The Power of Family Work: Findings Old and New

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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

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Interaction of patient symptoms and family
processA simple causal model

Family
Symptoms

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Effects of EE and medication on relapse in
schizophrenia
Bebbington and Kuipers, 1994
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Effects of EE and contact on relapse in
schizophrenia
Bebbington and Kuipers, 1994
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p lt 0.001 p 0.582
Tienari, et al, BJM, 2004
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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.

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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.

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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.

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Core Elements of Psychoeducation

• Joining
• Education
• Problem-solving
• Interactional change
• Structural change
• Multi-family contact

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Outcomes in family psychoeducation

• The evidence for being an evidence-based practice

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Relapse outcome, controlled trials, 1980-1997
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Comparison of single and multifamily formats
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Relapse outcomes in clinical trials
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• Hospitalizations before vs.
• during treatment

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Family Psychoeducation in Schizophrenia

• Psychoeducational multiple family group (PEMFG)
• vs..
• Psychoeducational single family treatment (PESFT)
• N 172

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Family Psychoeducation in SchizophreniaProject
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

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Psychiatric Characteristics of Patientsby
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

Total 19.0 5.8 85.1 11.2 3.7 4.8 5.1 63.8 36
.2
Modality differences all not significant
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Remission to 2 years
N PEMFG83 PESFT92Main effect, all cases
p.07 Main effect, completers plt.05
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Risk for relapse over two years
N MFG83 SFT89
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Medication dosages in MFG and SFT
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Risk factors and treatment typeEffects on
two-year relapse rates
Number of factors, any combination High EE,
high BPRS, white race
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Anxious depression, critical comments and
treatment typeDifferential effects on relapse
rates
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• Differential relapse rates by number of prior
  hospitalizations

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Functioning as an effect of repeated psychotic
episodes
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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

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Family satisfaction with treatment
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Negative symptom outcomesMFGs vs standard care
MFG vs SC plt.05, all f/u time points
Dyck, et al., 2000
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Family influences on work
Modeling Information
Encouragement Buffering
Guidance Adjusting expectations
Ancillary support Cueing
Personal connections
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• 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

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Work Outcome

• Employed at baseline
• 17.3
• 
  (p.001)

• Employed at 2 years
• 29.3
• Gain in employed
• PEMFG 16
• PESFT 8
• (n.s.)

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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

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• 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

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• 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

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• 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.
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RELAPSE OUTCOMEFACT vs. ACT
FACT (n36) ACT (n35)
8 (22) 14 (40) Ln
8.58" Pos 0.75"
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Employment outcome FACT vs. ACT only
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Washtenaw County, hospital rates ACT vs. MFGACT
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Selection Bias for the MFG?
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WCSTS ACT Employment/School
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• 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.
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• 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.

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• Clinical characteristics

VARIABLE

FACT
CVR
Diagnosis ()
Schizophrenia spectrum
73
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Mood spectrum
27
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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

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• Employment outcome, competitive jobs

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• Mean total income
• FACT vs. CVR

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Mental Health Employers Consortium

• Employment Outcomes
• An Employment Intervention
• Demonstration Project

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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

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Sample Description
137

• Total Receiving Service

Gender

Male
75 (54.7)
Female
62
Condition

Employers Consortium
67
Community employers
70
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• Employment rate in FACT combined with supported
  employment, by diagnosis

67
41
19
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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

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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

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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

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Cost-benefit ratios of PMFGs
Treatment Hospital Costs Treatment Net
/pt./yr. costs Usual/prior 6156
0 6156 Family PE 1539 300
1839 saved per pt./yr. 4317
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• Family psychoeducation and multifamily groups
• Basic techniques

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

• Stigma reversal
• Social network construction
• Communication improvement
• Crisis prevention
• Treatment adherence
• Anxiety and arousal reduction

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Phases and Interventions in Family
PsychoeducationYear 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

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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

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Structure of SessionsMultifamily 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.
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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 50employed
  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

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Summary