Slide1: Family psychoeducation and multifamily groups: Treatment of choice for psychotic disorders?
William R. McFarlane, MD
University of Vermont
Maine Medical Center
“…the basic defect in schizophrenia consists of a low threshold for (mental) disorganization under increasing stimulus input.” Epstein and Coleman, 1970: “…the basic defect in schizophrenia consists of a low threshold for (mental) disorganization under increasing stimulus input.” Epstein and Coleman, 1970
Slide3: DORSOLATERAL PREFRONTAL CORTEX HIPPOCAMPUS LIMBIC LOBE BRAINSTEM Attention Arousal Association Affect The brain in schizophrenia X
Slide4: Attention Arousal Interaction of attention and arousal
Functions of the prefrontal cortex: Functions of the prefrontal cortex Establishing a cognitive set
Problem-solving
Planning
Attention
Initiative
Motivation
Integration of thought and affect
Mental liveliness
Slide6: Low EE High EE 35 hrs. On med. No med. No med. On med. No med. On med. Total Expressed emotion and relapse 13% 51% 69% 28% 92% 53% 42% 15% 15% 12% N=
128 Low EE = 71
High EE = 57
Interaction of patient symptoms and family process: A biosocial causal model: Interaction of patient symptoms and family process: A biosocial causal model
Family distress and severity of illness: Family distress and severity of illness Family distress Severity Low High
Psychosis represents an unusual sensitivity to:: Psychosis represents an unusual sensitivity to: Sensory stimulation
Prolonged stress, strenuous demands
Rapid change
Complexity
Social disruption
Illicit drugs and alcohol
Negative emotional experience
Relapse vs. Recovery: Relapse vs. Recovery
Core Elements of Psychoeducation …creating an optimal social environment: Core Elements of Psychoeducation …creating an optimal social environment Joining
Education
Problem-solving
Interactional change
Structural change
Multi-family contact
Slide12: 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
Elements of engagement: Elements of engagement Exploration of precipitants
Review of prodromal symptoms/signs
Reactions of family to illness
Coping strategies
Social supports
Mourning
Contract for treatment
Preparation for multi-family group
The workshop is held in a classroom format: The workshop is held in a classroom format Promotes comfort
Families can interact without pressure
Encourages learning
Practitioners act as
educators
Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
Phases and Interventions in FPE Year One: Relapse Prevention: Phases and Interventions in FPE Year One: Relapse Prevention Engaging individual families
Multifamily educational workshop
Implementing family guidelines
Reducing stigma and shame
Lowering expectations
Controlling rate of recovery
Reducing negative intensity and exasperation
Components of groups: Components of groups Two co-facilitators
5-6 families with similar diagnoses
Meetings every other week for a minimum of 9 months, monthly after 12-18 months
Families, consumers, and practitioners become partners
On-going education about symptoms, medication, community life, work, etc.
Problem-solving format
Structure of Sessions Multifamily groups (MFG) and single-family treatment (SFT): Structure of Sessions Multifamily groups (MFG) 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.
Phases and Interventions in FPE/PMFGs Year Two: Rehabilitation: Phases and Interventions in FPE/PMFGs Year Two: Rehabilitation Gradually increasing responsibilities
Moving one step at a time; the internal yardstick
Monitored encouragement from family members
Establishing inter-family relationships
Cross-parenting
Focussing family interests outside family
Restoring family's natural social network
Relapse outcome in controlled trials 1980-1997: Relapse outcome in controlled trials 1980-1997
Relapse outcomes in clinical trials: Relapse outcomes in clinical trials
Slide21: Social contacts: OR=3.7
Isolation + stress: OR >4, in men
Functional support:
OR = 2.9 Social networks in cardiac mortality Orth-Gomer & Johnson, 1987
Ruberman, et al., 1984
Berkman, et al.,1992
Effects of social networks: Effects of social networks
Family network size
diminishes with length of illness
decreases in the period immediately following a first episode
is smaller at the time of first admission
Networks
buffer stress and adverse events
determine treatment compliance
predict relapse rate
correlate with coping skills and burden.
Social networks, received family stigma and over-involvement: In mothers of sons with schizophrenia: Social networks, received family stigma and over-involvement: In mothers of sons with schizophrenia
Slide24: A Biosocial Model for Relapse in Schizophrenia Stigma Isolation Arousal Distraction A Biosocial Model for Relapse Symptoms and Relapse Negative Intensity (EE)
Therapeutic processes in multifamily groups: Therapeutic processes in multifamily groups Stigma reversal
Social network construction
Communication improvement
Crisis prevention
Treatment adherence
Anxiety and arousal reduction
Slide26: COMMUNITY EXTENDED EXTENDED FAMILY MULTIFAMILY GROUP FAMILY PATIENT A B C D E F SOCIAL NETWORKS AND THE SEARCH FOR RESOURCES SOCIAL NETWORKS AND MULTIFAMILY GROUPS
Comparison of single and multifamily formats: Comparison of single and multifamily formats
Relapse outcomes in clinical trials: Relapse outcomes in clinical trials
Family Psychoeducation in Schizophrenia: Family Psychoeducation in Schizophrenia Psychoeducational multiple family group (PEMFG)
vs..
Psychoeducational single family treatment (PESFT)
N = 172
Sponsored by NYS OMH and NAMI-NY
Family Psychoeducation in Schizophrenia Project Sites: 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
Psychiatric Characteristics of Patients: Psychiatric Characteristics of Patients 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%
Sociodemographic Characteristics of Patients: Sociodemographic Characteristics of Patients Variable
N
Age
Mean
s.d.
Gender
Female
Male
Ethnicity
White
Black
Hispanic
Residence
With family
Comm. res. PEMFG PESFT
94 94
26.8 28.0
6.0 6.0
27.7% 26.6%
72.3% 73.4%
55.3% 54.3%
39.4% 37.2%
4.3% 6.4%
84.0% 83.0%
16.0% 17.0% Modality differences: all not significant Total
188
27.4
6.0
27.1%
72.9%
54.8%
38.3%
5.3%
83.5%
16.5%
Remission to 2 years: Remission to 2 years N: PEMFG=83; PESFT=92 Main effect, all cases: p=.07
Main effect, completers: p<.05
Initial relapses To two years: Initial relapses To two years N: MFG=83; SFT=89
Total hospital admissions Total sample over four years: Total hospital admissions Total sample over four years N = ???
Dosages in MFG and SFT: Dosages in MFG and SFT
Anxious depression, critical comments and treatment type: Differential effects on relapse rates: Anxious depression, critical comments and treatment type: Differential effects on relapse rates
Negative symptom outcomes: MFGs vs standard care: Negative symptom outcomes: MFGs vs standard care MFG vs SC: p<.05, all f/u time points Dyck, et al., 2000
Family satisfaction with treatment: Family satisfaction with treatment
Work Outcome: Work Outcome Employed at baseline
17.3%
(p=.001) Employed at 2 years
29.3%
Gain in % employed
PEMFG 16%
PESFT 8%
(n.s.)
Slide41: 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.
Relapse Outcome at 24 Months FACT vs. ACT: Relapse Outcome at 24 Months FACT vs. ACT FACT (n=36) ACT (n=35)
8 (22%) 14 (40%)
Ln 8.58" Pos 0.75"
Employment outcome FACT vs. ACT: Employment outcome FACT vs. ACT
Slide44: 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.
Family-aided Assertive Community Treatment (FACT): An Employment Intervention: Family-aided Assertive Community Treatment (FACT): An Employment Intervention Psychoeducational multifamily groups
Clinical case management using ACT principles and methods
Supported employment
Integrated, multidisciplinary teams
Cognitive assessments used in job accommodation
MH Employers’ Consortium
Slide46: 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
Slide47: 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
Slide48: 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.
Slide49: Demographic characteristics VARIABLE FACT CVR N 37 32 Age (years) Mean 34.4 31.1 SD 8.3 8.8 Sex (%) Male 65
75 Female 35 25 Marital Status (%) Never Married* 65 84 Separated, divorced 19 6 Married 16 10
Slide50: Clinical characteristics VARIABLE FACT CVR Diagnosis (%) Schizophrenia spectrum 73
56
Mood spectrum 27 44 Age of onset Mean 19.0 19.3 SD 8.4 8.8 Total prior admissions Mean 5.6 4.4 SD 6.1 3.9
Slide51: Employment outcome, competitive jobs
Slide52: Mean total income:
FACT vs. CVR
Mental Health Employers Consortium: Mental Health Employers Consortium Employment Outcomes
An Employment Intervention
Demonstration Project
Models Tested in Maine: 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
Intervention model : Intervention model
Slide56: Total Receiving Service 137 Gender Male 75 (54.7%) Female 62 Condition Employers Consortium 67 Community employers 70 Sample Description
Slide57: Employment Rate by Experimental Conditions
Slide58: Employment Rate by Month of Service
Slide59: Employment rate in FACT combined with supported employment, by diagnosis 67% 41% 19%
Better outcomes in family psychoeducation: 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 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 well-being and
Reduced friction and family burden
Reduced medical illness in family members
Doctor visits for family members decreased by over 50% in one year, in multifamily groups
Practitioners report... : Practitioners report... 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 Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
Cost-benefit ratios of PEMFGs: Cost-benefit ratios of PEMFGs Treatment Hospital Costs/pt./yr. Treatment costs Net
Usual/prior $6156 $0 $6156
Family PE $1539 $300 $1839
Difference ($ saved per pt./yr.) $4317
Slide63: Early prodrome Late prodrome Acute onset Biosocial causal interactions in late schizophrenic prodrome
Treatment of the prodromal state: Treatment of the prodromal state Multi-systems intervention
Social
Psychoeducational MFG
Supported education or employment
Friendship maintenance
Psychological
Focus on mastery, identity, meaning, validation
Neuropsychological
Cognitive support
Cognitive training
Treatment of the prodromal state: Treatment of the prodromal state Multi-systems intervention
Psychophysiological
Stress avoidance & management
Stress resistance
Biochemical
Nutrition and exercise
Antipsychotic medication
Cognitive enhancement
SSRIs
Preliminary outcomes: Preliminary outcomes First Year Data:
May 7, 2001- September 20, 2002
PIER Referrals and Patient Status: PIER Referrals and Patient Status
Study parameters: Study parameters Duration of study 16 months
Maximum exposure 14.8 months
Minimum exposure 2.2 months
Mean exposure 8.8 months
S.D. 2.9 months
Conversions Scoring 6 on SOPS, at any time: Conversions Scoring 6 on SOPS, at any time Cases not converted 22 81.5%
Cases converted, >0 days 5 18.5%
Cases converted, >4 days 1 3.7%
Cases converted, >7 days 0 0.0%
SOPS conversions* 0 0.0%
Scoring 6 X 4d/week X 1 month
Total days in conversion 18 (of 7209)
Who can benefit from FPE? : Who can benefit from FPE? Individuals with schizophrenia who are newly diagnosed or chronically ill
There is growing evidence of benefit for people with:
Mood disorders
OCD
Borderline personality disorder
Consumers without family members
Chronic medical disorders
Adolescents and young adults with pre-psychotic symptoms
Summary The psychoeducational multifamily group is the most cost-effective psychosocial treatment yet developed.: Summary The psychoeducational multifamily group is the most cost-effective psychosocial treatment yet developed.
Questions, Comments, Discussion: Questions, Comments, Discussion
Slide73: “ I would entreat professionals not to be devastated by our illness and transmit this hopeless attitude to us.
I urge them never to lose hope; for we will not strive if we believe the effort is futile.”
--Esso Leete, who has had schizophrenia for 20 years
Workshop: Workshop Family psychoeducation and multifamily groups:
The basics for clinicians
Slide75: Key characteristics of psychoeducational MFGs Rooted in the clinical care system
Assumes that family care-taking burden relief follows from reduction of symptoms, successful rehabilitation and recovery
Involves most of key members of care and social support system
Individualized coping skill training
Slide76: Key characteristics of psychoeducational MFGs Capacity to achieve clinical goals in absence of patient
Long-term perspective to treatment, rehabilitation and recovery
Higher costs than self-help or education alone
Need to re-train professionals and case managers in non-blaming paradigms
Slide77: Success in promoting change in behavior and attitudes requires:
The establishment of a cooperative, collegial, non-judgmental relationship among all parties;
Education supplemented with continued support and guidance;
Assumption of least pathology; Central assumptions of the psychoeducational model - I
Slide78: Central assumptions of the psychoeducational model - II Success in promoting change in behavior and attitudes requires:
Breaking problems into their components and solving them in a step-wise fashion;
Support comes from a network of well-informed and like-thinking people.
Core Elements of Psychoeducation: Core Elements of Psychoeducation Joining
Education
Problem-solving
Interactional change
Structural change
Multi-family contact
Identifying FPE Group Participants: Identifying FPE Group Participants Consumers with similar diagnoses
Families in search of psycho-education and support
People for whom this intervention would “make a difference” with relationships and life plans
Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
Multifamily group vs. single-family meetings: Multifamily group vs. single-family meetings MFGs are more effective for cases with social isolation, high distress and poor response to prior treatment
Some families prefer meeting with one practitioner for the entire time
Some families want to hear what other families have done and need support
Consumers and families may need the practitioner’s guidance to decide
Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
The Psychoeducational Workshop is the first time that families and individuals come together.: The Psychoeducational Workshop is the first time that families and individuals come together. 6 hours of illness education
relaxed, friendly atmosphere
co-leaders act as hosts
questions and interactions encouraged
Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
Elements of education: Elements of education History and epidemiology
Biology of schizophrenia
Treatment: effects and side effects
Family emotional reactions
Family behavioral reactions
Guidelines for coping and management
Socializing
Creating an optimal social environment Guidelines for recovery-I: Creating an optimal social environment Guidelines for recovery-I Go Slow
Keep It Cool
Give `Em Space
Set Limits
Ignore What you Can't Change
Keep It Simple
Creating an optimal social environment Guidelines for recovery-II: Creating an optimal social environment Guidelines for recovery-II Lower Expectations, Temporarily
Follow Doctor's Orders
Carry on Business as Usual
No Street Drugs or Alcohol
Pick Up on Early Warning Signs
Solve Problems Step By Step
Group logistics: Group logistics Provide snacks
Consider a time of day and day of week that is not a hardship for participants
Maintain the same time and location
Offer telephone reminders and meeting schedules to reduce “no shows”
Provide a take-home action plan following problem-solving
Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
The role of FPE practitioner : The role of FPE practitioner Collaborate with families and consumers to separate illness from personality
Assume the role of educator, family partner, and trainer-coach
Teach families and consumers to use the problem-solving method to deal with illness-related behaviors
Keep asking, “what’s next?” Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
The 1st and 2nd Groups: The 1st and 2nd Groups “Getting to know you”
Co-facilitators model behavior
Share personal information
Culturally normative introductions
Begin to develop trust and understanding “Experience with mental illness”
Co-facilitators model behavior
Personal stories of impact of M.I. Are shared
Continue to build relationships
Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
Slide89: Problem solving Source in organizational management
Value of multiple, new perspectives
Complexity of method matches complexity of the situations
Need to control affect and arousal
Need to compensate for information- processing difficulties in patients and some relatives
Need to be organized and systematic
Need to succeed and overcome failure
Brainstorming solutions: Brainstorming solutions All members can contribute
All suggestions are welcome
No suggestion is analyzed or critiqued during brainstorming
Suggestions are limited to 10 - 12 ideas
The person with the identified problem chooses 1 - 2 suggestions to try Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
Slide91: Problem solving Types of problem-solving
Hierarchy of problems
Based on clinical experience and family guidelines
Direct action and intervention by clinicians
Problem is agreed upon by all family members
Problem that is not agreed upon by all family members
Take action!: Take action! An action plan is developed for the chosen suggestion(s)
Tasks are identified and assigned
Consensus is achieved prior to leaving the meeting
The plan is reviewed at the next meeting to determine success or the need for further problem-solving Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
Slide93: A hierarchy for problem-solving Medication compliance
Street Drug and Alcohol Use
Life events
Problems generated by other agencies
Conflicts between family members
Conflicts with family guidelines
Slide94: Problem-solving conflict Validate all positions
Define the problem as illness-based, to the degree that is reasonable
Undertake a step-wise or sequential solution
Look at consequences of each position in the conflict itself >>> advantages and disadvantages
Reframe motives of all concerned
Support limit-setting
Phases and Interventions in PEMFGs Year Three: Network Formation: Phases and Interventions in PEMFGs Year Three: Network Formation Validating group competency
More socializing, less problem-solving
Encouraging social contacts outside the group
Shifting role of clinicians
Converting to an advocacy group
Converting to a vocational auxiliary
Starting a FPE group: Starting a FPE group Find a compatible co-facilitator
Attend a training and follow the manual
Explore your own motivation and enthusiasm since barriers will appear
Promote this model to your supervisor because you will need his/her support
Adhere to the problem-solving format since this is not group process
Evidence-Based Practices Copyright West Institute
William R. McFarlane, MD
Slide97: Costs are higher than self-help and may not be borne by some insurers in some states
Requires using existing professionals with training in negative family paradigms
Requires lengthy, though low intensity, work
Some results are abstract (e.g., remission) Disadvantages of family psychoeducation
Slide98: COMMUNITY EXTENDED EXTENDED FAMILY MULTIFAMILY GROUP FAMILY PATIENT A B C D E F SOCIAL NETWORKS AND THE SEARCH FOR RESOURCES SOCIAL NETWORKS AND MULTIFAMILY GROUPS
Slide99: Influences on treatment adoption
Trainers
Familiarity with the model
"Well-taught" basic training exercises
Content of training
Hearing about experiences of agencies and success stories of other MFGs
Also, successful local adaptations
Format
Role playing was particularly useful
Visual material
Two-day workshop allowed time to process information
Slide100: Influences on treatment adoption
Enthusiasm
"Being part of a larger process"
Gained motivation and inspiration
"Great enthusiasm is contagious"
Came from trainers and others whose agencies had already implemented
Testimonials from staff and families at booster training sessions
Slide101: Influences on treatment adoption
Stated reasons for progress
Belief in the model
Equally, staff effectiveness and outcomes
Grant support and free training
Depends upon the "drive, enthusiasm, and commitment of a determined individual"
Backed by a supportive administration
Skill and support of a trusted supervisor
Survey: "Use of outside consultants" most helpful item on survey (3.7/5)
Positive feedback processes
Success and positive outcomes beget further adoption, even between agencies
Slide102: Influences on treatment adoption
Barriers
Shortage of agency resources, especially time and energy, sometimes money
Survey: "Intense work pressure on staff" highest rating for obstacle (3.7/5)
Next highest: "Staff demands too high already" (3.3/5)
Patient and/or family participation
Rapid turnover of previously trained staff
Staff burnout, unrelated to adoption process
Insufficient administrative support
Better outcomes in family psychoeducation: 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
Summary Psychoeducational multifamily group is the most cost-effective psychosocial treatment yet developed.: Summary Psychoeducational multifamily group is the most cost-effective psychosocial treatment yet developed.
Slide105: “ I would entreat professionals not to be devastated by our illness and transmit this hopeless attitude to us.
I urge them never to lose hope; for we will not strive if we believe the effort is futile.”
--Esso Leete, who has had schizophrenia for 20 years