Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Family Psychoeducation
Fidelity Scale Protocol: Item Definitions and Scoring
Many of the items on this scale call for a calculation of % of families for which a particular element of FPE is documented on standardized charts. This methodology implies that documentation is critical to evidence-based practice. While documentation is an important ingredient, poor documentation for an item does not mean that there is a complete lack of fidelity, nor does excellent documentation guarantee high fidelity of implementation. Fidelity assessors should integrate their observations from multiple sources to reach a reasoned judgment about the ratings for each item. To achieve a “5” (full implementation), all data sources (program coordinator, clinicians, family members, and charts) should agree that the item is fully implemented. If most, but not all, of the clinicians understand and follow the principle or intervention measured by an item, then ordinarily that item would be rated “4.” If the organization cannot produce any written documentation whatsoever for implementation of an item, the item ordinarily should not be scored higher than “3.” Rate “3” if the documentation is missing, but some clinicians can explain the principle and can give specific examples during the interview. Rate “1” if the documentation is missing and clinicians cannot articulate the underlying principles.
1. Family Intervention Coordinator
Definition
One clinical administrator is designated as overseer of the family psychoeducation program for a substantial portion of his/her job (time depends on size of program). This person’s role includes activities such as:
- Establishing, monitoring, and automating family intake and engagement procedures
- Advocating cases to staff
- Monitoring caseloads
- Arranging for staff training
- Training and preparing new staff
- Arranging supervision for staff
Rationale
Delivery of services to families must be subject to accountability and tracking. One effective way for mental health centers to monitor the delivery of family services is to create a position of Family Intervention Coordinator, who would also serve as the contact person for interventions, facilitate communication between staff and families, and supervise clinicians.
Sources of Information
The first obvious question is whether the organization has someone who has a title or family coordinator or equivalent. This should be determined prior to the site visit. During the fidelity visit, interview program coordinator, clinicians, and family members.
Item Response Coding
Program coordinator is the primary source of information for this item. If other sources do not report these responsibilities performed the coordinator, then fidelity assessors should follow up with program coordinator with clarifying questions and documentation (at end of the fidelity visit day or in follow-up call). If the program does not have a designated position of coordinator (or equivalent), the item would be coded as “1.” If the program has a designated position of coordinator who performs all 6 tasks, the item would be coded as a “5.”
Probe Questions
For program coordinator
- What is your role in the FPE program? How much time do you devote to this? What kinds of responsibilities do you have? (Check which of the 6 tasks are performed by coordinator. Probe who performs tasks that were not mentioned, e.g., “What are your program’s family intake and engagement procedures?” “Who monitors caseload?” “Who trains your staff? How is the training done?”)
- Ask program coordinator to explain intake procedures, monitoring, training schedule, and supervision schedule.
For clinicians
- What functions does the program coordinator perform? Does anyone have responsibility for each of the following?
For family members
- What functions does the program coordinator perform?
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2. Session Frequency for Family Psychoeducation
Definition
Families participate in at least biweekly FPE sessions.
Rationale
It is presumed that families are more successful in benefiting if sessions are offered on a regular, predictable basis.
Sources of Information
Chart review, roster of sessions, and interviews with program coordinator, clinicians, and family members.
Item Response Coding
The primary evidence for coding this item would be attendance rosters or a calendar of scheduled events, if such documents exist. The program should have some way of documenting frequency of FPE sessions. If the documentation suggests that the organization provides at least biweekly FPE sessions, the item would be coded as a “5.”
Probe Questions:
For program coordinator and clinicians
- How often are FPE sessions held for family members? Do you have attendance rosters, calendar of events, or other documentation to verify this?
For family members
- How often are FPE sessions held for family members?
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3. Long-Term FPE
Definition
Families are provided with long-term FPE; specifically, at least one family member participates in FPE sessions for at least 9-months.
Rationale
In general, 6-9 months of biweekly equivalent FPE sessions are required for the families to learn necessary information and problem-solving skills. Following completion of the program, the families may also benefit from booster sessions or support groups.
Sources of Information
Chart review, roster of sessions, and interviews with program coordinator, clinicians, and family members.
Item Response Coding
The primary evidence for coding this item would be a report containing the number of families completing FPE and how long they attended, records of duration of FPE groups, or attendance sheets. In the absence of written records, the assessment will depend on interviews. Excluding dropouts, if there is evidence that = 90% of families receive at least 9 months of FPE sessions, the item would be coded as a “5.”
Probe Questions
For program coordinator and clinicians
- How long do family members attend FPE before they graduate? Do you have a list of the Do you have attendance rosters, calendar of events, or other documentation to verify this?
For family members
- How long attended FPE? How long do you intend to attend?
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4. Quality of Clinician-Family Alliance
Definition
In individual or group sessions (approximately three sessions), the clinician engages family members and consumer with warmth, empathy, acceptance, and attention to each individual’s needs and desires.
Rationale
When the alliance between clinician and family members is poor, family members are less likely participate fully or at all in FPE programs and, as a result, are less likely to benefit from FPE interventions.
Sources of Information
Interviews with clinician and family members, session observation.
Item Response Coding
The primary source for rating this item is direct observation. This item requires clinical judgment and is based on the fidelity assessor’s experience. Negative indicators would include comments in interviews, FPE sessions, or charts expressing judgmental or blaming attitudes. If sources consistently indicate a strong clinician-family alliance for all FPE clinicians, the item would be coded as a “5.”
Probe Questions
For clinicians
- How do you establish rapport or develop an alliance with family members?
- How would you rate or describe your alliance with Family X (select one family with whom the clinician works) in general?
- Are there any family members with whom you feel your relationship is counterproductive or poor?
For family members
- How would you describe your relationship with Clinician X?
- Do you feel that he/she has worked to establish a good relationship with you? What has he/she done to connect with you? What has he/she done that makes it more difficult for you to work with him/her?
- What would you change about your working relationship with Clinician X to make it better?
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5. Detailed Family Reactions
Definition
In individual or group sessions, the clinician(s) identify and specify the family’s reaction to their relative’s mental illness.
Rationale
A core principle of FPE is to help family members achieve a basic understanding of SMI as well as to resolve family conflict by listening and responding sensitively to each member’s emotional distress related to having a family member with an SMI.
Sources of Information
Chart review of treatment plan and interviews with coordinator, clinicians, and families.
Item Response Coding
The primary data source for this item is the treatment plans in the chart review. If documented for 80% or more of involved families, and these findings are corroborated by coordinator, supervisor, clinicians, and families, the item would be coded as a “5.”
Probe Questions
For program coordinator and clinicians
- In the FPE sessions, do you address how families react emotionally or behaviorally to their family member’s illness?
- What sorts of issues do you discuss?
- What sorts of activities do you engage in to help them deal with their reactions?
- Use a client chart for a family member seen by each clinician and ask the clinician to explain the specifics, including where in the chart this is documented.
For family members
- Do you spend time in the sessions discussing how you feel and react in regards to the illness?
- Does the clinician lead you in activities to help you deal with your feelings/reactions?
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6. Precipitating Factors
Definition
In individual or group sessions, the clinician(s) identify and specify precipitating factors to their relative’s mental illness.
Rationale
Exploration of factors that have precipitated relapse in the past is a crucial step to developing individualized relapse prevention and illness management strategies. Involving the consumer and the family as equal partners in the planning and delivery of treatment is a core principle of FPE.
Sources of Information
Chart review and interviews with coordinator, clinicians, and families.
Item Response Coding
The primary data source for this item is a standardized checklist or progress note in the client’s chart. If documented on standardized checklist for 80% or more of involved families, corroborated by coordinator, supervisor, clinicians, and families, the item would be coded as a “5.”
Probe Questions
For program coordinator and clinicians
- Do you discuss the precipitating factors of the illness with families? If yes. Can you describe the process you use to discuss them? Can you show me examples?
- Use a client chart for a family member seen by each clinician and ask the clinician to explain the specifics, including where in the chart this is documented.
For family members
- Do you discuss how to identify precipitating factors for the illness in the sessions? What sorts of things do you talk about? Please give examples.
- Do you discuss ways in which you can respond once you notice these factors occurring? Are these strategies reviewed in later sessions?
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7. Prodromal Signs
Definition
In individual or group sessions, the clinician(s) help families to identify and specify prodromal signs and symptoms of their relative’s mental illness.
Rationale
Exploration of the consumer’s prodromal signs is another crucial step to developing individualized relapse prevention and illness management strategies. Again, involvement of the consumer and the family as equal partners in the planning and delivery of treatment is a core principle of FPE.
Sources of Information
Chart review and interviews with coordinator, clinicians, and families.
Item Response Coding
The primary data source for this item is a standardized checklist or progress note in the client’s chart. If documented on standardized checklist for 80% or more of involved families, corroborated by coordinator, supervisor, clinicians, and families, the item would be coded as a “5.”
Probe Questions:
For program coordinator and clinicians
- Do you help identify prodromal symptoms for families? If yes. Can you describe the process you use to help identify them? What would be specific examples?
- Use a client chart for a family member seen by each clinician and ask the clinician to explain the specifics, including where in the chart this is documented.
For family members
- Do you discuss the signs that your family member may be becoming symptomatic?
- What sorts of things are suggested in your sessions for how to recognize the early symptoms of the mental illness? What would be specific examples? Are these suggestions reviewed in later sessions?
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8. Coping Strategies
Definition
In single-family joining sessions, the clinician(s) help to identify, describe, clarify and teach coping strategies that are used by families.
Rationale
Exploration of coping strategies that have and have not worked is another crucial step to developing individualized relapse prevention and illness management strategies. Insight into patterns of ineffective interactions and behaviors is likely to motivate the family towards desired change.
Sources of Information
Chart review and interviews with coordinator, clinicians, and families.
Item Response Coding
The primary data source for this item is a standardized checklist or progress note in the client’s chart. If documented on standardized checklist for 80% or more of involved families, corroborated by coordinator, supervisor, clinicians, and families, the item would be coded as a “5.”
Probe Questions
For program coordinator and clinicians
- Do you help identify coping strategies for families? If yes. Can you describe the process you use to help identify and implement them?
- Use a client chart for a family member seen by each clinician and ask the clinician to explain the specifics, including where in the chart this is documented.
For family members
- Do you discuss how to cope with your family members illness in the sessions? What sorts of things do you talk about?
- Do you discuss other possible ways of coping or responding? Are these strategies reviewed in later sessions?
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9. Educational Curriculum
Definition
In individual or group sessions, the clinician(s) use a standardized curriculum to teach families about mental illness. The curriculum covers six topics:
- Psychobiology of mental illness
- Diagnosis and treatment
- Family reaction and its stages
- Psychosis as a family trauma
- Relapse prevention
- Family guidelines
Rationale
An educational curriculum specifies what is taught and how it is taught. To effectively teach the families new information and skills requires structure and systematic use of specific evidence-based techniques and strategies. It is therefore critical that an FPE program has a written curriculum for its clinicians to follow.
Sources of Information
Coordinator and clinician interviews and curriculum review.
Item Response Coding
The primary data sources for this rating are a written curriculum accompanied by a schedule of completed sessions, corroborated with interviews. If = 90% of educational workshops (or single family sessions) cover all 6 areas, the item would be coded as a “5.”
Probe Questions
For program coordinator
- Does your program have a written curriculum for educational workshops? (If yes, request a copy for review.) How was it developed? How do you train your clinicians to use it? How do you ensure that your clinicians follow the curriculum? Do you periodically evaluate and update the curriculum? Do you have a schedule of completed sessions and their content?
- Ask about each of the listed areas above and whether they are included.
For clinicians
- Do you use a written curriculum or clinician’s manual for your educational workshops? (If yes) Are there any areas you teach differently from the curriculum/guide?
- Do you have a schedule of completed sessions and their content?
- Ask about each of the listed areas above and whether they are included.
For family members
- What has been the content of the FPE sessions?
- Ask about each of the listed areas above.
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10. Multimedia Education
Definition
Educational materials on illness, treatment, and guidelines can be provided in several formats (e.g., written, video, web sites).
Rationale
Depending upon the family, family members may benefit from receiving educational materials in a variety of formats. Some individuals may be more likely to watch a video or search a website than read the same information in a written format.
Sources of information
Interviews with coordinator, clinicians, and families.
Item Response Coding
The primary data source for this is the presentation of the actual materials and evidence that is made available to families. If documented on standardized checklist for 80% or more of involved families, corroborated by coordinator, supervisor, clinicians, and families, the item would be coded as a “5.”
Probe Questions
For program coordinator and clinicians
- In what form(s) do you provide educational materials to families? Do you always provide the information in the same format to each family? If not, how do you approach family members about what they need? How do you ensure that every family gets access to these materials?
- Ask to see the materials.
For family members
- What types of educational materials have you been provided with? If they suggest a variety of materials, ask : Did you have to ask for materials in that format, or was it offered by the clinicians or program coordinator? If they suggest only written materials have been provided, ask: Have you ever been offered or provided with videos, website addresses or material in other formats?
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11. Structured Group Sessions
Definition
FPE sessions follow a structured format consisting of:
- Socialization
- “Go-round” (i.e., turn-taking)
- Response to each family member
- Problem-solving component
- Socialization
Rationale
Families benefit most from structured sessions that follow a predictable pattern. Clinicians must also establish a clear agenda, goals and expectations for each session.
Sources of information
Observation of sessions and interviews with coordinator, clinicians, and families.
Item Response Coding
Primary data for this item is observation of a FPE session. If documented on standardized checklist for 80% or more of involved families, corroborated by coordinator, supervisor, clinicians, and families, the item would be coded as a “5.”
Probe Questions
For program coordinator and clinicians
- Can you describe the typical FPE multi-family group session? What activities do you engage in?
- Do you have specific goals for each of the FPE sessions?
For family members
- Can you describe what you do at the beginning of each session? In the middle? At the end?
- Does session leader seem to have a structured approach to each session?
- Is it clear to you what will be accomplished in each session?
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12. Structured Problem-Solving Techniques
Definition
In individual or group sessions, the clinician(s) use a standardized approach to help families with problem solving. The approach includes:
- Select a problem for one consumer/family
- Define the problem in behavioral terms
- Generate at least 8 suggestions for solution to the problem
- Explore with the consumer and family pros and cons for each suggestion
- Have consumer and family select the best suggestion
- With consumer and family, develop a step-by-step plan
Rationale
Studies show collaborative and structured problem-solving techniques involving setting realistic goals and priorities and breaking goals into small behavioral steps are effective in improving consumers’ functioning and families’ coping.
Sources of Information
Observation of a random sampling of sessions and interviews with coordinator, clinicians, and families.
Item Response Coding
The primary data source for this item is interviews with clinicians. If documented on standardized checklist for 80% or more of involved families, corroborated by coordinator, supervisor, clinicians, and families, the item would be coded as a “5.”
Probe Questions
For program coordinator and clinicians
- Do you focus on problem solving? If yes, what is/are your strategy(ies) for addressing this issue? Do you use the same set of strategies for each family?
- Listen for the list of 6 components given above. If a component is omitted, probe for whether it is included.
For the family members
- During FPE, do you discuss how to address problems that may arise? If yes, what sorts of activities do you do in the sessions to work on problems you may be having? Do you ever generate plans of action? Is it a step-by-step procedure? Can you describe the steps?
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TOC | Introduction | Cover Sheet
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