the power of family work: findings old and new
DESCRIPTION
The Power of Family Work: Findings Old and New. Recent Outcomes, New Models and Future Prospects Fifth Annual Grampians Mental Health Conference March 1-2, 2005 William R. McFarlane, M.D. Center for Psychiatric Research Portland, Maine University of Vermont. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/1.jpg)
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
![Page 2: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/2.jpg)
Interaction of patient symptoms and family process:
A simple causal model
![Page 3: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/3.jpg)
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 MedsNo meds.
Bebbington and Kuipers, 1994
![Page 4: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/4.jpg)
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 contactLow contact
Bebbington and Kuipers, 1994
![Page 5: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/5.jpg)
Effects of genetic risk and family functioning on eventual schizophrenia-spectrum disorders
5.8 4.8
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
![Page 6: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/6.jpg)
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.
![Page 7: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/7.jpg)
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.
![Page 8: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/8.jpg)
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.
![Page 9: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/9.jpg)
Core Elements of Psychoeducation
• Joining
• Education
• Problem-solving
• Interactional change
• Structural change
• Multi-family contact
![Page 10: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/10.jpg)
Outcomes in family psychoeducation
The evidence for being an evidence-based practice
![Page 11: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/11.jpg)
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
![Page 12: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/12.jpg)
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
![Page 13: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/13.jpg)
Relapse outcomes in clinical trials
65
41
159
0
10
20
30
40
50
60
70
No medication Individual therapy &medication
FPE & medication PEMFG & medication
![Page 14: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/14.jpg)
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
![Page 15: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/15.jpg)
Family Psychoeducation in Schizophrenia
Psychoeducational multiple family group (PEMFG)
vs..
Psychoeducational single family treatment (PESFT)
N = 172
![Page 16: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/16.jpg)
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
![Page 17: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/17.jpg)
Psychiatric Characteristics of Patients
by therapy modalityVariableAge 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%
![Page 18: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/18.jpg)
50
60
70
80
90
100
0 100 200 300 400 500 600 700 800
Days at risk
% in
rem
issi
on
MFG SFT
Remission to 2 years
N: PEMFG=83; PESFT=92Main effect, all cases: p=.07Main effect, completers: p<.05
![Page 19: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/19.jpg)
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
![Page 20: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/20.jpg)
850
656
751
875
400
500
600
700
800
900
1000
-5 0 5 10 15 20 25 30
Months
Chl
orpr
omaz
ine
equi
vale
nts
in m
gs.
MFG SFT MFG SFT
Medication dosages in MFG and SFT
![Page 21: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/21.jpg)
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
![Page 22: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/22.jpg)
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
![Page 23: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/23.jpg)
![Page 24: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/24.jpg)
Functioning as an effect of repeated psychotic episodes
0
20
40
60
80
100
120
0 1 2 3 4 5 6Number of episodes
Func
tioni
ng
![Page 25: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/25.jpg)
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
![Page 26: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/26.jpg)
Family satisfaction with treatment
0
5
10
15
20
25
30
Very high High Moderate Low Very low No resp.
![Page 27: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/27.jpg)
Negative symptom outcomes:MFGs vs standard care
66.5
77.5
88.5
99.5
Baseline 1-3 4-6 7-9 10-12
Months
SAN
S sc
ore,
mea
n
MFG Standard careMFG vs SC: p<.05, all f/u time points Dyck, et al., 2000
![Page 28: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/28.jpg)
Family influences on work Modeling
Information
Encouragement
Buffering
Guidance
Adjusting expectations
Ancillary support
Cueing
Personal connections
![Page 29: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/29.jpg)
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
![Page 30: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/30.jpg)
Work Outcome
Employed at baseline
17.3%
(p=.001)
Employed at 2 years
29.3%
Gain in % employed
PEMFG 16%
PESFT 8%
(n.s.)
![Page 31: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/31.jpg)
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
![Page 32: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/32.jpg)
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
![Page 33: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/33.jpg)
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
![Page 34: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/34.jpg)
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.
![Page 35: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/35.jpg)
RELAPSE OUTCOMEFACT vs. ACT
FACT (n=36) ACT (n=35)
8 (22%) 14 (40%)
Ln 8.58" Pos 0.75"
![Page 36: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/36.jpg)
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
mpl
oyed
, any
job
ACTFACT
![Page 37: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/37.jpg)
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
![Page 38: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/38.jpg)
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 5-01Future MFG clts, withACT only 5-99 to 5-01MFG + ACT 5-01 to 5-03Pre ACT hosp of Non-MFG 5-99 to 5-01Non-MFG ACT 5-99 to5-01Non-MFG ACT 5-01 to5-03
![Page 39: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/39.jpg)
WCSTS ACT Employment/School
0%10%
20%
30%
40%
50%
60%
70%80%
Employment or School March '03
ACTACT + MFPE
![Page 40: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/40.jpg)
Mental Health Employers Mental Health Employers ConsortiumConsortium
Employment OutcomesEmployment Outcomes
An Employment Intervention Demonstration Project
![Page 41: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/41.jpg)
Total Receiving Service137
Gender
Male 75 (54.7%)
Female 62
Condition
Employers Consortium 67
Community employers 70
Sample Description
![Page 42: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/42.jpg)
0
10
20
30
40
50
60
70
80
Months in Program
Percent Employed(n = 116)
SchizophreniaMood DisordersOther Disorders
Employment rate in FACT combined with supported employment, by diagnosis
67%
41%
19%
![Page 43: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/43.jpg)
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
![Page 44: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/44.jpg)
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
![Page 45: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/45.jpg)
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
![Page 46: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/46.jpg)
![Page 47: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/47.jpg)
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
![Page 48: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/48.jpg)
Family psychoeducation and multifamily groups:
Basic techniques
![Page 49: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/49.jpg)
Stages of a psychoeducational multifamily group
Joining
Family and patient separately3-6 weeks
Educa-tional
workshopFamilies only
1 day
Ongoing MFGFamilies and
patients 1-4 years
![Page 50: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/50.jpg)
Therapeutic processes in multifamily groups
• Stigma reversal • Social network construction• Communication improvement• Crisis prevention• Treatment adherence• Anxiety and arousal reduction
![Page 51: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/51.jpg)
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
![Page 52: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/52.jpg)
![Page 53: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/53.jpg)
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
![Page 54: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/54.jpg)
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.
![Page 55: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/55.jpg)
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
![Page 56: The Power of Family Work: Findings Old and New](https://reader036.vdocuments.us/reader036/viewer/2022070423/568167e5550346895ddd4fb0/html5/thumbnails/56.jpg)
Summary