny, M.D. Susan Deakins, M.D. Robert Dushay, Ph.D.

36. RELAPSE OUTCOME FACT vs. ACT FACT (n=36) ACT (n=35) 8 (22%) 14 (40%) Ln 8.58" Pos 0.75"

37. Employment outcome: FACT vs. ACT only

38. Washtenaw County, hospital rates ACT vs. MFG+ACT

39. Selection Bias for the MFG?

40. WCSTS ACT Employment/School

41. Employment outcomes in Family-aided Assertive Community Treatment FACT vs CVR William R. McFarlane, M.D. Peter Stastny, M.D. Susan Deakins, M.D. Robert Dushay, Ph.D.

42. Research design: entry criteria – Age: 18-45 – Diagnoses: Schizophrenia, schizoaffective disorder, bipolar disorder, major depression – Stable for at least six months – Family available – Interested in obtaining a job – In treatment at the site clinics – No contraindications for antipsychotic, - manic or -depressive drugs.

43. Clinical characteristics VARIABLE FACTCVR Diagnosis (%) Schizophrenia spectrum 7356 Mood spectrum2744 Age of onsetMean19.019.3 SD8.48.8 Total prior admissions Mean5.64.4 SD6.13.9

44. Employment outcome, competitive jobs

45. Mean total income: FACT vs. CVR

46. Mental Health Employers Consortium Employment Outcomes An Employment Intervention Demonstration Project

47. Models Tested in Maine Mental Health Employers Consortium & FACT employers work together to support each other employers pledge jobs employers supported by vocational program participant services delivered through FACT model Family-Aided Assertive Community Treatment ACT model family psychoeducation and family participation in rehabilitation, in multifamily groups supported employment cognitive assessments for job accommodation

48. Total Receiving Service 137 Gender Male75 (54.7%) Female62 Condition Employers Consortium67 Community employers70 Sample Description

49. Employment rate in FACT combined with supported employment, by diagnosis 67% 41% 19%

50. Evidence-based benefits for participants Promotes understanding of illness Promotes development of skills Reduces family burden Reduces relapse and rehospitalization Encourages community re-integration, especially work and earnings Promotes socialization and the formation of friendships in the group setting

51. Practitioners have found... Renewed interest in work Increased job satisfaction Improved ability to help families and consumers deal with issues in early stages Families and consumers take more control of recovery and feel more empowered

52. Who can benefit from FPE? Individuals with schizophrenia who are newly diagnosed or chronically ill Adolescents and young adults with pre- psychotic symptoms There is growing evidence that the following people can also benefit: - individuals with mood disorders - consumers with OCD or borderline personality disorder

54. Cost-benefit ratios of PMFGs Treatment Hospital CostsTreatment Net /pt./yr. costs Usual/prior$6156 $0$6156 Family PE$1539 $300 $1839 $ saved per pt./yr.$4317

55. Family psychoeducation and multifamily groups: Basic techniques

56. Stages of a psychoeducational multifamily group Joining Family and patient separately 3-6 weeks Educa- tional workshop Families only 1 day Ongoing MFG Families and patients 1-4 years

57. Therapeutic processes in multifamily groups Stigma reversal Social network construction Communication improvement Crisis prevention Treatment adherence Anxiety and arousal reduction

58. Phases and Interventions in Family Psychoeducation Year One: Relapse Prevention  Engaging individual families  Multifamily educational workshop  Implementing family guidelines  Reducing stigma and shame  Lowering expectations  Controlling rate of recovery  Reducing intensity and exasperation

60. Phases and Interventions in Family Psychoeducation Year Two: Rehabilitation  Gradually increasing responsibilities  Moving one step at a time--the internal yardstick  Monitoring encouragement from family members  Establishing inter-family relationships  Cross-parenting  Focusing family interests outside family  Restoring family's natural social network

61. Structure of Sessions Multifamily groups (MFGs) and single-family treatment (SFT) MFG SFT 1. Socializing with families and consumers 15 m.10 m. 2. A Go-around, reviewing-- 20 m. 15 m. a. The week's events b. Relevant biosocial information c. Applicable guidelines 3. Selection of a single problem 5 m. 5 m. 4. Formal Problem-solving 45 m. 25 m. a. Problem definition b. Generation of possible solutions c. Weighing pros and cons of each d. Selection of preferred solution e. Delineation of tasks and implementation 5. Socializing with families and consumers 5 m. 5 m. Total: 90 m. 60 m.

62. Better outcomes in family psychoeducation Over 16 controlled clinical trials, comparing to standard outpatient treatment, have shown: –Much lower relapse rates and rehospitalization Up to 75% reduction of rates in controls; 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 –Reduced negative symptoms, in multifamily groups –Improved family relationships and reduced friction and family burden –Reduced medical illness Doctor visits for family members decreased by over 50% in one year, in multifamily groups

63. Summary