The Power of Family Work: Findings Old and New

Recent Outcomes, New Models and Future Prospects

Fifth Annual Grampians Mental Health ConferenceMarch 1-2, 2005

William R. McFarlane, M.D.

Center for Psychiatric Research Portland, Maine

University of Vermont

Interaction of patient symptoms and family process:

A simple causal model

Effects of EE and medication on relapse in schizophrenia

44.3

57.7

18.4

27.9

0

10

20

30

40

50

60

High EE Low EE

AP Meds

No meds.

Bebbington and Kuipers, 1994

Effects of EE and contact on relapse in schizophrenia

58.8

41.7

18.323.9

0

10

20

30

40

50

60

High EE Low EE

High contact

Low contact

Bebbington and Kuipers, 1994

Effects of genetic risk and family functioning on eventual schizophrenia-spectrum disorders

5.84.8

36.8

5.3

0

5

10

15

20

25

30

35

40

High-risk, spectrum* Low-risk, spectrum**

% of sub-sample

Low OPAS ratings High OPAS ratings

* p < 0.001**p = 0.582

Tienari, et al, BJM, 2004

Positive Outcomes from FPE

• The patient and family work together towards recovery.

• Can be as beneficial in the recovery of schizophrenia and severe mood disorders as medication.

Research with Family Psychoeducation

• This treatment is an elaboration of models developed by Anderson, Falloon, McFarlane, Goldstein and others.

• Outcome studies report a reduction in annual relapse rates for medicated, community-based people of as much as 50% by using a variety of educational, supportive, and behavioral techniques.

Research with Family Psychoeducation

• Functioning in the community improves steadily, especially for employment.

• Family members have less stress, improved coping skills, greater satisfaction with caretaking and fewer physical illnesses over time.

Core Elements of Psychoeducation

• Joining

• Education

• Problem-solving

• Interactional change

• Structural change

• Multi-family contact

Outcomes in family psychoeducation

The evidence for being an evidence-based practice

Relapse outcome, controlled trials, 1980-1997

n Duration of treatment SF SF + MF MF Standard treatment

Falloon (1984) 36 24 17 83

Leff (1985) 19 24 14 78

Tarrier (1989) 44 9 33 59

Leff (1990) 23 24 33 36

Hogarty (1991) 67 24 32 67

Xiong (1994) 63 18 44 64

Zhang (1994) 83 18 15 54

Randolph (1995) 41 12 10 40

McFarlane (1995) 34 48 83 50

McFarlane (1995) 172 24 44 25

Schooler (1997) 313 12/24 29 35

Total 895 19.7 28.0 25.5 28.0 63

Comparison of single and multifamily formats

n Duration of

treatment, months

SF MF

Leff (1990) 23 24 33 36

McFarlane (1995) 34 48 83 50

McFarlane (1995) 172 24 44 25

Total 229 27.6 48.7 29.8

Relapse outcomes in clinical trials

65

41

15

9

0

10

20

30

40

50

60

70

No medication Individual therapy &medication

FPE & medication PEMFG & medication

Hospitalizations before vs.during treatment

1.08

0.27

0

0.2

0.4

0.6

0.8

1

1.2

Mean number of hospitalizations

per year2 yrs priorIn MFG tx

Family Psychoeducation in Schizophrenia

Psychoeducational multiple family group (PEMFG)

vs..

Psychoeducational single family treatment (PESFT)

N = 172

Family Psychoeducation in SchizophreniaProject Sites

Creedmoor Psychiatric CenterQueens, N.Y.

Harlem Hospital CenterNew York City

Hudson River Psychiatric CenterPoughkeepsie, N.Y.

Kings Park Psychiatric CenterIslip, N.Y.

Rochester Psychiatric CenterRochester, N.Y.

South Beach Psychiatric CenterStaten Island & Brooklyn, N.Y

Psychiatric Characteristics of Patients

by therapy modality

VariableAge of onset Mean s.d.Diagnosis Schizophrenia Schizoaffective SchizophreniformPrior hospitalization Mean s.d.Substance abuse No history Positive history

PEMFG PESFT

18.5 19.6 5.5 6.2

81.9% 88.3%13.8% 8.5% 4.3% 3.2%

4.0 5.5 4.5 5.5

61.7% 66.0%38.3% 34.0%

Modality differences: all not significant

Total

19.0 5.8

85.1%11.2% 3.7%

4.85.1

63.8%36.2%

50

60

70

80

90

100

0 100 200 300 400 500 600 700 800

Days at risk

% in

re

mis

sio

n

MFG SFT

Remission to 2 years

N: PEMFG=83; PESFT=92Main effect, all cases: p=.07Main effect, completers: p<.05

0

5

10

0 5 10 15 20 25

Months at risk

# of relapses

MFG SFT Linear (MFG) Linear (SFT)

Risk for relapse over two years

N: MFG=83; SFT=89

850

656

751

875

400

500

600

700

800

900

1000

-5 0 5 10 15 20 25 30

Months

Ch

lorp

rom

azi

ne

eq

uiv

ale

nts

in m

gs

.

MFG SFT MFG SFT

Medication dosages in MFG and SFT

48

38

29

1214

4953

57

0

10

20

30

40

50

60

70

Low a-d/Low CC Low a-d/High CC High a-d/Low CC High a-d/High CC

Cumulative two-year relapse rate (%)

MFG SFT

Anxious depression, critical comments and treatment type:Differential effects on relapse rates

Differential relapse rates by number of prior hospitalizations

19

35

4744

32

44

0

5

10

15

20

25

30

35

40

45

50

0 1 2 or moreNumber of prior hospitalizations

Percent of subsample relapsed in 2 years

MFGSFT

Functioning as an effect of repeated psychotic episodes

0

20

40

60

80

100

120

0 1 2 3 4 5 6Number of episodes

Fu

nct

ion

ing

Other effects in clinical trials

• Improved family-member well-being• Increased patient participation in rehabilitation• Substantially increased employment rates• Decreased psychiatric symptoms, including deficit

syndrome• Improved social functioning• Decreased family medical illnesses and medical

care utilization• Reduced costs of care

Family satisfaction with treatment

0

5

10

15

20

25

30

Very high High Moderate Low Very low No resp.

Negative symptom outcomes:MFGs vs standard care

6

6.5

7

7.5

8

8.5

9

9.5

Baseline 1-3 4-6 7-9 10-12

Months

SA

NS

sc

ore

, me

an

MFG Standard careMFG vs SC: p<.05, all f/u time points Dyck, et al., 2000

Family influences on work

Modeling

Information

Encouragement

Buffering

Guidance

Adjusting expectations

Ancillary support

Cueing

Personal connections

Rehabilitation effects of multifamily groups

Reducing family confusion and tension

Tuning and ratification of goals

Coordinating efforts of family, team, consumer and employer

Developing informal job leads and contacts

Cheerleading and guidance in early phases of working

Ongoing problem-solving

Work Outcome

Employed at baseline

17.3%

(p=.001)

Employed at 2 years

29.3%

Gain in % employed

PEMFG 16%

PESFT 8%

(n.s.)

Family-aided Assertive Community Treatment (FACT):

A clinical and employment intervention

• Psychoeducational multifamily groups

• Clinical case management using ACT principles and methods

• Integrated, multidisciplinary teams

• Supported employment

• MH Employers’ Consortium

• Cognitive assessments used in job accommodation

Vocational specialists on FACT teams: Principal tasks

–Developing contacts with employers–Case-specific job development–Job assessment –Assessment of patients' cognitive, physical and social capacities

–Setting career goals–Practicing interviews and resumes –Assistance with job interviews–On- or near-job support–Intervening with employers–Close coordination with clinicians

Rehabilitation effects of multifamily groups

Reducing family confusion and tension

Tuning and ratification of goals

Coordinating efforts of family, team, consumer and employer

Developing informal job leads and contacts

Cheerleading and guidance in early phases of working

Ongoing problem-solving

Outcomes in Family-aided Assertive Community

Treatment

FACT vs ACT

William R. McFarlane, M.D.Peter Stastny, M.D.

Susan Deakins, M.D.Robert Dushay, Ph.D.

RELAPSE OUTCOMEFACT vs. ACT

FACT (n=36) ACT (n=35)

8 (22%) 14 (40%)

Ln 8.58" Pos 0.75"

Employment outcome: FACT vs. ACT only

15.4% 15.4%

7.7% 7.7%3.7%

22.2%

37.0%

18.5%

0%

10%

20%

30%

40%

Baseline 12 mos. Gainedemploymt.

Lostemploymt.

% e

mp

loye

d, a

ny

job

ACTFACT

Washtenaw County, hospital rates ACT vs. MFG+ACT

0%5%

10%15%20%25%30%35%40%

Annual rate of hospitlaization

5-01 to 3-03

ACT

MFG & ACT

Selection Bias for the MFG?

0%

10%20%

30%40%

50%60%70%

80%

MFG Clients Non-MFG ACT

Annualized Hospitalization Rates

Future MFG clts, preACT 5-99 to 5-01

Future MFG clts, withACT only 5-99 to 5-01

MFG + ACT 5-01 to 5-03

Pre ACT hosp of Non-MFG 5-99 to 5-01

Non-MFG ACT 5-99 to5-01

Non-MFG ACT 5-01 to5-03

WCSTS ACT Employment/School

0%

10%

20%

30%

40%

50%

60%

70%

80%

Employment or School March '03

ACT

ACT + MFPE

Mental Health Employers Mental Health Employers ConsortiumConsortium

Employment OutcomesEmployment Outcomes

An Employment Intervention

Demonstration Project

Total Receiving Service137

Gender

Male 75 (54.7%)

Female 62

Condition

Employers Consortium 67

Community employers 70

Sample Description

0

10

20

30

40

50

60

70

80

Months in Program

Percent Employed(n = 116)

Schizophrenia

Mood Disorders

Other Disorders

Employment rate in FACT combined with supported employment, by diagnosis

67%

41%

19%

Evidence-based benefits for participants

• Promotes understanding of illness• Promotes development of skills• Reduces family burden• Reduces relapse and rehospitalization • Encourages community re-integration, especially

work and earnings• Promotes socialization and the formation of

friendships in the group setting

Practitioners have found...

• Renewed interest in work

• Increased job satisfaction

• Improved ability to help families and consumers deal with issues in early stages

• Families and consumers take more control of recovery and feel more empowered

Who can benefit from FPE?

• Individuals with schizophrenia who are newly diagnosed or chronically ill

• Adolescents and young adults with pre-psychotic symptoms

• There is growing evidence that the following people can also benefit:

- individuals with mood disorders

- consumers with OCD or borderline

personality disorder

Cost-benefit ratios of PMFGs

Treatment Hospital Costs Treatment Net /pt./yr. costs

Usual/prior $6156 $0 $6156

Family PE $1539 $300 $1839

$ saved per pt./yr. $4317

Family psychoeducation and multifamily groups:

Basic techniques

Stages of a psychoeducational multifamily group

Joining

Family and patient separately3-6 weeks

Educa-tional

workshop

Families only1 day

Ongoing MFGFamilies and

patients 1-4 years

Therapeutic processes in multifamily groups

• Stigma reversal

• Social network construction

• Communication improvement

• Crisis prevention

• Treatment adherence

• Anxiety and arousal reduction

Phases and Interventions in Family Psychoeducation

Year One: Relapse Prevention

Engaging individual families

Multifamily educational workshop

Implementing family guidelines

Reducing stigma and shame

Lowering expectations

Controlling rate of recovery

Reducing intensity and exasperation

Phases and Interventions in Family Psychoeducation

Year Two: Rehabilitation

Gradually increasing responsibilities

Moving one step at a time--the internal yardstick

Monitoring encouragement from family members

Establishing inter-family relationships

Cross-parenting

Focusing family interests outside family

Restoring family's natural social network

Structure of SessionsMultifamily groups (MFGs) and single-family treatment

(SFT)

MFG SFT1. Socializing with families and consumers 15 m. 10 m.

2. A Go-around, reviewing-- 20 m. 15 m.

a. The week's events b. Relevant biosocial information c. Applicable guidelines

3. Selection of a single problem 5 m. 5 m.

4. Formal Problem-solving 45 m. 25 m.

a. Problem definition b. Generation of possible solutions c. Weighing pros and cons of each d. Selection of preferred solution e. Delineation of tasks and implementation

5. Socializing with families and consumers 5 m. 5 m. Total: 90 m. 60 m.

Better outcomes in family psychoeducation

• Over 16 controlled clinical trials, comparing to standard outpatient treatment, have shown:– Much lower relapse rates and rehospitalization

• Up to 75% reduction of rates in controls; minimally 50%

– Increased employment• At least twice the number of consumers employed, and up to four times

greater--over 50%employed after two years--when combined with supported employment

– Reduced negative symptoms, in multifamily groups

– Improved family relationships and reduced friction and family burden

– Reduced medical illness • Doctor visits for family members decreased by over 50% in one year, in

multifamily groups

Summary