Family psychoeducation (FPE) interventions have been shown to reduce relapse rates and symptom levels and improve the social participation of people living with severe and persistent psychotic disorders. Although less known amongst psychologists, FPE has a well established evidence base that predates that of CBT for psychosis. Surprisingly, despite the strong evidence, FPEs are not routinely available for Australians living with psychosis and their families.
What is family psychoeducation?
Family psychoeducation for the treatment of psychosis aims to improve knowledge and coping skills in families and clients, to enable them to work together more effectively to address the challenges of living with psychosis. Sessions include: goal setting; information sharing about the disorder, early warning signs and relapse prevention; and practical skills training in coping, communication, problem solving and goal setting. Sessions can be conducted with single families or in a multi-family setting.
The approach originated with stress-diathesis models of mental illness, which suggest that for vulnerable individuals, interaction with a stressful environment can lead to the development or exacerbation of mental illness (Burbach & Stanbridge, 1998; Zubin & Spring, 1977). Expressed emotion (EE) research in the 1960s indicated that hostile or critical comments and emotional over-involvement were sources of such stress for people living with psychosis and were associated with increased relapse. Developments in behavioural and cognitive techniques in the late 70s and 80s provided a technology for emerging therapies where stresses reduced as families learned more about mental illness and practised more effective communication and self care. FPE is not psychosis specific; both the phenomenon of EE and effective FPE programs have been demonstrated for people living with bipolar disorder, major depressive disorder, anorexia nervosa and more recently for posttraumatic stress disorder. There are three major types of FPE: brief psychoeducation; single family multimodal; and multiple family groups (see Burbach (1996) and Fadden (1998) for further details).
Who is suited for FPE?
All clients and families can benefit from FPE, but sensitive and thoughtful adaptation to each family’s particular needs and background is necessary. Early evidence suggested that single family multimodal FPE interventions should be offered to high EE families, but recent research has obtained good results for families where EE is not specified. Clinical heuristics suggest that shorter duration FPE interventions be offered initially. If clients and carers require further support, then longer programs can be offered. Individual family members can also be referred for their own individual therapy if it becomes clear that personal issues need to be addressed.
FPE is not prescriptive about who is ‘family’ and thus ‘entitled’ to attend; all persons who are involved in supporting the client are welcomed. As part of a non-blaming and positive approach to families, FPE incorporates constructive attitudes to clients and families congruent with a recovery framework. Practitioners acknowledge that the family has been making their best efforts to date and incorporate the expertise and skill of the family in dealing with issues every day, in a collaborative recovery-oriented approach.
Benefits and evidence base of FPE
There is consistent evidence, from over 50 randomised control trials involving almost 2,000 clients, that family psychoeducation is effective for improving the mental health and functioning of both clients and their families across many cultures (Pharoah, Mari, Rathbone, & Wong, 2010).
FPE decreases the frequency and severity of relapse for clients by 20 to 50 per cent. Mental state, medication adherence, social engagement, employment and relations with family have all been shown to improve. Changes can be sustained for up to two years following treatment.
The outcomes for carers have been studied less but are positive in four main areas: decreased burden, decreased psychological distress, increased coping and increased social connection.
Although much is understood about client outcomes associated with FPE interventions, it is still unclear what the ‘active ingredients’ of the therapy are. However, some characteristics of effective programs are clear: they tend to be longer (approximately 9 months); include the client in most sessions; respond to the cultural background of clients and the phase of illness (e.g., first episode vs. later relapse); work in tandem with effective medication; and include strategies to improve coping, communication and problem solving.
Implementation in the Australian context
While the strong evidence for FPE for psychosis has led to recommendations in most treatment guidelines (Kreyenbuhl, Buchanan, Dickerson, & Dixon, 2010; McGorry, 2005), FPE is not widely available either here or overseas (Cohen et al., 2008). There is an urgent need to provide the mental health sector with evidence of effective ways to implement the research evidence for family involvement in mental health care, including how best to address barriers to implementation.
Barriers to implementation
There are many reasons for difficulties with implementation (Fadden, 2006). Within services, clinicians can be very busy, and may need to meet more immediate goals regarding care of their clients. There may be little incentive to take on the complexity of family work when other tasks are pressing (Drake et al., 2001) and they may not have the training to feel confident in family work. For some clinicians trained as individual therapists, there may be dilemmas around client confidentiality or dual roles.
At an administration level, it may be hard to set up flexible work systems to support family sessions that may occur out of hours. In addition, there are set-up costs for training and ongoing mentoring (Drake et al., 2001).
Although families and clients may have great need for assistance, the literature reveals that there are multiple barriers for them in joining a family program (Fadden, 1997). Practical needs such as transport, difficulties with scheduling sessions and other demands on their time are concerns. Family members may fear that the sessions will end up increasing rather than reducing demands on them, whereas clients may worry that they will be put under pressure. Both may not have been informed of the potential benefits.
For some families and clients, the stigma of mental illness stops them accessing services, and in particular makes group sessions unattractive. Families may have had very negative experiences in the past, typically feeling blamed for the client’s mental illness. Alongside this, families may feel hopelessness and resignation regarding the client’s condition. Also, clients may feel uncomfortable about losing their privacy or 'opening up' to the family (Drake et al., 2001).
Australian trials of FPE
Two services in the north-west region of Melbourne have introduced and evaluated FPE interventions and increased the understanding of effective implementation.
The first was a public community mental health service, which established a Behavioural Family Therapy program for clients and their families. Extensive training enabled virtually all professionals in a case manager role to become skilled, and ongoing mentoring groups supported the implementation effort. The result was that any case manager was capable of offering a program of evidence-based family sessions and ongoing collaborative care when sessions were completed. Evaluation data is being collated, but preliminary results show high levels of satisfaction, and positive relations between case manager, family and client. Staff reported their clinical experience was greatly enriched. Interestingly, clients did not report concerns with confidentiality, and in fact welcomed the chance to openly discuss their mental illness with family members in a supported environment. Nonetheless, it proved challenging to sustain FPE levels in the organisation due to staff turnover and the general demands of case management.
The second implementation program was through Mind – a large non-government mental health provider. This program was directed at families who were not case managed or registered with an Area Mental Health Service. It addressed a critical need to provide a service for families who had either been discharged to general practitioners, or for some other reason did not access services. This was the first time in Australia that FPE was offered in the community managed mental health sector. FPE was provided by a small number of practitioners who specialised in the intervention – a feature that was found to increase skills and confidence in working with families. In a program evaluation, clients and family carers entering the program showed substantial mental health challenges compared to community norms. Clients made significant gains in important areas such as quality of life, level of symptomatology and functioning, and social connection, and carers experienced significantly less burden at the conclusion of family sessions.
For both services, considerable innovation and problem solving was required to overcome typical implementation challenges. Since practitioners within the first program conducted family sessions alongside their major case management role, provision for co-working to enhance confidence proved to be an important strategy. Provision of dedicated time for FPE sessions was also important. Neither of these approaches was necessary within the second program which was set up as a team devoted entirely to this work. However, ongoing supervision and mentoring proved essential for sustaining practice in both services, as did enhancing skills in engagement of clients and families. In both cases an organisational commitment to developing the service and structures supporting the family practice were essential and included scope for after-hours work to suit families’ availability and ensuring that progress was monitored and provided through feedback to staff.
Conclusion
FPE interventions have a sound evidence base, can enhance recovery in people living with mental illness, and improve the lives of their family and support people. They are compatible with the Federal Government’s ‘Recovery’ framework for mental health services (Commonwealth of Australia, 2010) as they enhance collaborative relationships between practitioners, clients and families, support goal setting, facilitate self-efficacy and planning, use positive language, encourage problem solving and promote hopefulness. They respect the family culture, and respond to the values and circumstances of families and clients. FPE interventions can be implemented by private practitioners, staff in public mental health services and by suitably trained NGO workers. Given their origin in stress-diathesis models and their behavioural and cognitive skill set, they are worthy of substantially more attention from psychologists, professional training programs and funders.
The principal author can be contacted at [email protected]