Developments in Family Work

1. Developments in Family Work Advanced methods and modifications Meriden Family Conference Stratford-on-Avon William R. McFarlane, MD University of Vermont Maine Medical Center

2. A brief review of the psychobiology of schizophrenia

3. “…the basic defect in schizophrenia consists of a low threshold for (mental) disorganization under increasing stimulus input.”Epstein and Coleman, 1970

4. Psychosis results from a biologically-based sensitivity to: • Sensory stimulation • Prolonged stress, strenuous demands • Rapid change • Negative emotional experience • Complexity • Social disruption • Illicit drugs and alcohol

9. Cortical volume reduction, in childhood-onset schizophrenia, ages 14-19

10. The Brain in Schizophrenia DORSOLATERAL PREFRONTAL CORTEX Association LIMBIC LOBE Affect X HIPPOCAMPUS Attention BRAINSTEM Arousal

11. Functions of the Prefrontal Cortex • Establishing a cognitive set • Problem-solving • Planning • Social intelligence • Attention and multi-tasking • Initiative and motivation • Integration of thought and affect • Mental liveliness

12. Interaction of attention and arousal Optimal Distraction Inattention Arousal Attention

13. Effects of EE and medication on relapse in schizophrenia Bebbington and Kuipers, 1994

14. Effects of EE and contact on relapse in schizophrenia Bebbington and Kuipers, 1994

15. Effects of genetic risk and family functioning on eventual schizophrenia-spectrum disorders * p < 0.001 **p = 0.582 G X E interaction: p=0.018 Tienari, Wynne, et al, BJP, 2004

16. Risks for symptom exacerbation and relapseIntensity, negativity and complexity • Critical comments • Over-involvement • Lack of warmth • Crowding • Excessive pressure to perform • Interactions with conflict • Multiple sources of input

17. Risks for symptom exacerbation and relapseHigh rate of change • Excessive life events per unit of time • Disruption of social supports • Lack or loss of "bridging" cues • Entry into a new context • Multiple functional levels involved incompensating

18. Risks for symptom exacerbation and relapsePhysical and chemical factors • Stimulants • Hallucinogens • Dependence on depressants • Unknown environmental toxins • Loud noises • Distracting noises, echoes • Bright lights

19. Potential for relapse in schizophrenia Positive symptoms Negative symptoms Risk for relapse Prodromal phase 1 week-1 year Acute psychosis 1 week-1 month Recovery phase 6-36 months

20. Patient symptoms and family interaction:A simple causal model + Family Symptoms +

21. Relapse vs. Recovery

22. Advanced methods in family psychoeducation

23. Multifamily group vs.single-family meetings • MFGs are more effective for first episodes and cases with social isolation, high distress and poor response to prior treatment • Some families prefer meeting with one practitioner for the entire time • Some families want to hear what other families have done and need support • Consumers and families may need the practitioner’s guidance to decide

24. Comparison of single and multifamily formats

25. Relapse outcomes in clinical trials

26. Risk for relapse over two years N: MFG=83; SFT=89

27. Medication dosages in MFG and SFT

28. Risk factors and treatment type:Effects on two-year relapse rates Number of factors, any combination: High EE, high BPRS, white race Risk factors = high BPRS, high EE, whiterace

29. Phases and Interventions in Family PsychoeducationYear One: Relapse Prevention • Engaging individual families • Multifamily educational workshop • Implementing family guidelines • Reducing stigma and shame • Lowering expectations • Controlling rate of recovery • Reducing anxiety, uncertainty, intensity and exasperation

32. Phases and Interventions in Family Psychoeducation Year Two: Rehabilitation • Gradually increasing responsibilities • Competitive employment or continuing education • 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 • Maintaining or restoring family's natural social network

35. Phases and Interventions in Family Psychoeducation Year Three: Network Formation and Recovery • Validating group competency • More socializing, less problem-solving • Encouraging social contacts outside the group • Shifting role of clinicians • Converting to a vocational auxiliary 

36. CoreElements of Psychoeducation • Joining • Education • Problem-solving • Interactional change • Structural change • Multi-family contact

37. Family-aided Assertive Community Treatment (FACT): Clinical and functional intervention • Rapid, crisis-oriented initiation of treatment • Psychoeducational multifamily groups • Case management using key Assertive Community Treatment methods • Integrated, multidisciplinary team; outreach PRN; rapid response; continuous case review • Supported employment and education • Collaboration with schools, colleges and employers • Cognitive assessments used in school or job • Low-dose atypical antipsychotic medication • 10-20 mg aripiprazole, 2.5-7.5 mg olanzapine, 0.25-3 mg risperidone • Mood stabilizers, as indicated by symptoms: • SSRIs, with caution, especially with aripiprazole and/or a family history of manic episodes • Mood stabilizing drugs: lamotrigine 50-150 mg, valproate, 500-1500mg, lithium at therapeutic doses by blood level 0.6-1.2

38. Key clinical strategies in family intervention specific to prodromal psychosis • Strengthening relationships and creating an optimal, protective home environment: • Reducing intensity, anxiety and over-involvement • Preventing onset of negativity and criticism • Adjusting expectations and performance demands • Minimizing internal family stressors • Marital stress • Sibling hostility • Conceptual and attributional confusion and disagreement • Buffering external stressors • Academic and employment stress • Social rejection at school or work • Cultural taboos • Entertainment stress • Romantic and sexual complications

39. Stages of treatment in family psychoeducation Educa- tional workshop Ongoing sessions Families and patients 1-4 years Joining Family and patient separately 3-6 weeks Families only 1 day

40. What Happens During Joining? • Discuss personal interests = it’s a good way to facilitate getting to know one another • What the clinician does--techniques • Identify early warning signs of illness • Identify characteristic precipitants for increasing symptoms or relapse (“triggers”) • Identify coping strategies • Explore reactions to illness • Review family social networks • Contract for treatment

41. Educational needs of families of adolescents after initial episodes of psychosis Management of symptoms Management of stress Needs of the family Developmental issues for adolescents School Parenting in the new context Treatments

42. Educational needs of families of adolescents after initial episodes of psychosis Family guidelines Theories of psychosis Sibling issues Differential diagnosis Prognosis Medications Needs of the adolescent Common problems and solutions

43. Family psychoeducation in early phases • Building education and information-sharing on patient and family's unique and evolving experience • Defining psychosis as a reversible, treatable condition, like diabetes • Core problem is an unusual sensitivity to: • sensory stimulation, • prolonged stress and strenuous demands, • rapid change, • complexity, • social disruption, • illicit drugs and alcohol • negative emotional experience

44. Family psychoeducation in early phases • The role of blame and fault: patient and the family did not cause that sensitivity • It is part of the person's physical personhood, with both advantages and disadvantages • Do not blame yourself: this is a complex biological condition that can have several causes that are now poorly understood and is no one's fault • There is active research that is year by year clarifying what the causes are

45. Family psychoeducation in early phases • There is serious danger involved in ignoring the psychosis and the underlying condition. • It is a warning, with all the good and bad aspects of any warning. • The sensitivity needs to be respected, but the family need not be overwhelmed by it. • There will be a fair amount of uncertainty about causes and outcome, but providing treatment quickly and early has been shown definitively to greatly improve prospects and outcome.

46. Believe in your power to affect the outcome: you can. • Make forward steps cautiously, one at a time. • Go slow. Allow time for recovery. Recovery takes time. Rest is important. Things will get better in their own time. Build yourself up for the next life steps. • Consider using medication to protect your future. • A little goes a long way. The medication is working even if you feel fine. Work with your doctor to find the right medication and the right dose. Take medications as they are prescribed. Ways to hasten recovery and to prevent a recurrence.

47. Ways to hasten recovery and to prevent a recurrence. • Try to reduce your responsibilities and stresses, at least for the next six months or so. • Take it easy. Use a personal yardstick. Compare this month to last month rather than last year or next year. • Use the symptoms as indicators. • If they re-appear, slow down, simplify and look for support and help, quickly. • Learn and use your early warning signs and changes in symptoms. Consult with your family clinician or psychiatrist. • Anticipate life stresses.

48. Ways to hasten recovery and to prevent a recurrence. • Create a protective environment. • Keep it cool. • Enthusiasm is normal. Tone it down. Disagreement is normal. Tone it down too. • Give each other space. • Time out is important for everyone. It's okay to reach out. It's okay to say "no". • Observe limits. • Everyone needs to know what the rules are. A few good rules keep things clear.

49. Ways to hasten recovery and to prevent a recurrence. • Create a protective environment. • Ignore what you can't change. • Letsome things slide. Don't ignore violence or concerns about suicide. • Keep it simple. • Say what you have to say clearly, calmly, and positively. • Carry on business as usual. • Reestablish family routines as quickly as possible. Stay in touch with family and friends.

50. Ways to hasten recovery and to prevent a recurrence. • Solve problems step by step. • Make changes gradually. Work on one thing at a time. Look for coping methods that work for you, and work with your clinicians to find other methods when yours don't work. • Watch for large reactions to even little changes in relationships. • Have a plan for what to do and where to get help. • Don't get too vigilant.