Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Family Psychoeducation

Fidelity Scale: Introduction

Overview of FPE

FPE is an evidence-based psychiatric rehabilitation practice that aims to achieve the best possible outcome for consumers with severe mental illness (SMI) through collaborative treatment between clinicians and family members of the individual with SMI. Additionally, FPE attempts to alleviate the stress experienced by family members by supporting them in their efforts to aid the recovery of their loved one. Research has demonstrated that FPE results in a 20% - 50% reduction in relapse and rehospitalization rates among consumers whose families received psychoeducation than among those receiving standard individual services (Lam, Knipers & Leff, 1993; Penn & Kim, 1996; Falloon, Held et al., 1999). Moreover, families that receive education and support feel less burden and are more effective at helping their loved ones with SMI to manage their illnesses (Dixon & Lehman, 1995).

Although the existing models of family interventions vary, leaders in the field have reached a consensus on the critical ingredients of effective FPE. They include a collaborative relationship between the treatment team and family, basic psychoeducation about psychiatric illness and its management, social support and empathy, interventions targeted to reducing tension and stress in the family as well as improving functioning in all family members (and not just the consumer), and a program length of six months or more (Dixon, McFarlane et al., 2001).

What is meant by “family”?

The term “family” is used throughout this document. It should be interpreted broadly to including anyone in the client’s natural support system who is functioning as “family,” regardless of any legal or biological relationship to the client. A family member could include not only parents, siblings, spouses, children, and other relatives, but also friends.

Overview of the scale

The 12-item FPE Fidelity Scale has been developed to measure the adequacy of implementation of FPE programs. Each item on the scale is rated on a 5-point rating scale ranging from 1 (“Not implemented”) to 5 (“Fully implemented”). The standards used for establishing the anchors for the “fully-implemented” ratings were determined through a variety of expert sources as well as empirical research.

What is rated

The scale is rated on current behavior and activities, not planned or intended behavior. For example, in order to get the full credit for Item 1 (“Family Intervention Coordinator”), it is not enough that the program is currently planning to hire personnel to fill the position.

Unit of analysis

The scale is appropriate for organizations that are serving clients with SMI and their families. The purpose of the scale is to assess fidelity to evidence-based practices at the program level, rather than at the level of a specific clinician.

How the rating is done

To be valid, we believe that a fidelity assessment must be done in person, i.e., through a site visit. The fidelity assessment requires a minimum of 5 hours to complete, although a longer period of assessment will offer more opportunity to collect information and hence should result in a more valid assessment. The data collection procedures include chart review, session observation, and semi-structured interviews with the program coordinator, clinicians and supervisors, and family members.

If the FPE program has 3 or fewer clinicians, attempts should be made to interview all. If the program has more than 3 clinicians, a minimum of 3 should be sampled for an interview. It is recommended that interviews with clinicians be done in a group format.

For the items that require interviews with family members, we suggest that at least 3 family members (from unique families) be interviewed. The program coordinator should be contacted to help you identify and set up these interviews.

For some items that require chart review for rating, 10 charts shall be randomly selected. We suggest that you ask the program coordinator to select 20 charts beforehand and then randomly select and review 10 of those charts during your site visit. The charts should include one client whose family is seen for each FPE clinician to be interviewed.

Some items are to be rated by observing a session. The rating may be done either by observing a live session or by viewing a previously videotaped session, which should be determined by negotiating with each program.

Who does the ratings

The scale can be administered internally by a program or by an external review group. If it is administered internally, it is obviously important for the ratings be made objectively, based on hard evidence, rather than making ratings to “look good.” Circumstances will dictate decisions in this area, but we encourage agencies to choose a review process that fosters objectivity in ratings, e.g., by involving a staff person who is not centrally involved in providing the service. With regard to external reviews, there is a distinct advantage in using assessors who are familiar with the program, but at the same time are independent. The goal in this process is the selection of objective and competent assessors.

Fidelity assessments should be administered by individuals who have experience and training in interviewing and data collection procedures (including chart reviews). In addition, interviewers need to have an understanding of the nature and critical ingredients of FPE. We recommend that all fidelity assessments be conducted by at least two assessors.

Missing data

The scale is designed to be completely filled out, with no missing data on any items. Therefore, it is essential that assessors obtain the required information for every item. If information cannot be obtained at time of the site visit, it will be important for you to be able to collect at a later date.

References

Dixon, L. & Lehman, A.F. (1995). Family interventions for schizophrenia. Schizophrenia Bulletin, 21, 631-643.

Dixon, L., McFarlane, W.R. et al. (2001). Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatric Services, 52, 903-910.

Lam, D.H., Knipers, L., Leff, J.P. (1993). Family work with patients suffering from schizophrenia: The impact of training on psychiatric nurses’ attitude and knowledge. Journal of Advanced Nursing, 1S, 233-237.

Penn, L.D. & Mueser, K.T. (1996). Research update on the psychosocial treatment of schizophrenia. American Journal of Psychiatry, 153, 607-617.

Falloon, I.R.H., Held, T. et al. (1999). Psychosocial interventions for schizophrenia: A review of long-term benefits of international studies. Psychiatric Rehabilitation Skills, 3, 268-290.

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