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Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Family Psychoeducation
Workbook
Chapter 1: Introduction
This section provides an introduction to approaches to including families in the treatment and recovery of persons with severe mental illness.
General Aspects of the Workbook
What is Family Psychoeducation?
Family Psychoeducation is a method for working with families, other caregivers and friends who are supportive of persons with mental illness. Based on a family-consumer-professional partnership, it combines clear, accurate information about mental illness with training in problem solving, communication skills, coping skills and developing social supports. The goals are to markedly improve consumer outcomes and quality of life, as well as to reduce family stress and strain. It builds on and combines the complementary expertise and experience of family members, consumers and professionals to develop coping skills that lay the foundation for mastery and recovery.
The term family includes those who undertake the care and support of the person with a severe mental illness, regardless of whether they are related or live in the same household. The term is used in this Workbook to mean “family and supporters”, as used throughout the other Implementation Resource Kits in this series of Evidence- Based Practices.
Who is this workbook for?
For mental health practitioners and case managers learning and applying this approach to treatment and recovery.
For clinical supervisors and mental health program leaders as a reference for program development and ongoing administration.
Practitioners of all mental health disciplines—psychiatrists, psychologists,
social workers, nurses and nurse practitioners, counselors, occupational
therapists and licensed counselors—have proven to be remarkably capable
of conducting this model of treatment. In some carefully supervised situations,
para-professionals working closely with a professional clinician have effectively
conducted family psychoeducation.
The knowledge and skills presented here have become part of the competency
expectations for all professionals, in all disciplines, who work with consumers
with severe mental illness. These approaches are especially relevant in outpatient
and mental health centers, as hospital stays have become very short.
While all practitioners who do such work may not be able to implement Family
Psychoeducation (Family Psychoeducation) fully, the knowledge and skills, and
particularly the perspective on the family that are described here, are useful,
if not indispensable, in any work with such consumers. For instance, knowing
how to engage family members to collaborate in treatment and recovery is key
to those working on inpatient services or short-term outpatient services, because
that engagement, if done well, will facilitate families continuing in longer-term
work and greatly improve outcome for both consumer and family. This workbook
could be useful for family members who become co-teachers and/or co-leaders
in multifamily groups and for consumers who establish and run educational
services and programs for their peers.
For which consumers and which disorders is this workbook designed?
Family Psychoeducation has been demonstrated remarkable effectiveness when
provided to families and consumers, especially when there is a family member
available. This approach is particularly beneficial in the early years of the
course of a mental illness, when improvements can have a dramatic and long-term
effect and while family members are still involved and open to participation.
As well, consumers who experience frequent hospitalizations or prolonged unemployment
and families who are especially exasperated and confused about the illness benefit
substantially and often dramatically.
Clearly, it should be offered whenever consumers or family members request
assistance in learning more about a particular illness and how to overcome it.
It is particularly useful for families who have previously benefited from family-to-family
education programs and want to learn how to assist in treatment and recovery.
It is highly effective when the consumer wants family members to support him
or her in better ways and/or when the family wants to know how to provide better
support.
At present, Family Psychoeducation has been shown to be most effective for
individuals diagnosed with schizophrenia. There have been at least 20 controlled
trials, involving nearly 5000 consumers and their families and two are underway
in Scandinavia that will involve nearly 1000 consumers and their families. Outcome
has been remarkably consistent across all but two of these clinical trials.
Services have become routine in a few states, involving a few thousand consumers,
most with schizophrenia. For that reason, schizophrenia is the principal diagnostic
focus of this Workbook. Although not fully described within this Workbook, modifications
have been developed and tested for bipolar disorder, depression, borderline
personality disorder and OCD. Multifamily group versions for these disorders
have recently been described in William R. McFarlane’s Multifamily
Groups in the Treatment of Severe Psychiatric Disorders. The authors of
this Implementation Resource Kit have attempted to provide guidance to practitioners
that is as broad, diagnostically speaking, as can be justified by present empirical
evidence or by a consensus among experienced practitioners of the psychoeducational
approaches. Once practitioners have learned this approach by working with people
with schizophrenia, they find it relatively easy to carry out the modifications
specific to other disorders or, when necessary by circumstances, to lead multifamily
groups with people who have different diagnoses. We recommend that one’s
first experience as a practitioner be with a single disorder.
What skills do Family Psychoeducation practitioners need?
As families learn how to apply new information about mental illness to their
lives, it is important for a Family Psychoeducation practitioner to assume the
role of teacher. When practitioners become teachers, they interact with families
and consumers in a different manner than in traditional therapy. Like classroom
teachers, they have a specific curriculum that promotes distinct learning outcomes.
In this new role, they are immediately free to partner with family members and
consumers, they can cheer them on as new skills are learned and new challenges
are tackled. This may be an unfamiliar experience for many practitioners since
their training as therapists supports certain interpersonal boundaries and specific
methods to assist individuals with developing new skills. According to Christopher
Anderson, Ph.D., the three most effective qualities a practitioner can have
for meeting families’ educational needs are: 1.) collaborating with families
and demonstrating a commitment to recovery; 2.) providing information and advice;
3.) sharing about oneself within the boundaries of the teacher role.
Does this workbook contain all that one needs to learn to practice successfully?
This workbook presents an overview, which may be supplemented by the following
books described below and other materials referenced in Chapter 12.
- For conducting multifamily groups, the book Multifamily Groups in Severe
Psychiatric Disorders (William R. McFarlane, New York: Guilford Press,
2002) is important reading and serves as the treatment manual for this more
effective and more efficient format. It fully describes the approach for schizophrenia
and reviews key differences for several other disorders particularly bipolar
disorder and depression, as well as obsessive-compulsive disorder, borderline
personality disorder, integration with Assertive Community Treatment, and
applications when there is no family member available.
- When offering Family Psychoeducation in the single-family format, the approaches
that have been shown to be effective include Anderson’s Schizophrenia
and the Family and Falloon’s Family Care of Schizophrenia.
- For bipolar disorder, Miklowitz and Goldstein have described their model
in Bipolar Disorder: A Family-focused Treatment Approach.
In addition, it is best to be trained in this approach, usually over two to
three days of skills training, including explanations, demonstrations and practice
exercises, followed by about one year of consultation and supervision by an
experienced trainer. This workbook is part of an Implementation Resource Kit
which also provides fidelity and outcome measures to let you know how closely
your experience matches that of a large body of national and international practice
and study.
Is the Family Psychoeducation approach for the family’s benefit or
the consumer’s?
Both. The goal is to support recovery from a major mental illness. The Family
Psychoeducation approach asks family members to assist in that effort. Improvement
in their well being is a helpful step in the recovery process. Though it is
designed to achieve clinical and functional outcomes for the consumer, it also
provides what study after study, including those carried out by family advocates,
has suggested: the skills that families need to successfully contribute to recovery.
Thus, the whole family improves: the consumer’s symptoms and functioning
improve; family members find improvements with their own health, their understanding
of mental illness, and their ability to provide support to the consumer. One
study from the state of Washington found both a dramatic reduction in rehospitalizations
and negative symptoms among the consumer participants and a reduction in medical
illness among the family participants.
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