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To the Multi-Family
PsychoEducation Workshop
Today’s Agenda
9:30 – 9:45
Welcome Introduction
9:45 – 10:45
Risks for Symptom Exacerbation &
Relapse
10:45-11:00
Break
11:00-12:00
A Brief Introduction to the Psychobiology of Bipolar Disorder
12:00-12:30
Lunch
12:30-1:15
Principles of Addiction/Co-occurring Disorders
1:15 – 2:30
What is Family Psycho-Education? Structure and Format of the Group
Common Needs of Person
Coping with a Mental Illness
• Acceptance
• Clear understanding of what the illness is
and what it is not
• Recognition of Strengths
• Help with identifying needs and goals
• Support Network
• Low Stress Environment
NAMI Survey of Common
Family Needs
• Reduction of anxiety about the loved one
• Understanding appropriate expectations
• Learning to motivate the family member to
do more
• Assistance in times of crisis
• Assistance navigating the mental health
system
Some quotes from parents…
(Greenberg et al. 1993)
• …”My worry is ongoing: it’s a miserable life for him. I worry about how
he’ll cope when we’re gone.”
• …”My other children don’t care to come home any more. There is a
dark cloud overall of us. There’s tension in my spousal relationship”.
• …”We don’t have company to the house. We don’t try to make new
friends. We don’t have much of a social life…”
• …”I’ve felt afraid of my son & his illness. Sometimes I don’t know how
I’m going to be able to cope. I don’t know what to expect, and what not
to expect”.
• …”Having a child with mental illness is a very difficult experience for
anyone. It’s difficult to see someone you love be tormented. It has
affected every one of us”.
“The Four C’s”
You didn’t Cause it.
You can’t Cure it.
You can’t Control it.
But you can Cope with it.
David Karp, The Burden of Sympathy
Risks for Symptoms
Exacerbation & Relapse
Risks for Symptom Exacerbation and Relapse
High rate of change
• Excessive life events per unit of time
• Disruption of social supports
• Lack or loss of "bridging" cues
• Entry into a new context
• Multiple functional levels involved in
compensating
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
Risks for Symptom Exacerbation and Relapse
Intensity, Negativity and Complexity
• Critical comments
• Over-involvement
• Lack of warmth
• Crowding
• Excessive pressure to perform
• Interactions with conflict
• Multiple sources of input
Evidence-Based Practices
Copyright West Institute
William R. McFarlane, MD
Risks for Symptom Exacerbation and Relapse
Physical and Chemical Factors
• Stimulants
• Hallucinogens
• Dependence on depressants
• Unknown environmental toxins
• Loud noises
• Distracting noises, echoes
• Bright lights
Evidence-Based Practices
Copyright West Institute
William R. McFarlane, MD
Reducing Vulnerability to
Negative Emotions
1.
Treat PhysicaL Illness
Take care of you body.
See a doctor when necessary.
Take prescribed medication
2.
Balance Eating
Don’t eat too much or too little.
Stay away from foods that make
you feel overly emotional
3.
Avoid mood-Altering drugs:
Stay off non-prescribed drugs,
including alcohol
Reducing Vulnerability to
Negative Emotions
4.
Balance Sleep
5.
Get Exercise
6.
Build MASTERy
• Try to get the amount of sleep
that helps you feel good. Keep
to a sleep program if you are
having difficulty sleeping.
• Do some sort of exercise every
day; try to build up to 20
minutes of vigorous exercise.
• Try to do one thing a day to
make yourself feel competent
and in control
A way to remember these skills is to remember the term “PLEASE MASTE
Effects of Social Networks
• Family network size diminishes with length of
illness.
• Network size for patients appeared to decrease in
the period immediately following a first episode.
• Smaller network size at the time of first admission.
• Networks buffer stress and adverse events.
• Networks and families determine treatment
compliance.
• Social support predicts relapse rate.
• Social support is associated with coping skills and
burden.
Expressed Emotion
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Critical comments
Hostility
Guilt induction
Intrusiveness
Emotional over involvement
Pressure to perform/achieve
» Goldstein 1985
» Tienari 2004
Break
A Brief Introduction to the
Psychobiology of Bipolar Disorder
Mood Disorders
• ARE
– Biological disease of the brain
– Disabling and emotionally devastating for
many
– Common
– Misunderstood and stigmatized
– Treatable
• ARE NOT
– The fault of the family
– A personal weakness
Major Depression: DSM-IV
• Depressed mood, or loss of interest/
pleasure
• Other symptoms (total of 5)
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Increase or decrease in appetite/weight
Insomnia or hypersomnia
Agitation or slowing
Fatigue or loss of energy
Worthlessness or guilt
Poor concentration or indecisiveness
Recurrent thoughts of death or suicide
Major Depression: DSM-IV
(continued)
• Two week duration
• Impaired functioning in life roles
• Rule out “look alikes”
– Secondary depression
– Physical Illness
Major Depression: The Causes
• Limbic System
• Neurochemical
• Serotonin
• Norepinephrine
• Others
• Heredity
• Identical twins - 40%
• Environmental stresses
Major Depression: The Course
• Can occur at any age
– Usual onset similar to schizophrenia, or
later
– 10% have first episode after age 60
• More common in women (2:1)
• Lifetime prevalence 17%
• Recurrent in 50-60%
– Later episodes: longer, deeper, more
frequent, less of a trigger
• May be seasonal
Major Depression Severity
• Mild to severe
• May include psychosis, poor self care, suicide
• Abraham Lincoln describing his own
depression:
• “I am now the most miserable man living. If
what I feel were equally distributed to the whole
human family, there would not be one cheerful
face on earth. Whether I shall ever be better, I
cannot tell. I awfully forebode I shall not. To
remain as I am is impossible. I must die or be
better, it appears to me.”
BIPOLAR DISORDER
• A mental disorder characterized by severe
mood swings between depression and
mania.
• It affects between .8% and 1.6% of the
population.
• It affects both genders equally and is more
prevalent in people of middle to upper
socio-economic class.
Description of Mania
• “I walked into a really fancy restaurant with my
mother and started jumping around and running,
and there were these chandeliers on the ceiling.
I thought I was Superman or something, and I
leapt up to grab onto one of them and started
swinging on it… [when you’re manic] you think
you’re God… and that the world is revolving
around you, that you can change nature, and the
birds will come to you as if you called them.”
Description of Depression
• “[When I’m depressed] I feel like there’s no
hope… I feel like suicide is the only
solution. There’ve been days on end
where I would just stay in bed… I didn’t
want to talk or spend time with anybody,
not even my wife… I would call in sick and
just stay in bed. You just give up like
there’s not a future for you.”
Stages of Bipolar Disorder
Bipolar disorder often occurs in three
progressive stages.
• Stage 1 Prodromal Hypomanic Period
• Stage 2 Manic Escalation
• Stage 3 Mania accompanied by psychosis
Stages of Bipolar Disorder
• The variability of the illness progression in
bipolar patients means that some patients may
skip some stages, or have only brief periods
when these stages are identifiable.
• Depression often follows a manic episode.
• The exact length of a manic and depressive
episode is unpredictable, and the phenomenon
of rapid cycling between manic and depressive
episodes makes the illness frustrating and
difficult for family members.
Treatment Options
• There are several effective treatment
medications for bipolar disorder. Primarily
are mood stabilizers, although antipsychotics or anti-depressants may be
needed as well.
Mood Stabilizers:
Commercial Name/Generic Name
Lithobid/Lithium
Depakote/Divalproex, Divalproic acid
Tegretol/Carbamazepine
Effects of Bipolar Disorder on
Family Members
• Coping with Symptoms
Understand the differences between bipolar
disorder, depression, and schizophrenia to help
family members appreciate the types of illnesses.
Understanding symptom management, based on
illness is important.
• Coping with Disability
People with Bipolar disorder have periods of
relatively high functioning. It can be frustrating for
family members to cope with the rapid changes in
their relative’s ability.
Family Management of Bipolar
Disorder
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Medication Adherence
Stress Management
Clear Communication
Problem-Solving
Participating in Treatment Planning
Treatment of Mental Illness
• The following treatment approaches are used with Schizophrenia
and Bipolar disorder, usually in combination, rather than
separately:
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Medication Treatment
Psychosocial Treatment
Rehabilitation
Individual Psychotherapy
Cognitive Behavioral Psychotherapy
Family Education
Self Help Groups
Community and Social Support
Lunch
12:30 – 1:00
What about Substance Use
Disorders?
The History of Multifamily
Groups
• Originated 30+ years ago in a NY hospital
• Families were offered education in a group
format without consumers
• Consumers wanted to join
• Hospital staff noticed significant improvements,
e.g., Increased social skills and interest in
treatment amongst consumers, improved
family involvement and communication
Rehabilitation Effects of
Multifamily Groups
• Reducing family confusion and tension
• Tuning and ratification of goals
• Coordinating efforts of family, team, consumer and
employer
• Developing informal job leads and contacts
• Cheerleading and guidance in early phases of working
• Ongoing problem-solving
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
Evidence-Based Benefits for
Participants
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Promotes understanding of illness
Promotes development of skills
Reduces family burden
Reduces relapse and rehospitalization
Encourages community re-integration, especially
work and earnings
• Promotes socialization and the formation of
friendships in the group setting
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
Therapeutic Processes in
Multifamily Groups
• Stigma reversal
• Social network construction
• Communication improvement
• Crisis prevention
• Treatment adherence
• Anxiety and arousal reduction
Components of Groups
• Two co-facilitators
• 5-6 families with similar diagnoses
• Meetings every other week for a minimum of 9
months, monthly thereafter
• Families, consumers, and practitioners become
partners
• On-going education about symptoms,
medication, community life, work, etc.
• Problem-solving format
Copyright West Institute
Evidence-Based Practices
William R. McFarlane, MD
Evidence-based benefits for
participants
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Promotes understanding of illness
Promotes development of skills
Reduces family burden
Reduces relapse and rehospitalization
Encourages community re-integration,
especially work and earnings
• Promotes socialization and the formation of
friendships in the group setting
The First Meeting of the MFG
Laying the Foundation: “Getting to know
you”
• The first time families come together as a group
• Sharing personal information
• Keep it interesting and light
• Leaders begin by modeling the behavior
• Culturally normative introductions/behavior
• Begins to build trust and understanding
The Second Meeting of the MFG
“Experience with Mental Illness”
• Continue to build the relationships
• Information learned in the joining sessions is revisited
• Personal stories of the impact of mental illness are
shared
• Leaders begin by modeling the behavior
• “What did you lose, what would you like to get back?”
• Be available to help families process the experience
Family Guidelines
• Go Slow.
Recovery takes time. Rest is
important. This is a medical
illness like any other.
• Keep it cool.
Enthusiasm is normal, but
keep it toned down.
Disagreement is normal, but
keep this toned down too.
Family Guidelines
• Give each other
space.
Time out is important. It is
okay to reach out. It’s okay to
say no.
• Set limits.
Everyone needs to know what
the rules are. A few good rules
keep things clear. Structure
makes “keeping it cool and
warm” possible
Family Guidelines
Ignore what you can’t change.
Let some things slide but don’t ignore
threatening, violent or psychotic behavior.
Making an action plan ahead of time will help
avoid a major crisis if it can’t be ignored.
• Keep it simple.
Say what you have to say clearly,
calmly, and positively.
Family Guidelines
• Follow the doctors orders and treatment
plan.
Good communication among family, consumer, and providers is
essential to making mid-course corrections and getting it right!
Make changes as needed in conjunction with everyone.
• Carry on business as usual.
Re-establish family routines as quickly as possible. Watch for
problems, but keep living your lives.
Family Guidelines
• Avoid street drugs
and alcohol.
They make symptoms worse,
can cause relapse and prevent
recovery. Encourage
nonjudgmental attitudes and
open communication to
optimize recovery.
• Pick up on early
warning signs.
Note changes. Make a list
of
unique warning signs and
symptoms that indicate a
possible relapse.
Family Guidelines
• Solve problems stepby-step.
Follow a sequential process to
resolve concerns. Recovery is a
series of steps, not an event.
• Lower expectations,
temporarily.
Recovery from an episode
takes time and functioning is
affected. Use a personal
yardstick to guide progress.
FAMILY GUIDELINES: BIPOLAR ILLNESS
•ASSURE SAFETY (FOR EVERYONE)
•SET LIMITS AS NEEDED
•BE CLEAR, SIMPLE AND DIRECT
•ALLOW SPACE
•SUPPORT MEDICATION AND TREATMENT
•CARE FOR THE REST OF THE FAMILY, TOO
•BETWEEN EPISODES, TALK TOGETHER AND PLAN
Structure/Format
of Groups
Structure of Sessions Multifamily groups
(MFG)
MFG
1.
Socializing with families and consumers
15 m.
2. A Go-around and review
20 m.
a. The week's events
b. Relevant biosocial information
c. Applicable guidelines
3. Selection of a single problem
5 m.
4. Formal Problem-solving
45 m.
a. Problem definition
b. Generation of possible solutions
c. Weighing pros and cons of each
d. Selection of preferred solution
e. Delineation of tasks and implementation
5. Socializing with families and consumers
5 m.
Total:
90 m.
Type and Focus of ProblemSolving
• Direct action and intervention by clinician
• Clinical experience and observation/formulation
• The Family Guidelines
• Problem agreed upon by all family members
• Problem with disagreement among family members
• Next Steps
Problem-Solving Hierarchy
 SAFETY
 Medication adherence
 Drug and alcohol use
 Life events (precipitants)
 Conflicts between family members
 Problems generated by other providers/agencies
 Conflicts with Family Guidelines
Brainstorming the Possible
Solutions
• All members contribute
• All suggestions are welcome
• Save critique and analysis for the pros and cons section
• Limit number of solutions to 10-12
• Weigh advantages and disadvantages with similar non
judgmental approach
• Family/consumer pick 1-3 solutions
Develop the Action-Plan
Create a plan of action for each solution
Identify and assign tasks and achieve consensus
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Between now and next group meeting…
What needs to be done, by whom
When
Are there any barriers or obstacles
Who can help
If appropriate, offer to become part of the action plan
Today, FPE is offered in select locations
throughout the U.S. and in countries such
as Norway, Denmark, England, Australia,
China, Japan, Holland and Canada.
Training is generally offered through state
agencies or university programs.
Relapse outcomes in clinical
trials
70
65
60
50
41
40
30
20
15
9
10
0
No medication
Individual therapy &
medication
FPE & medication
PEMFG &
medication
Positive Outcomes from FPE
• The consumer and family work together
towards recovery.
• Can be as beneficial in the recovery from
schizophrenia and severe mood disorders
as medication.
Other effects in clinical trials
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Improved family-member well-being
Increased consumer participation in
recovery
Substantially increased employment rates
Decreased psychiatric symptoms,
including deficit syndrome
Improved social functioning
Decreased substance use
Reduced costs of care
Rehabilitation effects of
multifamily groups
 Reducing family confusion and tension
 Tuning and ratification of goals
 Coordinating efforts of family, team,
consumer and employer
 Developing informal job leads and contacts
 Cheerleading and guidance in early
phases of working
 Ongoing problem-solving
MI 9-08 Evidence-Based Practices
References

Family Psychoeducation Implementation Resource Kit: Evidence-Based Practice
Implementation Resource Kit developed through a contract (no. 280-00-8049) from the
Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental
Health Services (CMHS)

Multiple Family Group Family Guidelines: Family Institute for Education, Practice, and
Research, New York State

Anderson, C., Hogarty, G., Reiss, D., Schizophrenia and the Family, New York, NY, Guilford
Press, 1986

McFarlane, W.R., Multifamily Groups in the Treatment of Severe Psychiatric Disorders, New
York, NY, Guilford, 2002.

McFarlane, W.R. (2005) Psychoeducational Multifamily Groups for Families with Persons
with Severe Mental Illness. In. Lebow J. Ed. Handbook of Clinical Family Therapy: John
Wiley & Sons, Inc.

Schizophrenia Explained (Video) by William R. McFarlane, M.D. Produced by Maine Medical
Center, 22 Bramhall Street, Portland, ME 04102