SOCW 6311 WK 2 ASSIGNMENT: Assignment: Evidence-Based Practice Implementation—Anticipating Results
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SOCWwk2resource3.pdf
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
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
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
The overriding goal of FPE is to support consumers in their personal recovery process. The ability and right of consumers to make their own decisions is paramount, even when consumers’ decisions differ from the recommendations of their family and practitioners. Certain rare exceptions to this principle do exist, for example, when legal constraints such as an involuntary hospitalization protect consumers from themselves or others.
In general, avoid pressuring consumers to make certain treatment decisions and encourage families to do the same. Instead, accept consumers’ decisions and work with them to evaluate the consequences in terms of their personal goals.
Keeping the emphasis on consumers’ personal choice is key to establishing and maintaining a strong alliance with both consumers and families. FPE practitioners model how respecting consumer choices, despite disagreements, builds a trusting relationship that promotes positive change.
Establish a collaborative partnership
While FPE practitioners serve a variety of roles, they are primarily collaborators. The collaborative spirit of FPE reflects the fact that consumers, families, and practitioners work side by side in a nonhierarchical relationship.
FPE practitioners establish a working alliance with consumers and families. Together, they learn how to cope with the unique characteristics of consumers’ mental illnesses and make progress toward their personal recovery goals.
Demonstrate respect
Respect is a key ingredient for successfully collaborating in FPE. FPE practitioners respect consumers and families as human beings, capable decisionmakers, and partners in the treatment process. FPE practitioners accept that consumers and families may differ in their personal values and opinions. They respect consumers’ and families’ right to their own values and opinions. For example, consumers may disagree that they have a particular mental illness or that they have any mental illness at all.
Rather than actively trying to persuade consumers that they have a specific disorder, FPE practitioners respect their beliefs while searching for common ground as a basis for collaboration. Such common ground could include the following:
n Symptoms and distress that consumers experience (perhaps even conceptualized generally as stress, anxiety, or nerve problems);
n Desire to avoid hospitalization;
n Difficulties with independent living; or
n Specific goals they would like to accomplish.
By seeking common ground, FPE practitioners demonstrate respect for consumers’ beliefs and their right to make informed decisions based on their values and beliefs.
Module 1 6 Basic Elements and Practice Principles
Program standards
One of the unique features of FPE is that the important characteristics of this evidence-based model have been translated into program standards to help programs replicate effective services. An instrument called the FPE Fidelity Scale summarizes these characteristics and is available to help quality assurance teams assess how closely their program follows the evidence-based model (See Evaluating Your Program in this KIT). Your family intervention coordinator will give this scale to you to review and discuss during training.
Basic Characteristics of Family Psychoeducation
n Family intervention coordinator
n Session frequency
n Long-term FPE
n Quality of consumer-family-practitioner alliance
n Detailed family reaction
n Precipitating factors
n Prodromal signs and symptoms
n Coping strategies
n Educational curriculum
n Multimedia education
n Structured group sessions
n Structured problem-solving
n Stage-wise provision of services
n Assertive engagement and outreach
How we know that Family Psychoeducation is effective
FPE is based on research that shows that families and consumers who participated in the components of the evidence-based model experienced 20 to 50 percent fewer relapses and rehospitalizations than those who received standard individual services over 2 years (Penn & Mueser, 1996; Dixon & Lehman, 1995; Lam, Kneipers, & Leff, 1993; Falloon et al., 1999). Those at the higher end of this range participated for more than 3 months.
Studies also show that FPE improved family well- being (Dixon et al., 2001; McFarlane et al., 2003). Families reported greater knowledge of serious mental illnesses; a decrease in feeling confused, stressed, and isolated; and reduced medical illness and medical care utilization (Dyck, Hendryx, Short, Voss, & McFarlane,,2002).
FPE has been found to increase consumers’ participation in vocational rehabilitation programs (Falloon et al., 1985). Studies have shown employment rate gains of two to four times baseline levels, when combined with the evidence-based practice, Supported Employment (McFarlane et al., 1996; McFarlane et al., 1995; McFarlane et al., 2000).
Based on this significant evidence, treatment guidelines recommend involving families in the treatment process by offering the critical ingredients outlined in this evidence-based model (Lehman & Steinwachs, 1998; American Psychiatric Association, 1997; Weiden, Scheifler, McEvoy, Allen, & Ross, 1999).
Basic Elements and Practice Principles 7 Module 1
Adapting the evidence-based model
Research has shown the greatest amount of benefits rom FPE for families and consumers with schizophrenic disorders (Dixon et al., 2001). For this reason, we recommend that new practitioners first provide FPE services to consumers with these disorders.
Once practitioners have learned this approach by working with people with schizophrenia, they find it relatively easy to modify it for other disorders. Studies show that FPE may be effectively adapted and used for the following disorders:
n Bipolar disorder (Clarkin, Carpenter, Hull, Wilner, & Glick, 1998; Miklowitz & Goldstein, 1997; Moltz, 1993; Parikh et al., 1997; Miklowitz et al., 2000; Simoneau, Miklowitz, Richards, Saleem, & George, 1999);
n Major depression (Simoneau et al., 1999; Emanuels-Zuurveen & Emmelkamp, 1997; Leff et al., 2000);
n Obsessive-compulsive disorder (Van Noppen, 1999); and
n Borderline personality disorder (Gunderson, Berkowitz, & Ruizsancho, 1997).
This model also has been adapted and used effectively in a variety of countries and cultures. For more information about diagnosis-specific or cultural adaptations of this model, see The Evidence in this KIT.
Summary
This module reviewed the basic elements and core values of FPE. This evidence-based practice is based on a core set of practice principles, which have been translated into program standards that agencies may replicate. Substantial research has demonstrated its effectiveness.
The next modules give practitioners information about the core processes for providing FPE services.
Basic Elements and Practice Principles 9 Module 1
Exercise: Explore the Benefits of Family Psychoeducation
Studies that have explored what makes a difference in whether practitioners adopt a new approach to treatment have found that practitioners are more likely to adopt a practice if it addresses an area in which they feel they must improve. Share your experiences about where the traditional service delivery system has been inadequate and identify aspects of FPE that address those inadequacies.
Some experiences where the traditional service delivery system has been inadequate:
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How Family Psychoeducation may address those inadequacies:
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Basic Elements and Practice Principles 11 Module 1
Exercise: Examine Program Standards
n Distribute these documents:
o Family Psychoeducation Fidelity Scale;
o General Organizational Index; and
o Outcome measures that your agency will monitor (if available).
n Discuss how your Family Psychoeducation program will be evaluated based on these program standards.
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Module 2
The Core Processes of Family Psychoeducation Notes to the family intervention coordinator
Prepare for Module 2:
n Make copies of Module 2. Your copy is in this workbook; print additional copies from the CD-ROM in the KIT.
n Distribute the material to those who are participating in your group training. Ask them to read it before meeting as a group.
n Make copies of these exercises:
o Identify Consumers and Families
o Introduce Your Program
Do not distribute the exercises until the group training. Your copies are in this workbook; print additional copies from the KIT’s CD-ROM.
n Make copies of your agency’s policies and procedures for identifying consumers for FPE and discharging them from the program (if available). Guidelines for developing these policies are provided in Building Your Program in this KIT.
Conduct your second session:
n When you convene your group, discuss the content of Module 2.
n Distribute the following:
o Your agency’s policies and procedures for identifying consumers for FPE and discharging them from the program
o Exercises for this module
Note: This module has no corresponding Practice Demonstration Video component.
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Training Frontline Staff
Module 2: The Core Processes of Family Psychoeducation
Module 2 introduces you to the core processes of Family Psychoeducation, including joining with consumers and families, offering education, and understanding the nature of ongoing Family Psychoeducation (FPE) sessions. This module also discusses the goals and objectives of each phase of the program.
Core processes of Family Psychoeducation
n Consumers are identified as potential participants.
n Practitioners introduce Family Psychoeducation to consumers. Consumers who are willing to participate identify potential family members.
n Practitioners meet individually three or more times with consumers and families. The purpose of these joining sessions is to engage consumers and families in a working alliance.
n Once practitioners have finished joining sessions with five to eight consumers and their respective families, they offer a 1-day educational workshop.
n After completing the 1-day educational workshop, practitioners ask consumers and families to attend ongoing Family Psychoeducation sessions offered in either single-family or multifamily group format.
n Ongoing Family Psychoeducation sessions continue for 9 months or more. Practitioners, consumers, and families use a structured problem- solving approach to define and address current issues.
n Practitioners document consumers’ progress using Progress Notes tailored to each phase of the program.
n Practitioners meet weekly with the family intervention coordinator for group supervision.
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Although you might think that integrating Family Psychoeducation (FPE) core processes and paperwork into your daily routine is too time consuming and burdensome, these processes ensure that FPE services are effective and efficient.
Identify consumers
FPE is effective for a wide variety of consumers. However, some evidence shows that FPE is particularly beneficial for consumers and families with the following characteristics:
n Consumers who have recently experienced their first episode of mental illness or are early in the course of illness;
n Consumers who are experiencing acute psychiatric crisis;
n Consumers who experience frequent hospitalizations or prolonged unemployment;
n Consumers or families who have asked to learn more about serious mental illnesses;
n Families who have previously benefited from a family education program and want to learn how to better support their relative; or
n Families who are especially exasperated or confused about the illness.
FPE is particularly effective in working with families and consumers who are early in the course of illness, because most consumers and families report the most extreme distress during this time. Often in this early period, major rifts develop between consumers and families that may exacerbate symptoms and disability. FPE has prevented and often healed those rifts, as participants stop blaming themselves or one another and cooperate to help in the overall treatment and rehabilitation process.
Initially many agencies choose to offer FPE to consumers with schizophrenic disorders because the evidence for this model is strongest with this group. Once you have provided FPE services to consumers with schizophrenic disorders and their families, it relatively easy to modify your FPE program to provide services to families and consumers who have other diagnoses.
The number and types of consumers you identify depend on whether you offer FPE in a multifamily or single-family group format. If your agency intends to offer ongoing FPE services primarily in the multifamily format, identify five to eight consumers with similar diagnoses and offer multifamily group sessions to them. If your agency chooses to offer FPE in a single-family format, the number of consumers you should identify depends on the size of your FPE program.
During this training, your family intervention coordinator will review your agency’s policies and procedures for identifying consumers for FPE.
Introduce the program
Once your family intervention coordinator assigns consumers to your caseload, set up a face-to-face meeting to introduce them to the FPE program. In the meeting, emphasize that the program is for both consumers and their family members. While some psychoeducation programs are solely for either consumers or family members, FPE services are provided to both simultaneously.
Emphasize that participating in FPE is the consumers’ choice. After discussing the benefits and structure of the FPE program, ask consumers if they would like to identify a family member with whom they would participate in the program. Remember, the term family includes anyone who consumers believe is supportive and would like to
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participate in FPE. Therefore, consumers may identify people who are not blood relatives.
Most consumers welcome family involvement when it is clear that the goal is to help families better understand their illness and build support to help them achieve their personal recovery goals. However, if consumers are not interested in the program, respect their decision.
Confidentiality
Some states require that consumers sign a Release of Information Form before you may contact their family member. Your family intervention coordinator should review your agency’s confidentiality requirements as a part of this training. For more information, see Building Your Program in this KIT.
Length of the FPE program
Although the goal is to offer ongoing FPE services, some consumers and families may be initially unwilling to make long-term commitments. Instead, when you introduce FPE, simply ask consumers and families to participate for as long as they find it useful. Often once people participate for a few sessions, they choose to stay long term, especially in multifamily groups.
Conduct joining sessions
Once consumers agree to participate in FPE and identify a family member, arrange to meet with them. These initial introductory sessions are called joining sessions.
Joining sessions are considered the first phase of the FPE program. Complete this phase by meeting with consumers and families at least three times for approximately 1 hour.
The overall purpose of joining sessions is to engage consumers and families in a working alliance. This working alliance is essential to providing effective FPE.
Each joining session has distinct goals and objectives (see Module 3). Some of the goals of joining sessions are as follows:
n Understand consumers’ and families’ unique experiences and view of mental illnesses;
n Learn about consumer and family strengths and resources in coping with mental illnesses;
n Develop mutual, specific goals; and
n Instill hope and an orientation toward recovery.
You may hold joining sessions with consumers and their respective family members together or meet separately with them. (That means you would conduct six or more sessions instead of three or more.)
When deciding whether to meet with consumers and families jointly or separately, consider the following:
n Consumer and family preferences;
n Consumer diagnosis and illness characteristics; and
n The goals of the session.
Tell consumers and families that it is common to meet with them individually and jointly with their respective family members in the first phase of the FPE program. Ask consumers and families how they feel about joint and separate meetings. Logistical arrangements such as transportation or work schedules sometimes dictate whether consumers and families can meet jointly. Discuss preferences and logistical factors during your first meeting.
Decisions for offering joining sessions separately or jointly are also based on diagnosis and illness characteristics. For example, recent studies show that joining sessions for consumers with bipolar disorder are more effective when conducted
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separately (Moltz, 1993). Use your professional discretion to determine how best to accomplish the goals of each session. See Module 3 for more information.
It is important to fully complete this phase before you offer ongoing FPE sessions. Practitioners who shortchange this process often experience difficulties keeping consumers and families engaged in FPE services.
Conduct the educational workshop
Once you meet the goals of the joining sessions, you are ready to offer the second phase of the FPE program. In this phase, you will ask family members to attend a 1-day educational workshop.
Following a structured educational curriculum, the workshop is usually conducted in a formal, classroom setting. Two FPE practitioners who have completed joining sessions with consumers and families facilitate the workshop. The treating psychiatrist and other treatment team members are often invited to conduct part of the presentation. For more information about the structure and content of this workshop, see Module 3.
Typically the workshop is conducted solely with families—not with consumers—to give families a chance to get acquainted. The opportunity to interact with others who are in similar situations and to speak freely about their experiences allows families to bond and develop supportive relationships. It also increases families’ commitment to participate in FPE.
Some agencies involve consumers in part of the workshop to ensure that they receive the same educational information as their families. Others offer this information to consumers individually or in a separate consumer forum.
Use professional discretion to decide which educational format will be most effective for the consumers in your program. Consider the severity of consumers’ symptoms and their cognitive ability to absorb educational material when it is provided in the joint format. For example, recent studies show that joint educational sessions are effective for consumers with nonepisodic bipolar disorder (Moltz, 1993; Miklowitz & Goldstein, 1997).
If you plan to offer ongoing FPE sessions in a multifamily group format, complete at least three joining sessions with five to eight consumers and their respective family members before conducting the 1-day workshop. To ensure that consumers and families remain engaged, offer the workshop within 1 or 2 weeks after you complete the joining sessions. You may need to carefully coordinate this.
Offer ongoing Family Psychoeducation services
After completing three joining sessions and the 1-day workshop, ask consumers and families to attend ongoing FPE sessions. The third phase of the FPE program consists of providing ongoing FPE sessions for 9 months or more. You may provide these sessions in either the single-family or multifamily group format.
Choose a format
The format that you choose will depend on consumer and family preferences and needs. In general, single-family formats tend to be used for the following:
n Consumers and families with strong social support networks;
n Consumers and families who exhibit unusual resilience or strong coping skills; or
n Consumers who response positively to medications;
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Multifamily groups tend to be used for the following:
n Consumers who are experiencing their first episode with mental illness;
n Consumers who are not responding well to medication and treatment;
n Consumers who are experiencing other complicating issues such as additional medical illnesses;
n Families experiencing high stress;
n Families who have separated from their relative with mental illness; and
n Families who have been through divorce.
Although initially consumers and families may be reluctant to participate in a group, multifamily groups benefit both consumers and their families. For example, the social stigma related to mental illnesses causes many consumers and families to feel socially isolated. FPE in a multifamily group format connects consumers and families to others with similar experiences. It gives them a forum for peer support and mutual aid by allowing participants to share solutions that have worked for them. For this reason, we recommend offering ongoing FPE services in a multifamily group format, whenever possible.
FPE multifamily groups consist of five to eight consumers and their respective family members. They meet every 2 weeks for 1½ hours. Two FPE practitioners co-facilitate the group.
In the single-family format, one FPE practitioner meets with one consumer and his or her family members. Meetings are usually every 2 weeks for 1 hour.
FPE practitioners commonly work in both multifamily or single-family group formats. For example, when multifamily group members are unable to attend specific group sessions, you may offer single-family sessions to accommodate scheduling difficulties.
Use single-family sessions to re-engage consumers and families who no longer participate in FPE services. You may also offer single-family sessions to consumers and families who have completed an FPE multifamily group. Offer these sessions as needed to sustain ongoing family support and involvement.
If your agency is only able to offer ongoing FPE in a single-family format, refer consumers and families to local support groups to ensure that they can benefit from peer support and mutual aid.
Focus on current issues
The goal of ongoing FPE sessions is to identify the current issues that consumers and families face, and to partner with them to address these issues. FPE practitioners commonly use a structured problem- solving approach, provide information, and teach communication, coping, and social skills.
In general, FPE sessions reinforce the information learned in the educational workshop and focus on consumers’ personal recovery goals, which generally fall into the following categories:
n Issues related to re-entering the community; or
n Issues related to social and vocational rehabilitation.
Issues related to re-entering the community
Consumers who are experiencing or recovering from acute episodes for which they have been hospitalized often have issues related to re-entering the community. Personal recovery goals may relate to the following:
n Coping with symptoms;
n Medication; and
n Alcohol and substance use.
At times, the symptoms of mental illnesses may interfere with consumers’ ability to process information presented either verbally or in writing.
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Consequently, communication issues are common. Use communication and coping skills training to address these issues.
Communication skills training helps consumers and families learn new methods of interacting to address cognitive difficulties. These skills are especially useful for consumers who have experienced complications or have not responded well to treatment. Their families may feel exasperated and, consequently, may exacerbate their relative’s symptoms.
In ongoing FPE sessions, model simple and direct communication for family members. Reinforce the importance of communicating in a low, calm tone to counteract sensitivity to stimulation. Other techniques include breaking information down into small chunks and engaging consumers to ensure that they receive information accurately.
When communicating important ideas, encourage consumers and families to set aside a specific time to talk. Doing so gives consumers and families an opportunity to rehearse the communication skills that they learn during FPE sessions.
Coping skills training helps consumers and families learn new or enhance existing strategies to manage stress, problems, or persistent psychiatric symptoms. Steps used in coping skills training include the following:
1. Identify a problem or persistent symptom.
2. Conduct a behavioral analysis to determine situations in which the symptom is most distressing.
3. Identify coping skills that consumers used in the past.
4. Evaluate the effectiveness of previously used coping skills.
5. Increase the use of effective coping skills.
6. Identify new coping skills to try.
7. Model and practice new coping skills in role plays.
8. Gain feedback on the effectiveness of the new coping skills and the increased use of previously used ones.
9. Further tailor or adapt the coping strategies to meet consumers’ needs.
Coping strategies range from relaxation to cognitive-behavioral techniques. Practicing new coping skills is most effective when consumers involve family members and other supporters. For more information, see the Illness Management and Recovery KIT.
Issues related to social and vocational rehabilitation
For consumers who are in the rehabilitation phase, FPE sessions focus on their unique recovery goals. Consumers commonly identify situations that are likely to cause stress or barriers to achieving their goals. Use problem-solving, social skills training, and role plays to address these issues. For more information, see Modules 4 and 5.
Engage consumers and families continuously
Engaging consumers and families in FPE starts the moment that they are referred to the program. It is difficult, if not impossible, to engage consumers and families in any meaningful way unless you know their needs and goals. For this reason, we suggest conducting three or more joining sessions to build a rapport and a working alliance. Once consumers and families are involved in ongoing FPE sessions, your challenge is to focus FPE services on helping them meet their immediate needs and goals.
The engagement process never stops. Whenever you meet with consumers and families, you learn more about them. If you want consumers and families to stay engaged, you must continue to help them progress in a way that is meaningful to them.
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Some consumers and families have had negative experiences with specific practitioners or with mental health services. Discussing these experiences during joining sessions can help to overcome them. It may take some consumers and families a while to realize that you offer something different from what they have received in the past.
At any point, if consumers and families disengage from the FPE program, assertively reach out to engage them again. Contact consumers and families on an ongoing basis through a variety of means (by phone, mail, etc.). When appropriate, offer to meet with consumers and families in their home or their community. Gently encourage and demonstrate tolerance of different levels of readiness by offering flexible services to meet consumer and family needs.
Complete Progress Notes
After every FPE session, fill out an FPE Progress Note to document the services that you provided. The Progress Notes will help you demonstrate that you did the following:
n Met the goals of each joining session;
n Provided all components of the educational workshop; and
n Followed the structured problem-solving approach.
Progress Notes also help you track consumer and family goals, and the progress that they make toward achieving them. Make sure that the goals consumers develop in the FPE program are reflected in their treatment plan.
Ask your family intervention coordinator for a copy of FPE Progress Notes tailored to each phase of the FPE program.
Participate in supervision
It is important for new FPE practitioners to receive supportive supervision. As part of an FPE team, you are expected to meet weekly with your family intervention coordinator for individual or group supervision. Weekly supervision meetings are critical to coordinate the timing of joining sessions and the educational workshop, to answer questions about the model, and to reinforce FPE skills and techniques.
Talk with your family intervention coordinator and fellow FPE practitioners about how to best respond to issues that arise in your FPE sessions. Discuss consumers’ goals and the progress that they are making toward their recovery.
Every 6 months, your family intervention coordinator will also present the results and recommendations from your FPE fidelity assessment. Discuss this information as a team to determine how your FPE program may be improved. For more information about the FPE fidelity assessments, see Evaluating Your Program in this KIT.
Summary
In summary, this module introduced the core processes of FPE, including joining with consumers and families, offering education, and understanding the nature of ongoing FPE sessions. The next module discusses two of these processes—joining sessions and educational workshops—in greater detail.
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Exercise: Identify Consumers and Families
Answer the following questions to help reinforce your understanding of your agency’s FPE policies and procedures.
1. What are your agency’s policies for identifying and referring consumers to your FPE program?
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2. Under what circumstances will consumers be discharged from FPE?
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Exercise: Introduce Your Program
n Role play: Conduct a role play to practice introducing your FPE program. Select three group members to play the roles of consumer, family, and practitioner.
n Group discussion: Discuss how you would engage a family member who is overcoming negative experiences with the mental health system.
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Module 3
Joining Sessions and Educational Workshops Notes to the family intervention coordinator
Prepare for Module 3:
n Make copies of Module 3. Your copy is in this workbook; print additional copies from the CD-ROM in the KIT.
n Distribute the material to those who are participating in your group training. Ask them to read it before meeting as a group.
n Make copies of these exercises:
o Review Progress Notes for Joining Sessions and Educational Workshops
o Practice What You’ve Learned About Joining Sessions
Do not distribute them until the group training. Your copies are in this workbook; print additional copies from the CD-ROM.
n Make copies of your agency’s Progress Notes tailored to joining sessions and educational workshops.
Conduct your third training session:
n When you convene your group, view the following segments of Practice Demonstration Video (approximately 30 minutes):
o Introduction
o Joining with Individuals and Families
o Joining Session 1
o Joining Session 2
o Joining Session 3
o Educational Workshop
n Discuss the video and the content of Module 3.
n Distribute the exercises and Progress Notes and complete them as a group
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Training Frontline Staff
Module 3: Joining Sessions and Educational Workshops
Module 3 provides details on two phases of the Family Psychoeducation program: joining sessions and educational workshops. Completing these phases is essential to the process of engaging consumers and families both initially and throughout the program.
Joining sessions
Joining sessions are the first phase in the Family Psychoeducation (FPE) program. FPE practitioners meet three or more times with each FPE consumer and their respective family members. Meetings typically last for 1 hour.
The purpose of joining sessions is to build rapport, convey hope, and engage consumers and families in a working alliance.
Develop a working alliance
Joining means to connect, bring together, or unite. Developing a working alliance with consumers and families is essential to providing effective FPE. Agencies that shortchange this process often have difficulties keeping consumers and families engaged in FPE services.
In these alliances, FPE practitioners ask consumers and families to partner with them in the treatment process. Consumers and families help carry out the treatment, rather than participate as objects of treatment.
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The object of treatment is the illness, not consumers or families. This may appear to be a matter of semantics to some, but the differences are a key for providing effective services. FPE practitioners work with, not on, consumers and families.
FPE practitioners recognize consumers’ and families’ vast knowledge and expertise. The working alliance is built on the idea that FPE practitioners, consumers, and families join their expertise and strengths to support consumers in achieving their personal recovery goals. This collaborative approach is the foundation for the evidence-based model.
To foster this relationship, FPE practitioners do the following:
n Demonstrate genuine concern for consumers and their families;
n Validate consumers’ and families’ experiences;
n Avoid treating consumers or families as patients; and
n Avoid blaming consumers or families for causing the mental illness.
To create a relaxed, informal atmosphere, FPE practitioners set the stage for forming a working alliance by socializing at the beginning and end of each joining session. Socializing helps decrease anxiety and allows you to get to know consumers and family members as people beyond the illness. To engage consumers and families, FPE practitioners are also open and forthcoming about who they are as people.
From the first meeting, practitioners actively guide the conversation. Because each joining session has tasks to be completed, you must structure them. Following a prescribed structure reassures both consumers and families, letting them know what to expect and what will be accomplished. The tasks for each joining session are described on the following pages.
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Joining Session 1
Purpose: To develop a rapport and build a working alliance with consumers and families.
Developing a rapport and building a working alliance is a long process. It is important to build the relationship beyond the illness, so keep your manner positive, informal, and collegial. Begin the joining session by socializing. After socializing, review the session’s agenda.
If your first contact with consumers and their families is during an acute psychiatric episode, you may have a special opportunity to build a strong working alliance. Respond quickly to the immediate needs that consumers and families present. Demonstrate willingness to help, especially in concrete ways.
Establish yourself as a resource and support. If consumers and families seek particular assistance, offer it. Prompt attention reassures both consumers and families and demonstrates your commitment to partnering with them in consumers’ recovery process.
Do not be afraid to step in and take on roles not traditionally practiced. You may act as an advocate in navigating the mental health system, make a referral for more services, or even help consumers and families obtain entitlements or benefits.
If consumers are not currently experiencing an acute psychiatric episode, review the last episode that they experienced. Identify precipitating events and early warning signs with consumers and families. To do so, guide them through a review of the previous weeks. Emphasize any changes in consumers’ symptoms, thoughts, or feelings during that time. These changes—which may be either quite apparent or barely noticeable—constitute the prodromal signs and symptoms for that consumer. In most cases, idiosyncratic behaviors come before
more common prodromal symptoms, for example, poor sleep, anorexia, pacing, restless behaviors, and irritability. These behaviors become even more important in the future to help prevent relapse.
Next, ask both consumers and their families how they coped with symptoms. Explore the types of strategies that were helpful and those that were not. It is important to understand consumers’ and families’ unique experiences with mental illnesses.
Managing an acute psychiatric episode is always a difficult experience. Show that you appreciate this fact and validate the feelings that consumers and families share. Relate in a humanistic, caring, and hopeful manner.
Some practitioners skip or shorten this phase of the FPE program to more rapidly begin clinical work. However, shortchanging this step usually backfires since consumers and families who do not complete joining sessions are more likely to disengage prematurely from FPE services.
Tasks for Joining Session 1
n Socialize.
n Review a present (or past) acute psychiatric episode.
n Identify precipitating events.
n Explore prodromal signs and symptoms.
n Review family experiences in providing support and validate their experience as normal human responses.
n Identify consumer and family strengths and coping strategies that have been successful.
n Identify coping strategies that have not been helpful.
n Socialize.
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Joining Session 2
Purpose: To explore the emotional impact of serious mental illnesses.
In general, you may conduct joining sessions either jointly or separately, depending on consumer and family preference. However, hearing about families’ frustration and anger about the effects of consumers’ symptoms is usually best done in an individual session. For this reason, FPE practitioners often choose to conduct this session separately for consumers and their families.
Begin and end each joining session by socializing to reduce anxiety and set the tone for developing a working alliance. Encourage consumers and families to discuss the impact that serious mental illnesses have had on their lives. Support, validate, and recognize normal human reactions such as feelings of loss, despair, grief, anger, frustration, and guilt associated with serious mental illnesses.
Next, learn about consumers’ social support network. You may complete a genogram (a visual representation of family relationships simialr to a family tree) during the session. Remember to define social supports broadly by including neighbors, landlords, employers, or any other supportive people.
It is also important to understand the experiences that consumers and families have had with the mental health system. When those experiences are left unexpressed, they can form a barrier to developing a strong working alliance, cause repetitive complaints, and hinder your ability to work on current issues. Acknowledge and validate feelings such as anger or frustration to help
consumers and families overcome past negative experiences and allow progress to be made.
Many consumers and family members feel that mental health practitioners blame and criticize them. Blaming consumers or families for the illness is not constructive or helpful and should be avoided.
Share basic information about consumers’ mental illnesses. Demonstrate the resources that you have to offer while showing respect for consumers’ and families’ first-hand experience in managing their illnesses.
Convey optimism that consumers will be able to reduce relapses and achieve their personal recovery goals by partnering in the treatment process. Having answers for every question is less important than conveying a commitment to working together to find solutions.
Tasks for Joining Session 2
n Socialize.
n Explore feelings and reactions to having a mental illness or a relative with a mental illness.
n Identify consumers’ social support network.
n Construct a genogram or family tree.
n Review past experiences with the mental health system.
n Convey basic information about the consumer’s specific mental illness.
n Socialize.
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Joining Session 3
Purpose: To identify consumer and family strengths, interests, and goals and to introduce the next phases of the FPE program.
If you schedule consumers and their families to meet separately for this session, consider meeting with consumers first. After exploring consumers’ strengths and interests, work with them to identify goals they would like to work on during the FPE program. Setting and pursuing personal goals is an essential part of recovery. In FPE, consumers define what recovery means to them and identify three short- and long-term goals.
Explain to consumers that people are often more effective in getting what they want when they set clear goals. Help consumers identify goals by reviewing areas of their lives with which they are satisfied and those that they wish to change. Once consumers identify one or two areas on which they would like to work, help them break the areas down into smaller goals or steps that can be achieved within the next few months. Start with goals that are relatively small.
Introduce consumers to the last two phases of the program—the 1-day educational workshop and ongoing FPE services. Describe the benefits of giving information to family members and say that you would like to invite family members to attend the 1-day educational workshop. Tell them about the format and components of the standardized educational curriculum. If your agency plans to involve consumers in part of the workshop or to offer a parallel workshop for them, describe those details and invite consumers to attend.
Next, describe the last phase—ongoing FPE sessions. Review the goals that consumers identified earlier and ascertain their support for working on them. Explain that ongoing FPE sessions will focus on supporting their efforts to achieve those goals. Introduce the structured problem-solving approach and explain that this is one tool they can use to
pursue personal goals. Ask consumers if you may share their interests and goals with their family members. Tell them that you may offer ongoing FPE sessions in a single-family or multifamily group format and describe the benefits of participating in multifamily groups. Ask if they would be willing to participate with their families. If consumers are unsure, continue to explore the decision during additional single-family sessions.
Once consumers give their permission to share their interests and goals with family members, meet with their family member for a third joining session. Review consumers’ interests and goals and ascertain family support for those goals. If family goals differ from the consumer’s goals, probe to fully understand the differences. When possible, search for common ground.
Next, introduce family members to the last two phases of the FPE program. Review the benefits of participating in the workshop and multifamily group sessions. Ask about their experiences in attending group sessions and what concerns they might have, including confidentiality, shyness, and feeling pressured to speak in groups or in the workshop. Assure them that they may contribute only as much as they wish. If families are unsure about continuing with the next two phases of the FPE program, schedule additional joining sessions as needed to continue the engagement process.
Tasks for Joining Session 3
n Socialize.
n Identify personal strengths, hobbies, interests.
n Identify short- and long-term goals.
n Introduce the next phases of the FPE program.
n Socialize.
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Pacing and format
The pacing of joining sessions and whether you will be able to complete these tasks in three sessions will depend on individual circumstances. For example, if a consumer is in crisis, you might need to shorten the initial joining sessions and complete these tasks by conducting additional sessions.
You may choose to conduct joining sessions jointly with consumers and families or with consumers and families separately. As discussed in Module 2, decisions about the format may be influenced by consumer and family preferences, diagnosis and illness characteristics, and the goals of the session. For example, FPE practitioners often schedule separate sessions to discuss highly personal matters such as romantic entanglements, drug abuse, or sexual side effects of medications.
Others believe that it is easier to engage consumers and families if they have at least one individual joining session. They believe that doing so allows consumers and families to speak more openly. Use your professional discretion for these decisions and remember to remain flexible and responsive.
Educational workshops
Education is one of the essential ingredients of FPE. This section introduces you to a recommended standardized curriculum that you may use to teach families about their relatives’ mental illnesses. Information about the timing, structure, and format of the 1-day educational workshop is also outlined below.
Why offer informational resources?
When people do not have accurate information about mental illnesses, they may adopt mistaken beliefs or rely on intuition. Unfortunately, many effective interpersonal and rehabilitative approaches are often counter-intuitive. Consequently, despite having their relative’s best interest in mind, their actions may interfere with recovery. Therefore, it is important to give families the information and guidance they need to promote recovery and rehabilitation.
Information can help create a shared language that allows consumers, families, and practitioners to work together. The first message is that no one is to blame for mental illnesses. Blaming consumers or families is not constructive or helpful.
Next, families must understand basic information about their relative’s serious mental illnesses. One critical aspect of family education is that it gives families hope that they will be able to alter the course of illness.
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Timing
You must respond to the immediate needs of consumers and families and answer questions as they arise. For this reason, the educational process begins during the first joining session and continues throughout each phase of the FPE program.
While education is ongoing, the main focus on education occurs in the second phase of the FPE program. Once consumers and their respective family members have completed three or more joining sessions, invite family members to attend a 1-day or 8-hour educational workshop. Typically, the 1-day workshop is offered to a group of family members.
During the joining sessions, explain the nature and purpose of the workshop. Explain that family members will be expected to attend this type of workshop only once as a part of their participation in the FPE program.
If you offer ongoing FPE sessions in a multifamily group format, plan to have the five to eight families who will participate in the multifamily group attend the same workshop. The workshop gives them an opportunity to get acquainted before the multifamily group begins.
Schedule the workshop for a time that meets the needs of family members. Typically, workshops are held on weekend days.
Participants
The workshop is most often conducted solely with families—not with consumers—to give families a chance to get acquainted. The opportunity to interact with others who are in similar situations and to speak freely about their experiences allows families to bond and develop supportive relationships. It also increases families’ commitment to participate in FPE.
Some agencies involve consumers in part of the workshop to ensure that they receive the same educational information as their families. Others offer this information to consumers individually or in a separate consumer forum. For more information about providing information about mental illness to consumers, see the Illness Management and Recovery KIT.
Educational curriculum
We recommend using the following standardized curriculum to teach families about mental illnesses. To provide enough specific information, we recommend that workshops focus on one specific mental illness. For example, all family members would have relatives with schizophrenic disorders and the information presented would relate primarily to these disorders.
The Educational Curriculum Covers Six Topics
n Psychobiology of the specific mental illness including the basics of brain function and dysfunction, and the possible causes of the mental illness
n Diagnosis including symptoms and prognosis
n Treatment and rehabilitation including an overview of treatment options and how they promote effective coping and illness management strategies
n Impact of mental illnesses on the family including how mental illnesses affect families as a whole
n Relapse prevention including prodromal signs and symptoms, and the role of stress in precipitating episodes
n Family guidelines or recommended responses to help families maintain a home environment that promotes relapse prevention
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Presenter selection
Family members often feel more comfortable if the practitioner who knows them and their consumer relative facilitates the workshop. For this reason, we recommend that the same FPE practitioners conduct the joining sessions, educational workshop, and ongoing FPE sessions.
Two FPE practitioners usually facilitate the workshop. Facilitators are not expected to be experts in all areas of the educational curriculum. Instead, they choose to present areas in which they are comfortable and invite colleagues with particular areas of expertise to present the remaining educational components. For example, the treating psychiatrist should present the material on the psychobiology of the specific mental illness.
Once you have selected all of the presenters and assigned them areas of the educational curriculum, schedule a practice presentation to review the materials before the workshop. Practicing with colleagues helps increase confidence and gives an opportunity for feedback on clarity and rate of speech. It may help to videotape or audiotape the practice presentations and to rehearse responses to common questions.
Educational techniques
The roles of educator may be new for FPE practitioners. When educating consumers and families, keep the following techniques in mind:
Use an interactive, not didactic teaching style
Teaching in an interactive style makes learning an interesting, lively activity. Interactive learning involves frequently pausing when presenting information to get consumer and family reactions and perspectives. Talk about what the information means and answer any questions that may arise. An interactive teaching style conveys to consumers and families that they have important contributions
to make to the learning process and that you are interested in what they say.
Present the material in a conversational tone by summarizing the key points and giving relevant examples. Avoid the monotony of having just one person speak. At all times, communication should be two-way; it must never seem like a lecture. People learn information by actively processing it in a discussion with someone else.
Periodically review information that you already covered
Begin and end each segment with a brief summary of the key points. Make connections between previously learned and new material. To check if consumers and families retained the information and to reinforce topics that you previously discussed, ask them to summarize what they remember.
Adopt common language to facilitate communication
People have their own ways of understanding their experiences, thinking about their lives, and looking into the future. The more you can speak the same language, the easier it will be to make connections and avoid unnecessary misunderstandings.
Break information down into small chunks
Some mental illnesses cause impairment in cognitive functioning, which can result in a slower rate of processing and the need to present information in very small chunks or in a simplified format. When educating consumers, take into account individual needs.
Consumers who are experiencing psychiatric symptoms may need information to be presented in different formats, individually, or in shorter group sessions. By presenting small amounts of information at a time, consumers can learn at their own pace.
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Check for understanding
How often you check for understanding of the information will vary from person to person. Avoid asking yes or no questions. Have consumers and families summarize information in their own words. Hearing them explain their understanding of basic concepts allows you to know which areas they understood and which need clarification.
Multimedia education
Offer the information in the standardized curriculum to families in a variety of formats such as videos, slide presentations, lectures, discussion, and question-and-answer periods. Give each family member a folder with handouts of the information that will be presented, as well as resource lists and Web sites that they can use to find more information.
For example, you might want to include a copy of the following Family Guidelines. During the session, review each guideline in detail, and ask family members for their reactions, questions, and experiences. Illustrate the guidelines with examples based on the kinds of problems that your families described during joining sessions.
Family Guidelines
1. Go slow. Recovery takes time. Things will get better in their own time.
2. Keep it cool. Enthusiasm is normal. Tone it down. Disagreement is normal. Tone it down, too.
3. Give each other space. Time out is important for everyone. It’s okay to reach out. It’s okay to say, “No.”
4. Set limits. Everyone needs to know what the rules are. A few good rules keep things clear.
5. Ignore what you can’t change. Let some things slide. Don’t ignore violence.
6. Keep it simple. Say what you have to say clearly, calmly, and positively.
7. Partner with your relative’s treatment team. Understand your relative’s goals and the steps outlined in their treatment plan.
8. Carry on business as usual. Re-establish family routines as quickly as possible. Stay in touch with family and friends.
9. Do not use street drugs or alcohol. They make symptoms worse, can cause relapses, and prevent recovery.
10. Pick up on early warning signs. Note changes. Consult with your consumer relative and the treatment team, if possible.
11. Solve problems step by step. Make changes incrementally. Work on one thing at a time.
12. Adjust expectations. Use a personal yardstick. Compare this month to last month rather than to last year or next year.
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Tailor your curriculum
While we recommend that you follow a standardized curriculum, your workshop will be most effective if you tailor the information as much as possible to the participants. Connecting families who have relatives with similar diagnoses is only the first step. Pay close attention to the educational
needs that families reveal in joining sessions and emphasize this information in the workshop. Responding to family needs is the key to keeping them engaged in the FPE program.
To ensure that all components of the standardized curriculum are covered, follow the agenda below.
Sample Agenda of the Educational Workshop
9:00–9:15 Coffee and socializing
9:15–9:30 Formal introductions and explanation of the format for the day
9:30–10:30 Psychobiology and diagnosis of the specific mental illness
Basics of brain function and dysfunction
Possible causes of the specific mental illness
Diagnosis
Symptoms
Prognosis
10:30–10:45 Coffee break and socializing
10:45–11:15 Psychiatric medications How they work
Outcomes
Side effects
11:15–12:00 Other treatments options Overview of other treatment options
How they work
Outcomes
12:00–1:00 Lunch and socializing
1:00–3:00 The impact of mental illness on the family
The needs of the consumer
The needs of the family
Common family reactions to the illness
Common problems that consumers and families face
What the family can do to help
Family guidelines
The problem-solving method
3:30–4:00 Wrap Up Question and answer period
Scheduling, logistical, and questions about multifamily group sessions
Socializing
Agenda adapted from Anderson et al., 1986, p. 76.
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To start, offer refreshments in an informal setting to prompt spontaneous socializing. Have refreshments available throughout the workshop. To develop an atmosphere of partnership, during the breaks make sure that you spend time with families, not solely with colleagues.
To start the formal program, introduce yourself, distribute the educational packets, and explain the day’s agenda. For example, say:
Welcome and thank you for coming on this beautiful Saturday morning! My name is Bob Smith and this is Peg Rutherford. Some of you already know us because we’ve been meeting individually for quite some time now.
We want you to know as much as possible about this illness—what’s known, and what’s not known, as of now. Schizophrenia is a very complex and confusing illness. We have found that the more information family members have, the better equipped they are to deal with problems as they occur.
This workshop is only one step of our work together. After the workshop, we will regularly meet as a group of families and consumers. We will continue to give you relevant information and assistance. We have found with the FPE program that working together with consumers and families results in fewer relapses and rehospitalizations.
We will answer as many questions as possible in this workshop today. If we cannot answer something, we will find someone who knows the information and will get back to you.
While it is important to cover all components of the standardized curriculum, present information in an open, collegial manner that encourages participation. Create an atmosphere that encourages families to comfortably ask questions and tailor the curriculum to respond to their needs. It is important to continue the engagement process and strengthen the working alliance.
By sharing experiences, families will discover that their problems are similar. This realization
normalizes families’ experience with mental illnesses and counters feelings of isolation. They often begin to bond during the workshop and build a strong social support network through their contact in the multifamily group.
Invite family members to talk about their reactions to the information presented. Some common reactions are relief at finally knowing some facts, anger at being kept in the dark, sadness, despair, hopefulness about this approach, and eagerness to get on with the work.
Keep in mind that family members are not obligated to speak during the workshop. Respect families’ decisions about how much they wish to share by encouraging discussion and eliciting reactions without demanding them.
If you have not done so already, outline the format for multifamily groups, emphasizing the structured problem-solving approach and its usefulness for consumers and families. Present the agenda for the first two meetings to generate enthusiasm for upcoming sessions.
Give examples of how life has improved for consumers and families who have participated in FPE. End the workshop on a positive note. If possible, families should leave the workshop feeling optimistic about being involved in the FPE program.
If you have not done so already, share contact information in case families need to reach you between sessions. Make sure that you have responded to the questions and concerns that families have raised, especially questions about the upcoming multifamily group. Thank all participants for coming to the workshop.
This workshop is modeled after the workshop described by Anderson and colleagues (1986). For more information about conducting educational workshops with consumers and families, see The Evidence in this KIT.
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Exercise: Review Progress Notes for Joining Sessions and Educational Workshops
Distribute a copy of your agency’s FPE Progress Notes for joining sessions and educational workshops. Review the components of these forms and discuss as a group.
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Exercise: Practice What You’ve Learned About Joining Sessions
Select three members of your training group to play the roles of practitioner, consumer, and family member. Conduct role plays of Joining Sessions 1, 2, and 3.
Discuss the following:
n How would you engage a consumer who is reluctant to involve a family member in the FPE program?
n How would you respond if consumers or family members become upset when discussing how mental illness has affected their lives?
n How would you respond to a consumer or family member who shares past negative experiences with group sessions?
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Module 4
Ongoing Family Psychoeducation Sessions Notes to the family intervention coordinator
Prepare for Module 4:
n Make copies of Module 4. Your copy is in this workbook; print additional copies from the CD-ROM in the KIT.
n Distribute the material to those who are participating in your group training. Ask them to read it before the group training.
n Make copies of the following exercises:
o Practice What You’ve Learned About Multifamily Groups
o Review the Progress Note for Ongoing Family Psychoeducation Sessions
Do not distribute them until the group training. Your copies are in this workbook; print additional copies from the CD-ROM in the KIT.
n Make copies of your agency’s Progress Notes for ongoing FPE sessions (if available). For a model form, see Building Your Program in this KIT.
Conduct your fourth training session
n When you convene your group, view the last two segments on the Practice Demonstration Video (approximately 50 minutes):
n Multifamily Groups
o Problem-Solving
o Discuss the video and content of Module 4.
n Distribute the exercises to the group and complete them
Ongoing Family Psychoeducation Sessions 1 Module 4
Training Frontline Staff
Module 4: Ongoing Family Psychoeducation Sessions
Module 4 describes the last phase of the program—ongoing Family Psychoeducation sessions. When possible, these sessions should be offered in the multifamily group format. For this reason, the module describes the first three sessions of the multifamily group sessions in detail and draws applications to the single-family model.
Conduct ongoing Family Psychoeducation sessions
Once consumers and families have completed three or more joining sessions and families have participated in the 1-day educational workshop, invite consumers and families to attend ongoing Family Psychoeducation (FPE) sessions.
You may conduct these sessions in either the single-family or multifamily group format. Since you discuss and select format options with consumers and families during joining sessions, information for selecting a format is presented in Module 2.
When possible, offer ongoing FPE sessions in a multifamily group format. Multifamily groups consist of five to eight consumers and their respective family members.
Two FPE practitioners who have conducted the joining sessions and educational workshop facilitate the sessions. Multifamily groups meet every 2 weeks for 1½ hours. For consumers and families to gain the full effectiveness of the FPE program, offer ongoing FPE sessions in either format for 9 months or more.
While this phase of the FPE program has been found to be most effective when offered long term, many FPE practitioners
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do not emphasize the long-term nature of FPE during the engagement process. Asking consumers and families to commit long term may provoke anxiety. For this reason, tell consumers and families that this last phase of the FPE program will continue for as long as they find it helpful.
Structure of multifamily groups
The structure of the first two multifamily group sessions differs from the structure of later sessions. In the first two sessions, the goal is to establish a partnership among group members. Up to this point, the working alliance has been limited to the consumer, family, and practitioner. When consumers and families begin participating in multifamily groups, the goal is to extend the working alliance to include all group members.
Why structure the first two groups differently?
Consumers and families need to get to know one another apart from the effects of mental illnesses on their lives. The first two sessions are designed to help group members learn about one another and bond as a group.
Traditional group therapy models emphasize expressing feelings. This often sparks conflict between family members, disagreement about the group’s purpose, and anger or confrontation with facilitators. Consequently, consumers and families may become overwhelmed and give up on the group. In contrast, FPE focuses on addressing current issues that pose barriers to consumers’ personal recovery goals. Group members work together by participating in a structured problem- solving approach. For this approach to be effective, group members must share ideas and be open to accepting them. It is best to proceed slowly and take time to develop trust and empathy.
Through the joining sessions, you developed a working alliance with consumers and families in the group. In the first two multifamily group sessions, you will extend that partnership by giving group members an opportunity to bond and build their group identity.
Overview of the first session
The goal of the first session is for FPE practitioners, consumers, and family members to get to know one another in the best possible light. The first session is not intended to be an opportunity to share deep emotions and feelings about the illness or about the group itself. Rather, it is a time for group members to get to know one another and discover common interests, issues, and concerns. For this reason, encourage group members to talk about topics that are unrelated to the illness, such as their personal interests, hobbies, or daily activities.
Set up the room
Arrange chairs around a table or in a semi-circle so that group members can easily see and hear one another. Use the same setup at every session. Be aware that once the problem-solving sessions begin (after the second group session), groups often like to be in a semi-circle so they can see the blackboard, flipchart, or chalkboard.
Have refreshments available to prompt socializing before and after the group. At the start of the session, tell group members that they are free to move around, get a drink, or use the restroom. Make sure that consumers know they can leave the room whenever necessary.
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Be an effective facilitator
During the first two group sessions, be a good host. Introduce group members, point out common interests, and guide conversations to more personal subjects such as interests and hobbies.
Act as a role model. Demonstrate by example that you expect people to talk about topics other than the illness. This means that you should be prepared to share a personal story of your own.
Pay close attention to group members who speak and thank them when they finish. Prompt reluctant group members with questions or encourage them to talk. Some group members may benefit from a slow conversational pace to better absorb information that they hear.
Think of the group in terms of any group of people who meet one another for the first time. Guide the conversation to topics of general interest such as the following:
n Where people live;
n Where they were born and grew up;
n What kind of work they do both inside and outside the home;
n What their hobbies are;
n How they like to spend their leisure time;
n Which recent movies they have seen; and
n What holiday or vacation plans they have.
Structure the first session
Welcome group members and review the format for the first two sessions and future group sessions. Begin with introductions. Group members commonly want to talk about the illness during their introduction. Guide the discussion by clearly setting the agenda for the first group and modeling the type of introduction that you expect. For example, say:
Tonight, the goal is to begin to get to know one another. Let’s go around the room and each say something about ourselves. It is understandable to want to talk about the effects of a mental illness, but we will get to that during our next meeting.
Tonight, the goal is to talk about other parts of our lives. Let’s start by sharing the things that we are proud of. I would like to start by telling you about myself.
If consumers and families have joined thoroughly with you, they will feel less need to focus on the illness during the first group session. When you participate and talk about yourself, it gives the group a model and creates a feeling of partnership.
Some FPE practitioners find it uncomfortable to share personal information, since this is a departure from the way of conducting traditional therapy groups. However, you must create a friendly, comfortable atmosphere among group members. It may help to rehearse with your co-facilitator ahead of time. Think of a few positive, engaging stories about family, favorite activities, interests, and hobbies.
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Be prepared to talk for about 5 minutes. For example, say:
Hi, my name is Margaret Hanson. Some of you have already met me, and some are meeting me for the first time tonight. I am a social worker and have worked in the community mental health center for 15 years.
I grew up in this area and my parents still live in the house I grew up in. I have three teenage girls who keep my husband and me very busy and challenged! Even though the girls are growing up and going in different directions, we still like to do things together as a family. One thing we like to do is go camping.
Over the years, we’ve acquired a lot of equipment so the girls could each invite a friend along on our trips. This summer, we’re planning a trip to the White Mountains, and we’re bringing two large canoes since the girls are inviting friends. I especially enjoy these trips since I don’t do much of the cooking— my husband does! It’s so peaceful to camp and to spend time in a less harried environment.
We have an old yellow lab that stays home when we go camping, but when we’re home, she likes to take me for a walk every morning, usually as the sun comes up. In my spare time, I garden, scout flea markets, spend time with friends, sew, and read. Occasionally, my husband and I see a movie, go out to eat with friends, or walk the beach when the tourists aren’t around. Well, that’s enough about me for now. I’m looking forward to getting to know all of you better as time goes by.
Then turn to the next person and have group members continue around the circle. Thank group members after they contribute. Have your co- facilitator sit halfway around the circle and take a turn in sequence.
Redirect group members
If group members begin to talk about the illness or the impact of the illness on their lives, redirect the conversation. For example, say:
We will have time to talk about the illness later on. For right now, let’s try to get to know other things about one another.
Prompt group members
You may have to prompt some group members who offer only a minimal amount of information. Ask questions to help them give more details. For example, if they like to watch television, ask which shows they watch or if they say they like to cook, ask which recipes they enjoy most. Strive to point out similarities or interests that group members share. For example, say:
I notice that several of us like to go to the movies. Maybe we can talk about our most recent favorite films.
This helps develop relationships and group cohesion.
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Overview of the second session
The second multifamily group session focuses on how mental illnesses have changed the lives of members in the group. In this session, the goal is to continue building trust among group members and help them develop a sense of a common experience of having a mental illness or a relative with a mental illness. The mood of this session is usually less light-hearted than the first session, but it is the basis for developing a strong group identity.
Structure the second session
Welcome members to the group as they arrive and direct them to the refreshments. To start the group, outline the agenda for the session by saying:
Thanks for being here tonight. Last time we spent time getting to know one another. Tonight, let’s begin by catching up for 15 minutes. Then we will discuss how mental illnesses have affected our lives.
Begin the socializing with a comment or question that is unrelated to the illness such as following up with a group member about a planned activity or event mentioned during the first session. It is important to begin groups by socializing. Encourage participation by modeling, pointing out connections between group members, and asking questions.
After socializing, say:
Now it’s time to focus on our topic for the evening. Mental illnesses have touched all of our lives in some way. Tonight, you will each have a chance to share your personal story of how mental illness has affected your life. You can share as much or as little as you would like, but also feel free to ask questions and to support one another.
Start by sharing your own professional and personal experience. For example, share a story about a friend or family member with mental illnesses, talk about how you became interested in your work, or how you have been affected by treating people with mental illnesses. When you finish sharing, turn to the next group member and ask:
How has it been for you? How has mental illness affected your life?
After group members have each briefly shared a story, thank them. Point out any similarities to another group member’s experiences.
Save 5 minutes to socialize before ending the session. Prompt discussions on concrete topics such as weekend or holiday plans. The purpose of socializing is to stimulate and encourage interpersonal connections. Socializing promotes developing social support networks. At the end of the session also remind group members of the time and date of the next session.
Try some tips for common difficulties
During this session, it may be difficult for group members to confide their problems. Offer plenty of support and validation to encourage people to talk. Be careful to respect personal boundaries by conveying that group members can say as much or as little as they wish. Ask questions to keep reluctant group members talking and to promote connections such as similar problems, worries, or stories.
This group session may be the first time some group members realize that they are not alone. Encourage them to express any feelings that surface while discussing these difficult experiences. For example, feelings that families commonly have but are reluctant to talk about include anxiety, confusion, fear, guilt, sadness, and grief. Compared to the first meeting, the mood of this session may be sad.
Sometimes group members express their unhappiness with the mental health system, the agency, or a member of the treatment team. Validate these feelings and experiences and ask for specific details. But be careful not to let a specific problem dominate the session.
Group members who have had an opportunity to discuss their experiences during joining sessions will be less likely to focus on these issues during
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group sessions. For this reason, we recommend that you complete all three joining sessions with consumers and families before introducing the next phases of the FPE program.
If group members start to talk about specific problems they want to solve immediately, help them return to the agenda by saying:
During the next session, we will begin to look at specific problems and work together to find solutions. Right now, let’s give [name] a chance to share with us how mental illness has affected her life.
Depending on the situation, you may also suggest meeting outside the group to discuss the problem.
Other difficulties that you may encounter during group sessions include people having side conversations, interrupting, monopolizing, or speaking for others. Address these issues with positive redirecting remarks, such as:
That’s interesting; I wonder if Mr. Smith has something to say about this.
Your wife says she thinks you’re over the flu. How long were you sick?
Understand the importance of humor
Early on, it helps to introduce humor into the group dynamic. Let group members know that it is acceptable to have fun and laugh. Model this behavior as well, when appropriate.
Ongoing multigroup sessions
Many consumers and families have expressed dissatisfaction with traditional group therapy models because of the high degree of emotion and low degree of productivity. FPE responds to these concerns by offering a clear agenda for each session and a structured problem-solving approach to help consumers and families make gains in working toward personal recovery goals.
Follow the session agenda
Beginning with the third session, the agenda for multifamily group sessions is as follows:
Multifamily Group Session Agenda
Socialize 15 minutes
Go-around—identify current issues
20 minutes
Select a single problem 5 minutes
Use structured problem-solving 45 minutes
Socialize 5 minutes
Total 90 minutes
As in the first two sessions, two FPE practitioners continue to co-facilitate the group. One FPE practitioner acts as the primary facilitator and leads the group through the agenda and structured problem-solving. The other serves as co-facilitator and ensures group participation, monitors the overall process, and records the problem- solving process.
Record the proceedings on a blackboard, flipchart, or chalkboard. At the end of the session, document the session on a Progress Note that you can put in consumers’ charts. Give consumers and families a copy to take home.
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Similar to the first and second group sessions, socialize at the beginning and end of each group session. Give consumers and families the opportunity to recapture and practice any social skills they may have lost due to isolation or exposure to high levels of stress.
After socializing, begin the go-around to identify current issues related to mental illness that consumers and families are managing. It is often helpful to prompt the go-around discussion by writing this question at the top of a blackboard:
How have you been affected by the illness since we last met?
Prompts such as these help group members focus on the purpose of the go-around. This is also the time to follow up on consumers’ progress toward their goals or on their action plan. As each group member checks in, have your co-facilitator list the current issues on the blackboard.
Discuss each issue individually. Do not point out similarities between the concerns of group members because doing so causes group members to express problems in more general terms. Instead, for the purposes of problem-solving, encourage group members to use their own words to describe their current issues in detail. This will provide a clearer and more accurate picture of the issues.
Once you have completed the go-around, review each issue. Remember to recognize any progress that consumers have made in achieving steps toward their goals. If any issues can be readily solved, offer direct assistance or advice based on the family guidelines.
Many issues that consumers and families identify will be too complex to easily resolve. Instead, choose one for the group to work on during the session. Ask consumers and families for their permission to focus on the issue as the group’s topic. If agreed, discuss this problem for the remainder of the session.
Use structured problem-solving
Structured problem-solving is a six-step approach that helps break problems down into a manageable form so that solutions can be implemented in small, easy-to-follow steps. Experiencing success in small steps gives consumers and families hope that change is possible. Often a small success will motivate consumers to apply the method to other aspects of their lives.
Six Steps of Structured Problem- Solving
n Define the problem.
n Generate solutions.
n Discuss advantages and disadvantages of each solution.
n Choose the best solution.
n Form an action plan.
n Review the action plan.
Select the problem
The first step of the structured problem-solving approach is to select one problem from the list of current issues and define it in detail. Selecting and defining the problem, while sometimes viewed as a rather simple process, is often the most difficult step. If the problem is not properly defined, consumers, families, and practitioners become frustrated and convinced that it cannot be solved.
Some common difficulties that groups experience are the following:
n Choosing a problem that is too large or too general (for example, “I want to get a job”);
n Not reaching consensus on how to define the problem; and
n Phrasing the problem inaccurately.
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Tell group members that the problem definition stage can be challenging. Acknowledging that the process is not simple may alleviate some frustration later.
To select a problem for the group to discuss, review the list and consider the scale of the problems identified. For initial sessions, select simpler problems so that the group members learn the structured problem-solving approach, gain trust in one another, and achieve a few successes. Only address long-standing or previously intractable problems if you can break them down into more solvable subproblems.
Share your reasoning for selecting specific problems. Thinking aloud while selecting a problem helps
group members learn how to simplify, clarify, and prioritize concerns.
Once you have selected a problem and the consumer and family have agreed that the issue can be the focus of the group session, emphasize that the goal is to teach the problem-solving approach and that, with practice, group members may begin to use the approach outside the group. It is also important to say:
Although the problem may not currently be a problem in your life, it is likely that many of you have faced or will face a similar issue. Hopefully, we can share our experiences and together find some possible solutions. Remember if your issue isn’t the focus for this session, over the course of the group, we will address everyone’s issues.
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Evaluate Common Problems
Safety issues Safety is always of primary importance. As you review the issues, address any potential threats to safety.
Clarify the issue. If the issue is too emotionally charged or is likely to disrupt the group process, address the issue apart from the group, and update the group about how it was resolved. Discuss your reasons and plans in as much detail as possible so that group members have the best possible learning experience.
If the issue is not too emotionally charged or disruptive and can be broken down into manageable parts, ask the consumer if you may select the problem for the group to discuss.
Managing symptoms, substance use, and medication issues
Reports of actual or potential exacerbation of symptoms are common problems that you may address in the group. Issues about medications and substance use are also important. Because these are potentially emotional issues, present or reframe the problem in nonblaming terms. Blaming consumers or families is not constructive or helpful. Modeling a nonjudgmental, nonblaming approach often can be a good learning opportunity for group members.
Life events Sometimes, major events occur (for example, divorce, death, marriage, graduation, a birth), that can be unsettling for the whole family and especially for someone with mental illness. It is natural for stress levels to rise at such times, even with positive stress.
Changes sometimes occur within mental health agencies, such as a move to another building or a practitioner’s resignation that may be as distressing to consumers and families as other major life events. You may be able to address these issues in the group.
Disagreement among consumers and family members
It is natural for consumers and family members to disagree at times. When exploring issues such as these, consider the following:
The intensity of the disagreement
Sometimes an issue surrounded by intense disagreement is better resolved in single- family sessions. In such a case, suggest an outside meeting to help with the problem. If the disagreement does not seem extreme and is selected for problem-solving, keep criticism and emotions to a minimum. Consider reviewing the Family Guidelines outlined in Module 3.
Whether the disagreement is a consequence of the mental illness
If the disagreement is a consequence of the mental illness, problem-solving in the group can be helpful and elicit solutions that are pragmatic and stress-reducing. However, when a consumer and family member are disagreeing, it may be difficult to agree on the definition of the problem. One approach is to define the problem broadly, such as: How can the Smith family manage their disagreement so that John will not be overwhelmed and relapse?
Module 1 10 Basic Elements and Practice PrinciplesModule 4 10 Ongoing Family Psychoeducation Sessions
Define the problem
The next step is to ask consumers and families for more information to help the group clearly understand and define the problem. Ask detailed questions such as the following:
n What is the current issue?
n When did you first notice the problem?
n When does it occur? How often? In what situations?
n Has the problem changed in any way recently?
n Whom does the problem affect? How?
n With what activities does the problem interfere?
n What have you tried to alleviate the problem? What were the results?
n Who seems to have the most impact on the problem?
Seek consensus on the definition of the problem by summarizing it in a single sentence or phrase and asking consumers and families if the definition makes sense to them. Make sure that you accurately define the problem. Incorrectly phrasing the problem can cause the group to generate ineffective solutions. For example, consumers or family members may indicate that the person is the problem. Remember, the problem is the problem; the person is never the problem.
Once a problem has been defined in a way that is acceptable to each member of the family, write it on the blackboard.
Generate solutions
Once you define the problem, ask group members to offer whatever solution they think may help. Do not evaluate solutions now since doing so dramatically reduces the number of solutions people present. It is often helpful to say:
We know it is difficult to resist discussing suggestions as people generate them. However, we have found that by discussing them as we go, some solutions are left unspoken. Therefore, let’s delay evaluating solutions until after all suggestions have been made.
The goal is to generate as many ideas as possible about solving the problem. The more solutions generated, the more likely one will adequately address the problem. For this reason, ask all group members to contribute at least one solution. Take all ideas seriously and write them on the blackboard, even if a suggestion seems wild or silly. It is important that group members feel their ideas are respected and no idea is discounted.
Discuss advantages and disadvantages of each solution
After people have presented all their solutions, invite group members to weigh the advantages and disadvantages of each. On the blackboard, simply write a plus [+] next to the solution when someone identifies an advantage and a minus [-] after the solution when someone identifies a disadvantage. When possible, take time to evaluate the solutions as a group. When time is short, some facilitators streamline the evaluation process by presenting the solutions to the group to review and select. Unfortunately, when this process is shortchanged, consumers do not fully benefit from the others’ experiences.
Choose the best solution
When you evaluate all solutions, review the list emphasizing solutions that have the most advantages and fewest disadvantages. Then ask consumers which solutions they would like to test for themselves over the next 2 weeks. Stress that testing solutions is for the benefit of everyone in the group because everyone is looking for solutions that work.
Ongoing Family Psychoeducation Sessions 11 Module 4
Form an action plan
Once you select a solution, develop a detailed action plan. Typically, you will break the solution down into small steps or tasks. Specify each step by asking:
n What needs to happen first?
n Who will do that step?
n When will that step happen?
n Where will people meet for that step?
Discuss each step or task and assign someone responsibility for completing it by a specific date. Some plans include tasks that all group members may try. Others are designed specifically for the consumer and family who presented the problem.
Once you develop the action plan, have your co- facilitator record the steps on a Progress Note form. Make copies for the consumer’s chart and for the consumer and family.
Review the action plan
When appropriate, tell the consumer and family that you may check on their progress during the coming week and that you are available for help. Remind them that the group will look forward to an update during the next session.
At the beginning of the next session (during the go- around), review the action plan and followup on the consumer’s progress. Ask:
n What steps were completed?
n What went well?
n What did not go so well?
Praise all efforts and point out any progress. If steps were not completed, explore obstacles and alternatives. If consumers encountered significant challenges that cannot be resolved quickly, suggest meeting individually with the consumer and family outside the group to explore the issue in greater detail. When possible, update the group about the outcome to ensure that others can learn from the experience.
Module 1 12 Basic Elements and Practice PrinciplesModule 4 12 Ongoing Family Psychoeducation Sessions
Difficulties encountered
At any point during the group, if consumers or families who have identified the problem begin to struggle with the process, make sure you have accurately defined the problem and that the group is addressing the true problem. It is better to stop the process and clarify the problem definition than to generate solutions that are irrelevant to the current issues that consumers and families are facing.
Many issues that the group presents are perceived as unsolvable. These are often long-standing problems that have resisted all attempts to make them better. Group members seldom have much hope that things will change. With this in mind, collect as much information as possible when you select and define problems so that you may break large problems down into smaller parts and work on them incrementally. When things do change, acknowledge the efforts of those involved in the change.
In some instances, stray from the structured problem-solving approach
Use the problem-solving approach for most multifamily group sessions. However, occasionally group members may identify issues that are best addressed with a different approach. In this case, alter the approach by bringing in guest speakers or by offering specific skills training. For example, research shows that interspersing skills training targeted to the symptoms of obsessive-compulsive disorder is an effective adaptation of FPE for families and consumers with this illness (Van Noppen, 1999).
Throughout the FPE program, continue to share educational materials targeted to specific mental illnesses in different formats (for example, video, print, and website resources). Remaining responsive to the needs of consumers and families will keep them engaged in FPE services.
When needed, offer ongoing Family Psychoeducation services in a single-family format
You can easily adapt the goals of ongoing multifamily sessions to the single-family format. Introduce consumers and families to the structured problem-solving approach and work with them to identify current issues that may be addressed collaboratively. Follow the guidelines described in the multifamily group format.
While consumers and families will not have the benefit of other group members’ experiences, it is still possible to identify strengths, resources, and strategies that have worked in the past. With consumers and families, generate solutions and evaluate each one to select the best choice. Next, collaborate with the consumer and family to develop a detailed action plan.
Tailor single-family sessions to the needs of the consumer and family. Keep your work with consumers and families task oriented and focused on consumers’ personal recovery goals. For more resources on the single-family format, see The Evidence in this KIT.
Ongoing Family Psychoeducation Sessions 13 Module 4
Exercise: Practice What You’ve Learned About Multifamily Groups
n Role play: Conduct a role play to practice introducing the format of the first two multifamily group sessions. Practice how you may introduce yourself during the first group session.
n Group discussion: Discuss as a group how you would redirect a consumer or family member who becomes upset during the second multifamily group session.
Ongoing Family Psychoeducation Sessions 15 Module 4
Exercise: Review the Progress Note for Ongoing Family Psychoeducation Sessions
Distribute a copy of your agency’s Progress Note for ongoing FPE sessions. Review the components of this form and discuss as a group.
Problem Solutions from Actual Practice 17 Module 5
Module 5
Problem Solutions from Actual Practice Notes to the family intervention coordinator
Prepare for Module 5:
n Make copies of Module 5. Your copy is in this workbook; print additional copies from the CD-ROM in the KIT.
n Distribute the material to those who are participating in your group training. Ask them to read it before the group training.
n Make copies of the following exercise:
o Practice What You’ve Learned About Problem-Solving
Do not distribute them until the group training. Your copies are in this workbook; print additional copies from the CD-ROM in the KIT.
Conduct your fifth training session:
n Discuss the content of Module 5.
n Distribute the exercise and complete it as a group.
Note: This module has no corresponding Practice Demonstration Video component.
Problem Solutions from Actual Practice 1 Module 5
Training Frontline Staff
Module 5: Problem Solutions from Actual Practice
Module 5 presents case studies of actual multifamily groups and catalogues a variety of responses to two commonly presented issues: finding or keeping a job and using medications. Although these examples capture problems and solutions that have emerged from real groups, they also apply to single-family sessions.
Overview of the module
Every group is unique. One approach will not solve all difficulties that consumers and families face. To be successful, solutions must be relevant and acceptable to consumers and families. This module presents the experiences of those who have participated in FPE programs. We selected two areas—employment-related and medication-related issues—because they are commonly raised and especially challenging. Also, they are a frequent source of tension and conflict for consumers, families, and practitioners.
Disagreements can be destabilizing or, at least, can prevent rehabilitation if left unresolved. Rather than trying to resolve disagreements directly, the structured problem-solving approach allows practitioners, consumers, and families to alleviate the effects of conflicts by finding alternative paths or identifying common ground.
Module 5 2 Problem Solutions from Actual Practice
Employment issues
This section begins with two case studies that show you how the problem-solving approach has been used to define and address employment-related issues. It also presents a log of similar problems and solutions identified through FPE multifamily groups. In some cases, staff from evidence-based practice Supported Employment programs have co-facilitated these groups.
Pedro’s story
Pedro, a man in his mid-30s, has struggled with serious mental illnesses since his late teens. He has been able to maintain an apartment and stay on medication for years with minimal support, but until recently had been unemployed. He is working closely with an employment specialist to make his part-time job successful, but shares some concerns with the multifamily group.
Step 1 Define the problem
In Step 1, the goal is to narrow the definition of the problem so that the group can generate practical, concrete solutions. To better understand Pedro’s concerns, the facilitator asked him to talk about his typical workday. Next, the facilitator asked Pedro’s sister more questions to understand her perspective. This process revealed that, since Pedro had not had much work experience, he was uncomfortable with co-workers. The facilitator defined the problem as:
How can Pedro become more comfortable with his co-workers?
Pedro and his sister agreed with the definition of the problem and the co-facilitator wrote it on the blackboard.
Step 2 Generate solutions
All members of the group brainstormed and generated the following list:
n Tell yourself there’s no pressure to be friends with everyone.
n Ask for support.
n Connect with people who do the same job.
n Do the best job you can.
n Plan activities outside of work.
n Make small talk.
n Compliment people.
n Give yourself credit.
n Use humor.
n Join work-related activities such as lunch.
n Bring in food to share.
n Ask questions to get to know others.
Step 3 Discuss advantages and disadvantages
The facilitator read each solution aloud and asked group members:
What are the main advantages of this solution?
After the co-facilitator recorded the advantages, the facilitator asked, “What are the disadvantages of this solution?” The co-facilitator wrote all responses on the blackboard.
Step 4 Choose the best solution
The facilitator reviewed the solutions for which the disadvantages outweighed the advantages. In these cases, the group agreed to cross out these solutions. Of the remaining solutions, the facilitator asked Pedro which he would like to try. Pedro chose the following solutions; his sister agreed that they are good ones to try:
n Join a work-related activity; and
n Bring in food to share.
Problem Solutions from Actual Practice 3 Module 5
Step 5 Form an action plan
The group helped Pedro break the solutions that he chose down into manageable, concrete, specific steps.
Pedro’s Action Plan
n Set aside grocery money.
n Make a shopping list.
n Shop for apricot bread ingredients during the week.
n Bake bread on Saturday afternoon.
n Bring bread to work on Sunday.
n Join co-workers for lunch on Sunday.
Step 6 Review the action plan
In the go-round of the next group meeting, the facilitator asked Pedro about his experience in working on his action plan. The group learned that Pedro set aside the grocery money, made a shopping list, and bought the ingredients for apricot bread. Unfortunately, he burned the bread and was unable to bake a second loaf before work on Sunday.
Although he didn’t have any bread to share, he did join his co-workers for lunch. He shared his breadmaking story and his co-workers laughed. He reported that it helped break the ice and he felt more comfortable with his co-workers. Facilitators and group members praised his courage and efforts.
Module 5 4 Problem Solutions from Actual Practice
Sharon’s story
Sharon is a 38-year-old woman with a schizoaffective disorder. She lives alone with her cat and works part-time (every morning for 4 hours) in the mailroom of a large insurance company. The bus stop to work is within easy walking distance of her apartment. She likes the routine of working every day and has become quite efficient at her job, which does not vary too much from day to day. Recently, however, some of her work duties have changed.
Step 1 Define the problem
The facilitator asked Sharon to explain how her work has changed. Sharon explained that the company is handling bulk mailings that must go out quickly, increasing tension at the worksite. Sharon told the group that she found the fast pace difficult and stressful. The facilitator defined the problem as:
What can Sharon do to feel less overwhelmed at work when bulk mailings must go out quickly?
Sharon and her parents agreed with the problem definition and the co-facilitator wrote it on the blackboard.
Step 2 Generate solutions
The facilitator asked group members for possible solutions. They generated the following list:
n Quit.
n Talk to the supervisor.
n Set limits for yourself.
n Take more frequent breaks.
n Go to the gym to relieve tension.
n Get a massage.
n Reduce your hours at those times.
n Scream into a pillow.
n Practice stress reduction techniques.
n Seek peer support.
Step 3 Discuss advantages and disadvantages
The group discussed the advantages of each suggestion first, then the disadvantages. The co- facilitator wrote all responses on the blackboard.
Step 4 Choose the best solution
After reviewing the advantages and disadvantages, the group eliminated several solutions. Sharon chose the following solutions; her parents agreed they are good ones to try:
n Talk to your supervisor.
n Practice stress reduction techniques.
Step 5 Form an action plan
With the group’s help, Sharon and her parents developed the following action plan:
n Approach the supervisor first thing in the morning to ask for a meeting time.
n Meet with the supervisor.
n Use stress reduction techniques before and after work for 1 week.
Then they conducted a role play in the group so Sharon could practice what she wants to say to her supervisor. Next, the facilitator introduced a stress reduction technique. All group members practiced the technique once together.
Step 6 Review the action plan
At the next group session, Sharon reported that she had not approached her supervisor during the previous 2 weeks. She practiced her stress reduction technique, which she liked. Although work was still tense sometimes, she reported that she feels better about it.
Problem Solutions from Actual Practice 5 Module 5
The following log outlines other employment-related problems and solutions that FPE multifamily groups identified.
Log of Other Employment-Related Problems and Solutions
Problem Possible solutions
Finding work n Look through want ads.
n Walk or drive around the community in search of job openings.
n Talk with members of your social support network.
n Use the yellow pages to identify jobs of interest.
n Visit jobs of interest.
n Enroll in a Supported Employment program.
Adjusting to a new job n Prepare for your first day (set an alarm clock, pack lunch, practice a bus route).
n Ask questions, as needed, about the job.
n Review your written job description.
n Arrive early to get comfortable with the place.
n Take one day at a time.
n Work with an employment specialist.
Managing symptoms and stress at work
n If symptoms affect your concentration, make notes to remember tasks or instructions.
n Ask for an accommodation such as a quiet workspace or regular breaks.
n Use stress reduction strategies.
n Identify a buddy at work with whom you can talk.
n Carry PRN medication.
n Work with an employment specialist.
Module 5 6 Problem Solutions from Actual Practice
Medication issues
The following case study shows you how the problem-solving approach has been used to define and address medication issues. This section also presents a log of other medication-related problems and solutions identified through FPE multifamily groups. In some cases, a psychiatrist or nurse co- facilitated these groups.
Darcy’s story
Darcy is a 29-year-old woman who has schizoaffective disorder. She is the mother of two young children. It is important to her to function well enough to care for her family, as well as to take one course each semester as she works toward her undergraduate degree. Following the advice of her doctor, Darcy recently started taking a new medication.
Step 1 Define the problem
The facilitator asked Darcy to explain the concerns that she had about the new medication she is taking. Darcy explained that the medication makes her feel tired. She was unable to concentrate in class and frequently nodded off.
The facilitator defined the problem as:
What can Darcy do if she’s experiencing side effects from her medication?
Darcy and her family agreed with the problem definition and the co-facilitator wrote it on the blackboard.
Step 2 Generate solutions
The facilitator asked all group members to contribute possible solutions. The group generated the following solutions:
n Call the doctor.
n Cut down on the medication.
n Ask someone to take notes in class.
n Bring a tape recorder to class.
n Drink coffee.
n Ask a classmate to wake her.
Step 3 Discuss advantages and disadvantages
The group discussed the advantages of each suggestion first, then the disadvantages. The co- facilitator wrote all responses on the blackboard.
Step 4 Choose the best solution
After reviewing the advantages and disadvantages, the group eliminated several solutions. Darcy chose the following solutions; her family members agreed they are good ones to try:
n Bring a tape recorder to class.
n Call the doctor.
Step 5 Form an action plan
With the group’s help, Darcy and her family developed the following action plan:
n After class on Wednesday, Darcy will set up an appointment with her professor. She will tell her professor that she is sleepy in class because of the side effects of a medication and she will ask if she can record the class until her dose is corrected.
n Tomorrow morning, Darcy will call to set up an appointment with her doctor. Her family member agrees to go with her to the appointment for support.
Problem Solutions from Actual Practice 7 Module 5
Step 6 Review the action plan
One week later, the facilitator called Darcy to see how she is doing and if she needed any help with the action plan. Darcy reported that she had set up her appointments. They reviewed what she wished to say during each meeting.
At the next group session, Darcy reported that she received permission to tape record her class. She
still fell asleep twice last week but her doctor suggested taking her medication at night and that seems to help. Her doctor agreed that she should lower the dose of her medication if the side effects continue for another 2 weeks.
The following log outlines other medication-related problems and solutions that FPE multifamily groups identified.
Log of Other Medication-Related Problems and Solutions
Problem Possible solutions
Forgetting to take medications
n Take medications at the same time every day.
n Set a timer.
n Combine taking medications with another daily activity such as brushing your teeth.
n Ask a buddy to call and remind you.
n Leave yourself a note.
Difficult medication regimes
n Talk with your doctor to see if your medication schedule can be simplified.
n Write a schedule on your calendar.
n Keep a medication record.
n Use a pill container. Ask a buddy for help.
Communicating medication issues to your doctor
n Ask for a longer appointment time.
n Role-play how you would present your concerns to your doctor.
n Ask other treatment team members to speak to your doctor with you.
n Ask a family member to join you for your appointment.
n Write down your concerns or keep a medication record and share it with your doctor.
Many concerns that consumers raise about medications may be viewed as decisional conflicts. In other words, consumers may feel conflicted about their decision to take medication as prescribed. The structured problem-solving approach is an effective way to address such concerns as long as consumers agree with the way
that the problem is defined and actively participate in weighing the advantages and disadvantages of the solutions generated. It is important to create an environment in which all group members feel comfortable voicing their ideas and consumers feel supported in weighing the options and choosing the best solution.
Problem Solutions from Actual Practice 9 Module 5
Exercise: Practice What You’ve Learned About Problem Solving
Select three members of your training group to play the roles of practitioner, consumer, and family member. Conduct role plays to practice using the structured problem-solving approach in either a single-family or multifamily group format.
n Conduct a role play to address an issue related to employment.
n Conduct a role play to address an issue related to medication.
HHS Publication No. SMA-09-4422 Printed 2009
26171.0709.7765020404
- Cover
- Title Page
- Acknowledgments
- Training Frontline Staff
- What’s in Training Frontline Staff
- Training Frontline Staff How Family Intervention Coordinators Should Use This Workbook
- Prepare program-specific information
- Prepare agency-specific information
- Visit an existing team
- Arrange for didactic training
- Recruit a consultant
- Cross-train
- For more information
- Module 1: Basic Elements and Practice Principals
- What is Family Psychoeducation?
- The phases of Family Psychoeducation
- Practice principles
- The family experience
- Core values in Family Psychoeducation
- Program standards
- How we know that Family Psychoeducation is effective
- Adapting the evidence-based model
- Summary
- Exercise: Explore the Benefits of Family Psychoeducation
- Exercise: Examine Program Standards
- Module 2: The Core Processes of Family Psychoeducation
- Identify consumers
- Introduce the program
- Conduct joining sessions
- Conduct the educational workshop
- Offer ongoing Family Psychoeducation services
- Engage consumers and families continuously
- Complete Progress Notes
- Participate in supervision
- Summary
- Exercise: Identify Consumers and Families
- Exercise: Introduce Your Program
- Module 3: Joining Sessions and Educational Workshops
- Joining sessions
- Educational workshops
- Exercise: Review Progress Notes for Joining Sessions and Educational Workshops
- Exercise: Practice What You’ve Learned About Joining Sessions
- Module 4: Ongoing Family Psychoeducation Sessions
- Conduct ongoing Family Psychoeducation sessions
- Structure of multifamily groups
- Overview of the first session
- Overview of the second session
- Ongoing multigroup sessions
- Exercise: Practice What You’ve Learned About Multifamily Groups
- Exercise: Review the Progress Note for Ongoing Family Psychoeducation Sessions
- Module 5: Problem Solutions from Actual Practice
- Overview of the module
- Employment issues
- Medication issues
- Exercise: Practice What You’ve Learned About Problem Solving
