Adapted from a presentation by Susan Gingerich

1
IDDT Case Conference Family Interventions June
28, 2006

• Center for EBPsOhio SAMI CCOE Ohio SE CCOE
• Case Western Reserve UniversityCleveland, Ohio

2
Overview of workshop

• 1000am1015am Review case vignette
• 1015am1030am Didactic lecture
• Benefits of family involvement in treatment
• Range of intervention options
• Practitioner roles
• 1030am1130am Panel Presentation
• Outpatient -Paula Clay Central Ohio MH Ctr
• Inpatient -TBD
• NAMI - Marci Dvorak/Toledo
• 1130am1150pm Large group discussion
• 1150am1200pm Summary remarks and evaluations

3
Update

• 25 and 50 of clients with dual disorders live
  with family members
• Evidence showing that families will be involved
  in programs
• Evidence showing that comprehensive family
  programs reduce relapse rates

4
Research Results

• 11 controlled studies (Dx Schizophrenia)
• Family programs reduced relapse rates 25 to 75
• Programs improved functioning of all family
  members

5
Combined Results 11 Studies of Family programs, 2
yr cumulative relapse rates
6
Inclusion of Family Involvement in Evidence-Based
Practices

• Family Psychoeducation
• Integrated Treatment for Dual Disorders
• Illness Management and Recovery

7
What can families do to help?

• Contribute to a lower stress, more supportive
  environment
• Provide some of clients basic needs
• Provide information about disorders
• Communicate with treatment team
• Reinforce small steps towards improvement
• Encourage adherence to medication
• Discourage substance use abuse

8
Why important to involve families of clients?

• 25 to 50 of those with DD live with family
  members
• help them meet basic needs
• Family stress
• negative effect on course of disorders
• Families interested in learning more about
  disorders
• Dual disorders increases risk of problems
• that can eventually lead to loss of family
  support

9
Additional reasons for involving families

• Loss of family support
• a major contributor to housing instability and
  homelessness
• Many families have substance abuse problems
• Family interventions
• among the most potent psychosocial interventions
  currently available

10
Several family models are helpful

• Behavioral Family Therapy (Falloon, et al, Mueser
  Glynn, Miklowitz, NIMHs Treatment Strategies
  in Schizophrenia research program)
• Multifamily Psychoeducational Groups (McFarlane)
• Multifamily Support Groups (NIMHs TSS research
  program)
• Family-to-Family (Joyce Burland, adopted by NAMI)

11
What do the different family models have in
common?

• Foster the development of all family members
• Educate families about disorders
• Improve communication skills
• Improve problem-solving skills
• Encourage family members to develop social
  supports outside the family
• Instill hope for the future
• Take the long-term perspective

12
Provider Skill Sets

• Non-confrontational approach
• Active listening
• Gradual process of engagement
• Identifying and pursuing personal goals
• Providing information as needed
• Providing strategies skills as needed
• Recognition that change takes time

13
IDDT Family Fidelity Items

• Outpatient Model
• Inpatient Adaptation

14
Outpatient IDDT Fidelity ScaleItem T9 Family DD
Treatment

• Definition
• Clinicians always attempt to involve family/
  support network to give DD psychoeducation and
  promote collaboration with treatment team
• based on number in contact with provider

15
Probe

• How many clients in contact w/ family or social
  support weekly?
• Community based estimates suggest about 60 of DD
  patients have weekly contact with their families
• Of those, how many is your program in contact
  with?
• Reasons not? What happens then?
• How are clients engaged to involve family/social
  support members?
• How many receive family tx services? Psychoed?
• Outreach to refusals?

16
Inpatient IDDT Fidelity Scale AdaptationItem 22
Interventions for DD Patients Families

• Definition
• Family/social support intervention by
  professionals is designed to educate family
  members about DD, help reduce stress in the
  family, and to promote collaboration with the
  treatment team. This includes
• family involvement in the patients treatment
  team
• phone contact with the hospital social worker
• referral of the family to community supports
• referral of the family to family counseling, and
  receipt of services.

17
Probe

• How many patients are in contact with family
  members (or significant others) on a weekly
  basis?
• Estimates suggest about 60 of DD patients have
  weekly contact with their families
• Of those patients, how many families have
  received family services?
• How are clients engaged to involve family/social
  support members?
• Do you do outreach to families? How?
• What services are usually provided to families?

18
Stages of Recovery for Families

• Engagement
• Persuasion
• Active treatment
• Relapse prevention
• Mueser, et al, Integrated Treatment for Dual
  Disorders, page 203.

19
Engagement

• Family members are in contact with a
  practitioner and are in the process of developing
  a working alliance.

20
Persuasion

• Family members have begun to discuss the
  clients substance abuse and may be receptive to
  education about mental illness and the effects of
  substance abuse.

21
Active Treatment

• Family members are engaged in treatment. They
  are learning information, strategies and skills
  to help person with managing mental illness and
  reducing their substance abuse.

22
Relapse prevention

• The client has achieved a reduction in
  substance use (or abstinence) for at least 6
  months and the family members continue to offer
  support and practical assistance.

23
Families/Significant Others Should Receive

• Outreach
• Education about dual disorders
• Coping skills for problems related to the
  clients mental illness and substance use
• Collaboration with the treatment team
• Support

24
Outreach

• Ask each client who their family members and
  significant others are
• Ask each client whom he or she spends time with
  and/or turns to for support
• Ask each client who many hours he or she spends
  with significant other per week
• Especially focus on those who have weekly contact

25
Outreach - contd

• Ask for permission to contact significant others
  to let them know of the positive step client is
  taking in being involved in treatment or
• to offer assistance to the significant others
  based on their expressed needs
• Call significant other, give info about program,
  ask if he or she has questions, offer to send
  written material
• Alert significant others to relevant resources,
  such as NAMI

26
Basic Education about Mental Illness

• Basic Facts about Mental Illness
• Medications
• The Stress Vulnerability Model
• Basic Facts about Alcohol and Drug Use
• Role of the Family
• Keys to Good Communication
• handouts available in Mueser, et al., 2003

27
Basic Education about Substance Use

• Alcohol and Drugs Motives and Consequences
• Treatment of Dual Disorders
• Infectious Diseases
• handouts available in Mueser, et al., 2003

28
Coping Skills Training

• Strategies for lowering stress in the environment
• Coping with symptoms of mental illness (such as
  hallucinations, delusions)
• Modifying stressful communication styles
• Taking a problem-solving approach
• Strategies for common problems
• Setting limits
• Suggestions in Mueser Glynn, 1999 Mueser, et
  al, 2003, Mueser Gingerich, in press

29
Collaboration with Treatment Team

• Frequent communication
• Ongoing interactive education about mental
  illness, substance abuse, and treatment
  recommendations
• Invitations to participate in meetings
• Suggestions in Mueser, et al, 2003, pages
  195-204

30
Support

• Reinforcing positive actions
• Offering hope
• Expressing interest in their well-being
• Helping solve variety of problems
• Helping family members/significant others to know
  that they are not to blame and not alone in their
  situation
• Suggestions in Mueser, et al, 2003, pages
  195-204

31
Some Families Benefit from More Systematic
Intervention

• Behavioral Family Therapy
• Multifamily Support Group
• Multifamily Psychoeducation Group

32
Behavioral Family Therapy (BFT)

• Single family model
• Interested in improving quality of life for all
  family members
• Incorporates psychoeducation, communication
  skills training and problem-solving training
• Can be tailored to reach a variety of families
• Can be provided at home or agency

33
Books Describing Behavioral Family Therapy in
Detail

• Mueser Glynn, Behavioral Family Therapy for
  Psychiatric Disorders, 1999. Includes
  reproducible forms and handouts.
• Mueser et al, Family Collaboration and
  Behavioral Family Therapy in Integrated
  Treatment for Dual Disorders, pages 195-235.
  Includes reproducible forms and handouts.

34
Summary of BFT Model

• Engagement/connecting
• Assessment/establishing personal goals
• Psychoeducation (6 - 8 sessions)
• Communication training as needed (4 - 8 sessions)
• Problem-solving training (5 -15 sessions)
• Gradual decline of sessions/termination

35
Communication skills - examples

• Active listening
• Expressing positive feelings
• Making positive requests
• Expressing negative (unpleasant) feelings
• Compromise and negotiation
• Requesting a time-out

36
Problem-solving Examples of topics for families
to work on

• Identify alternative socialization outlets
• Responding to offers to use substances
• Determining strategies for dealing with
  persistent symptoms
• Exploring alternative recreational activities
• Finding work or other meaningful activities

37
Problem-Solving Steps

• 1. Define the problem
• 2. Brainstorm possible solutions
• 3. Evaluate solutions (pros cons)
• 4. Choose the best solution or combination
• 5. Plan how to implement the solution
• 6. Follow up the implementation
• See Mueser et al, page 463

38
Interventions

• Multifamily Groups

39
Multifamily Groups

• Multifamily Groups teach families knowledge and
  skills similar to content of BFT
• Provide social support, opportunities to learn
  from others experience, and hear other
  suggestions for solving problems

40
Two Main Models of Multifamily Groups

• Multifamily Support Group (NIMH Treatment
  Strategies In Schizophrenia description in
  Mueser, et al)
• Psychoeducational Multifamily Group (W.
  McFarlane)

41
Interventions

• Multifamily Support Groups

42
Multifamily Support Group

• Time unlimited
• Include client
• Conducted monthly (or every two weeks)
• 60 - 90 minute sessions
• Scheduled in the evening
• Start with 3-5 families (6-10 individuals)
• Avoid groups larger than 25

43
Multifamily Support Groups - contd

• Clients with different diagnoses can be included
• If necessary, client can attend without family
  and vice versa
• Co-leaders highly recommended
• Educational presentation for each session
• Send out reminders
• See description in Mueser, et al, 2003. P.
  227-235

44
Stages of Multifamily Support Groups

• Engagement (phone calls, family session)
• Multifamily group sessions

45
Interventions

• Psychoeducational
• Multifamily Groups

46
Psychoeducational Multifamily Groups

• Time-unlimited
• Include the client
• Conducted every two weeks (sometimes declining to
  monthly sessions)
• Single diagnosis, closed groups recommended
• If necessary, family members can attend without
  the client and vice versa
• Co-leaders highly recommended
• Send out reminders
• See MacFarlane Dixon Toolkit. See
  MacFarlane, 2002.

47
Advantages of different models of family
intervention
48
Combining BFT and Multifamily Groups

• Successful pilot study done by Mueser and Fox
  (2002)
• Families received BFT as a single family
• Families attended monthly sessions of multifamily
  support group
• Data on six families all clients made progress
  in dual disorder treatment

49
Interventions

• Getting Started

50
Suggestions for Structure for Providing Family
Intervention

• Each team needs at least two family clinicians
• Each team needs a family supervisor/coordinator
  or shares one with with another team or with the
  rest of their agency
• Time needs to be protected

51
Family Clinicians

• Are trained to engage families,
• conduct individual family sessions,
• and lead multifamily groups.
• Work with at least 2-4 individual families in the
  first year of implementation
• Start a multifamily group in the first year of
  implementation

52
Family clinicians - contd

• Provide ideas and suggestions to teammates about
  working with families of clients
• Identify families who would benefit from more
  systematic intervention
• Need protected time to work with families (3-5
  hours) and
• receive weekly supervision (in a group with other
  family clinicians)

53
Family Supervisor

• Same training as family clinicians
• Expected to work with 1-2 families individually
  and start a multiple family group
• Provides weekly supervision to family clinicians
  (up to 6 in a group)
• Monitors the delivery of family services meets
  regularly with team leader or agency director
• Needs protected time for working with families,
  providing supervision, and monitoring services
  (3-5 hours, unless supervising more than one
  group of clinicians)

54
Team Leader or Agency Director

• Attends some of the training
• Demonstrates support of family work on the team
  or within the agency
• Meets regularly with Family Supervisor/Coordinator
  
• Troubleshoots obstacles to providing family work

55
Option Family Services Coordinator for an
Entire Agency

• Identifies and trains clinicians in family work
• Works with families
• Supervises family clinicians (in groups of up to
  6)
• Monitors the delivery of family services
• Develops, implements, oversees family programs
• Works with a family advocate as a liaison with
  NAMI
• Participates in continuing education activities
• Has approximately 10 hours designated for these
  responsibilities

56
Implementation Questions

• What aspects of your organizations culture,
  experience and skills would be particularly
  advantageous to working with families?
• How many family clinicians would there be?
• Who would be the family clinicians?
• Who would be the Family Supervisor/Coordinator?
• How would you get the word out to all staff?
  Families/Significant Others?

57
Implementation Questions - contd

• How many clients have regular contact with
  families/significant others?
• Which clients would you approach first?
• How would the family clinicians have protected
  time for working with families?
• How would the family supervisor/coordinator have
  protected time?
• How would your administration support the overall
  implementation of family work?

58
Setting Goals

• Time frame What How Who
• 3 month
• 6 month
• 12 month

59
Identify

• Obstacles to implementation
• Strategies to overcome those obstacles

60
Contacts

• Christina Delos Reyes, MD
• Patrick E. Boyle, MSSA, LISW, LICDC
• Center for Evidence Based Practices at Case
• Ohio SAMI CCOE - Ohio SE CCOE
• Behavioral Healthcare
• 1756 Sagamore Road
• Cottage 7, Room 304
• Northfield, OH 44067-1086
• Ph 330-468-8663 Fax [phone]
• Patrick.boyle_at_case.edu
• www.ohiosamiccoe.case.edu