Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Family Psychoeducation
Workbook
Chapter 5: Educating Families Using a Workshop Format
Introduction
Family Psychoeducation begins with the joining process, but intensifies when a formal educational workshop is offered to multiple families. Carol Anderson developed this pragmatic, classroom format as a way to offer families current information about the psychobiology of illness, while receiving the latest information about medication, normal reactions to illness, and possible coping mechanisms. In the Single-Family Psychoeducation model, this format is optional. For instance, Ian Falloon found that the same workshop format could be used on an individual basis in a family’s home and be effective. However, the single-family method eliminates the possibility of families exchanging valuable information.
Education is one of the four essential components of Family Psychoeducation, along with joining, problem-solving and social network expansion. Education consists of sharing information with family, other caretakers, and consumers themselves about the underlying biological and social processes. The goal is to relieve families of their guilt and anxiety so they can contribute to the treatment and rehabilitation of their family member.
When families do not have information about the illness, they tend to adopt the beliefs of their own families, culture or community. While they may have the best interest of the person with illness in mind, their actions may actually interfere with recovery, since the most effective interpersonal and rehabilitative approaches are often counter-intuitive. Therefore, it is the responsibility of professionals to give concerned families the information and guidance that they need to promote recovery and rehabilitation.
Rationale
Information creates a shared language that allows families and practitioners to work together. The message for families is: schizophrenia is a very difficult illness for families to live with, but it will become easier if we learn skills to cope with it. It is especially important that families understand that they did not cause the illness.
The family advocacy movement of NAMI supports involving families in treatment decisions and in their loved ones’ diagnoses, treatment and longer-term prospects. The psychoeducational workshop takes it one step further by sharing information and ideas among several families at once. Thus, the educational aspects of this approach empower families and, over time, those with the illness.
Tip
While the educational process begins in the joining meeting, it continues throughout the workshop and in every subsequent meeting. There will always be new information discovered and new questions to answer.
In order for families to successfully solve problems of illness management, they must understand the physiology and psychology of schizophrenia or other disorders at a basic level. Eventually, they can develop their own strategies based on their particular circumstances.
One critical aspect of family education is that it gives families hope that they will be able to alter the course of illness. As the educational process continues with families, they see increasing evidence of their own effectiveness. As the consumers improve, they join in the process as partners. They become interested in the information and in achieving their own rehabilitative goals. Of the nearly six hundred families that have attended these workshops, in no instance has the information had a significant negative effect. On the contrary, there have been hundreds of examples of relieved and grateful families.
Conducting a Psycho-educational Workshop
The Psychoeducational Workshop helps families understand:
- the seriousness of the disorder
- the role of stress in precipitating episodes
- early signs of relapse
- symptoms, especially the negative variety
- the basics of brain function and dysfunction in mental illnesses
- how psychiatric medications affect brain function and cause side effects
- how severe mental illness in one of their members affects families
- effective coping strategies and illness management techniques
- the causes and general prognosis of the illness
- the psychoeducational treatment process itself
Psychoeducation is an opportunity for families to begin learning to cope with, and improve the outcome of schizophrenia and other major mental illnesses. However, those solutions must fit the family’s individual history and style. The challenge for practitioners is to adapt the educational process for each participant. Anderson and her colleagues have emphasized that the workshop is most effective if the information is tailored as much as possible to the actual participants. Further, education for a minority group and/or another cultural group will require careful consideration of the differences in content, language, style of delivery and expectations of professional in each culture represented within a workshop audience. For instance, a Spanish-language version of the educational videotape for families is available on request from the toolkit authors.
Guidelines for Practitioners
In some cases, teaching and giving direct advice may be new skills for practitioners. The presentations should be empathic as well as informative. Practitioners should use group leadership skills to elicit comments and experiences from the audience, in a manner that invites, but does not obligate, participants to respond. Even if multifamily group co-facilitator is a new role for the practitioner, family members usually prefer to work with the same person who has been working with their ill relative.
Practitioners will also have to keep current with any breakthroughs in research. This increases their credibility with families. It is less helpful if families hear about new developments before the practitioners hear it. They need to broaden their own knowledge and always recognize and share the limits of what they know.
Tip
Group leaders are not expected to be expert in all areas of psychology and biology. It is helpful if they can call on colleagues with particular areas of expertise, such as a nurse, psychologist or doctor specialist. Materials from any previous workshops should also be used, if available—it is not necessary to reinvent the wheel.
Practicalities and Procedures
The all-day Family Psychoeducation workshop is usually held on a weekend day after families have had at least three joining sessions. Sensitivity to the needs and schedules of the family members in scheduling this is important. This workshop is modeled after the workshop described by Anderson and her colleagues [96].
The workshop provides information about the key disorder and effective ways of managing the illness. The leaders present in an open, collegial manner, encouraging families to comfortably ask questions. Families will discover that their experiences and problems are similar. Because the workshop is conducted by the two multifamily group co-facilitators, it is the first time families meet the other members of the group and the other practitioner. The psychiatrist who is working with the consumers should present the material on the psychobiology of the illness. Other staff may be invited to contribute their expertise.
Tip
Group leaders should review the materials before the workshop. Practicing presentations with colleagues helps increase confidence and provides an opportunity for feedback on clarity, rate of speech, etc. It may be helpful to videotape or audiotape the practice presentations and to rehearse responses to common questions.
Tip
The workshop should be organized in a classroom format, with the speaker in front and a board to write on. The classroom arrangement invites a more neutral atmosphere.
Tip
Refreshments are supplied throughout the all-day workshop, including morning coffee, lunch and afternoon tea. Only decaffeinated beverages are served and there is no smoking in the meeting room. Refreshment breaks provide an informal setting for spontaneous socializing. The group leaders act as hosts and hostesses during these times; it is strongly recommended that they spend time during the breaks with families and other attendees and not solely with their colleagues.
Starting the Workshop
The practitioners introduce themselves and explain the day’s agenda. For example, a co-facilitator might say,
“Welcome, and thank you for coming on this beautiful Saturday morning! My name is Bob Smith and this is Peg Rutherford. Some of you already know us because we’ve been meeting individually for quite some time now. Today, we want you to know as much as possible about this illness --what’s known, and what’s not known, as of now. Schizophrenia is a very complex and confusing illness. We have found that the more information people have, the better equipped they are to deal with problems as they occur. We will also be discussing some guidelines for coping that have been shown to be helpful.
“This workshop is only one step of our work together. After the workshop, we will be meeting together as a group of families, including consumers, on a regular basis and we will continue to provide relevant information and assistance to you. We have found that working together with consumers, families and the treatment team in this program has resulted in fewer and less severe relapses. We will answer as many questions as possible in this workshop today. If we cannot answer something, we will find someone who knows the information and get back to you.”
Outline of the Educational Workshop
(Adapted from Anderson, et al., 1986, p.76)
9:00 - 9:15 Coffee and Informal Interaction
9:15 - 9:30 Formal Introductions/Explanation of the Format for the Day
9:30 - 10:30 Information about the Phenomenology, Etiology, Course, and Outcome of the Illness
Biochemical theories
Genetic theories
Socio-cultural theories
Family theories
The private experience of schizophrenia
The public experience of schizophrenia
10:30—10:45 Coffee Break and Informal Discussion
10:45 – 11:15 Treatment of Schizophrenia with Medications
How it works
Why it is needed
Impact on outcome
Side effects
11:15—12:00 Other treatments
Family Psychoeducation and multifamily groups
Social skills training
Day treatment
Vocational rehabilitation and Supported Employment
Psychotherapies
Megavitamin and other dietary treatments
Management of the illness
Health
Diet
Stress
12:00 - 1:00 Lunch and Informal Discussion
1:00 - 3:00 The Family and Schizophrenia
The needs of the consumer
The needs of the family
Family reactions to the illness
Emotional reactions
Common interactions
Common Problems that Consumers and Families Face
“What the Family can do to Help”
Family Guidelines
The problem-solving method
3:30 - 4:00 Questions Regarding Specific Problems
Description of the multifamily group process
Having patience with the slow pace of improvement
Keeping hope alive
Wrap up and scheduling
Informal interaction
Since there is a lot of information to cover, is important to stick to the agenda and to keep track of time. Often, questions asked by families will be answered by content covered later in the day. Therefore, practitioners may ask families to write and save their questions until after the appropriate section is presented. If necessary, discussions can also be continued either after the workshop or during a subsequent meeting of the multifamily group.
Family Guidelines
The Family Guidelines are based on the specific effects of schizophrenia on the consumers and families. People present at the workshop should have a copy of the “Family Guidelines” that they can refer to as the practitioners review them, one by one. This will not be the first time families have heard about the “Family Guidelines”, but it is first time they will be fully discussed. Practitioners take turns reading a guideline, connecting it to the biological information discussed in the morning, and asking family members for their reactions, questions, and experiences. It is helpful to illustrate the guidelines with examples based on the kinds of problems described by families during joining sessions.
The Family Guidelines
Here’s a list of things everyone can do to help make things run more smoothly:
- GO SLOW. Recovery takes time. Rest is important. Things will get better in their own time.
- KEEP IT COOL. Enthusiasm is normal. Tone it down. Disagreement is normal. Tone it down, too.
- GIVE EACH OTHER SPACE. Time out is important for everyone. It’s okay to reach out. It’s okay to say “no”.
- SET LIMITS. Everyone needs to know what the rules are. A few good rules keep things clear.
- IGNORE WHAT YOU CAN’T CHANGE. Let some things slide. Don’t ignore violence.
- KEEP IT SIMPLE. Say what you have to say clearly, calmly, and positively.
- FOLLOW DOCTOR’S ORDERS. Take medications as they are prescribed. Take only medications that are prescribed.
- CARRY ON BUSINESS AS USUAL. Re-establish family routines as quickly as possible. Stay in touch with family and friends.
- NO STREET DRUGS OR ALCOHOL. They make symptoms worse, can cause relapses and prevent recovery.
- PICK UP ON EARLY SIGNS. Note changes. Consult with your family.
- SOLVE PROBLEMS STEP BY STEP. Make changes gradually. Work on one thing at a time.
- LOWER EXPECTATIONS, TEMPORARILY. Use a personal yardstick. Compare this month to last month rather than last year or next year.
Tip
Practitioners should explain that while the Family Guidelines may seem counter-intuitive, they are based on a great deal of experience. Also, some Family Guidelines apply at different times and in different situations. The work of the group is figuring out how to apply these guidelines.
Tip
Printed handouts are important. Family members should each receive a folder containing the information the leaders will be presenting, along with the Family Guidelines, diagrams and other aids they can follow throughout the day. Leaders should suggest that people post the Family Guidelines at home where they will be handy as a reference.
Concluding the Workshop
The workshop ends on a positive note. The practitioners should make sure that families feel their optimism about this approach. It is helpful to give examples of how life improves for the consumer and family with this process. Then, the practitioners should outline the format for multifamily groups, emphasizing the problem-solving method and its usefulness for families and consumers. The agenda for the first two meetings is presented and any questions about the multifamily group are addressed. Group members should know how to contact the practitioners in case they have questions or crises between sessions. The group co-facilitators should remind families that improvement will occur very slowly and to be patient: “Slow and steady wins the race” should be a theme.
Finally, family members should be invited to talk about their reactions to the workshop. Some common reactions are relief at finally knowing some facts, anger at being kept in the dark, sadness, despair, hopefulness about this approach and eagerness to get on with the work. Since consumers will be invited to all subsequent multifamily group meetings, this is a good time to briefly discuss any misgivings family members may have about those with an illness being present. The practitioners should conclude by again thanking all participants for coming to the workshop on a day off.
Tip
When providing education and information to people with illness, group co-facilitators should take into account their illness and preferable methods for self-management. Since clinically unstable consumers do not attend the psychoeducational workshop, they need to learn about the guidelines in a different setting. This may happen in a shorter “consumers only” workshop or in the whole group, as a repeat or an update, after the consumers have achieved clinical stability.
Tip
It is important that practitioners keep in mind that group members are not obligated to speak during the workshop. However, since there are few places during this session where facilitators have opportunities to ask probing questions, they do need to be creative in explaining what sorts of responses they expect. It is part of the practitioners’ skill to elicit reactions without demanding them.
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