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Psykoeducational family work
Åse SvilandClinical spesialist psychiatric nurse Anvor LotheClinical social worker/ family therapistFamily departmentPsychiatric divisionStavanger University Hospital
Norway
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Plan for the Presentation• Schizophrenia and optimal treatment• Background for familywork in Norway• National guidelines• Main tasks of family work• Guiding principles for family work• History and research• Familys encounter, challenge and role• Psycho educational mulitfamily group• Recovery• Organizing of familywork in Stavanger
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Schizophrenia
• Schizofrenia is one of the most serious of the mental illnesses
• It has a great impact on the life of both patient and the patient`s family
• It strokes mostly young people between the ages of 15 and 25
• And the treatment of schizophrenia has had a difficult history.
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Optimal treatment
• Treatment with antipsychotic medicasion.
• Psychotherapeutic treatment from an experienced therapist
• Hospitaliaized within an appropriate therapautic environment
• Psychoeducational family approach
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Background
• Patient`s relatives appreciated meeting other relatives
• Multifamily- group with the patient
• The modell of William Mcfarlane
• Weekend seminar
• Roleplay
• 1 year before pilot-groups
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National guidelines for the treatment of psychosis
• All families will be offered contact within three days after starting treatment.
• All families will be offered calls for their own benefit, education, aid to problem solving and effective communication.
• Siblings and children are invited into their own conversations.
• Services to families should be needs-oriented
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General guidelines for family work
• To ensure an effective treatment for the patient
• Relating to family members' needs in relation to the affected family member's psychotic condition
Burbach, Fadden og Smith 2008
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The main tasks of family work in psychosis
• To engage the family in a therapeutic adapted collaboration with professionals.
• To offer family members the time to talk about what has happened.
• To normalize the reactions and offer emotional support.
• To talk with each family member separately, in order to gain an understanding of each individual's situation, how they are affected by development.
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The main tasks of family work continue…
• An overview of how family members relate to each other and
• how those systems relate to their experiences.• To convey understanding and help them to deal
with the situation they are experiencing as a result of psychosis development.
• Helping them to make contact with other family members who are in a comparable situation to reduce the experience of isolation and stigma
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Conclusion
The best results are when
the family participates
in the treatment
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Guiding principles for family work
• Collaboration between patient, family and the professionals who work with them.
• Challenges that arise, meet on an objective basis and the solution that is developed between the parties forming the basis for problem-solving efforts.
• Methodology in family work is based on a non-judgmental attitude towards family members.
• Focus of the work is here and now oriented and forward looking.
• The emphasis on an honest and open exchange of information with all family members where the patient is included
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3 claims
1.Treatment works best when the patient knows how to work, and how patient themselves can contribute
2.Patient knows best how he can collaborate and contribute when he knows what the disease is and what the treatment involves
3.The environment knows best how patient can be helped when they know how the disease is
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What is communicated
• Actual knowledge
• Attitudes
• Seriousness
• Activity
• Safety
• Confidence
• Community
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HistoryNeuroleptica is introduced in the treatment of serious mental illnesses. Optimism is high. Many patients are being dismissed from the hospitals, but unfortunately a large percentage return after a short time
George Brown (England) examines 229 patients after their dismission from hospital. He identifies two types of families: (Leff and Vaughn, 1985)
1950
1968
High Expressed Emotion-families (EE)- Highly critical- Overinvolving- Hostile
Low Expressed Emotion-families (EE)- Warm (loving)- Accepting
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HistoryThe Camberwell – interview
”made to measure” EE• Methods of treatment to lower EE in the
family are introduced. Relapse is reduced from 60 % to 20 % in one year.
(Borchgrevink 1999, Kavanagh 1992, Leff and Vaughn 1985)
• Main elements are
Education Communication Problem solving
1972
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ResearchHogarty et al.(1986) Mc Farlane et al. (1990)
Relapse after one year (%)
41 Outpatient treatment
23,5 Single family work
Familywork including 0 social skills training
20 Social skills training 12,5 Multifamily
educational groups
Familywork including 19 education and
problem solving
42,9 Dynamically oriented multifamily work
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Recent Research
Psykoeducational terapy give better results- reduce relapse- reduce symptoms- better psykososial function- more knowledge about psychoses- better coopertion about medication(Pitchel-Waltz et al, 2001, Pekkala & Merinder 2002, Bentsen 2003,
Murray-Swank & Dixon, 2004)
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The family's encounter with psychosis
• Sadness - despair – crisis
Shame and stigma
• Isolation
Economic problems
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The family's challenge
• Understand the incomprehensible behavior
• Maintain a dialogue
• Provide assistance
• Take care of the rest of the family
• Fulfill their own needs
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The family's role
Family is not responsible for the development of psychotic disorders
Family members are doing the best they can in relation to the help they get to understand the disease and what they can do to help
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Effective psychosocial treatments
• Emphasizes education about the disease
• Based in the stress / vulnerability model
• Works to enhance natural coping mechanisms
• Mobilize all available support
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Familywork
• One family• Multifamily• With patient• Without patient
The groupleader gets a different relation to the patient
The relatives get a different relation to the patient
The patient changes attitude/behaviour
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Goals• Better cooperation bethween patient, relatives and professionals• Reduce the risk of relapse
By giving the family• Knowledge• Support and advice
By helping the family• Better manage living with the patient• Better handling difficult situations• Ease the burden
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Step 1 Step 2 Step 3
Meetings between the familygroupleaders, the patient and each individual family. At least one meeting without the patient.
Education seminar for all the families participating, during a full Saturday or maybe spread over two nights.
Multifamily groups meetings: five families meet every other week, 90 minutes sessions during at least two years. Two family group leaders in each group
Multifamilygroups
Focus on the family work is
Education Communication Problem solving
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Family-work structurealliance talks
Relatives• Introducing the family-
work program, contents and goals
• Crisis concerning the illness
• Draw a geneogram (family tree)
• Learning about warning signs and possible signs of relapse
Patient• Introducing the family-
work program, contents and goals
• The groupleaders and the patient is getting to know each other
• Draw a genogram (family tree)
• Learning about warning signs and signs of possible relapse
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Educasion - seminar
Program• Understanding psychoses• Expressed Emotion• Stress- vulnerability model• Different symptoms• Drugs / psychoses• Treatment: milieu therapy, medication,
rehabilitation, psychotherapy• Crisis theory• The Law concerning mental health service
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Multifamily groups-structure• First meeting: Presentation of all the group-members• Second meeting: the group members talk about how
the illnes have affected their lives.• Following meetings: Problem solving method
» McFarlane
First year• Avoiding relapse• Gradually reestablishing normal functioning within the family and amongst friends
Second year• Rehabilitation• Education / Work planning• Reestablishing normal social functioning
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Meeting structure
15 min small talk
20 min around
5 min choose aproblem
45 minproblemsolving
5 min end of meeting
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Problem solving / choosing a problem
Two main areas of concern1. Factors that can lead to relapse2. Factors involving the next step in getting betterPriorities• Safety at home• Medication• Drugs and alcohol• Life events• Experiences beyond one’s influence• Disagreement between family members
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Solution Plan
Define a problem or a preferred activity
Make a list of all possible solutions
Discuss all possible solutions
Make a detailed plan:
How to get started? When do you want to start?• • •
What resources will you need?• • •
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Solutions in practice
• All successfull solutions are credited the family.
• The failures are put on the shoulders of the group leaders
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When a certain problem is not solved
• Give a suggestion to the solution and ask for a response on the next group meeting
• Refer to earlier similar problem solution
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Communication rules
• No mind reading
• Talk for yourself
• Respect the views of others
• No ”deep” discussions
• Help each other with explanations
• Give positive feedback and support
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Advice to relatives during patient’s psychosis
Expectations Goals Violence
Clear speach Plan your day• ___________• ___________
Responsibility
Medication Warning signs Problems
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• improvement is a gradual process• often go in waves• need rest periods to be stable• pressure for change in these periods
causes stress• pace of change is individually
• TAKE ONE STEP AT A TIME !!!!
RecoveryPhases in the improvement process:
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How we organize familywork in Stavanger?
• In Norway, we have a common national educational programme consist of 60 hours of theori.
• Participants in the training engage in role play
• there is monthly supervision for groupleaders
• In Stavanger 2012: 20 multifamiliegroup and 40 group leaders in activity
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Thank you
for listning!