Psykoeducational family work

Åse SvilandClinical spesialist psychiatric nurse Anvor LotheClinical social worker/ family therapistFamily departmentPsychiatric divisionStavanger University Hospital

Norway

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Plan for the Presentation• Schizophrenia and optimal treatment• Background for familywork in Norway• National guidelines• Main tasks of family work• Guiding principles for family work• History and research• Familys encounter, challenge and role• Psycho educational mulitfamily group• Recovery• Organizing of familywork in Stavanger

Schizophrenia

• Schizofrenia is one of the most serious of the mental illnesses

• It has a great impact on the life of both patient and the patient`s family

• It strokes mostly young people between the ages of 15 and 25

• And the treatment of schizophrenia has had a difficult history.

Optimal treatment

• Treatment with antipsychotic medicasion.

• Psychotherapeutic treatment from an experienced therapist

• Hospitaliaized within an appropriate therapautic environment

• Psychoeducational family approach

Background

• Patient`s relatives appreciated meeting other relatives

• Multifamily- group with the patient

• The modell of William Mcfarlane

• Weekend seminar

• Roleplay

• 1 year before pilot-groups

National guidelines for the treatment of psychosis

• All families will be offered contact within three days after starting treatment.

• All families will be offered calls for their own benefit, education, aid to problem solving and effective communication.

• Siblings and children are invited into their own conversations.

• Services to families should be needs-oriented

General guidelines for family work

• To ensure an effective treatment for the patient

• Relating to family members' needs in relation to the affected family member's psychotic condition

Burbach, Fadden og Smith 2008

The main tasks of family work in psychosis

• To engage the family in a therapeutic adapted collaboration with professionals.

• To offer family members the time to talk about what has happened.

• To normalize the reactions and offer emotional support.

• To talk with each family member separately, in order to gain an understanding of each individual's situation, how they are affected by development.

The main tasks of family work continue…

• An overview of how family members relate to each other and

• how those systems relate to their experiences.• To convey understanding and help them to deal

with the situation they are experiencing as a result of psychosis development.

• Helping them to make contact with other family members who are in a comparable situation to reduce the experience of isolation and stigma

Conclusion

The best results are when

the family participates

in the treatment

Guiding principles for family work

• Collaboration between patient, family and the professionals who work with them.

• Challenges that arise, meet on an objective basis and the solution that is developed between the parties forming the basis for problem-solving efforts.

• Methodology in family work is based on a non-judgmental attitude towards family members.

• Focus of the work is here and now oriented and forward looking.

• The emphasis on an honest and open exchange of information with all family members where the patient is included

3 claims

1.Treatment works best when the patient knows how to work, and how patient themselves can contribute

2.Patient knows best how he can collaborate and contribute when he knows what the disease is and what the treatment involves

3.The environment knows best how patient can be helped when they know how the disease is

What is communicated

• Actual knowledge

• Attitudes

• Seriousness

• Activity

• Safety

• Confidence

• Community

HistoryNeuroleptica is introduced in the treatment of serious mental illnesses. Optimism is high. Many patients are being dismissed from the hospitals, but unfortunately a large percentage return after a short time

George Brown (England) examines 229 patients after their dismission from hospital. He identifies two types of families: (Leff and Vaughn, 1985)

1950

1968

High Expressed Emotion-families (EE)- Highly critical- Overinvolving- Hostile

Low Expressed Emotion-families (EE)- Warm (loving)- Accepting

HistoryThe Camberwell – interview

”made to measure” EE• Methods of treatment to lower EE in the

family are introduced. Relapse is reduced from 60 % to 20 % in one year.

(Borchgrevink 1999, Kavanagh 1992, Leff and Vaughn 1985)

• Main elements are

Education Communication Problem solving

1972

ResearchHogarty et al.(1986) Mc Farlane et al. (1990)

Relapse after one year (%)

41 Outpatient treatment

23,5 Single family work

Familywork including 0 social skills training

20 Social skills training 12,5 Multifamily

educational groups

Familywork including 19 education and

problem solving

42,9 Dynamically oriented multifamily work

Recent Research

Psykoeducational terapy give better results- reduce relapse- reduce symptoms- better psykososial function- more knowledge about psychoses- better coopertion about medication(Pitchel-Waltz et al, 2001, Pekkala & Merinder 2002, Bentsen 2003,

Murray-Swank & Dixon, 2004)

The family's encounter with psychosis

• Sadness - despair – crisis

Shame and stigma

• Isolation

Economic problems

The family's challenge

• Understand the incomprehensible behavior

• Maintain a dialogue

• Provide assistance

• Take care of the rest of the family

• Fulfill their own needs

The family's role

Family is not responsible for the development of psychotic disorders

Family members are doing the best they can in relation to the help they get to understand the disease and what they can do to help

Effective psychosocial treatments

• Emphasizes education about the disease

• Based in the stress / vulnerability model

• Works to enhance natural coping mechanisms

• Mobilize all available support

Familywork

• One family• Multifamily• With patient• Without patient

The groupleader gets a different relation to the patient

The relatives get a different relation to the patient

The patient changes attitude/behaviour

Goals• Better cooperation bethween patient, relatives and professionals• Reduce the risk of relapse

By giving the family• Knowledge• Support and advice

By helping the family• Better manage living with the patient• Better handling difficult situations• Ease the burden

Step 1 Step 2 Step 3

Meetings between the familygroupleaders, the patient and each individual family. At least one meeting without the patient.

Education seminar for all the families participating, during a full Saturday or maybe spread over two nights.

Multifamily groups meetings: five families meet every other week, 90 minutes sessions during at least two years. Two family group leaders in each group

Multifamilygroups

Focus on the family work is

Education Communication Problem solving

Family-work structurealliance talks

Relatives• Introducing the family-

work program, contents and goals

• Crisis concerning the illness

• Draw a geneogram (family tree)

• Learning about warning signs and possible signs of relapse

Patient• Introducing the family-

work program, contents and goals

• The groupleaders and the patient is getting to know each other

• Draw a genogram (family tree)

• Learning about warning signs and signs of possible relapse

Educasion - seminar

Program• Understanding psychoses• Expressed Emotion• Stress- vulnerability model• Different symptoms• Drugs / psychoses• Treatment: milieu therapy, medication,

rehabilitation, psychotherapy• Crisis theory• The Law concerning mental health service

Multifamily groups-structure• First meeting: Presentation of all the group-members• Second meeting: the group members talk about how

the illnes have affected their lives.• Following meetings: Problem solving method

» McFarlane

First year• Avoiding relapse• Gradually reestablishing normal functioning within the family and amongst friends

Second year• Rehabilitation• Education / Work planning• Reestablishing normal social functioning

Meeting structure

15 min small talk

20 min around

5 min choose aproblem

45 minproblemsolving

5 min end of meeting

Problem solving / choosing a problem

Two main areas of concern1. Factors that can lead to relapse2. Factors involving the next step in getting betterPriorities• Safety at home• Medication• Drugs and alcohol• Life events• Experiences beyond one’s influence• Disagreement between family members

Solution Plan

Define a problem or a preferred activity

Make a list of all possible solutions

Discuss all possible solutions

Make a detailed plan:

How to get started? When do you want to start?• • •

What resources will you need?• • •

Solutions in practice

• All successfull solutions are credited the family.

• The failures are put on the shoulders of the group leaders

When a certain problem is not solved

• Give a suggestion to the solution and ask for a response on the next group meeting

• Refer to earlier similar problem solution

Communication rules

• No mind reading

• Talk for yourself

• Respect the views of others

• No ”deep” discussions

• Help each other with explanations

• Give positive feedback and support

Advice to relatives during patient’s psychosis

Expectations Goals Violence

Clear speach Plan your day• ___________• ___________

Responsibility

Medication Warning signs Problems

• improvement is a gradual process• often go in waves• need rest periods to be stable• pressure for change in these periods

causes stress• pace of change is individually

• TAKE ONE STEP AT A TIME !!!!

RecoveryPhases in the improvement process:

How we organize familywork in Stavanger?

• In Norway, we have a common national educational programme consist of 60 hours of theori.

• Participants in the training engage in role play

• there is monthly supervision for groupleaders

• In Stavanger 2012: 20 multifamiliegroup and 40 group leaders in activity

Thank you

for listning!