Successful Single Family Engagement

1. Successful Single Family Engagement Be friendly Listen Be curious about families’ actual experience Don’t censor empathic responses to tragic events Use the “Sorry” strategy Come to terms with not being the only one with knowledge and skills Be responsive to requests and give practical help as asked

2. Successful Multi-Family Engagement Tell them it works Model non- pathologising and non-judging Reassurance about being better or worse than others Stigma busting Reassurance about confidentiality Help in managing symptoms “What do I have to offer” “What can other families offer me”

3. Psychoeducation Workshop What we are aiming for? • Families feel well informed about current biological, psychological and social information and options for individual and family well being • Families have felt able to share their experiences with others • Both ill and non-ill family members are viewed as skilled and knowledgable • Families engage well with each other

4. Psychoeducational Workshop You are the dinner event host.......for a group of people who are anxious, have special needs and who don’t know each other

5. Psychoeducation WorkshopProcess • Keep it interactive and explorative • Encourage everyone to be involved • Use inclusive language (Take a “we” and “us” stance not a “they” stance) • Accommodate many knowledges rather than trying to impose one framework or a “right way” • Float hypotheses and dilemmas to generate discussion • Promote “bilingualism” (psychiatric lingo as well as the lived experience)

6. Private Experience Sensitive to stimulus: “I can taste and hear everything” “I’m super-sensitive” Confusion: “scrambled newspaper” Feeling overwhelmed: “There’s too much going on” Distracted: “I can’t read or concentrate” “my head is racing all the time” Special experiences “stuck on something” “It feels like the world is depending on me” “I thought I was God” Feeling unsafe & suspicious Finding it hard to sleep/ “I can’t sit still” Psychiatric Terms Disturbed Arousal and Attention Thought Disorder Disorganisation Delusions Hallucinations Withdrawal Paranoia Loss of motivation Psychiatric Bilingualism

7. Bilingualism Working in families’ own language Favourite metaphors of mental illness from clients, families .. or yourself

8. Thoughts on Engagement “Everyone was treated equally. Coming to group made ill people feel not ill” (M- non-ill partner) “It was helpful that other people were being so open and nobody was treating you like an idiot. It gave me confidence to open up” There was that safety from disapproval and criticism and just not being understood” (B-non-ill mother) “The skills of the workers in helping people feel confident to speak is very important” (Pa-ill family member) “The group was a healthy shift in focus because it wasn’t too serious. There’d be food on the table, tea and coffee. It wasn’t a lot of long faces around the table. So there was a sort of lightness about it instead of a dead seriousness that sometimes happens” (B-carer mother)

9. Psychoeducation WorkshopContent Causes of mental illness Common illness experiences The role of medication and non-medical treatments Family impact/ trauma Families' sharing their lived experience The service system Coping skills that families find useful

10. It comes down to Arousal Attention and Integration The relationship between arousal and attention is sensitive.. We need to be aroused on a sensory level to pay attention to the world around us In a psychotic state, people are over-aroused. This means they find it hard to pay attention and to process information properly. Low attention and arousal can result in negative symptoms

11. Brain Changes • Prefrontal cortex (underactive) Problem-solving, planning, attention, initiative, motivation • Limbic system (overactive) Heightened arousal • Cingulate cortex (underactive) Emotional lability and disconnection of thoughts/feelings

12. Causes: The Likely Culprits Some genetic predisposition • activation of underlying codes • may be more so for illness consisting of negative symptoms Some trauma impact (Brian Koehler, John Read (9.3X Psychosis) • sensitisation to stress (cortisol pathways) • purposeful adaptations • may be more prevalent for illness consisting of positive symptoms Some interactional stress (Helm Stierlin) • strategy for resolution of intractable conflict (intra personal, family and /or social) • purposeful positioning

13. Stress Vulnerability Model Variable individual stress thresholds Biological and psychological vulnerability Multiple stressors or triggers (primary & seocondary)

14. Family Communication Stress (EE) High Expressed Emotion = Intensity, negativity and complexity (Leff & Vaughan) e.g. • Critical comments • Over-involvement • Lack of warmth • Crowding • Excessive pressure to perform • Interactions with conflict • Multiple sources of input or... Changes to family perceptions of ill person that lead to changed communication (Barrowclough)

15. Content: Available Treatment Physical issues (Sleep, drugs, vitamins, natural remedies) Medical treatment/ CTOs Non-medical ways of dealing with primary impact (thinking skills, managing symptoms, managing arousal/ triggers) Dealing with secondary impact (social skills, personal development, employment)

16. Content: Family Impact Discarded ideas of families as causing mental illness (be up front about this) How families deal with trauma impact Changes to life cycles/family roles Challenges to communication and conflict resolution Coping skills Options: Single Family work, Debriefing and Multi-family group work

17. Inner West MFG Evidence Ill family members in the MFG had significantly less relapse than those who were in case management only 12% of MFG group vs 36% of CM group immediately after the group 25% of MFG vs 63% of CM group after 18 months Significant reduction in psychiatric symptoms for families in MFG Ill family members in the MFG were more involved in employment-related activities

18. Content: The service system Outline the roles of the various teams including emergency options, case management and ISPs Identify non-government psychiatric support services, centrelink and CRS services Describe individual and family therapy services Describe client and carer advocacy services mental illness fellowship, SANE, ARAFEMI

19. Content: Coping Skills • Revise expectations, temporarily • be realistic • determine your own yardstick • Keep the emotional environment low key • enthusiasm is normal; tone it down • disagreement is normal; tone it down • Give people space • Time out is important for everyone • It is okay to offer. Its okay to refuse. • Be clear about limits • Create reasonable rules for living together. • Rules and limits can help create a low key predictable home environment

20. Content: Coping Skills • Ignore the unimportant stuff • No one can change everything at once. • Keep communication simple • Discuss what you have to say to each other calmly, clearly and positively • Be clear about the best use of medication • Let the doctor know about side effects or concerns • Keep track of medicationusage • Develop a normal family routine • Keep many family routines independent of the person with the illness • Pick up early warning signs • take time to study and identify particular warning signs • discuss them at times of low tension • initiate contact with mental health workers

21. Ongoing Group: Format • socialising 10 • go round (past two weeks) 20 • defining a focus for work 10 • simple problem • narrative problem • solution focussed exceptions • generate ideas (no holds barred) 10 • toss around up and down side 20 • locate workable solutions5 • generate a plan with the family5 • socialising 10

22. Picking the problem • Don’t ignore medication, safety or drug issues! • Simplify • Narrow • Concentrate on behavior • Focus on relapse risk • Avoid crisis issues too complex or risky for the group setting

23. Brainstorming • All members can contribute • All suggestions are welcome • No suggestion is analyzed or critiqued during brainstorming • Suggestions are limited to 10 - 12 ideas • The person with the identified problem chooses 1 - 2 suggestions to try

24. Taking Action • An action plan is developed for the chosen suggestion(s) • Tasks are identified and assigned • Consensus is achieved prior to leaving the meeting • The plan is reviewed at the next meeting to determine success or the need for further problem-solving

25. Working on Problems It was great to have that creativity from the group by exploring it on the whiteboard and then getting a photocopy on different issues and different suggestions (E- ill family member) “It was a space where we could actually have mental health issues talked about. My dad and I had never spoken about it (E- ill family member) “Being with people in the same boat means you are compelled to find solutions” (A-ill family member) One older member talked about the importance of forgiving each other so their change in behaviour was not always as great as their way of thinking” (A-facilitator)