Family psychoeducation and multifamily groups:

Treatment of choice for psychotic disorders?

William R. McFarlane, MD
University of Vermont
Maine Medical Center

The brain in schizophrenia

Dorsolateral Prefrontal Cortex

Interaction of attention and arousal

Functions of the prefrontal cortex

• Establishing a cognitive set
• Problem-solving
• Planning
• Attention
• Initiative
• Motivation
• Integration of thought and affect
• Mental liveliness

Expressed emotion and relapse

This chart shows one outcome of how people with low or high levels of expressed emotion fare when the individuals
interact with their families for 35 hours a week (more or less) and either take or don't take medications. For people with
low levels of expressed emotion (13% of the sample), there were low levels of relapse whenever they used medication
(12% relapse) or they didn't (15% relapse.) For people who had high levels of expressed emotion (57%) there were two
different groups in the study sample. One group (people who had less than 35 hours per week of contact with their families
(28%) had very different rates of relapse depending on their taking of medicine. For those on medications, there was only a 15%
relapse rate but a 42% relapse rate for those who didn't take medication. For those who had more than 35 hours of family contact
(69%), if they were on medications their relapse rate was 53% and if they weren't, it was 92%.

Interaction of patient symptoms and family process:

A biosocial causal model


The patient symptoms are directly affected by the family process and its interaction.

Family distress and severity of illness

Psychosis represents an unusual sensitivity to:

• Sensory stimulation
• Prolonged stress, strenuous demands
• Rapid change
• Complexity
• Social disruption
• Illicit drugs and alcohol
• Negative emotional experience

Core Elements of Psychoeducation
.creating an optimal social environment

• Joining
• Education
• Problem-solving
• Interactional change
• Structural change
• Multi-family contact

Stages of a psychoeducational multifamily group


There are three stages of the psycho educational multi family group intervention. 1^st the joining stage includes joining with
family and patient separately and lasts 3-6 weeks. Then the family moves to stage 2 - educational workshop where only the
family (not the patient) attends the 1-day workshop. Finally, the family and patient move to stage 3 - ongoing multifamily group
where they attend the group for 1-4 years.

Elements of engagement

• Exploration of precipitants
• Review of prodromal symptoms/signs
• Reactions of family to illness
• Coping strategies
• Social supports
• Mourning
• Contract for treatment
• Preparation for multi-family group

The workshop is held in a classroom format

• Promotes comfort
• Families can interact without pressure
• Encourages learning
• Practitioners act as educators

Phases and Interventions in FPE
Year One: Relapse Prevention

• Engaging individual families
• Multifamily educational workshop
• Implementing family guidelines
• Reducing stigma and shame
• Lowering expectations
• Controlling rate of recovery
• Reducing negative intensity and exasperation

Components of groups

• Two co-facilitators
• 5-6 families with similar diagnoses
• Meetings every other week for a minimum of 9 months, monthly after 12-18 months
• Families, consumers, and practitioners become partners
• On-going education about symptoms, medication, community life, work, etc.
• Problem-solving format

Structure of Sessions
Multifamily groups (MFG) and single-family treatment (SFT)

Phases and Interventions in FPE/PMFGs
Year Two: Rehabilitation

• Gradually increasing responsibilities
• Moving one step at a time; the internal yardstick
• Monitored encouragement from family members
• Establishing inter-family relationships
• Cross-parenting
• Focussing family interests outside family
• Restoring family's natural social network

Relapse outcome in controlled trials 1980-1997

Relapse outcomes in clinical trials


According to clinical trials; 65% experienced a symptom relapse, 38% experienced a relapse when both
individual therapy and medication were used but only 16% experienced symptom relapse when family psycho
education and medication were employed.

Social networks in cardiac mortality

Effects of social networks

• Family network size
  • diminishes with length of illness
  • decreases in the period immediately following a first episode
  • is smaller at the time of first admission
• Networks
  • buffer stress and adverse events
  • determine treatment compliance
  • predict relapse rate
  • correlate with coping skills and burden.

Social networks, received family stigma and over-involvement:
In mothers of sons with schizophrenia

% of mothers overinvolved


This shows that mothers who are socially isolated have a higher rate of overinvolvement with their schizophrenic
sons. When socially isolated 19% of the mothers, in an environment where there was low stigma, were overinvolved,
22% of mothers in similar environments of social isolation were overinvolved where there was high degrees of received
stigma. When the mothers were not in socially isolated environments, none were overinvolved when there was low
received stigma levels and only 14% were overinvolved when there were high levels of received stigma.

A Biosocial Model for Relapse


A Biosocial Model for Relapse indicates that stigma can lead to isolation which can
lead to negative intensity (EE). Negativity intensity, arousal, and distraction may lead
to symptoms and relapse.

Therapeutic processes in multifamily groups

• Stigma reversal
• Social network construction
• Communication improvement
• Crisis prevention
• Treatment adherence
• Anxiety and arousal reduction

Social Networks and Multifamily Groups

The patient is influenced by a chain of social networks, beginning first with his/her own family, then the multifamily group
created through this intervention, then one individual's extended family and finally by the community at large. These layers also
interact with each other to form complex social networks.

Comparison of single and multifamily formats

Relapse outcomes in clinical trials


According to clinical trials, 65% experience a symptom relapse when no medication is used. 38% experienced relapse when
attending individual therapy and using medication, 16% had symptom relapse when using FPE and medications, but only
9% experienced symptom relapse when using psychoeducation multifamily groups and medication.

Family Psychoeducation in Schizophrenia

Psychoeducational multiple family group (PEMFG)

vs..

Psychoeducational single family treatment (PESFT)

N = 172

Sponsored by NYS OMH and NAMI-NY

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

Psychiatric Characteristics of Patients

Sociodemographic Characteristics of Patients

Modality differences: all not significant

Remission to 2 years


This is a graphic representation of how remission of the symptoms of schizophrenia was influenced by participation in either
multifamily groups or single family therapy. The groups were looked at from both percentage of remission and amount of days at risk.
When individuals were at risk for a short time (a few days) both single family therapy and multifamily therapy interventions
had high rates of remission, but as the days at risk expanded over time, one multifamily group showed a higher percentage of remission.

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

Initial relapses
To two years


This graphic representation shows that for multifamily group interventions versus single family group interventions, the single
family interventions over time had fewer numbers of relapses.

N: MFG=83; SFT=89

Total hospital admissions
Total sample over four years


This graphic representation shows that people in the study, while in treatment, were able to reduce admissions to the hospital.

Dosages in MFG and SFT


This graphic representation shows that people who were in one study in multifamily group treatment increased their usage of
chlorpromazine over time whereas people in the simple family treatment decreased dosage rates.

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

This graphic representation shows that people in one multifamily group intervention over a two year period had a low
relapse rate (12%) when compared to more in the simple family group intervention if they were individuals who had high degrees
of anxious depression and other critical components of relapse. The only condition in which the single family
intervention was more effective than the multi-family intervention in lowering relapse rates was when individuals had low
levels of both anzious depression and critical conditions.

Negative symptom outcomes:
MFGs vs standard care


This graphic representation shows that for those in multifamily group intervention, negative symptoms reduced over
time as compared to standard care.

Family satisfaction with treatment

The graphic representation shows that more than 50% of the families in the study were either very highly satisfied or highly
satisfied with one treatment.

Work Outcome

This table shows that for an employment outcome, those people who participated in the
multi-family group intervention doubled (from 8% to 16%) their employment rate.

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 Outcome at 24 MonthsFACT vs. ACT

FACT (n=36)        ACT (n=35)

8(22%)              14 (40%)

Employment outcome

FACT vs. ACT


This graphic representation compares employment outcomes from people in the FACT and ACT treatment
intervention.The comparison between the two groups is overtime (baseline to 12 months). The FACT model
(whose families are members of one ACT team) showed a more than doubled rate of employment from ACT
(from 15 to 37%) and gains in both getting and retaining employment.

Employment outcomes in Family-aided Assertive Community Treatment

FACT vs CVR

William R. McFarlane, M.D.
Peter Stastny, M.D.
Susan Deakins, M.D.
Robert Dushay, Ph.D.

Family-aided Assertive Community Treatment (FACT):
An Employment Intervention

• Psychoeducational multifamily groups
• Clinical case management using ACT principles and methods
• Supported employment
• Integrated, multidisciplinary teams
• Cognitive assessments used in job accommodation
• MH Employers' Consortium

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

Research design: entry criteria

• Age: 18-45
• Diagnoses: Schizophrenia, schizoaffective disorder, bipolar disorder, major depression
• Stable for at least six months
• Family available
• Interested in obtaining a job
• In treatment at the site clinics
• No contraindications for antipsychotic, -manic or -depressive drugs.

Demographic characteristics

Clinical characteristics

Employment outcome, competitive jobs


This graphically describes the results overtime (12 months) for employment outcomes in competitive jobs for people in the FACT
program compared to people receiving employment services from community vocational rehabilitation providers. For people in FACT
interventions, the competitive outcomes are consistently higher and by 12 months had differed by almost 30% greater (37.1%
to 7.7%)

Mean total income:

FACT vs. CVR


This chart has a subsample of people compared from both participation in the FACT program and participation in community
vocational rehabilitation services. The comparison concerns how both groups fared with regard to total earnings in three categories;
all employment options, competitive jobs, and a category called competitive workers only. In each of these categories the people in FACT
fared significantly better than the community vocational services group in earnings.

Mental Health Employers Consortium

Employment Outcomes

An Employment Intervention Demonstration Project

Models Tested in Maine

• Mental Health Employers Consortium & FACT
  • employers work together to support each other
  • employers pledge jobs
  • employers supported by vocational program
  • participant services delivered through FACT model
• Family-Aided Assertive Community Treatment
  • ACT model
  • family psychoeducation and family participation in rehabilitation, in multifamily groups
  • supported employment
  • cognitive assessments for job accommodation

Intervention model


This series of circles with arrows is a graphic depiction of an intervention model designed to help patients find a job. The helpers
listed are: employment support specialists, occupational therapist, clinicians, families, multi-family group members and other
families.

Sample Description

Employment Rate by Experimental Conditions


This graph shows the percentage of individuals employed by whether or not they were a part of the consortium developed
through this research project or they were finding jobs using community resources. Over time, the consortium participants had
a higher percentage of employment.

Employment Rate by Month of Service


This graph depicts the numbers and months and percentage of employment for people in three types of programs.

• Over 20 controlled clinical trials, comparing to standard outpatient treatment, have shown:
  • Much lower relapse rates and rehospitalization
    • Up to 75% reductions 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 well-being and
  • Reduced friction and family burden
  • Reduced medical illness in family members
    • Doctor visits for family members decreased by over 50% in one year, in multifamily groups

Practitioners report...

• 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

Cost-benefit ratios of PEMFGs

Biosocial causal interactions in late schizophrenic prodrome


This series of circles and arrows shows a progression from the early (prodrome) stage of schizaphrenia to one acute
onset of a psychosis. It depicts the interaction of biosocial causes such as anxiety, insomnia, social withdrawal,
panic, and other factors.

Treatment of the prodromal state

• Multi-systems intervention
  • Social
    • Psychoeducational MFG
    • Supported education or employment
    • Friendship maintenance
  • Psychological
    • Focus on mastery, identity, meaning, validation
  • Neuropsychological
    • Cognitive support
    • Cognitive training

Treatment of the prodromal state

• Multi-systems intervention
  • Psychophysiological
    • Stress avoidance & management
    • Stress resistance
  • Biochemical
    • Nutrition and exercise
    • Antipsychotic medication
    • Cognitive enhancement
    • SSRIs

Preliminary outcomes

First Year Data:
May 7, 2001- September 20, 2002

PIER Referrals and Patient Status

Study parameters

Conversions

Scoring 6 on SOPS, at any time

Who can benefit from FPE?

• Individuals with schizophrenia who are newly diagnosed or chronically ill
• There is growing evidence of benefit for people with:
  • Mood disorders
  • OCD
  • Borderline personality disorder
  • Consumers without family members
  • Chronic medical disorders
  • Adolescents and young adults with pre-psychotic symptoms

Summary

Questions, Comments, Discussion

" I would entreat professionals not to be devastated by our illness and transmit this hopeless attitude to us.

I urge them never to lose hope; for we will not strive if we believe the effort is futile."

--Esso Leete, who has had schizophrenia for 20 years

Workshop

Key characteristics of psychoeducational MFGs

• Rooted in the clinical care system
• Assumes that family care-taking burden relief follows from reduction of symptoms, successful rehabilitation and recovery
• Involves most of key members of care and social support system
• Individualized coping skill training

Key characteristics of psychoeducational MFGs

• Capacity to achieve clinical goals in absence of patient
• Long-term perspective to treatment, rehabilitation and recovery
• Higher costs than self-help or education alone
• Need to re-train professionals and case managers in non-blaming paradigms

Central assumptions of the psychoeducational model - I

• Success in promoting change in behavior and attitudes requires:
  • The establishment of a cooperative, collegial, non-judgmental relationship among all parties;
  • Education supplemented with continued support and guidance;
  • Assumption of least pathology;

Central assumptions of the psychoeducational model - II

• Success in promoting change in behavior and attitudes requires:
  • Breaking problems into their components and solving them in a step-wise fashion;
  • Support comes from a network of well-informed and like-thinking people.

Core Elements of Psychoeducation

• Joining
• Education
• Problem-solving
• Interactional change
• Structural change
• Multi-family contact

Identifying FPE Group Participants

• Consumers with similar diagnoses
• Families in search of psycho-education and support
• People for whom this intervention would "make a difference" with relationships and life plans

Multifamily group vs. single-family meetings

• MFGs are more effective for 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

The Psychoeducational Workshop is the first time that families and individuals come together.

• 6 hours of illness education
• relaxed, friendly atmosphere
• co-leaders act as hosts
• questions and interactions encouraged

Elements of education

• History and epidemiology
• Biology of schizophrenia
• Treatment: effects and side effects
• Family emotional reactions
• Family behavioral reactions
• Guidelines for coping and management
• Socializing

Creating an optimal social environment

Guidelines for recovery-I

• Go Slow
• Keep It Cool
• Give `Em Space
• Set Limits
• Ignore What you Can't Change
• Keep It Simple

Creating an optimal social environment

Guidelines for recovery-II

• Lower Expectations, Temporarily
• Follow Doctor's Orders
• Carry on Business as Usual
• No Street Drugs or Alcohol
• Pick Up on Early Warning Signs
• Solve Problems Step By Step

Group logistics

• Provide snacks
• Consider a time of day and day of week that is not a hardship for participants
• Maintain the same time and location
• Offer telephone reminders and meeting schedules to reduce "no shows"
• Provide a take-home action plan following problem-solving

The role of FPE practitioner

• Collaborate with families and consumers to separate illness from personality
• Assume the role of educator, family partner, and trainer-coach
• Teach families and consumers to use the problem-solving method to deal with illness-related behaviors
• Keep asking, "what's next?"

The 1st and 2nd Groups

Problem solving

• Source in organizational management
• Value of multiple, new perspectives
• Complexity of method matches complexity of the situations
• Need to control affect and arousal
• Need to compensate for information-processing difficulties in patients and some relatives
• Need to be organized and systematic
• Need to succeed and overcome failure

Brainstorming solutions

• 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

Problem solving

• Types of problem-solving
  • Hierarchy of problems
  • Based on clinical experience and family guidelines
  • Direct action and intervention by clinicians
  • Problem is agreed upon by all family members
  • Problem that is not agreed upon by all family members

Take 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

A hierarchy for problem-solving

• Medication compliance
• Street Drug and Alcohol Use
• Life events
• Problems generated by other agencies
• Conflicts between family members
• Conflicts with family guidelines

Problem-solving conflict

• Validate all positions
• Define the problem as illness-based, to the degree that is reasonable
• Undertake a step-wise or sequential solution
• Look at consequences of each position in the conflict itself >>> advantages and disadvantages
• Reframe motives of all concerned
• Support limit-setting

Phases and Interventions in PEMFGs

Year Three: Network Formation

• Validating group competency
• More socializing, less problem-solving
• Encouraging social contacts outside the group
• Shifting role of clinicians
• Converting to an advocacy group
• Converting to a vocational auxiliary

Starting a FPE group

• Find a compatible co-facilitator
• Attend a training and follow the manual
• Explore your own motivation and enthusiasm since barriers will appear
• Promote this model to your supervisor because you will need his/her support
• Adhere to the problem-solving format since this is not group process

Disadvantages of family psychoeducation

• Costs are higher than self-help and may not be borne by some insurers in some states
• Requires using existing professionals with training in negative family paradigms
• Requires lengthy, though low intensity, work
• Some results are abstract (e.g., remission)

Social Networks and Multifamily Groups

Influences on treatment adoption

• Enthusiasm
  • "Being part of a larger process"
  • Gained motivation and inspiration
  • "Great enthusiasm is contagious"
    • Came from trainers and others whose agencies had already implemented
    • Testimonials from staff and families at booster training sessions

Influences on treatment adoption

• Stated reasons for progress
  • Belief in the model
    • Equally, staff effectiveness and outcomes
  • Grant support and free training
  • Depends upon the "drive, enthusiasm, and commitment of a determined individual"
    • Backed by a supportive administration
  • Skill and support of a trusted supervisor
    • Survey: "Use of outside consultants" most helpful item on survey (3.7/5)
  • Positive feedback processes
    • Success and positive outcomes beget further adoption, even between agencies

Influences on treatment adoption

• Barriers
  • Shortage of agency resources, especially time and energy, sometimes money
    • Survey: "Intense work pressure on staff" highest rating for obstacle (3.7/5)
    • Next highest: "Staff demands too high already" (3.3/5)
  • Patient and/or family participation
  • Rapid turnover of previously trained staff
  • Staff burnout, unrelated to adoption process
  • Insufficient administrative support

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

" I would entreat professionals not to be devastated by our illness and transmit this hopeless attitude to us. I urge them never to lose hope; for we will not strive if we believe the effort is futile."

--Esso Leete, who has had schizophrenia for 20 years