ps1504 winnie kung

Pilot Study of Ethnically Sensitive Family Psychoeducation for Chinese American Caregivers of Persons Suffering from Schizophrenia為居美華人精神病患者的照顧者而設的家庭精神衛生教育計劃研究初探 : 

Pilot Study of Ethnically Sensitive Family Psychoeducation for Chinese American Caregivers of Persons Suffering from Schizophrenia為居美華人精神病患者的照顧者而設的家庭精神衛生教育計劃研究初探 Winnie W. Kung, Ph.D. 龔惠明博士 Associate Professor 副教授 Graduate School of Social Service 社會工作學院 Fordham University 富敦大學

Background & Lit. Review研究背景與文獻探討 : 

Background & Lit. Review研究背景與文獻探討 The relapsing course of schizophrenia exerts enormous stress on patients’ families Families, however, can be allies in treatment 精神分裂症週期復發的性質對病人的家庭造成極大的壓力。 不過，精神病患者的家庭可以加入聯手治療的行列。 2

Background & Lit. Review研究背景與文獻探討 : 

Background & Lit. Review研究背景與文獻探討 Negative interactional cycles in these families: Patients’ deficits in thought processes => greater vulnerability to internal and external stimuli Positive symptoms (e.g. delusions, hallucination and disruptive behaviors) + negative symptoms (e.g. inertia and paucity of affects) => relatives’ anxiety, guilt & frustration => intensify criticism and overprotection => heightens patient stress => increases relapse rate 這些家庭中負面的互動循環︰ 病人思考能力的不足→對內在和外在的刺激更脆弱。 正性的症狀(例如︰妄想、幻覺，和擾亂性的行為)與負性的症狀(例如︰無動力和缺乏情緒反應) →家屬的焦慮、罪惡感和挫折感→加強批評與對病人過度保護→增加病人的壓力→提高復發率。 3

Background & Lit. Review研究背景與文獻探討 : 

Background & Lit. Review研究背景與文獻探討 Family psychoeducation for individuals with schizophrenia found to be a robust intervention in reducing caregiver burden and patient relapse However, these interventions were not tested with minority groups taking into consideration their cultural beliefs and immigrant experience 研究發現為患有精神病者提供家庭精神衛生教育，是一種降低照顧者負荷和病人疾病復發的極有效的介入方法。 不過這些介入方法尚未在少數種族進行檢試，考慮到他們的獨特文化信念和移民經驗。 4

2. Study Aim研究目標 : 

2. Study Aim研究目標 to test the feasibility and receptivity of an ethnically sensitive family psychoeducation designed specifically for Chinese American patients and their families 檢定為居美華人精神病患者及照顧者而設的家庭精神衛生教育計劃的可行性和被接納程度。 5

3. Adaptation in Intervention Protocol調整介入模式 : 

3. Adaptation in Intervention Protocol調整介入模式 6 mths Involves both multifamily group and single family groups Additional relative initiated group topics 六個月 同時進行多元家庭小組與單一家庭小組 加上家人提出的小組討論主題 6

Multifamily group多元家庭小組 : 

Multifamily group多元家庭小組 Meets alternative weeks Facilitated by 2 clinicians patients not present original design: 2 caregivers from each family Impart knowledge on mental illness and skills in managing patient behavior Sharing and support among caregivers A topic is designated for each group session based on predetermined themes and caregiver input 每隔週聚會一次。 由兩位精神衛生專業人員帶領。 病人無需出席。 原本設計︰每個家庭有兩位照顧者出席。 提供與精神病有關的知識和與病人相處的有關技巧。 家庭照顧者彼此分享和支持。 每次小組根據事前設計的主題和照顧者的建議，選定一個題目。 7

Single family groups單一家庭小組 : 

Single family groups單一家庭小組 Meets once or twice a month at the clinic or patients’ homes facilitated by one of the two clinicians of multifamily group resolves conflicts arising in the care-giving process Promote effective communication between patient and caregivers Help caregivers implement what they learned in the multifamily group with patient input 在中心或病人家中舉行，每月會面一至兩次。 由多元家庭小組其中一位精神衛生專業人員帶領 解決照顧過程中引起的衝突 促進病人和照顧者之間有效溝通。 因應病人的需要及反應，協助照顧者實踐從多元家庭小組當中所學到的。 8

5. Study Design研究設計 : 

5. Study Design研究設計 Original design: An experimental design with random assignment of intervention and control groups; difficulty in recruitment=> comparison group with families interested but can’t come Participants: 9 families in intervention group, 3 families in comparison group 原本設計︰隨機分派實驗組與控制組的實驗設計；招募有困難→有興趣但 無法出席的家庭加入比較組。 參加者︰實驗組有九個家庭，比較組有三個家庭。 9

Inclusion Criteria選入標準 : 

Inclusion Criteria選入標準 Chinese American patient with a schizophrenic form of disorder Both patient and relative speak Mandarin or Cantonese Both age 18 or above Patient currently receiving service for medication and individual counseling or day treatment both caregiver and patient willing to participate all relationships of caregivers accepted 經診斷患有精神分裂症的居美華人。 病人和家屬都會說廣東話或普通話/國語。 病人的家屬均須年滿十八歲。 病人現正接受門診藥物治療和個人輔導或日間治療服務。 病人的家屬都願意參加研究計畫。 接受與病人有任何關係的照顧者。 10

6. Recruitment of Participants招募參加者 : 

6. Recruitment of Participants招募參加者 Through referrals from clinicians at the family service center and day treatment program of a mental health clinic in N.E. of the U.S. 透過美國東北一所精神衛生機構家庭服務中心和日間治療計劃的精神衛生專業人員轉介。 11

7. Outcome Evaluation結果評估 : 

7. Outcome Evaluation結果評估 Treatment outcome and satisfaction with the program assessed at baseline, 3 months, termination, and 3-month follow-up evaluated by patients, caregivers and psychiatrist through individual interviews 在(1)接受介入之前，(2)介入開始三個月後， (3)介入結束時，和(4)介入結束三個月後，由病人、家屬和精神科醫生評估結果以及對計劃的滿意程度。 12

Measures: Caregivers outcome評估照顧者結果的測量工具 : 

Measures: Caregivers outcome評估照顧者結果的測量工具 Burden Assessment Scale (Reinhard, Gubman, Horwitz, & Minsky, 1994) Perceived Social Support and Social Conflict Scales (Goodman, 1991) Mental Health Belief (Krause, 1991) North-Sacher Family Life Questionnaire (North, Pollio, Sacher, Hong, Isenberg & Bufe, 1998) Caregiver Satisfaction (Kung, 2008) Patient Rejection Scale (Krelsman, Slmmens, & Joy, 1979) Perceived Criticism Scale (Hooley & Teasdale, 1989) 照顧者負荷評估量表 (Reinhard, Gubman, Horwitz, & Minsky, 1994) 社會支持和社會衝突感知量表 (Goodman, 1991) 精神健康的信念 (Krause, 1991) North-Sacher家庭生活問卷 (North, Pollio, Sacher, Hong, Isenberg & Bufe, 1998) 照顧者滿意程度 (Kung, 2008) 照顧者拒絕病人程度量表 (Krelsman, Slmmens, & Joy, 1979) 挑剔量表 (Hooley & Teasdale, 1989) 13

Measures: Patient outcome評估病人結果的測量工具 : 

Measures: Patient outcome評估病人結果的測量工具 Patient perspective: Wisconsin Quality of Life (Becker, 2000) Caregiver perspective: Specific Level of Functioning Scale (Schneider & Struening, 1983) Perceived Criticism Scale (Hooley & Teasdale, 1989) Psychiatrist perspective: Brief Psychiatrc Rating Scale (BPRS, Overall & Gorham, 1962) Scale for Assessment of Negative Symptoms (SANS, Andreasan, 2000) 病人評估方面︰ 威斯康辛生活品質 (Becker, 2000) 照顧者評估方面︰ 具體的功能程度量表 (Schneider & Struening, 1983) 挑剔量表 (Hooley & Teasdale, 1989) 精神科醫生評估方面︰ 簡要精神症狀評估量表 (BPRS, Overall & Gorham, 1962) 負性症狀評估量表 (SANS, Andreasan, 2000) 14

Measures: Satisfaction on program評估計畫滿意程度的測量工具 : 

Measures: Satisfaction on program評估計畫滿意程度的測量工具 Topic and content relevance Opportunity to share and obtain support Offer of practical help Promotion of communication within family Overall satisfaction Suggested changes 內容的相關性。 在小組中分享與得到支持的機會。 從小組得到實際幫助的程度。 促進家庭溝通的程度。 整體滿意程度。 建議可改進之處。 15

8. Topics covered小組所討論的題目 : 

8. Topics covered小組所討論的題目 Affirmation of strengths and satisfaction in life as a start Sharing of caregiver experience Nature of schizophrenia and treatment (psychiatrist) Communication with patients: dos and don’ts (2) Rule setting for unacceptable patient behaviors and prioritize problematic behaviors 首先肯定照顧者的強項，以及他們生活上滿意的地方。 分享照顧病人的經驗。 精神病之本質及治療(精神科醫生講解)。 與病人溝通時應當作的和不應做的(兩次) 建立規則， 訂立不可接受之病人行為， 以及設定問題行為的優先次序。 16

Topics covered小組所討論的題目 : 

Topics covered小組所討論的題目 6. Stress management (2) 7. Relapse prevention 8. How to discuss sexual and emotional intimacy needs with patients 9. Consideration of Marriage 10. Spirituality and meaning making of adverse experiences 6. 壓力管理 (兩次) 。 7. 預防精神病復發。 8. 如何與病人討論性和情感親密的需求。 9. 慎重考慮婚姻。 10.從屬靈的角度和深層意義的探索來理解不幸的經驗。 17

9. Format形式 : 

9. Format形式 Dinner Brief lecture with handouts Discussion/role play/problem solving Relaxation exercises 晚餐 簡短的演講並提供講義 討論/角色扮演/問題解決 紓壓運動 18

10. Results from quantitative data量化資料的分析結果 : 

10. Results from quantitative data量化資料的分析結果 Patients: Mean age: 38 (15), range: 18-58 Education: 11(3), range: 6-16 Care-givers: Relationship with patient: quite a variety: parents, spouses, siblings, sons, live-in boy-friend, but mostly mothers 42% Mean age: 52 (16), range: 20-79 Years of migration: 22, range: 1-70 Education: 12 yrs or less: 67% 病人方面︰ 平均年齡︰38 歲，分布於 18-58 歲之間。 教育年數︰11 年，分布於 6-16 年之間。 照顧者方面︰ 有各種照顧者與病人關係︰父母、配偶、手足、兒子、同居男友，但多數是母親 (42%) 。 平均年齡︰52 歲，分布於 20-79 歲之間。 移民年數︰ 22 (美國)，分布於 1-70 年之間。 教育年數︰12 年或以下 (67%) 。 19

Results from quantitative data量化資料的分析結果 : 

Results from quantitative data量化資料的分析結果 Family income: all under $40,000 annual family income, low income households Attendance: Despite recruitment difficulties, none of the families dropped out. All except one family attended over 80% of the groups 家庭收入︰所有家庭年收入皆低於$40,000，屬於低收入戶。 出席情況︰雖然招募不容易，家庭全未中途退出。除了一個家庭以外，所有家庭出席 80% 以上的多元家庭小組。 20

Results from quantitative data量化資料的分析結果 : 

Results from quantitative data量化資料的分析結果 Due to the small sample size, statistical analyses only aimed to examine the direction of change Patients’ symptomatology was reduced both at termination and follow-up, and the intervention group had greater reduction relative to the comparison group 由於樣本小，統計分析的目標在於檢驗介入對於結果改變的方向。 在介入結束時及三個月後的追蹤評估，病人均降低症狀。而且和比較組的病人相比，治療組的病人症狀降低更多。 21

Results from quantitative data量化資料的分析結果 : 

Results from quantitative data量化資料的分析結果 Caregivers’ mental health beliefs, burden, control, shame and guilt over relatives’ illness had improved, while their perceived patient functioning, caregiving satisfaction, social support and social conflict did not improve 照顧者精神健康的信念、負荷、控制能力、以及因精神病家人引起的丟臉與罪惡感都有改善。 不過，他們看病人的功能程度、照顧者滿意感，與社會支持和社會衝突程度並未改善。 22

Results from quantitative data量化資料的分析結果 : 

Results from quantitative data量化資料的分析結果 Caregivers: 67% very satisfied with multifamily group, 71.4% very satisfied with single family group Patients: 11% very satisfied with the single family group, 67% mostly satisfied 照顧者︰有 67% 的照顧者非常滿意多元家庭小組， 71.4% 非常滿意單一家庭小組。 病人︰有 11% 的病人非常滿意單一家庭小組，67% 大部分滿意。 23

11. Reflections and analyses from qualitative data 質化資料的分析結果和反思 : 

11. Reflections and analyses from qualitative data 質化資料的分析結果和反思 Specific issues of immigrant Chinese families Consideration of arranged marriage from Mainland China Financials concern and practical/tangible help Language barrier of both patients and caregivers: limited socialization with outside world Deeply entangled relationship with extended family and in-laws Stressful work situation Stress from racial discrimination 華人移民家庭的特別議題 考慮從中國大陸為子女安排結婚 經濟狀況不佳，以及需要實際和具體的協助 病人和照顧者都有語言的隔閡︰與外界社會的接觸受到侷限 和大家庭以及姻親之間極度糾纏的關係 工作壓力 種族歧視的壓力 24

Reflections and analyses from qualitative data質化資料的分析結果和反思 : 

Reflections and analyses from qualitative data質化資料的分析結果和反思 Obstacles for caregiver participation Health concern of caregiver themselves Preoccupation with other familial responsibility Improvement of patient condition Bad weather: snow 阻礙照顧者參加治療的因素 照顧者本身的健康問題 其他家庭責任的牽絆 病人情況已改善 天氣不佳︰下雪 25

Reflections and analyses from qualitative data質化資料的分析結果和反思 : 

Reflections and analyses from qualitative data質化資料的分析結果和反思 Incentive for caregiver participation Sense of support Socialization opportunity Dinner before meeting Reimbursement for public transportation Patients: more understanding and support from family Monetary incentive for evaluation interviews for both caregivers and patients 鼓勵照顧者參加計劃的因素 相互支持感 社交的機會 聚會前供應晚餐 補償交通費 病人︰從家人方面獲得更多的了解和支持。 為感謝照顧者和病人參加評估訪問而提供的金錢奬賞。 26

Reflections and analyses from qualitative data質化資料的分析結果和反思 : 

Reflections and analyses from qualitative data質化資料的分析結果和反思 Revelations of unforeseen important family dynamics through other family involvement and home visits 透過其他家人參與和家訪揭示未預料到的重要的家庭動力。 27

Reflections and analyses from qualitative data質化資料的分析結果和反思 : 

Reflections and analyses from qualitative data質化資料的分析結果和反思 Structural issues: Proportion of info, sharing, support, and problem-solving Needs longer program duration Recruitment difficulties: Billable activities? Hierarchy and power struggle of Asian mental health agencies? 結構方面的議題︰ 在多元家庭小組中提供資訊、分享與支持，和問題解決的比重分配。 增加計劃為期的長度 招募的困難︰活動是否包括在保險的範圍內﹖亞裔精神衛生機構的等級制度和權力鬥爭﹖ 28

Slide 29: 

Thank you for your attention!! 多謝聆聽!! Contact聯絡: Winnie Kung, Ph.D.龔惠明博士 Fordham University kung@fordham.edu