family psychoeducation

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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. > 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

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