Family psychoeducation for serious mental illness

Training Frontline Staff

Family Psychoeducation

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Mental Health Services www.samhsa.gov

http://www.samhsa.gov
Family Psychoeducation

Training Frontline Staff

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

Acknowledgments

This document was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract number 280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. Department of Health and Human Services (HHS). Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served as SAMHSA Government Project Officers.

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors and do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), SAMHSA, or HHS.

Public Domain Notice

All material appearing in this document is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization from the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be downloaded or ordered at http://www.samhsa.gov/shin. Or, please call SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration. Family Psychoeducation: Training Frontline Staff. HHS Pub. No. SMA-09-4422, Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2009.

Originating Office Center for Mental Health Services Substance Abuse and Mental Health Services Administration 1 Choke Cherry Road Rockville, MD 20857 HHS Publication No. SMA-09-4422 Printed 2009

http://www.samhsa.gov/shin
Family Psychoeducation

Training Frontline Staff

This five-module workbook will help family intervention coordinators teach practitioners about the principles, processes, and skills necessary to deliver effective Family Psychoeducation services. The workbook includes the following topics:

n  Basic elements and practice principles;

n  The core processes of Family Psychoeducation;

n  Joining sessions and educational workshops;

n  Ongoing Family Psychoeducation sessions; and

n  Problem solutions from actual practice.

For references see the booklet, The Evidence.

This KIT is part of a series of Evidence-Based Practices KITs created by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

This booklet is part of the Family Psychoeducation KIT that includes a DVD, CD-ROM, and seven booklets:

How to Use the Evidence-Based Practices KITs

Getting Started with Evidence-Based Practices

Building Your Program

Training Frontline Staff

Evaluating Your Program

The Evidence

Using Multimedia to Introduce Your EBP

What’s in Training Frontline Staff

How Family Intervention Coordinators Should Use This Workbook . . . . . . . . . . . . . . . . . . . .A Prepare program-specific information . . . . . . . . . . . . . . . . . B Prepare agency-specific information . . . . . . . . . . . . . . . . . . C Visit an existing team . . . . . . . . . . . . . . . . . . . . . . . . . . . . C Arrange for didactic training . . . . . . . . . . . . . . . . . . . . . . . D Recruit a consultant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D Cross-train . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D

Module 1: Basic Elements and Practice Principles . . . . . 1 What is Family Psychoeducation? . . . . . . . . . . . . . . . . . . . . 1 The phases of Family Psychoeducation . . . . . . . . . . . . . . . . 2 Practice principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The family experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Core values in Family Psychoeducation . . . . . . . . . . . . . . . . 4 Program standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 How we know that Family Psychoeducation is effective. . . . . 6 Adapting the evidence-based model . . . . . . . . . . . . . . . . . . 7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Exercise: Explore the Benefits of Family Psychoeducation . . . 9 Exercise: Examine Program Standards . . . . . . . . . . . . . . . . 11

Family Psychoeducation

Module 2: The Core Processes of Family Psychoeducation . . . . . . . . . . . . . . . . . . . . 1 Identify consumers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Introduce the program . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Conduct joining sessions . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Conduct the educational workshop . . . . . . . . . . . . . . . . . . . 4 Offer ongoing Family Psychoeducation services . . . . . . . . . . 4 Engage consumers and families continuously . . . . . . . . . . . 6 Complete Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Participate in supervision . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Exercise: Identify Consumers and Families . . . . . . . . . . . . . . 9 Exercise: Introduce Your Program . . . . . . . . . . . . . . . . . . . 11

Module 3: Joining Sessions and Educational Workshops . . . . . . . . . . . . . . . . . . . 1 Joining sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Educational workshops . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Exercise: Review Progress Notes for Joining Sessions and Educational Workshops . . . . . . . . . . . . . . . . . . . . . . . 13 Exercise: Practice What You’ve Learned About Joining Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Module 4: Ongoing Family Psychoeducation Sessions . . 1 Conduct ongoing Family Psychoeducation sessions . . . . . . . 1 Structure of multifamily groups . . . . . . . . . . . . . . . . . . . . . 2 Overview of the first session . . . . . . . . . . . . . . . . . . . . . . . . 2 Overview of the second session . . . . . . . . . . . . . . . . . . . . . 5 Ongoing multigroup sessions . . . . . . . . . . . . . . . . . . . . . . . 6 Exercise: Practice What You’ve Learned About Multifamily Groups . . . . . . . . . . . . . . . . . . . . . . . . 13 Exercise: Review the Progress Note for Ongoing Family Psychoeducation Sessions . . . . . . . . . . . . . . . . . . . . . . . . . 15

Module 5: Problem Solutions from Actual Practice . . . . 1 Overview of the module . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Employment issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Medication issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Exercise: Practice What You’ve Learned About Problem Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Training Frontline Staff A

Training Frontline Staff

How Family Intervention Coordinators Should Use This Workbook

Training Frontline Staff introduces practitioners to the basic principles and skills they need to deliver effective Family Psychoeducation (FPE) services. Use this workbook with the Practice Demonstration Video and the English or Spanish Introductory Video on the DVD in this KIT.

Because being part of a team and learning how to process information together are essential parts of FPE, we recommend that you conduct group training sessions rather than simply give FPE practitioners the workbook to read on their own.

To make the content easy to manage, we divided the training into five modules.

The Five Family Psychoeducation Modules in Training Frontline Staff

1 Basics Elements and Practice Principles.

2 The Core Processes of Family Psychoeducation

3 Joining Sessions and Educational Workshops

4 Ongoing Family Psychoeducation Sessions

5 Problem Solutions from Actual Practice

B Training Frontline Staff

How to Complete this Five-Session Training

n  Arrange for FPE practitioners to meet at least once a week for 5 weeks. You will cover up to one module each week.

n  In this workbook, on the page before each module, you’ll find Notes to the family intervention coordinator. Review the notes to prepare for the training.

n  Copy and distribute the module’s reading materials so that practitioners can read them before the training session. You’ll find this booklet on the KIT’s CD-ROM.

n  Copy the exercises for each module so that you can complete them during each training session. You’ll find the exercises in this booklet on the KIT’s CD-ROM.

n  For each session, ask a different group member to facilitate.

n  Begin each training session by showing the corresponding segments of the Practice Demonstration Video.

n  Discuss the information on the video and in the workbook.

n  Complete the suggested exercises for that module.

The ultimate purpose of this workbook is to have practitioners understand the principles behind the FPE model, how FPE is delivered, and the skills necessary to provide effective services. We have found that practitioners prefer to read one module at a time and then discuss that module with colleagues as a group. Working through these modules as a group creates an opportunity to discuss and master the core values and teaching principles that are essential to effective FPE practice.

Prepare program-specific information

In addition to providing the materials in this workbook, you should prepare to give FPE practitioners information about FPE policies and procedures. These include the following:

n Procedures for identifying consumers for the program;

n  Conditions under which consumers will be discharged from the program;

n Procedures for completing FPE Progress Notes;

n Criteria for assessing the program’s fidelity to the FPE model; and

n Outcomes that will be monitored.

For sample forms, see Building Your Program and Evaluating Your Program in this KIT.

Training Frontline Staff C

Prepare agency-specific information

You should also develop a plan to train practitioners about other policies and procedures that may be relevant to the agency in which the FPE program operates. These might include the following:

n Consumers’ rights: Practitioners should be aware of the state and federal consumer rights requirements.

n Billing procedures: Practitioners must know how to document and bill for FPE services.

n Safety: Many agencies with existing community- based programs have materials about safety. If training in this area is not already available, plan for training in de-escalation techniques.

n Mandated reporting: Practitioners must know how to report suspected abuse and neglect. They also must know what to do if they find out about other illegal activity and threats of harm to self or others.

n Other policies and procedures: Consult your agency’s human resources office to learn of other program, agency, or state policies that the staff should know.

Visit an existing team

After your FPE team completes this workbook, we suggest that new practitioners observe an experienced, high-fidelity FPE program. If you are familiar with these materials before your visit, your visit will be more productive. Rather than using time to explain the basics, the host program will be able to show the new FPE practitioners how to apply the basics in a real-world setting.

Arrange for didactic training

After using this workbook and visiting an experienced FPE program, FPE practitioners will be ready for a trainer who will help them practice what they have seen and read. Some family intervention coordinators choose to hire an external trainer to help their team practice FPE principles, processes, and skills. The initial training should take 2 to 3 days.

Recruit a consultant

Once FPE practitioners begin working with consumers, you—along with the agency director— are responsible for ensuring that they follow the evidence-based model. This task can be challenging.

You must facilitate a staff development process, apply what you have just learned about FPE in your own clinical work with consumers, and, at the same time, ensure through clinical supervision that FPE practitioners follow the model.

It is easy to stray from the evidence-based model and do something similar to but not quite the same as FPE. Sometimes this happens because practitioners believe they are diligently following the FPE model, but they miss some of the more subtle aspects of it. In other cases, FPE services start well, but, as more consumers are admitted to the program and pressure mounts, practitioners revert to older, more familiar ways of working.

To ensure that your team follows the FPE model, work with an experienced consultant throughout the first year of operation. A consultant can provide ongoing telephone and in-person support to help you with your challenging leadership role.

D Training Frontline Staff

Cross-train

It is important that staff throughout your agency develop a basic understanding of FPE. Cross- training will ensure that other staff members support the work that the FPE team undertakes.

As discussed in Building Your Program, we also recommend that you train members of your FPE advisory group. The more information that advisory group members have about FPE, the better they will be able to support the program and its mission.

Training is also an opportunity for FPE practitioners and advisory group members to become familiar with one another. Make sure that the advisory group members and FPE practitioners introduce themselves and that they are familiar with each other’s roles.

To help you conduct your training, we include these multimedia materials in the FPE KIT:

n Introductory PowerPoint presentation;

n Sample brochure; and

n Introductory Video.

Once trained, you or your staff will be able to use these materials to present routine, inservice seminars to ensure that all staff members within the agency and advisory group members are familiar with the FPE program.

For more information

The information in this workbook provides a detailed overview of the FPE model. For more information, see the following resources:

Anderson, C., Hogarty, G., & Reiss, D. (1986). Schizophrenia and the family. New York: Guilford Press.

McFarlane, W. R., (Ed.). (2002). Multifamily groups in the treatment of severe psychiatric disorders. New York: Guilford.

We consistently found that agencies used these additional resources with this KIT to develop and manage their FPE programs. For this reason, we recommend the first resource to those implementing FPE in a single-family format and the second resource to those implementing FPE in the multifamily group format. For additional resources, see The Evidence in this KIT.

Basic Elements and Practice Principles E Module 1

Module 1

Basics Elements and Practice Principles Notes to the family intervention coordinator

Prepare for Module 1:

n Make copies of Module 1. Your copy is in this workbook; print additional copies from the KIT’s CD-ROM.

n Distribute the material to the FPE practitioners who will participate in your group session. Ask them to read it before meeting as a group.

n  Make copies of these exercises:

o Explore the Benefits of Family Psychoeducation

o Examine Program Standards

n Make copies of these documents found in Evaluating Your Program in this KIT:

o The Family Psychoeducation Fidelity Scale

o General Organizational Index

o Outcome measures that your agency will monitor (if available)

Do not distribute them until your group training .

Conduct your first session:

n When you convene your group, view the Introductory Video. Discuss the video and the content of Module 1.

n Distribute the following:

o The Family Psychoeducation Fidelity Scale

o General Organizational Index

o Outcome measures that your agency will monitor (if available)

o The exercises for this module

n Review the distributed materials and complete the exercises as a group.

Facilitating the dialogue: One of the roles of a family intervention coordinator is to facilitate the dialogue during group training sessions. Some people have difficulty speaking in a group, perhaps because they are timid or soft-spoken. Others may feel professionally intimidated by those with more experience or higher degrees. Conversely, some practitioners will be self-confident and outspoken and will need to learn to listen openly to what others have to say.

As you work together on each module, encourage those who are more withdrawn to express their views and make sure that the more vocal people give others a chance to speak. Group training also gives you the opportunity to assess the anxiety that FPE practitioners may feel about providing FPE services. Use your group training time to explore and address issues openly.

Basic Elements and Practice Principles 1 Module 1

Training Frontline Staff

Module 1: Basic Elements and Practice Principals

Module 1 explains the basic elements of Family Psychoeducation, including the practice principles of the model. This module orients practitioners to how consumers and families may benefit from the evidence-based practice.

What is Family Psychoeducation?

Family Psychoeducation (FPE) is an approach for partnering with consumers and families to treat serious mental illnesses. FPE practitioners develop a working alliance with consumers and families.

The term psychoeducation can be misleading. While FPE includes many working elements, it is not family therapy. Instead, it is nearly the opposite. In family therapy, the family itself is the object of treatment. But in the FPE approach, the illness is the object of treatment, not the

family. The goal is that practitioners, consumers, and families work together to support recovery.

Serious mental illnesses such as schizophrenia, bipolar disorder, and major depression are widely accepted in the medical field as illnesses with well- established symptoms and treatment. As with other disorders such as diabetes or hypertension, it is both honest and useful to give people practical information about their mental illnesses, how common they are, and how they can manage them.

Many consumers and families report that this information is helpful because it lets them know that they are not alone and it

Module 1 2 Basic Elements and Practice Principles

empowers them to participate fully in the recovery process. Similarly, research shows that consumer outcomes improve if families receive information and support (Dixon et al., 2001). For this reason, a number of family psychoeducation programs have been developed over the past two decades.

Models differ in their format (whether they use multifamily or single-family format); duration of treatment; consumer participation; and location. Research shows that the critical ingredients of effective FPE include the following (Dixon et al., 2001):

n Education about serious mental illnesses;

n Information resources, especially during periods of crises;

n Skills training and ongoing guidance about managing mental illnesses;

n Problem-solving; and

n Social and emotional support.

The phases of Family Psychoeducation

FPE services are provided in three phases:

n Joining sessions;

n An educational workshop; and

n Ongoing FPE sessions.

Joining sessions

Initially, FPE practitioners meet with consumers and their respective family members in introductory meetings called joining sessions. The purpose of these sessions is to learn about their experiences with mental illnesses, their strengths and resources, and their goals for treatment.

FPE practitioners engage consumers and families in a working alliance by showing respect, building trust, and offering concrete help. This working

alliance is the foundation of FPE services. Joining sessions are considered the first phase of the FPE program.

Educational workshop

In the second phase of the FPE program, FPE practitioners offer a 1-day educational workshop. The workshop is based on a standardized educational curriculum to meet the distinct educational needs of family members.

FPE practitioners also respond to the individual needs of consumers and families throughout the FPE program by providing information and resources. To keep consumers and families engaged in the FPE program, it is important to tailor education to meet consumer and family needs, especially in times of crisis.

Ongoing Family Psychoeducation sessions

After completing the joining sessions and 1-day workshop, FPE practitioners ask consumers and families to attend ongoing FPE sessions. When possible, they offer ongoing FPE sessions in a multifamily group format. Consumers and families who attend multifamily groups benefit by connecting with others who have similar experiences. The peer support and mutual aid provided in the group builds social support networks for consumers and families who are often socially isolated.

Ongoing FPE sessions focus on current issues that consumers and families face, and address them through a structured problem-solving approach. This approach helps consumers and families make gains in working toward consumers’ personal recovery goals.

FPE is not a short-term intervention. Studies show that offering fewer than 10 sessions does not produce the same positive outcomes (Cuijpers, 1999). We currently recommend providing FPE for 9 months or more.

Basic Elements and Practice Principles 3 Module 1

In summary, FPE practitioners provide information about mental illnesses, and help consumers and families enhance their problem-solving, communication, and coping skills. When provided in the multifamily group format, ongoing FPE sessions also help consumers and families develop social supports.

Practice principles

FPE is based on a core set of practice principles. These principles form the foundation of the evidence-based practice and guide practitioners in delivering effective FPE services.

Practice Principles

Principle 1: Consumers define who family is.

In FPE, the term family includes anyone consumers identify as being supportive in the recovery process. For FPE to work, consumers must identify supportive people they would like to involve in the FPE program. Some consumers may choose a relative. Others may identify a friend, employer, colleague, counselor, or other supportive person.

Principle 2: The practitioner- consumer-family alliance is essential.

Consumers and families have often responded to serious mental illnesses with great resolve and resilience. FPE recognizes consumer and family strengths, experience, and expertise in living with serious mental illnesses.

FPE is based on a consumer-family-practitioner alliance. When forming alliances with consumers and families, FPE practitioners emphasize that consumers and families are not to blame for serious mental illnesses. Blaming consumers or families is not constructive or helpful and should be avoided. FPE practitioners partner with consumers and families to better understand consumers and support their personal recovery goals.

Principle 3: Education and resources help families support consumers’ personal recovery goals.

Consumers benefit when family members are educated about mental illnesses. Educated families are better able to identify symptoms, recognize warning signs of relapse, support treatment goals, and promote recovery. Provide information resources to consumers and families, especially during times of acute psychiatric episodes or crisis.

Principle 4: Consumers and families who receive ongoing guidance and skills training are better able to manage mental illnesses.

Consumers and families experience stress in many forms in response to mental illnesses. Practical issues such as obtaining services and managing symptoms daily are stressors. Learning techniques to reduce stress and improve communication and coping skills can strengthen family relationships and promote recovery. Learning how to recognize precipitating factors and prodromal symptoms can help prevent relapses. For more information, see Training Frontline Staff in this KIT.

Principle 5: Problem-solving helps consumers and families define and address current issues.

Using a structured problem-solving approach helps consumers and families break complicated issues into small, manageable steps that they may more easily address. This approach helps consumers take steps toward achieving their personal recovery goals.

Principle 6: Social and emotional support validates experiences and facilitates problem- solving.

FPE allows consumers and families to share their experiences and feelings. Social and emotional support lets consumers and families know that they are not alone. Participants in FPE often find relief when they openly discuss and problem-solve the issues that they face.

Module 1 4 Basic Elements and Practice Principles

The family experience

Mental illnesses bring about such significant changes in people’s lives that many families think in terms of how life was before and after the onset of the illness. Families often provide emotional and instrumental support, case management functions, financial assistance, advocacy, and housing to relatives with mental illnesses. Doing so can be rewarding, but also imposes considerable stress.

Family members often find that they lack access to needed resources and information. Stressors range from practical problems such as paying medical bills and obtaining services to issues related to the symptoms of mental illnesses.

Family members also must cope with their own emotional responses to having a relative with mental illnesses. Emotional responses vary from optimism and hope to denial, guilt, and grief (Tessler & Gamache, 2000; Hatfield & Lefley, 1987). These feelings may interfere with their capacity to support and help their relative in the recovery process.

In addition, consumers and families may face stigma while coping with serious mental illnesses. They may find that friends and relatives begin to avoid them. They may isolate themselves from natural support networks if they perceive that others cannot relate to their experiences. Stigmatization and isolation can lead people to feel exasperated, abandoned, and demoralized.

Stress, isolation, and stigma can cause tension and disagreements between consumers and families. Disagreements can be destabilizing or, at least, can prevent rehabilitation if they are left unresolved. Therefore, addressing these issues not only helps to improve the overall functioning of the family but also promotes recovery.

FPE addresses these issues by focusing on consumer and family strengths. Consumers and families often show great resolve and resilience

when faced with crises related to mental illnesses. They demonstrate more adaptive coping when they feel affirmed, respected, and valued for the information and skills that they possess. For this reason, FPE sees families as partners and asks them to share their resources and expertise to help consumers achieve their recovery goals.

Core values in Family Psychoeducation

FPE is based on several core values that permeate the relationship among consumers, families, and practitioners. These values include the following:

n Building hope;

n Recognizing consumers and families as experts in their own experience of mental illnesses;

n Emphasizing personal choice;

n Establishing a collaborative partnership; and

n Demonstrating respect.

Build hope

The long-term course of mental illnesses cannot be predicted, and no one can predict anyone’s future. However, studies suggest that consumers and families who actively participate in their treatment and who develop effective coping skills have the most favorable course and outcome, including a better quality of life (Mueser et al., 2002). The ability to influence your own destiny is the basis for hope and optimism about the future.

FPE practitioners convey hope and optimism to consumers and their families. In providing FPE, practitioners present information and skills as being potentially useful tools that consumers can use in pursuing their goals. Informed and involved families will feel more empowered to support their relatives’ recovery goals. FPE practitioners keep an attitude of hope and optimism, even when consumers and families may be pessimistic.

Basic Elements and Practice Principles 5 Module 1

Recognize consumers and families as experts

While FPE practitioners have professional expertise about information and skills for managing and recovering from mental illnesses, consumers and families have experience in living with mental illnesses. Consumers and families know which strategies have worked in the past for them and which have not.

FPE practitioners encourage consumers and families to share their unique experiences with mental illnesses and response to treatment. By paying close attention to consumers’ and families’ expertise, you can more effectively help consumers progress toward their personal goals.

Emphasize personal choice