The Power of Family Work: Findings Old and New

1. 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

2. Interaction of patient symptoms and family process:A simple causal model + Family Symptoms +

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

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

5. * p < 0.001 **p = 0.582 Tienari, et al, BJM, 2004

6. 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.

7. 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.

8. 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.

9. Core Elements of Psychoeducation • Joining • Education • Problem-solving • Interactional change • Structural change • Multi-family contact

10. Outcomes in family psychoeducation The evidence for being an evidence-based practice

11. Relapse outcome, controlled trials, 1980-1997

12. Comparison of single and multifamily formats

13. Relapse outcomes in clinical trials

14. Hospitalizations before vs. during treatment

15. Family Psychoeducation in Schizophrenia Psychoeducational multiple family group (PEMFG) vs.. Psychoeducational single family treatment (PESFT) N = 172

16. Family Psychoeducation in SchizophreniaProject Sites Creedmoor Psychiatric Center Queens, N.Y. Harlem Hospital Center New York City Hudson River Psychiatric Center Poughkeepsie, N.Y. Kings Park Psychiatric Center Islip, N.Y. Rochester Psychiatric Center Rochester, N.Y. South Beach Psychiatric Center Staten Island & Brooklyn, N.Y

17. Variable Age of onset Mean s.d. Diagnosis Schizophrenia Schizoaffective Schizophreniform Prior 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% Psychiatric Characteristics of Patientsby therapy modality Total 19.0 5.8 85.1% 11.2% 3.7% 4.8 5.1 63.8% 36.2% Modality differences: all not significant

18. Remission to 2 years N: PEMFG=83; PESFT=92Main effect, all cases: p=.07 Main effect, completers: p<.05

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

20. Medication dosages in MFG and SFT

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

22. Differential relapse rates by number of prior hospitalizations

24. Functioning as an effect of repeated psychotic episodes

25. 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

26. Family satisfaction with treatment

27. Negative symptom outcomes:MFGs vs standard care MFG vs SC: p<.05, all f/u time points Dyck, et al., 2000

28. Family influences on work Modeling Information Encouragement Buffering Guidance Adjusting expectations Ancillary support Cueing Personal connections

29. 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

30. Employed at baseline 17.3% (p=.001) Employed at 2 years 29.3% Gain in % employed PEMFG 16% PESFT 8% (n.s.) Work Outcome

31. 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

32. 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 Vocational specialists on FACT teams: Principal tasks

33. 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

34. 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.

35. RELAPSE OUTCOMEFACT vs. ACT FACT (n=36) ACT (n=35) 8 (22%) 14 (40%) Ln 8.58" Pos 0.75"

36. Employment outcome: FACT vs. ACT only

37. Washtenaw County, hospital rates ACT vs. MFG+ACT

38. Selection Bias for the MFG?

39. WCSTS ACT Employment/School

40. Mental Health Employers Consortium Employment Outcomes An Employment Intervention Demonstration Project

41. Sample Description 137 Total Receiving Service Gender Male 75 (54.7%) Female 62 Condition Employers Consortium 67 Community employers 70

42. Employment rate in FACT combined with supported employment, by diagnosis 67% 41% 19%

43. 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

44. 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

45. 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 withmood disorders - consumers with OCD or borderline personality disorder

47. 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

48. Family psychoeducation and multifamily groups: Basic techniques

49. Stages of a psychoeducational multifamily group Educa- tional workshop Ongoing MFG Families and patients 1-4 years Joining Family and patient separately 3-6 weeks Families only 1 day

50. Therapeutic processes in multifamily groups • Stigma reversal • Social network construction • Communication improvement • Crisis prevention • Treatment adherence • Anxiety and arousal reduction