1. Introduction to Multifamily Groups Alex Kopelowicz, MD Thomas E. Backer, PhD Human Interaction Research Institute New Haven, CT October 28, 2011

2. Agenda 9:00 - 9:15 amWelcome and introductions 9:15 - 10:00 amDefinition of MFG and evidence for its effectiveness 10:00 – 10:30 amSteps for implementing MFG in New Haven 10:30 – 10:45 amBreak 10:45 – 12:00 pmOverview of MFG components 12:00 – 1:00 pmLunch 1:00 -1:30 pmTailoring MFG for New Haven 1:30 – 2:00 pmWorkplace Fundamentals to augment MFG 2:15 – 2:30 pmChallenges of implementing MFG 2:30 – 2:45 pmEvaluating process and outcomes of MFG 2:45 – 3:00 pmNext steps

3. Why Focus on the MFG Approach with Families ? Clients and relatives need information to help them better understand mental disorders or other problems Clients and relatives need information to help them better understand mental disorders or other problems Clients want and need the support of their families Clients want and need the support of their families Relatives often provide assistance, and want to be a part of the client’s recovery and success Relatives often provide assistance, and want to be a part of the client’s recovery and success Clients want to develop skills and benefit from the help of their relatives Clients want to develop skills and benefit from the help of their relatives Relatives need help reducing caregiver burden Relatives need help reducing caregiver burden Families need help reducing stress at home Families need help reducing stress at home

4. PORT Treatment Recommendations PORT Treatment Recommendations Patients who have on-going contact with their families should be offered a family psychosocial intervention which spans at least nine months and which provides a combination of education about the illness, family support, crisis intervention, and problem solving skills training. Such interventions should also be offered to non-family caregivers. Patients who have on-going contact with their families should be offered a family psychosocial intervention which spans at least nine months and which provides a combination of education about the illness, family support, crisis intervention, and problem solving skills training. Such interventions should also be offered to non-family caregivers.

5. Approaches to Working with Families Psychoeducation Psychoeducation Communication skills training Communication skills training Problem solving techniques Problem solving techniques Social network development Social network development

6. Principles of Multifamily Groups Engage Families on their Own Terms Psychoeducation is Ongoing and Interactive Keep Tension and Conflict in Family Meetings to a Minimum Family Work is Oriented Toward the Future The Needs of the Whole Family are Addressed, Not Just the Client Avoid Blaming the Family

7. 7 Critical Ingredients of an Effective MFG Longer-term (6-9 months or longer) Longer-term (6-9 months or longer) Delivered by trained facilitators Delivered by trained facilitators 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 Education of families Concern and empathy demonstrated for individual and relatives Concern and empathy demonstrated for individual and relatives Avoidance of blaming or pathologizing family Avoidance of blaming or pathologizing family Fostering development of all family members Fostering development of all family members

8. Better Outcomes in Family Psychoeducation Better Outcomes in Family Psychoeducation Over 20 controlled clinical trials, comparing to standard outpatient treatment, have shown: 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% 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 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 Doctor visits for family members decreased by over 50% in one year Dixon et al 2003

9. Efficacy of MFG – RCT Study Results 174 Mexican- American subjects 1 year of treatment 1 year of follow-up Overall log-rank Χ 2 =13.3, df=2, p=.001.

10. Implementing MFG in New Haven Step 1 - Initial analysis of site population and environment Step 1 - Initial analysis of site population and environment Step 2 - Site orientation and learning (October 28) Step 2 - Site orientation and learning (October 28) Step 3 - Creation of adapted MFG for employment Step 3 - Creation of adapted MFG for employment Step 4 - Site staff training (date TBA) Step 4 - Site staff training (date TBA) Step 5 - Family psychoeducation session (date TBA) Step 5 - Family psychoeducation session (date TBA) Step 6 - Implementation and operation of MFG (6-9 months) Step 6 - Implementation and operation of MFG (6-9 months) (including two troubleshooting visits by Dr. Kopelowicz) Step 7 - Evaluation of MFG process and outcomes Step 7 - Evaluation of MFG process and outcomes Step 8 - Analysis of MFG and report to Casey Foundation Step 8 - Analysis of MFG and report to Casey Foundation

11. Stages of a Multifamily Group Joining Family and Client separately 3-6 weeks Psycho- educa- tional workshop Families only 1 day Ongoing MFG Families & Clients 6-9 months

12. Joining with Families & Clients Joining with Families & Clients JOINING means to CONNECT, BUILD RAPPORT, CONVEY EMPATHY, ESTABLISH AN ALLIANCE, ENGAGE JOINING means to CONNECT, BUILD RAPPORT, CONVEY EMPATHY, ESTABLISH AN ALLIANCE, ENGAGE It is the first stage of treatment It is the first stage of treatment Designed to create a bond between client/family members and facilitators Designed to create a bond between client/family members and facilitators Facilitators as advocates Facilitators as advocates

13. Joining Procedures THREE Joining Meetings THREE Joining Meetings  SEPARATELY with Relatives and Clients  WEEKLY – 1 HOUR with Relatives, ½ HOUR with Clients Start sessions ASAP after crisis such as hospitalization Start sessions ASAP after crisis such as hospitalization Gain an understanding of family’s stresses, problems, reactions to client’s problems, etc. Gain an understanding of family’s stresses, problems, reactions to client’s problems, etc.

14. Joining – I 15 Minutes of SOCIAL TALK 15 Minutes of SOCIAL TALK Review any recent CRISIS: Who and What Helped or Didn’t Review any recent CRISIS: Who and What Helped or Didn’t IDENTIFY WARNING SIGNS – PRODROMAL SIGNS – PRECIPITANTS IDENTIFY WARNING SIGNS – PRODROMAL SIGNS – PRECIPITANTS Distribute to Families & Keep for Future Reference Distribute to Families & Keep for Future Reference Describe the Plan for Ongoing MFG sessions Describe the Plan for Ongoing MFG sessions 5 Minutes SOCIALIZING 5 Minutes SOCIALIZING

15. Joining – II 15 Minutes of SOCIAL TALK 15 Minutes of SOCIAL TALK FAMILY’S EXPERIENCE DURING EPISODES FAMILY’S EXPERIENCE DURING EPISODES  The Sharing of Painful Events: A Crucial Aspect of “Joining”  The Client/Family’s Understanding of the Client’s Problems Family’s Social Network & Resources (Material & Emotional) Family’s Social Network & Resources (Material & Emotional) 5 Minutes SOCIALIZING 5 Minutes SOCIALIZING

16. Joining – III 15 Minutes of SOCIAL TALK 15 Minutes of SOCIAL TALK FAMILY’S SOCIAL NETWORK & RESOURCES FAMILY’S SOCIAL NETWORK & RESOURCES SHORT & LONG-TERM GOALS (e.g., Prevent Relapse) SHORT & LONG-TERM GOALS (e.g., Prevent Relapse) Preparation for Workshop & MFGs Preparation for Workshop & MFGs

17. Family Psychoeducation Workshop (sample for families of adults with serious mental illnesses) 9:00-10:00amWhat is Mental Illness? 9:00-10:00amWhat is Mental Illness? -Causes - Symptoms -Duration - Hope 10:00-10:15amBreak 10:00-10:15amBreak 10:15-12:00pmTreatment of Serious Mental Illness 10:15-12:00pmTreatment of Serious Mental Illness-Medication-Hospitalization -Family Psychoeducation -Social Skills Training 12:00-1:00pmLunch 12:00-1:00pmLunch 1:00-4:00pmThe Family and Serious Mental Illness 1:00-4:00pmThe Family and Serious Mental Illness -Familial Reaction -Family Problems -Family Support

18. Elements of MFG Sessions Five to eight families Five to eight families Two facilitators Two facilitators 1 ½-Hour sessions – biweekly 6-9 months 1 ½-Hour sessions – biweekly 6-9 months Refreshments/snacks are provided Refreshments/snacks are provided Initial sessions avoid emphasis on clinical issues 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 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. First MFG Session “GETTING TO KNOW EACH OTHER”  Go Around the Room  Background  Hobbies  Occupation  Interests  Facilitator Goes First (Discloses/Shares with Group) SETTING BASIC RULES  Regular ATTENDANCE (for Relatives)  CONFIDENTIALITY (No Pressure to Disclose)  INTERACTION AMONG MEMBERS  PHYSICAL/EMOTIONAL CONTROL  PHYSICAL/EMOTIONAL CONTROL

20. Second MFG Session Group process Group process  Building a SENSE OF TRUST & COMMITMENT  Sense of COMMON EXPERIENCE (Listen to each other)  Strengthening GROUP IDENTITY & SENSE OF RELIEF  The CLIENT’S INNER EXPERIENCES  Facilitators emphasize the vital role of SHARING GRIEF, CONFUSION, GUILT, FEAR with those “on the same boat” CONFUSION, GUILT, FEAR with those “on the same boat” AND HOPE AND HOPE Remind participants about Problem Solving (next session) Remind participants about Problem Solving (next session)

21. General Points on MFG New Members New Members Late-Arriving Members Late-Arriving Members Reminders about Attending Reminders about Attending Crises & Emergencies Crises & Emergencies COMMUNICATION & INTERACTIONS COMMUNICATION & INTERACTIONS  Facilitators DON’T speak for clients or relatives  Interaction among members is essential  Clients are ENCOURAGED (not pressured) to participate participate  Respect other’s turn and avoid criticism  Respect other’s turn and avoid criticism

22. Problem Solving in MFGs The CORE of MFG Sessions The CORE of MFG Sessions Designed to compensate for Information-Processing Deficits Designed to compensate for Information-Processing Deficits FORMAT: FORMAT: Checking in15 Minutes Go-round20 Minutes Selecting a Problem to Solve5 Minutes Solving the Problem45 Minutes Wrap-up Socializing5 Minutes Facilitators should GET READY and HAVE A PLAN – IN ADVANCE Facilitators should GET READY and HAVE A PLAN – IN ADVANCE

23. Selecting a Problem to Solve TOPICS: TOPICS: Safety in The Home Medication Compliance Drugs and Alcohol Life Events Outside Agency Events Disagreements among Family Members Conflict with a Family Guideline “REJECTED” PROBLEMS: “REJECTED” PROBLEMS: Make a Direct Suggestion and Review Outcome Meet Outside the Group (e.g., Crises) Refer to Past Solutions that Apply Refer to Solution/Family with Successful Outcome

24. The Problem-Solving Method 1. Define the Problem or Goal 2. List Possible Solutions 3. Evaluate Advantages and Disadvantages of each Solution 4. Choose “the Best” Solution 5. Implement Plan to Carry Out Solution 6. Review Implementation and Outcome

25. MFG is Flexible MFG programs have been created for adults and adolescents MFG programs have been created for adults and adolescents Clinical populations have included clients with schizophrenia, depression, ADHD and many other problems Clinical populations have included clients with schizophrenia, depression, ADHD and many other problems This MFG will focus on employment problems This MFG will focus on employment problems

26. The key question is: What are the factors that need to be considered prior to implementing the employment-focused MFG intervention with the target population in New Haven?

27. Target Population for Employment-Focused MFG Adults who are hard to serve/hard to employ/hard to house Adults who are hard to serve/hard to employ/hard to house Many have concurrent mental health, addiction and trauma problems Many have concurrent mental health, addiction and trauma problems Employment options include supported employment, subsidized employment, day labor, part time (typically not benefitted jobs) Employment options include supported employment, subsidized employment, day labor, part time (typically not benefitted jobs)

28. Tailoring MFG to the Needs of Clients in New Haven Attitudes Attitudes –Clients’ assumptions about employment and the benefits of services are targeted Subjective Norms Subjective Norms –Emphasis on encouraging family members to actively support the client’s employment efforts Perceived Behavioral Control Perceived Behavioral Control –Utilization of problem solving techniques to overcome financial, insurance and transportation obstacles to employment

29. Workplace Fundamental Skills How work changes your life How work changes your life Learn about your workplace Learn about your workplace Identify your own stressors Identify your own stressors Manage symptoms and meds Manage symptoms and meds Interactions to improve job Interactions to improve job Appropriate socialization Appropriate socialization Supports and motivation Supports and motivation

30. Challenges of Implementing MFG Is the MFG relevant for families of clients in my agency? Is the MFG relevant for families of clients in my agency? Are potential MFG trainers (or family facilitators) available at my agency? Are potential MFG trainers (or family facilitators) available at my agency? Are resources available to support implementing the MFG at my agency? Are resources available to support implementing the MFG at my agency? Are there two or more staff who can commit to the two-day MFG training sessions? Are there two or more staff who can commit to the two-day MFG training sessions?

31. Evaluating MFG Process and Outcomes Staff Training Pre- and Post-Surveys Staff Training Pre- and Post-Surveys Family Member Pre-Interviews Family Member Pre-Interviews Family Member Post-Interviews Family Member Post-Interviews Client Pre-Data Client Pre-Data Client Post-Data Client Post-Data Facilitator and Administrative Interviews Facilitator and Administrative Interviews Evaluation forms are available online Evaluation forms are available online

32. Contact Information Dr. Alex Kopelowicz, akopel@ucla.edu Dr. Alex Kopelowicz, akopel@ucla.eduakopel@ucla.edu Dr. Tom Backer, tomhiri@aol.com Dr. Tom Backer, tomhiri@aol.comtomhiri@aol.com We look forward to working with you! We look forward to working with you!