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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Family Psychoeducation

Information for Public Mental Health Authorities

To help shape public mental health service delivery systems, public mental health authorities need current and accurate information about the goals and challenges of treating and providing services for people with severe mental illness. There is a growing body of research, known as evidence-based practices (EBP), which are principles and practices demonstrating the most effective services for people with severe mental illness. Family psychoeducation is one of those evidence- based practices.

What is family psychoeducation?

Family psychoeducation is a method of working in partnership with families to help them develop increasingly sophisticated and beneficial coping skills for handling problems posed by mental illness in their family and skills for supporting the recovery of their loved one. It respects and incorporates their individual, family, and cultural realities and perspectives. It almost always engenders hope in place of desperation and demoralization. Families of people diagnosed with the more severe forms of mental illness benefit the most from this treatment approach.

Family psychoeducation involves:

Joining with consumers and their families.

The practitioner establishes a respectful, trusting, and helpful relationship with family members, incorporating cultural perspectives on the meaning of mental illness and its treatment.

Education about the illness and useful coping skills.

The practitioner helps family members better understand their loved one’s illness and what they can do about it.

Problem-solving strategies for difficulties caused by illness.

The practitioner works with the family to identify strategies for handling difficult situations, making use of effective behavioral, cognitive, and communication techniques.

Creating an optimal environment for recovery from mental illness.

The practitioner works with the family to establish a strengths-based environment where all members are respectful of one another.

Creating social and support groups.

The practitioner often carries out the treatment in multi-family groups. Families establish connections with others who have similar experiences and gain a broader social network. The other families in the psychoeducational workshop and ongoing multi-family groups support each other. Participation in local family support groups (National Alliance for the Mentally Ill) is also recommended.

Families of people diagnosed with schizophrenia or schizoaffective disorder benefit from this treatment approach. Many younger consumers being treated in outpatient clinics and those consumers who are unemployed will benefit as well by finding and keeping a job. This approach also has applications for bipolar illness, major depression, or borderline personality disorder. It has been combined with assertive community treatment and supported employment to great advantage, clinically and vocationally.

What does the evidence say?

Extensive research demonstrates that implementing family psychoeducation in routine mental health settings dramatically improves the lives of people with severe mental illness. For consumers whose families participate, relapse rates and rehospitalizations decrease significantly within the first year following hospitalization when compared to groups who only use medication, with or without individual therapy. In several studies, relapse and rehospitalizations decreased in frequency by 50% or more. Family psychoeducation programs have provided the psychosocial supports consumers need to extend recovery, re-enter the work force, and develop social skills. Families report a decrease in feeling confused, stressed, and isolated. Recent studies have shown employment rate gains of two to four times baseline levels, especially when combined with supported employment, another EBP. Medical care costs for family members are reduced as well. Combined effects over several years lead to about 50% of consumers achieving five years without relapse, a very strong base for going on to recovery.

Family psychoeducation has proven to be markedly effective in reducing the cost of caring for people with severe mental illness. While the implementation of family psychoeducation may involve some up-front costs, studies consistently indicate a very low cost-benefit ratio, especially in savings from reduced hospital admissions, reduction in hospital days, and in crisis intervention contacts.

To help public mental health authorities implement family psychoeducation services into the system of care, resource kits have been developed to help agency administrators and mental health program leaders implement this approach for consumers and their families.

Why provide family psychoeducation?

To achieve the best possible outcome for the individual with mental illness through an inclusive and collaborative care model.
To reduce confusion and stress among family members, by informing and supporting their efforts to support the recovery of their loved one.
To coordinate all elements of treatment and supportive services to ensure that everyone is working toward the same goals in a collaborative relationship.
To listen to families and treat them as equal partners.
To explore family members' expectations and assess a family's strengths and limitations in supporting recovery.
To help resolve family conflict through sensitive response to emotional distress.
To address feelings of loss among family members and consumers.
To provide relevant information for consumers and families about mental illness and treatments that support recovery.
To provide training for the family in structured problem-solving techniques.
To encourage the family to expand their social support networks.
To be flexible in meeting the needs of the family.

What is the role of families?

Family is defined as anyone committed to the care and support of the person with mental illness, regardless of whether they are related or live in the same household.

Families help create an optimal home and social environment for the individual with mental illness, as a key aspect of recovery. With consumer’s consent, families participate in the treatment team’s decision-making processes about the individual’s case, living situation, and recovery while being guided by the individual consumer’s wishes and perspective.

Are there cost savings with family psychoeducation?

Implementing a family psychoeducation program has initial costs related to training and organizational operations and procedures. In experimental studies the cost-benefit ratios of family psychoeducation are impressive. In a statewide study in New York, for every $1 in costs for FPE in multi-family groups, there was a $34 savings in hospital costs during the second year of treatment. In a typical hospital in Maine, there was an average net savings of $4,300 per consumer per year over two years. The minimum reduction in hospitalizations has been about 50%, with some studies achieving up to 75% reductions over time. There is, however, variability in the costs and cost savings by different authorities in different states.

Non-fiscal savings are achieved as complaints from families about services decrease and family support for the agency and the PMHA grows. In many communities this has translated into political support for funding for expanded and improved services.

How can family psychoeducation be funded?

Funding mechanisms may vary from agency to agency and state to state. For the most part, funds are used from the state Division of Mental Health and Medicaid. State leaders from the agencies work out a mechanism on how to pool monies that can be used to reimburse the services of family psychoeducation programs. In some cases Medicaid rules and codes have been rewritten to allow reimbursement for family psychoeducation. One state has adopted a case-rate approach, which fits well with implementation and promotes use of the modality. In this instance, the provider agency is reimbursed on a monthly basis for each consumer to cover bundled direct and indirect costs.

What training materials are available regarding family psychoeducation?

An implementation resource kit for family psychoeducation has been developed. Training components include: information sheets, introductory and training videos, workbooks, outcome and fidelity measures, and website supports. The materials have been developed for the major stakeholders, including consumers, families and supporters, practitioners and clinical supervisors, mental health program leaders, and public mental health authorities.

Family psychoeducation training is available from selected training institutes. Implementation should include, but is not limited to:

Orientation programs for building understanding and consensus about family psychoeducation.
Introduction to using the materials and learning the program philosophy and interventions.
Clinical training workshops for practitioners interested and willing to adopt the practice.
Supervision, conducted most commonly in groups, via live meetings, teleconferencing, phone, videotaping, or web groups.
Initial and as-needed consultation to mental health program leaders and funding sources for problem solving.
How will agencies know if they have a successful program?

How successful a family psychoeducation program is in improving outcomes depends, in part, on how closely the program follows the recommended practice. Programs that only partially adopt the practice or that allowed it to “drift” back into old ways of providing services may not produce the beneficial outcomes associated with family psychoeducation. A program fidelity scale has been developed that measures adherence to the family psychoeducation model. According to studies, programs that score high on this fidelity scale have better outcomes.

What is the role of the public mental health authority?

There are a variety of roles to play to turn a vision into reality.

Articulate the vision. For example, family psychoeducation programs will be a core component of mental health services in our state.
Disseminate the information about family psychoeducation to major stakeholders.
Gain the interest and support of CEOs and clinical directors of outpatient and community mental health organizations.
Promote the implementation of family psychoeducation through performance outcomes and financial incentives.
Persuade clinical leaders and program executives of the need to institute services based on value—better outcomes at reduced overall cost and improvement in lives.
Work with and develop partnerships with mental health centers, trade associations, and consumer and family advocacy groups to help adopt this approach.
Provide financial and political support, including helping to resolve financial and organizational barriers.
Arrange for and support financially ongoing training and staff development.
Arrange for practitioners from the cultural groups represented in the catchment area, as well as interpreters as needed.
Measure results and provide feedback to those who practice the approach.

For more information

This document is part of an evidence-based practice implementation resource kit developed through a contract (no. 280-00-8049) from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Mental Health Services (CMHS) and a grant from The Robert Wood Johnson Foundation (RWJF). These materials are in draft form for use in a pilot study. No one may reproduce, reprint, or distribute this publication for a fee without specific authorization from SAMHSA.

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